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O. O. Bogomolets national medical university




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The chart of the case report.


O.O.BOGOMOLETS NATIONAL MEDICAL UNIVERSITY

Department of Neurosurgery


Chief of department

Academician of NAMS of Ukraine V.I.Tsymbaliuk

Teacher:


CASE REPORT

Surname of patient, name, patronymic name _____________________________________________

____________________________________________________________________

Clinical Diagnosis:

__________________________________________________________________

Surname and name of student,

____________________________________________________________________

Course________________Faculty_____________Group________________


Kyiv -2011

Case report №

Surname, name, patronymic name of the patient_______________________________________________________________

By whom the patient is directed __________________________________________________________________

Age______________________ Female/Male_________

Occupation ___________________________________________________________________

Domestic address_____________________________________________________________

Date of hospitalization______________ Date of discharge from the hospital __________________

Diagnosis during hospitalization

Diagnosis clinical

Concomitant diseases

Operation (date)_______________________________________________________________________________________________________________________________

Complication (date) _________________________________________________________________

Postoperative diagnosis___________________________________________________________

Result (convalescence, improvement, without the changes, worsening, death) Capacity (well-kept, reduced, lost (temporally, forever)


Complaints of patient during hospitalization in the moment of review


Anamnesis of nowaday disease (time of disease, first symptoms of disease, loud speaker of development of symptoms, conducted treatment to hospitalization in a clinic, his results. In the case of trauma - to mark the date of trauma, circumstances and mechanism of trauma, given first help.
^

Anamnesis of life.




I. General examination.

Common state of patient (build, features of structure of body, position of patient at bed)

Form, size and position of head

Skinning covers and visible mucous membranes

Lymphatic knots

Cardio-vascular system

Breathing organs

Organs of abdominal region

Local changes (trophic disorders, wounds, scars, defects of bones, bedsores and other)

Bloody pressure _______ Pulse__________Breathing rate ____________________

II. Special exemination (information of neurological review).

І. ^ General cerebral symptoms (headache, nausea, vomitting, discomfort and other)

2. State of consciousness (orientation in a place and time). Conduct at the inspection, attitude toward the disease. __________________________________________________________________


3. Meningeal symptoms (rigid neck of muscles of the back of head, the Kernig, Brudzinsky symptoms)

2. Cranial nerves.

I pair. Olfactory nerve. Verification on either side

II pair. Visual nerve. Field and sharpness of sight

III, IV, VI pair. N. oculomotorius, n, trochleares, n.abducens. Form and size of pupils, reaction on light, convergence, accommodation. Width of eyeing slit. Motion of eyeballs, presence of cross-eye, doubling of objects

V pair. Tregeminal nerve. Sensitiveness on face. Morbidity of points of output of branches of trigeminal nerve. Corneal and conjunctival reflexes. State of masticatory musculature ________________________________________________

VII pair. Facial nerve. Symmetry of person. Wrinkle (up) one's forehead, screwing up of eyes. Presence of asymmetry of nasolabial folds at mimic tests _________________

VIII pair. N. vestibulo-cochlearis. (sharpness of ear, nystagmus)


IХ, X pairs. N. glossopharingeus, N. vagus. State of swallowing and phonation. Nasal tint of broadcasting, mobility of soft palate. Reflexes from a soft palate and from the back wall of gullet. Taste.

XI pair. N. abducens. State of груднино-ключично-papillary muscle, turn of head in sides and down, raising of shoulders. _____________________________

XII pair. N. hypoglossus. Pulling out of tongue, declination of him in sides. State of muscles of tongue, atrophy, fibrilar twitch(ing) _______________________________

3. Motor sphere.

Volume of active motions in the joints of hands and feet. Muscular force (force of symmetric groups which are explored; estimation is given after the fiveball system). Passive motions, their volume. Muscular tone and his changes. Atrophy of muscles. Fibrilar and fascicular twitch(ing). hyperkinesis, their character, localization and degree of expression. ____________________

4. Reflexes.

To the tendon reflexes (from two-headed and tricepses, knee and achill). Periostal reflexes (from subulate sprout of radial bone). Skinning reflexes (abdominal, sole). _________________________________

Pathological reflexes (extensive – Babinsky’s, Gordon”s, Sheffer”s symptoms; bending –Rossolimo”s, Bechterev”s etc., protective reflexes; clonus of patella) ________________________________________


5. Sensitiveness.

Superficial types of sensitiveness. Muscular-joint feeling. Vibration feeling and feeling of pressure. Difficult types of sensitiveness (stereognosis, discrimination of two points. Awareness of position of body and his parts in space).

Morbidity of nervous trunks.

6. Coordination of motions.

Static test (the Romberga’s symptom ). Locomotoric tests (finge-nose probe, khee- calcaneal probe). diadochokinesis. Step (hemiplegic,spastic, heretic).______

7. Speech (scansion, disartria,anartria, with a nasal tint)

Aphasia (motor, sensitive, amnestic)

8. Letter, reading, accounting.

9.Vegetative nervous system (dermografismus, hyperhydrosis)..

Functions of pelvic organs.

III. Previous diagnosis. (substantiation of the topic and nosology diagnosis)


IV. Plan of diagnostics. (substantiation of the necessity of the performing methods for clarification of diagnosis, choice of tactic of treatment)


1. Review of adjoining specialists: ophtalmologict, otoneurologist, physician etc.

2. Diagnostic methods.


laboratory (blood test, urines, CSF), X-Ray methods, EchoEG, EEG, LP (liquor pressure, liqurodinamic tests)

contrasting methods of research, their grounds (angiography, pneumoencephalography, ventriculography, cystography, myelography)

CT, MRI, radioisotope methods

Consultations of specialists (otoneurologist, ophtalmologist etc.)

V. Differential diagnosis (4-5 nosology , which have similar symptoms)

VI. Clinical diagnosis (final)

VII. Treatment: surgical (substantiation of the operation, protocol of operation);

Conservative treatment (general principles and prescriptions of 4-5 medicines)

VIII. Clinical flow of illness (2-3 diaries)

IX. Epicrisis

X. Recommendations at the discharge from the hospital

XI. Autopsy protocol in the case of death of patient


Signature of doctor


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