Last name, first name of the patient and his age
Final diagnosis
Basic disease______________________________________
Complication _____________________________________________
Concomitant disease___ ___________________________________
Counsel_________________________________________________________________
Beginning of curatio_______________
Ending of curatio_________________
Passport part (Praefatio)
Last name, first name _________________________________
Age_______________________________________________
Address____________________________________________
Profession____________________________________________
Place of work, post___________________________________
Date of the admission _ _discharging ________________________
Amount of bed-days__________________________________
Diagnosis of the establishment, wich sent the patient________________
Diagnosis at the admission_____________________________
Clinical diagnosis____________________________________
Final diagnosis______________________________________
Basic disease________________________________________
Complication_________________________________________
Concomitant diseases_________________________________
Complaints of the patient (Querellae aegroti)
- chief and additional on organs and systems (chief complaints are described during the admission and at the moment of review).
It is necessary to transfer feeling of patient with their detailed analysis. All complaints exposed at a patient are described in detail. Complete description of complaints of patient must be described one time, that there was no necessity of search of separate details in other sections of hospital chart. A counsel writes down complaints after conducting of complete inspection of sick, selecting chief. Consistently fixs complaints, that specify on pathology of one system, or such which unite in syndromes. Then in detail describes general complaints on organs and systems, if such are at a patient.
Anamnesis of disease (Anamnesis morbi)
Find out, when (date, time) and what circumstances the first signs of disease what was the beginning of disease (acute, gradual). In detail the first displays and symptoms of disease are laid out, their dynamics, sequence of appearance of new signs of disease. The presence of prodromal period is exposed, characterize it (possible selection of syndromes). Obligatory detailed exposition of displays of intoxication, appearance of pouring out, description of temperature reaction and etc.
It is necessary to find out the primary address to the doctor which was set diagnosis, what is appointed for medical treatment at home or in permanent establishment (preparations, doses, duration of reception of medications and their bearable), influence of medical treatment on the progress of illness.
At presence of at the patient of results of laboratory and instrumental researches desirably with them to familiarize. Necessarily it should be noted dynamics of disease in times of stay in permanent establishment, character and efficiency of the conducted therapy (to beginning of curatio).
Epidemiological anamnesis (Anamnesis eridemiologica)
1 What the patient connects with his illness.
2 Questioning about the possible running with the source of infection: intercourse with a similar patient, method and terms of life of sick (dwelling in
epidemically unfavorable locality or endemic hearth of infection, cases of infectious diseases in a house, an apartment, at work); care of animal (sick, healthy).
3 Questioning from the mechanism of transmission of infection: use of unboiled water, milk, unwashed fruits, not fresh food products; place of feed (at home, in a dining-room); journey per rail, visit of bath-house, market, shop, barber shop; presence of ectoparazitis, blood transfution, operations, medical treatment at stomatology, instrumental inspection, injections for the last 6 months (where and when); presence of wounds, bite by an animal, splinters. Profession of patient and possible its communication with the disease.
4 Immunological status. past infectious diseases (what, when). Prophylactic inoculations (what, when, how many times, intervals, reactions on the inoculation). Introduction of medical serum (what, when, method of introduction and bearable of them).
Allergist anamnesis (Anamnesis alergologisa)
When and what allergic diseases were carried by a patient. Do his parents, brothers, sisters, children, have the allergic diseases? Reaction on introduction of drugs. Communication of the allergic states with times of year and professional badness.
Anamnesis of life(Anamnesis vitae)
Short biographic data from the life of sick are cited. Development and state of health in childhood. Beginning of teaching, as it passed. Education. Beginning of independent labour activity and subsequent professional route (post). Terms of labour. Professional badness and intoxication. Domestic life. Health of family members.
Household-material terms. Habitation (disposed, sanitary-hygienic description). Diet. Harmful habits (alcohol, smoking, drug addiction, tocsicomaniya).
The past diseases, traumas, operations, wounds are transferred in a chronologic sequence.
Familial tendency. State of health, cause of deaths of close relatives, their past diseases, that have a clinic similar to the disease of the patient.
Objective inspection of patient (Status praesens objectivus)
General review (Inspectio)
General state of the patient. Temperature. Consciousness. Posture of the patient in a bed. Conduct of patient, reaction on surrounding. Motive activity, cramps (tonic, clonic, their duration).
Physique, height, weight. Constitution of the patient.
Skin: colouring, elasticity, humidity, temperature, eruption. Mucous membrane (lips, mouth cavity, lids).
Hypodermic cellulose.
Lymph nodes (localization, size, form, consistency, pain, mobility, state of skin above them).
Thyroid gland.
Muscles (degree of development, atrophy, pain).
Bone (pain, deformations).
Joints (pain, pathological rejections).
Respiratory system (Systema respiratorium)
Nose breathing, selection from a nose, nose-bleeds, voice.
Review of thorax: form, type, symmetry, pathological changes; a dynamic review - symmetry during breathing, breathing type, breathing frequency, dyspnea.
Palpation: pain, elasticity of thorax, tactile fremitus.
Comparative percussion of lungs: character of sound, localization.
Topographical percussion of lungs: apexes, low bounds of lungs, mobility of lower bound of lungs.
Auscultation of lungs: character of breath sounds, presence of pathological sounds, bronhofoniya.
Cardiovascular system (Systema cardiovascularia)
Pulse, its characteristic.
Review and palpation of cardiac region, maximal impulse, pulsations. Percussion: retromanubrial dullness relative and absolute. Auscultation: rhythm, frequency, tones and their sonority, strengthening of tones, additional tones, noises, their description. Arterial pressure.
Gastrointestinal system (Systema digestorium)
Review of mouth cavity: tongue, teeth, gums, palate soft and hard, pharynx, tonsils.
Review of abdomen: configuration, presence of peristalsis, dilated veins, state of navel, scars, eruption.
Superficial palpation: tension of muscles, localization of tension, pain, symptoms of irritation of peritoneum.
Deep methodical sliding palpation by Obraztsov-Stragesco: intestine (sigmoid colon, blind gut, transverse colon, ascending and descending colon), stomach.
Percussion of abdomen, determination of liquid in an abdomin cavity.
Liver, percussion, sizes of liver by Courlov in sm, palpation - description of edge, surfaces, closeness, pain.
Gall-bladder.
Pancreas.
Spleen.
Genitourinary system (Systema uropacticum)
Review of region of kidneys. Palpation of kidneys. Pain in the region of urinary tracts. Pasternatsky’s symptom.
Diuresis, dysuria phenomena.
Nervous system (Systema nervosum)
Mental development, intellect, memory.
Orientation in space and time. Contact with a patient (adequate, laboured, impossible). His conduct during the inspection.
Motive sphere: step, Romberga’s symptom, phenomena of irritation of motive sphere (cramp, never, tongue, fingers trembling).
Sensible sphere: a superficial ensitivity to pain, temperature, deep (feeling of passive motions, pressure), violation of ensitivity (hyperesthesia, hyposthesia). Research of reflexes from mucous membrane (corneal, conjunctival, swallowing), cutaneous, tendon. occipital musclar rigidity, Cerniga-Broudzinscogo’s symptoms (overhead, middle, lower).
Dermografism.
Placing of eyeballs, exophthalmos, nistagm, strobism, ptosis, anisocoriya, diplopiya, state of pupils and their reaction on light, presence of "fog", "nets" before eyes, convergence. Acuity of vision.
Hearing changes.
Note: those organs and systems which are most pathology expressed are described in detail.
Previous diagnosis and its justification (Diagnosis praeliminaris)
On the basis of data of questioning and objective inspection are selected conducting and second-rate syndromes. A previous diagnosis belongs on the basis of displays and signs only typical for the disease. Thus impermissible the exposition of anamnesis and other data repeated.
Example of the diagnosis justification
1th: on the basis of complaints of the patient (headache, absence of appetite, disorders of sleep, dizziness); data of anamnesis (sharp beginning, fever within the limits of 40-41 °S, delirium, appearance of rash on a body on the 5th day of illness); data of epidanamnesis (intercourse with similar patients in two weeks to this disease); objective data (presence of the typhus state, petehial-maculopapular rash on a trunk, internal surface of upper extremities, abdomen and internal surfaces of thighs, Yanovski’s and Govorova-Godele’s symptoms, volubility, euphoria, hallucinations, motor excitation, face puffiness and hyperemia, it is possible to make a previous diagnosis – epidemic typhus.
2th: a diagnosis " viral hepatitis" was made on the basis of complaints of the patient - weakness, absence of appetite, nausea, unpleasant feeling in the region of right hypochondrium, dark urine, light excrement; data of anamnesis, which represent typical development of disease with the expressed recurrence: gradual beginning, presence of expressive pre-icteric period, course during 8 days after an arthrargic type, subsequent icteric period (from the 9th day of illness dark urine and discoloured excrement, from 11 th day - sclera icteric, from a 12th day - icteric of skin), from the moment of its appearance the patient’s health had not changed; data of epidanamnesis: 2 months prior to the given disease a patient was operated, haemotransfusion were conducted; objective data: at the phenomena of the moderately expressed intoxication expressive icteric of scler and skin, bradycardia, low blood pressure, tongue edema, moderat enlargement of liver, slightly sensible, and respiratory mobility of lower edge 7,5 sm, enlargement of spleen.
3th: on the basis of complaints of (according to the patient’s woman): the increase of temperature to 38,9 C, bad arching headache without certain localization, which increases at the change of body position, actions of bright light, loud scream, expressed splitting vomits (by a «fountain»), which does not bring facilitation and is not related with acceptance of meal and arises up on height of headache, loss of consciousness; taking into account a presence in anamnesis of disease cerebral symptoms: diffuse headache which increases for actions of any external irritant, vomits that does not bring facilitation, psychic and motoric excitation, tonic and clonic cramps, violation of consciousness; data of epidemiological anamnesis (contact with a patient with a flu); data of objective inspection: violation of consciousness after the type of sopor, expressed eye-facial phenomenon, positive Poulatov’s, Behterev’s, Mendel’s symptoms; pain in Cerrer’s points; general hyperesthesia, hyperacusis, fotofobiya; positive meningeal symptoms: resistance of occipital muscles 4,5-5 sm, positive Kernig’s symptom on either side, upper and lower Broudzinski’s symptoms; focus cerebral symptoms: Babinski’s, Openheim’s reflexes; punctate hemorrhagic rash in the armpit area, single elements of rash on the skin of the right ankle joint, on the skin of the right knee-joint and on a left thigh – stellate hemorrhagic rash, dense by touch, which rises above the level of skin, with a presence of necrosis in the center, it is possible to make a previous diagnosis: meningococcal infection, generalized form, severe degree. Acute purulent meningoencephalitis. Meningococcemia.
Plan of additional inspection (Planum examinationis additae)
It is folded according to the proposed diagnosis, obligatory specification of necessary laboratory researches. Laboratory and instrumental data must be used during conducting of differential and justification of final diagnosis.
Example of plan of additional inspection
1 Clinical blood examination, prothombin index, coagulation time, bleeding time.
2 Blood glucose.
3 Clinica urine examination.
4 Urine glucose.
5 Bacterial research of urine (determination of presence of bacteria in urine, in the case of positive result the research on a sensitiveness to the antibiotics is conducted).
6 Biochemical blood examination (it is conducted for determination of the functional state of liver and kidneys).
7 Blood test on RMP.
8 Blood test on a group and Rh-factor.
9 Coagoulogramm (determination of blood rolling up factors for the early exposure of DIC).
10 Blood sterility and gemoculture (it is conducted for determination of presence of microorganisms and salmonel in a blood in communication with a presence of fever in the patient’s clinical picture).
11 Examination of feces on the eggs of intestinal parasites.
12 Spinal liquid examination (the changes in a spinal liquid, characteristic for bacterial or viral nature of affection).
13 ECG (early exposure of possibility of toxic myocarditis development).
14 Echoentsefalogramm (determination of focus changes in a brain).
15 Consultation of cardiologist, neurologist, ophthalmologist, urologist (necessity of exposure of concomitant pathology or complications from the side of other organs and systems).
Plan of medical treatment (Planum curationis)
According to the proposed previous diagnosis with pointing of form, dose, duration of introduction of medical preparations.
1 Regimen.
2 Diet.
3 Medicine (Latin transcription).
4 Setting of other methods of medical treatment.
Data of laboratory and instrumental methods of research (Data methodorum investigationis)
The results of laboratory, instrumental and other methods of inspection of the patient bring in in a dynamics to the hospital chart. It is needed to do a conclusion from every research.
Example
1 Clinical blood examination (17.02.08): haemoglobin – 114 g/l, erythrocytes – 3,49 * 1012/l, thrombocytes – 55 * 109/l, leucocytes – 22,7 * 109/l, differential blood count: basophils – 0,5 %, eosinophils – 1 %, band neutrophils – 12 %, segmented neutrophils – 78 %, monocytes – 3 %, lymphocytes – 6 %, ESR – 8 mm/h, hematocrit – 0,38.
Conclusion: in the clinical blood examination: decline of the level of haemoglobin, amount of erythrocytes and thrombocytes, increase of amount of leucocytes due to segmented neutrophils and band neutrophils (with the deviation of the differential count to the left).
2 Clinica urine examination (17.02.08): total amount 80 ml, a color is yellow, poorly cloudy, reaction, specific gravity 1,017, protein 0,46 g/l, leucocytes 0-1, flat epithelium 2-3, mucus a little.
Conclusion: decline of transparency, the presence of protein can testify to the toxic defeat of kidneys.
3 Spinal liquid examination (17.02.08): amount 0,9 ml, colourless, poorly cloudy, protein 6,6 g/l, positive Pandi’s reaction, positive Nonn-Appelt’s reaction, pleocytosis 4645 cells in ml due to neutrophils, glucose 1,4 mmol/l, microscopically in the painted preparations the diplococcuses are exposed inside and outside leucocytes.
Conclusion: a spinal liquid has a purulent character, promoted amount of protein, positive globulin Pandi’s Nonn-Appelt’s reaction, considerable neutrophil pleocytosis, cellular-protein dissociation (there is the increase of maintenance of protein on 1 g/l approximately per every thousand of cells accordingly), microscopically the diplococcuses are exposed inside and outside leucocytes.
Diary (Decursus morbi)
There is couratsii for all days after such chart
| Date | State of patient | Prescription |
| Temperature Pulse Arterial pressure (AP) Respiratory rate | Estimation of state of the patient. Complaints for a past day. Short objective data on organs and systems with the obligatory reflection of their dynamics. The damaged systems are described in detail. | 1. Diet 2. Regimen. 3. Additional researches 4. Treatment |
Signature of counsel
A temperature chart with the curves of temperature, pulse, breathing, marks of arterial pressure, character of stool and presence of pathological admixtures in an excrement is necessarily added (mucus, blood).
Example of diary registration
| 02.03.08 T – 36,6 C Ps – 80/m AT – 110/70 Rr – 16/m | The patient complains of the increase of temperature to 37,4 C in the last evening, the pain in the left knee and elbow joints, violation of sleep through the pain in joints. Objectively: the common state is moderate, consciousness is not broken. The reaction on a review is adequate. Skin and visible mucous are ordinary colouring, the elements of hemorrhagic rash are not present. The left elbow and knee joints are megascopic in a volume, the mobile at them is limited, they are painful in palpation. A tongue is wet, not coated. Heart sounds are rhythmic, loud. Lungs auscultation: vesicular reppiration, rales are not listened. The abdomen is soft, unsickly at palpation, evenly takes part in the act of breathing. Neurological status: eye cracks, pupils S=D, there is the insignificant asymmetry of the nasolabial triangle, tongue deviation to the right. Tendon and periostal reflexes S=D. In Romberg’s position there is an insignificant ataxia. The patient is asthenic, emotionally labile. Stool: 1 time per a day, formed. Urination is free, not painful, diuresis is sufficient. Doctor__________ | 1. Keep to bed. 2. Diet №15. 3. 3.03 - diagnostic spinal puncture. 4. Consultation of orthopaedist. 5. Treatment: -Rp.:Sol. Diclofenaci 2,5 % - 3 ml D.t.d. N. 10 in ampull. S. Intramuscularly 3 ml twice a day. - Rp.: Ung. Voltareni 2 % - 50,0 D. S. To inflict on the area of damaged joints twice a day. |
Differential diagnosis (Diagnosis differentialis)
It is conducted concretely in relation to the disease in the patient, and must be detailed, unfolded and no less than with five illnesses.
Taking into account the data of anamnesis, results of clinical, laboratory, instrumental methods of researches, it is necessary to justificate the necessity of conducting of differential diagnosis with the series of diseases, that have similar symptoms with illness in the patient. It is needed to go by the logical exception from less reliable to more reliable disease.
General symptoms are selected at the beginning, then those, that is in the patient, but are not observed at the disease which is eliminated, and, finally, signs characteristic for the last, but is absent in the patient. After it the results of laboratory methods of research are brought over and a short conclusion is formulated.
Example of conducting of differential diagnosis
General symptoms: the patient complaints of a bad headache, a bad sleep, an absence of appetite, a retention of stool, an acute general weakness; a tongue is furred and dry, there is a typhoid maculopapular rash on a body, a bronchitis, an abdomen is blown away, an enlargement of spleen, there is a delirium at night.
Difference of symptoms
| № | Patient’s symptoms | Epidemic typhus |
| Gradual Beginning | Acute | |
| Fever - 4 weeks | Fever - 14 days | |
| Headache is in a frontal area | Headache is in the nape | |
| Face is pale | Face is hyperemic, puffy | |
| Brilliance of eyes is marked | Positive Yanovski’s symptom (rabbit eyes) | |
| A tongue is thickened, there are the imprints of teeth, furred at a root, dryish, a tag and edges are clean | A tongue is thin, furred, Govorov-Godele’s symptom | |
| A rash appears on the 8th day of illness | A rash appears on the 5th day of illness | |
| Rash is typhoid maculopapular on a trunk, single elements | Rash is maculopapular petechial on the internal surfaces of upper and lower extremities | |
| There is a phenomenon of “pouring in addition” | There is no a phenomenon of “pouring in addition” | |
| There is a tonsillitis | There is no a tonsillitis | |
| Symptoms of bronchitis | Tracheitis, laryngitis | |
| Relative bradycardia | Tachycardiya | |
| Catacrotic pulse from the 2th week | It is not | |
| Positive Padalka’s symptom | Negative | |
| Grumbling in the ileocecal region | There is no grumbling in the ileocecal region | |
| Oppression, apathy, unsociability | Euphoria, motor excitation, volubility | |
| Leucopenia, aneosinophilya, relative lymphoсytosis, thrombocytopenia | Moderate leucocytosis, neutrophilosis, thrombocytopenia, monocytosis | |
| Found typhoid fever bacterium (in a blood, urine and excrement); positive indirect haemagglutination test with complex salmonellosis diagnosticum in a dynamics | Positive reactions with Rickettsia prowazekii: agglutination reaction, compliment-fixation reaction, heterohaemagglutination test. |
On the basis of this data the conclusion is formulated.
A differential diagnosis can be formulated in a narrative form.
Final diagnosis (Diagnosis terminalis)
The patient’s diagnosis justification is conducted by the synthesis of anamnesis, objective and laboratory-instrumental data, taking into account the conducted differential diagnostics. The diagnosis must be nosologic, etiologic, pathogenic, morphological and functional. The clinical form, stage of disease, degree of severity and also complications are justificated.
It is necessary to justificate the diagnosis of concomitant diseases more briefly. In a conclusion the final diagnosis is formulated according to the generally accepted classifications.
Diagnosis of the basic disease__________________________
Complications_________________________________________
Concomitant diseases_________________________________
Example of formulation of diagnosis
Diagnosis of the basic disease: Meningococcal infection (N. meningitidis+), generalized form, meningococcemia, meningitis, severe degree.
Complication: Toxic shock syndrome ІІ. DIC ІІ.
Concomitant diseases: Ischemic heart disease. Diffuse cardiosclerosis. Cardiac decompensation ІІ. FC ІІ.
