Bukhara State medical institute

Department of infectious diseases

Head of department D.M.S, professor A.R.Obloqulov

Teacher: _____________________________
(full name)

MEDICAL HISTORY

Clinical diagnosis: basic_________________________________________

(the clinical type of disease and the severity of disease)

Complications: ______________________________

Concominant diseases: ________________________________________________

Student: __________________________
(full name)

Faculty: _____________________________

Group: __________________________

Bukhara-2023
 Official information
1. The patient’s name_______________________
2. Age________________
3. Patient’s permanent adress________________________________________________
4. Workplace and position_________________________________________
5. Referral location_____________________________________________________
6. Date of hospital admission___________________________________________________
7. Day of illness_______________
8. Diagnosis of referral location____________________________________________
9. Diagnosis of reception___________________________________________________________
10. Clinical: diagnosis: basic________________________________________________________
complications________________________________________________________________
Concominant diseases _________________________________________________________
11. Type of
transportation______________________________________________________________
(ambulance , private car and etc)
Patient complaints:
History of disease(anamnesis morbi): onset of the disease ,development , date of onset of
illness( month ,hour), rate of onset, communication with patients ,symptoms (describe fully) The
emergence of symptoms of the disease should be covered step by step, day by day. In patients with viral
hepatitis, all symptoms of the initial (pre-jaundic) period should be interpreted in such a way that a
specific variant (dyspeptic, catarrhal, asthenovegetative, arthralgic and mixed) should be clearly visible.
Body temperature, level (duration of morning and evening temperature).
1. General symptoms of intoxication (headache, muscle spasms, malaise, etc.).
2. Probability of rashes (duration, nature, location, abundance).
2. In case of symptoms of gastrointestinal activity, express them clearly (vomiting, its number,
diarrhea and its description, whether there is a pathological mixture). The color of urine in
patients with viral hepatitis is orange. Faeces are pale, in the eyes. It is possible to indicate the
dates of the appearance of jaundice on the skin.
The history of the disease is summarized at the end. For example, the patient's disease started
slowly, the pre-jaundice period was 12 days, followed by a mixed syndrome (dyspeptic and
asthenovegetative), and the patient's condition worsened with the appearance of jaundice .
Epidemiological anamnesis. It is necessary for the study of infectious diseases and is
considered an important part of the medical history.
The following should be determined by questioning the patient:
1. Communication with infectious patients (at home, office, neighbors, on the street). The
patient's lifestyle and conditions at home and at work.
2. The profession of the patient and its relation to this disease.
3. Sanitary condition of the place of residence and observance of its rules of cleanliness.
4. Information about eating conditions, provision of food products and drinking water.
5. During the last 6 months, the patient received a blood transfusion. Information about surgical
procedures, dental, ENT, gynecologist, urologist and other internal procedures (when and where)
treated or under examination.
6. Piercing
7. Tattoo
8. Going abroad

Anamnesis vitae. When interpreting this section, the following should be taken into
account:
- factors affecting the patient's growth (being born and raised in different weather
conditions, moving to a different environment);

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 - the regular periodicity of the onset of menstruation in women, pregnancy, childbirth, the
number of miscarriages (abortions) and their complications, diatheses, mental illnesses, tumors,
tuberculosis, alcoholism;
-unconscious habits, addiction to alcohol, drug addiction;
- It is necessary to pay special attention to previously transmitted and non-pregnant diseases, the
time and duration of suffering from them, where they were treated, and additional diseases that
appeared during the examination.
Allergological anamnesis - sensitivity to food products, antibiotics, measles and vaccines and
other drugs, intolerance is recorded. Current condition of the patient (on the day of
examination)
Sick day________________
The day you spend in the hospital_________________________
body temperature
From the moment of the initial consultation, it is necessary to pay attention to the patient's
behavior, his attitude to the environment, all the manifestations related to his appearance
(slackness, indifference, paleness, impressionability, talkativeness).
- general condition of the patient (severe, moderately severe, satisfactory);
- the patient's face: dullness, duskiness, paleness, mental impressionability;
- skin: normal color, discolored, pale, bruised, yellow (increased level), itching,
symptoms of itching, tension, wetness and dryness, dense or repeated rash, location;
- size of lymph nodes, size-softness, pain, etc.
-subcutaneous adipose tissue is underdeveloped, average, excessive;
-bones are deformed, painful;
-shape of joints, deformed, painful, swollen, red, active and inactive range of motion.
Pulmonary :On the day of the examination, the patient's complaints: chest pain,
shortness of breath, flu, spitting up blood, dry cough, sputum, hoarse cough.
- breathing through the nose (freely, with difficulty), movement of the wings of the nose
(throbbing, smelly, odorless), nosebleeds;
- larynx - mucus, condition of membranes, tonsils, their color, coverings and its size;
- voice: clear, low, muffled, silent;
- the shape of the chest: straight barrel-shaped, paralyzed, rickets with a ditch;
- breathing: the number of breaths per minute, rhythm (rhythm, Cheyne-Stokes breathing,
accelerated slowed breathing);
- comparative percussion (knock): clear sound, muffled, muffled, drum-like, boxy;
- lung boundaries (upper and lower);
Cardiovascular: - complaints, pain at the level of the heart, a feeling of stopping, rapid
heartbeat and palpitations;
- speed of blood vessels, rhythm (arrhythmia), proportionality to body temperature;
- visibility of neck blood vessel war, direction of veins (heart war, its location and level
of feeling);
- palpitation is the limit of the relative evaporation of the heart (left, right, top);
- blood pressure.
Gastrointestinal: Complaints: thirst, dry mouth, drooling, symptoms of dyspepsia
(nausea, belching, urinating, vomiting), pain in the abdomen, pain during defecation (pain during
defecation), tenesmus (pregnancy pain), false urge to defecate, etc. k.
- swallowing: easily, painfully, with difficulty, not being able to swallow;
- ease of mouth opening. Trizm "laughter in the drugstore". Odor of the mouth (the usual
smell, the smell of decay, the smell of gum, ammonia, the smell of apples, etc.);
- the color of the mucous membrane of the oral cavity, coatings, ulcers, etc.;
-tongue wetness, dryness, clean or dry, color of the look, raspberry, varnished; sores, teeth
marks on the edges, trembling of the tongue, involuntary movement of the tongue;

