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GENERAL INFORMATION
◊ Name:
◊Sex:
◊Age:
◊Profession:
◊Address:
◊Date of admission:
◊Time of admission:
◊ Referral Source :
COMPLAINTS
ANAMENESIS MORBI
ANAMENESIS VITAE
1. Childhood period:
2. Current Medications (list)
3. Occupation and Education
4. Housing conditions:
5. Allergic Anamnesis:
6. Family anamnesis:
7. Concomittant diseases:
Past medical history (list)
Childhood Illness
Adult Illness
Any major MEDICAL illness and of chronic problem ask about control and stability,
hospitalizations
SURGICAL illnesses: include surgeries, and complications
OBSTETRIC/GYNECOLOGIC illnesses: include obstetric hx, major gynecological
illnesses, menstrual cycle hx: menarche, menopause, cycle frequency, length, flow,
date of LNMP
PSYCHIATRIC illnesses: major psychiatric illnesses, hospitalizations, treatments
-serious injures: injury, date, resulting disability
-transfusions: date, reason, # of units, reaction
8. Harmful habits:
STATUS PRAESENS
1. General State
2. Consciousness
:
3. Position of the patient:
4. Height
:
5. Weight
:
6. Body Temperature :
Skin and mucosa:
Subcutaneous fatty tissue:
Lymphatic system:
Muscular-skeletal system:
Joints:
RESPIRATORY SYSTEM
Complaints:
Visual examination of chest
● Palpation of thorax:
 Topographic Percussion:
● Comparative Percussion:
●Auscultation:
CIRCULATORY SYSTEM
Complaint:
Examination of the precordial area :
PALPATION of the apex beat
PERCUSSION of the heart borders
AUSCULTATION
General description: - Heart sounds are rhythmic and muffled,
1. Apex- l configuration of S1 AND S2, murmur or splitting sound.
2. Aortic valve- S2 accents, murmur or splitting sound
3. Pulmonary valve- S2 , accents, murmur or splitting sound
4. Tricuspid valve- configuration of S1 AND S2, murmur or splitting
sound.
5. Botkin’s point- murmur
HR, BP
Examination of vessels: Palpation of the radial, carotid, and femoral.
DIGESTIVE SYSTEM
Complains:
Examination of oral cavity:
Examination of the abdomen:
Palpation of abdomen:
Superficial palpation:
Deep methodical slipping palpation:
Percussion:
Auscultation of the stomach: peristaltic sounds could be heard.
Stool
LIVER
Complains:
Examination:
Palpation:
Percussion:
SPLEEN
Complains:
Palpation:
Percussion:
UROGENITAL SYSTEM
Complaints:
General inspection:
Palpation: sensitiveness and pain in projection of kidneys
Percussion: filling of the bladder, Pasternatsky syndrome
ENDOCRINE SYSTEM
Complaints:
General inspection:
Palpation of the thyroid gland:
NEURO-PSHYCOLOGICAL INDEX AND SENSORY
ORGANS
Complains:
Intellect:
Memory:
Meningeal symptoms:
Signs of Stroke:
PRELIMINARY CLINICAL DIAGNOSIS
PLAN OF INVESTIGATION
LAB ANAlYSIS
Urine analysis
General Blood Test
Clinical biochemistry blood tests
ADDITIONAL INVESTIGATIONS
Dates
CLINICAL DIAGNOSIS
Main diseases:
Complication of the main diseases:
Concomitant diseases:
Basis of diagnosis
DIFFERENTIAL DIAGNOSIS:
3-4 Diseases to differentiate
Definition
Risk factors
Pathology
Clinical presentation: Clinical signs and symptoms. Physical
examination data.
Relevant lab tests and additional examination data
TREATMENT
Recipes.
Mechanism of action of drugs
DIARIES
•
Discharge summary
•
Patient Information
Complaints
•
Clinical Diagnosis:
•
Anamnesis Morbi:
•
Status Presens on Admissions
•
Additional Examination:
Lab analysis
Treatment: Daily doses and days of treatment
RECOMMENDATIONS
General:
MEDICAL: