State Medical and Pharmaceutical University

„Nicolae Testemiţanu”

Department

Head of Department
Lecturer gr.
Curator
Grup year
Faculty

CASE HISTORY

Date of curation

- Chisinau 2013 -

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 CLINICAL EXAMINATION

I. PASSPORT DATA
Name,Surname
Age
Sex
Adress
Ocupation
Data of hospital admission
Hour
Admission diagnosis

CLINICAL DIAGNOSIS.

II. Complaints
At the day of curation:

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At the admission day:

III. History of present illlness

IV. Personal history

1. Biographic data

2. Sexual history

3. Comorbidities

4. Harmful habits

5. Family history

6. Allergic history
Intolerance of medicines
Vaccines
Food

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 V. GENERAL HABITUS.

1. Inspection.

General state
Consciousness
Pozition
Facies
Constitution
height _____weight_____

Skin, mucous membranes and skin appendages

humidity şi tissue_____
tension ___
Hypodermis
Edema
Lymphatic nodes
Head region
Neck
Pathologic pulsation of carotid

Muscles:

Pain at palpation

Bones:

Joints: deformation, edema, rash,

pain______

decline of motions

2. Respiratory system.

COMPLAINTS.

INSPECTION.

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PALPATION.

PERCUTION.
Comparative:. _____

Topographic:

AUSCULTATION.

3. CARDIOVASCULAR SYSTEM.

COMPLAINTS.

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PALPATION.
Caracteristics of heart beat

PERCUTION.
Relative heart limits

Absolute heart limits

AUSCULTATION.

Cardiac rate per minute

Pulse
Blood pressure :

4. GASTROINTESTINAL TRACT
COMPLAINTS.

INSPECTION.

PALPATION.
Superficial

Obrasţov-Străjescu method

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PERCUTION.

Liver and gall bladder

Spleen

5. URINOEXCRETORY SYSTEM.

COMPLAINTS.

PALPATION:

PERCUTION:

6. HEMATOPOETIC SYSTEM.
COMPLAINTS.

PALPATION OF THE BONES

(PAINFULL REGIONS)

7. ENDOCRINE SYSTEM.

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 8. NEUROMENTAL STATE.

Consciousness: clear, diffuse, coman, sopor, stupor, delirium,

halucination ___________

Mood: indiferent, apathic, ordinary, irritated

9. SENSE ORGANS.

Sensibility
Vision
Hearing_____

VI. DERMATOLOGIC EXAMINATION (status localis)

_A.Four cardinal features: _

1. Distribution of the lesions:
a. Extent or involvement:
b. Pattern:
c. Characteristic location:

2. Type of lesion:

3.Shape of individual lesions:

4.Arrangement of multiple lesions:

_B. Three major characteristics:

1. Color:
2. Consistency and feel of lesion:
3. Anatomic components of skin primarily
affected:

C. Special procedures for dermatologic diagnosis:

1.Palpation of the lesion:
2.Diascopy or vitropressure:

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4. Raclage of lesions:

VII. CARACTERISTICS OF DERMATOSES WHICH PATIENT HAS.

VIII. PRESUMPTIVE DIAGNOSIS

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IX. INVESTIGATION’S LIST.

X. RESULTS OF LABORATORY TESTS.

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XI. DIFFERENTIAL DIAGNOSIS.

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XII. CLINICAL DIAGNOSIS, ARGUMENTATION

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XIII. DISEASE EVOLUTION

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XIV. PRESCRIPTIONS AND PROGNOSIS

XVI. EPICRISIS

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