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 - the shape of the abdomen (as in the brochure, swollen, relaxed, tense) is very soft, participates
in breathing;
- percussion and palpation - knocking and palpation, muffled sound with a lot of palpation,
tension of the muscles of the abdominal wall, pain
- intestine: movements, pain, laughter, thickened part of the large intestine;
- Liver: Liver weight, determination of boundaries (in centimeters), the upper and lower
boundaries of the liver should be determined in three directions along the right front axillary line,
mid-spinal line and chest line.
- palpation of the gallbladder
- Spleen enlargement, shape, edges, pain, firm tenderness;
- the number, quality, pathological mixtures, color, pain of feces, whether there is relief after
defecation without pain, constipation.
Urinary: Complaints: in the lumbar region, the amount of urine (voluntary, involuntary),
the number of urinations, pain, false calls, difficulty urinating, color, dark and clear;
- examination of the kidney level. Pasternatsky symptom. Urine examination.
Neurologic and mental status: Consciousness: clear, unconscious, active, giddiness,
depression, confusion, unreasonable suspicion, smells.
- headache, dizziness, fainting, sleep disturbance, etc.;
- twitching (general, local, clinical, tonic) muscle, skin traction, tremors, tremors, paresis
and paralysis;
Meningeal signs: neck muscles, tension, Kernig's symptom, etc. paralysis, drooping
eyelids, slurred speech, different pupil sizes, anisocoria, nystagmus (involuntary movement of
the eyelids). Palpation of the thyroid gland: hardness-softness, volume.
Presumptive diagnosis and its justification. Hypothetical diagnosis is made on the
basis of complaints, medical history, epidemiological anamnesis and direct examination of the
patient. The art of diagnosis requires the judge to be able to identify the symptoms of the disease,
observe it, distinguish them from the group of symptoms.
Laboratory test data. The results of laboratory equipment and X-ray examinations
carried out in dynamics should be written in the patient history. After each analysis, record the
changes found and write your conclusion about whether they support the hypothesis diagnosis..
Diary. The patient's condition, the course of the disease, the field of symptoms, the level
of isolation should be clearly reflected in the daily records. Prescribed medicines should be
suitable for the determined condition of the patient and the period of the disease. Complaints,
identified changes should be explained. It is recommended to leave a space of 3 cm on the right
edge of each page when writing a medical note. The temperature sheet with the results of
laboratory tests based on blood pressure and blood pressure should be attached to the diary.
Comparative diagnosis. In comparative diagnosis, it is necessary to exclude at least
three diseases in the same patient. It is recommended to give general symptoms of each
compared disease. After that, different symptoms, medical history, epidamnosis, factors
identified during the examination and laboratory data are explained, and comparison in this order
is distinguished from similar diseases.
Clinical diagnosis and its justification. This diagnosis is made on the basis of
established hypothetical diagnosis, laboratory data (results of examination with specific changes
of this disease, with reference to units of measurement), comparative diagnosis, and the
development picture of the disease observed on the basis of information provided in the diary. In
this case, the unit, form, complications and additional diseases are written down.
Epicrisis. The following aspects are the components of epicrisis:
1. The time of the patient's admission to the hospital, the day of illness, the day of
admission, the diagnosis of the referral, the condition of the patient on the day of arrival.
2. Clinical diagnosis (on what basis).

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 3. Course of the disease (form, severity, presence or absence of symptoms, their
justification, progression of the course of the disease, reduction of symptoms, periods of
disappearance).
Additional diseases and complications.
4. Details of the treatment (various treatment groups, duration, amount).
5. Outcome, patient's condition, results of bacteriological, virological, biochemical,
serum, blood, urine, feces, last examinations. Statement of terms and conditions of discharge of
the patient from the hospital.
6. Recommendations to the patient.
Theoretical part. A brief description and relevant analysis of the course of the disease that
occurred
For example: The source of the pathogen is a sick person and a virus carrier. The virus is
enteral and transmitted by the following ways:
1. household communication.
2. through water.
3. alimentary tract.
- In my patient: the infection was acquired through the alimentary route.
Seasonality for the disease is autumn and winter, children under 14 years of age are often
affected. My patient is 3 years old, he got sick in winter. The incubation period of the disease is
14-45 days.
- In my patient, this period was 3 days.
After the treatment part, it is necessary to write prescriptions of 5 used drugs.