M. I. Pirogov vinnytsia national medical university department of endocrinology with the course of postgraduate preparation icon

M. I. Pirogov vinnytsia national medical university department of endocrinology with the course of postgraduate preparation




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M.I. PIROGOV VINNYTSIA NATIONAL MEDICAL UNIVERSITY


Department of endocrinology with the course of postgraduate preparation


Manager of department: prof.M.V.Vlasenko

Teacher: ______________________________


HOSPITAL CHART

Surname, name and patronymic

Diagnosis:

basic disease ___________________________________________________________________

_______________________________________________________________________________

complication of basic disease ______________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

concomitant diseases _____________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Beginning of curation: “_____” _____________________________ in 200__ year

End of curation: “_____” _____________________________ in 200__ year

Curator: student _____ course ______ groups ___________________ faculty


Surname, name and patronymic

^ PASSPORTS DATES

1. Surname, name and patronymic_______________________________________________

2. Age (how many complete years) ________ (date and year birth) ____________________

3. Sex_____________________________________________________________________

4. Home adress______________________________________________________________

5. Place of work_____________________________________________________________

6. Occupation_______________________________________________________________

7. Does not work (pensioner)__________________________________________________

8. Invalid (group, on what disease)______________________________________________

9. Date of hospitalization _____________________________________________________

10. Date of discharging ________________________________________________________

Result of illness treatment: convalescence, improvement, without the changes, worsening

12. Diagnosis during hospitalization _________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

13. Conclusive diagnosis ___________________________________________________________

a) Basic disease___________________________________________________________________

_______________________________________________________________________________

b) Complication of basic disease _____________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

c) Concomitant diseases ____________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

^ COMPLAINTS OF PATIENT


General complaints (with detailization)

General weakness (no, moderate, strong, permanent, periodic, character during the day)__________________________.

Xerosis in the mouth (no, yes). Poplydipsia (no, yes), drinks liquids ____L per day______________________________.

In the last months body mass (was increased, was gone down, was not changed) on _____kg _____________________.

Weight lost (no, yes) on ______ kg; Obesity (no, yes) on ______ kg _________________________________________.

Pruritus of skin (no, yes), pruritus of genitals (no, yes)____________________________________________________.

Pigmentation (no, yes), easy, moderate, considerable, localization ___________________________________________.

Sweatness (no, yes); furunculosis (no, yes); dermatoses (no, yes) ____________________________________________.

Edemata (feet, shins, face, general; in the morning, tonight, permanent) ______________________________________.

Worsening of vision (no, yes); Flashing of midges before eyes (no, yes) ______________________________________.

Cuting in eyes (no, yes); tearflow (no, yes) _____________________________________________________________.

Fall of hairs (no, yes), on the head, eyebrows, in subaxillary regions, on pubis _________________________________.

Change of voice (no, yes); tremor (no, yes) _____________________________________________________________.

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

^ Breathing. Heart. Vessels

Shortness of breath (no, at rest, after the insignificant loading, during ordinary work, ortopnoe).

Asphyxia (no, yes) ________________________________________________________________________________.

Heartbeating (no, yes) periodic, permanent, at rest, at the physical loading, at anxiety ___________________________.

Interruptions in heart work (no, yes), periodic, permanent, at rest, at loading, at anxiety__________________________.

Pain in the heart region (no, yes), periodic, permanent, at rest, at loading, at anxiety. Strong, weak, behind sternum, in the apex region, with left arm irradiation, with scapula irradiation, with right arm and other region irradiation. It is taken off after nitroglycerine, validol and other medications intake, at rest, at physical loading ________________________________________________________________________________________________.

Pain in legs (no, yes); in fingers, in feet, in shins; aching, prickly, burning, insignificant, sharp. Appear at rest, at night, at walking _______________________________________________________________________________________.

Interremittent claudication (no, yes). Drop the legs temperature (no, yes). Cramps of shins muscles (no, yes) ________________________________________________________________________________________________.

