DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY

Department of Propaedeutic to Internal Medicine

Head of the Department: MD, Prof. Dutka R.J._________________________________

Supervisor: ____________________________________________________

MEDICAL HISTORY OF A PATIENT

(CASE HISTORY)

Name of the patient_________________________________________________________

Clinical diagnosis_______________________________________________________________

Done by a student of Medical Faculty (Name):

year of study__3__, group №_________

20__-20__ years of study

 PASSPORT PROFILE

Name of the patient________________________________________________________

Birth date (age)____________________________________________________________
Home address____________________________________________________________
Occupation______________________________________________________________
Date of the admission to the hospital, the department,
ward___________________________________________________________________
Date of the 1-st examination of the patient by the
student__________________________________________________________________

COMPLAINTS
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ANAMNESIS MORBI - HISTORY OF ILLNESS

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ANAMNESIS VITAE - PERSONAL HISTORY

1. Family History
mother: age__________
medical condition___________________________________________________
father: age___________
medical condition___________________________________________________
brothers: age _________
medical condition___________________________________________________

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sisters: age __________
medical condition___________________________________________________
children: age __________
medical condition______________________________________________________

2. Social History:
Living conditions_________________________________________________________
Marital status__________________________________________________________________
Occupation____________________________________________________________________
Retired_______________________________________________________________________

3. Pharmacological Anamnesis:
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4. Allergologic History:
Allergic responce to:
medications___________________________________________________________
food_________________________________________________________________
animals______________________________________________________________
insects___________________________________________________________________
dust_________________________________________________________________
dye__________________________________________________________________
cosmetic chemicals_____________________________________________________
Manifestation of allergic responce:
skin manifestation___________________________________________________
conjunctivitis_______________________________________________________
respiratory manifestation______________________________________________
anaphylaxis in the past________________________________________________

5. Gynaecological Anamnesis:

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Menstruation___________________________________________________________________
Menopause____________________________________________________________________
Number of children, number of spontaneous miscarriages or
abortions______________________________________________________________________
Gynaecological surgeries_________________________________________________________
Hormone contraceptives__________________________________________________________

6. Epidemiologic History:
Past infectious disease_____________________________________________________
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Visits to foreign countries in the last 6 months: yes, no. Contact with infectious patient
within 21 day before admission to the hospital: no, yes
(date of contact, kind of disease)_____________________________________________

7. Personal History:
Past operations_________________________________________________________________
Bad habits:
Smoking________________________________________________________________
Alcohol drinking__________________________________________________________
Coffee or tea drinking______________________________________________________
Past diseases of all body systems:
Cardiovascular diseases____________________________________________________
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Metabolic and endocrine diseases_____________________________________________
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Digestive disorders________________________________________________________
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Urinary problems_________________________________________________________
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Diseases of lower extremities________________________________________________
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Neurological diseases______________________________________________________
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 REVIEW OF SYSTEMS
The general condition of the patient___________________________________________
Body temperature______________Consciousness_______________________________
Position of the patient in bed ________________________________________________
Constitution (constitutional type)_____________________________________________
Weight (kg)___________________Height (cm)________________BMI_____________
Skin: color and its disorders_____________elasticity____________humidity__________
presence of pathological changes_____________________________________________
Conjunctivas_____________________________________________________________
Subcutaneous tissue______________________________________________________
Edema_____________________________ pastosity____________________________
Neck vessels_____________________________________________________________
Lymph nodes___________________________________________________________
Thyroid gland___________________________________________________________

Respiratory system
Breathing through the nose _______________________________________________
Number of breaths per minute_____________________________________________
Breath, depth___________________________________________________________
Breath rhythm_________________________________________________________
Type of breathing_______________________________________________________
Shape of the chest_______________________________________________________
Palpation of the chest______________________ elasticity of the chest______________
Comparative percussion - Percussion sound_____________________________________

Topographic percussion: Lower borders of the lungs

Topographic lines Right lung Left lung

Parasternal

Midclavicular

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 Anterior axillary

Midaxillary

Posterior axillary

Scapular

Paraspinal

Respiratory excursion o f the lower border of lungs in cm.

Topographic Right lung Left lung
lines
Inspiration Expiration Total Inspiration Expiration Total

Midclavicular

Midaxillary

Scapular

Auscultation of the lungs:___________________________________________________

Breath sounds:____________________________________________________________
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Cardiovascular system
Apex beat in_____________________________________________________________
Pulse rate per minute_______rhythm_____________tension__________filling________
Blood pressure mm Hg: left hand______/_____ mm Hg, right hand_____/______ mm Hg,
lower extremities: left __________/______ mm Hg, right __________/________ mm Hg.
Border of relative cardiac dullness:
Right ___________________________________________________________________
Left ___________________________________________________________________
Upper __________________________________________________________________
Border of absolute cardiac dullness:

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Right___________________________________________________________________
Left ____________________________________________________________________
Upper __________________________________________________________________
Auscultation: Tones (heart sounds) their sonority
First point (mitral valve)_____________Second point (pulmonary valve)______________
Third point (aortic valve)____________Fourth point (tricuspid valve)________________
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Digestive system
Oral cavity ______________________Tongue__________________________________
Inspection of the abdomen: size_________________________form _________________
Palpation _______________________________________________________________
Percussion: percussion sound__________________fluctuation symptom _____________
Auscultation: Peristaltic sounds______________________________________________
Liver dimensions by Kurlov:
by the right midclavicular line _____by the median line _____by the left costal arch ____
The lower edge of the liver__________________________________________________
Spleen ___________________________Gall bladder_____________________________
Pancreas______________________________________Bowel movements ________day

Urinary system
Area of kidneys___________________________________________________________
Palpation of the kidneys ____________________________________________________
Pasternatsky symptom _____________________________________________________
Edema __________________________, pastosity _______________________________
Dysuric signs____________________________________________________________
Daily diuresis __________liters per day

Osteoarticular system
The joints:______________________________________________________________
Swollen_________________painful _________________deformed_________________
Range of movements______________________________________________________

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 PREVIOUS DIAGNOSIS

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PLAN OF EXAMINATION
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DAILY CUMULATIVE REPORT

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DAILY CUMULATIVE REPORT

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CLINICAL DIAGNOSIS

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Student signature____________________________________________________

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