________________________________________________________________________________________________

Digestion

Appetite (stored, increased, reduced) __________________________________________________________________.

Difficult swallowing (no, yes) _______________________________________________________________________.

Pain in the abdomen region (no, yes): strong, weak, periodic, permanent, or pain linked with the meal reception (yes, no) ________________________________________________________________________________________________.

Pain region: epygastrium, right subcostal region ________________________________________________________.

Nausea (no, yes) ________________________. Heartburn (no, yes)_________________________________________.

Vomit, abdomen swelling, constipation, diarrea. Blood, mucus, undigested meal are presence in the excrement________________________________________________________________________________________.

^ Nervous system

Head pain (no, yes). Vertigo (no, yes). Noise (tinkling) in a head (no, yes)_____________________________________.

Irritability, emotional lability, tearfulness_______________________________________________________________.

Memory disorder (no, yes); somnolence, insomnia _______________________________________________________.

Waves of heat to the face (no, yes, how many times per a day) ______________________________________________.

Legs parestesias, feeling that ants crawl________________________________________________________________.

________________________________________________________________________________________________

^ Urogenital system

Complaints (no, yes). Nictury, polyury, diuresis_____L___________________________________________________.

Pain in lion (no, yes). Disuric disorders (no, yes) ________________________________________________________.

Potency (normal, reduced). Libido (normal, reduced). Sterileness ___________________________________________.

Motion of menstruations (periodicity ______, regularity _______, amount of excretions ______), Amenory _____ (years), oligomenory, opsomenory, menoragy ___________________________________________________________

________________________________________________________________________________________________.


^ HISTORY OF DISEASE (ANAMNESIS MORBI)

1. In what year became ill __________________________________________________________________________.

2. First symptoms of disease _________________________________________________________________________.

3. Beginning of illness: gradual, rapid, with remissias _____________________________________________________

4. What with the disease joined: infection, psyhotrauma, carried diseases and other causes___________________________________________________________________________________________

________________________________________________________________________________________________.

5. Appearance sequence of different symptoms (year, month) ____________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

6. Treated oneself before: in policlinic, in home, in hospital, as often _____________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

6. What the patient accepted ambulatory _______________________________________________________________ ________________________________________________________________________________________________.

7. Results of treatment: improvement, worsening, without the changes _______________________________________.

8. When and which the last treatment was conducted (name of preparations, doses, way of introduction)___ ________________________________________________________________________________________________________________________________________________________________________________________________.

9. What worsening was caused: stopping of treatment, change of medications dose, infections, physical loading, negative emotions, diet violations, other reasons, it is unconnected with anything ____________________ ________________________________________________________________________________________________.

10. Disease process: stable, progressive, for patients with diabetes mellitus - propensity to hypoglycaemia, cetoacidosis, diabetic and hypoglycaemic commas __________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________.

________________________________________________________________________________________________.

^ HISTORY OF LIFE (ANAMNESIS VITAE)

Conditions of life: satisfactory, bad.

Carried diseases, operations, wounds, traumas, contusions (when)_____________________________ ________________________________________________________________________________________________.

Allergic reactions, medications intollerance, food idiosyncrasy___________________________________ ________________________________________________________________________________________________

Mensis from _____ years old, regular, irregular, menopause from _____years old, pregnancies _____, births _____, abortions ________________________________________________________________________________________

Diseases, that carried by parents and relatives: does not remember, hypertonic disease, myocardial infarction, vitium cordis, stroke, died suddenly (father, mother, brother, sister), diabetes mellitus, obesity, disease of thyroid gland (which) ________________________________________________________________________________________________.

Milk, meat, fat and carbohydrate meal (potato, mealy wares, sweetnesses) predominates in a food ration ____ ________________________________________________________________________________________________.

Patients work: physical, mental ______________________________________________________________________.

Physical activity after work _________________________________________________________________________.

Patient is engaged in sports, physical culture (walking, running, bicycle______________________________________).

Home condition: beautiful, satisfactory, unsatisfactory ____________________________________________________.

Overstrain: physical, psychical ______________________________________________________________ ________________________________________________________________________________________________.

Misuse of alcohol (duration, amount, frequency)__________________________________________________________

________________________________________________________________________________________________.

Smoking (amount of cigarettes for days)_______________________________________________________________.

Additional dates___________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________.

^ OBJECTIVE RESEARCH

1. Common state is satisfactory, middle degree of severity, severe______________________________________.

2. Constitutional type: normostenic, astenic, hyperstenic _____________________________________________.

3. Build: correct, uncorrect; acromegaloid lines of face (no, yes), of extremities (no, yes), prognatism (no, yes) __.

4. Growth ___________ sm, body mass __________ kg, body mass index _______________________________.

5. The muscular system is developed well, satisfactorily, poorly, atrophy of shins and feet muscles ____________.

6. Muscular tonus: normal, reduced, increased _____________________________________________________.

7. Cyanosys (no, yes) of face, trunk, acrocyanosis __________________________________________________.

8. Foliculites (no, yes); skin turgor (stored, reduced) _________________________________________________.

9. Subdermal adiposum (normal, obesity, atrophy) __________________________________________________.

10. Crimson-red strias (no, yes), localization ________________________________________________________.

11. Dryness of skin (no, yes) ____________________________________________________________________.

12. Sweatness (no, yes) ________________________________________________________________________.

13. Temperature of feet palpatory (normal, reduced) __________________________________________________.

14. Xantomatosis (no, yes) ______________________________________________________________________

15. Hyperpigmentation (no, yes), localization _______________________________________________________.

16. Lypodystrophy (no, yes) _____________________________________________________________________.

17. Hyperceratosis (no, yes) _____________________________________________________________________.

18. Nails (normal, increased fragility) _____________________________________________________________.

19. Hairs (normal, increased fall (localization)) ______________________________________________________.

20. Edema (no, feet, trunk, under eyes) ____________________________________________________________.

21. Edemates are soft, dense _____________________________________________________________________.

22. Puffiness (no, yes), localization _______________________________________________________________.

23. Peripheral lymphatic nodules: normal, megascopic (localization) _____________________________________.

24. Exophtalmus (no, yes) ______________________________________________________________________.

25. Symptom of Grefe, Mebius, Ellinec, Koher _____________________________________________________.

26. Conjuctival injection (no, yes)________________________________________________________________.

Organs of breathing

Percussion sound above lungs: normal, like a box, blunting (localization) _____________________________________.

Low bounds of lungs:

Place of percussion

Right lung

Left lung

Parasternal line







Medioclavicular line







Anterior axilar line







Average axilar line







Posterior axilar line







Scapular line







Paravertebral line







Breathing vesicular, hard, bronchial, weakened (localization) _______________________________________________.

Wheezes: no, moist, dry (localization) _________________________________________________________________.

Additional information _____________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________.

^ Organs of blood circulation

Pulse ____ per minute. Deficit of pulse ___. Pulses size is middle, little. Rhythmical, urrhythmical, extrasistolia, blinking arrhythmia _______________________________________________________________________________.

Arterial pressure on a left shoulder ___________________ mm Hg, on a right shoulder ___________________ mm Hg.

lying ________________________________ mm Hg. standing ______________________________________ mm Hg.

A cardiac beat is ordinary, increased, displaced to the left, displaced to the downward ___________________________.

Boarders of relative cardiac bluntness:

right: ___________________________________________________________________________________________;

superior: ________________________________________________________________________________________;

left: ____________________________________________________________________________________________.

First tone on cardiac apex in normal, intensified, weakened, split ____________________________________________.

Noises: systolic, diastolic, rough, tender _______________________________________________________________.

Conducting of noise (where) _____________________. Accent of second tone above a pulmonary artery, aorta, split ________________________________________________________________________________________________.

Noises on heart basis: aorta ___________________________, pulmonary artery _______________________________.

Skin of lower extremities: pallor (no, yes), cyanosis (no, yes), marbleness (no, yes) _____________________________.

Puffiness of shins, feet, no. Edema of shins, feet, no; feet are cold, warm _____________________________________.

Dryness of feet skin (no, yes) ________________________________________________________________________.

Pulsation of back artery of foot (right, left) is not changed, weakened, absent (right, left) _________________________.

Pulsation of back fibular artery of shin is not changed, weakened, absent (right, left) ____________________________.

Pulsation of popliteal arteries (right, left), is not changed, weakened, absent (right, left) _________________________.

The pulsation of femoral artery (right, left) is not changed, weakened, absent (right, left) ________________________.

Violation of nails trophy (no, yes) ____________________________________________________________________.

Trophic skin changes of feet (no, yes) _________________________________________________________________.

Trophic ulcers (no, yes) (localization, size _____________________________________________________________).

Additional information ____________________________________________________________________________ ________________________________________________________________________________________________ _______________________________________________________________________________________________.

_______________________________________________________________________________________________.


^ Organs of digestion

Tongue is clean, assessed, dry, thickened, papillas are smoothed out _______________________________________.

Abdomen is normal, exaggerated ___________________________________________________________________.

Pain at abdomen palpation (no, yes), localization _______________________________________________________.

Liver: normal sizes, megascopic (on ______sm below right costal arc) ______________________________________.

Liver edge is painful, painless, dense, soft, sharp ________________________________________________________.

Symptom of Kera (+ -), Ortnera (+ -) _________________________________________________________________.

Spleen is not megascopic, megascopic _________________________________________________________________.

Additional information _____________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________.

^ Nervous system

Tremor of fingers (no, yes, character)__________________________________________________________________.

Tendinal reflexes are normal, increased, reduced ________________________________________________________.

Pathological reflexes ______________________________________________________________________________.

Symptoms of Trusso (no, yes); Chvosteca (no, yes)______________________________________________________.

_______________________________________________________________________________________________.


^ Endocrine system

Thyroid gland is not megascopic, megascopic (degree of increase - 0, Ia, Ib, II, III, IV)__________________________.

________________________________________________________________________________________________.

Thyroid gland consistency: soft, dense, elastic. Thyroid gland surface is smooth, hilly___________________________.

The presence of nodulus in thyroid parenchima (no, yes), localization ________________________________________.

Painful of thyroid gland (no, yes). Mobile, little mobile, not mobile __________________________________________

________________________________________________________________________________________________.


^ Sexual development

Normal, hypoplasia of uterus, ovaries, penis, testes, cryptorchism (right, left), monorchism (right, left, testes are located in an inguinal channel (right, left). Scrotum is normal, pigmentation sufficient, pigmentation weak ________________________________________________________________________________________________.

Second sexual signs (normally, poorly expressed, undevelopment appears in what ______________ _______________________________________________________________________________________________).

Gynecomastia (right, left), discharge from mammary glands (no, yes).

Additional dates___________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________.


^ PREVIOUS DIAGNOSIS:


Basic disease ____________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________.

________________________________________________________________________________________________

^ Complication of basic disease ________________________________________________________ ________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________.

________________________________________________________________________________________________

Concomitant diseases _____________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________


_______________________________________________________________________________________________.

_______________________________________________________________________________________________.

_______________________________________________________________________________________________

Conclusion from data of anamnesis and objective research (ground of diagnosis)


^ PLAN OF INSPECTION

1.

2.

3.

4.

5.

6.

7.

8.

9.

10

11.

12.

13.

14.

15

DATAS OF LABORATORY AND INSTRUMENTAL METHODS RESEARCH


Complete blood count

Indexes

Data

Data

Hemoglobin

Red blood cells

Colored index

White blood cells

- Еosinophile

- Basophile

- Neutrophile:

metamyelocytes

stick nuclear

segmented nuclear

- Lymphocytes

- Monocytes

Platellets

Erythrocyte segmentation rate






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