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SCHEME OF CASE HISTORY

IDENTIFICATION
1. First name, full name; surname.
2. Age.
3. Address.
4. Profession.
5. Nationality.
6. Date of hospitalization.

A. SUBJECTIVE EXAMINATION

I. COMPLAINTS (WITH DETAILING)

II. SYSTEM REVIEW

RESPIRATORY SYSTEM
Breathing through the nose (easy, difficult).
Running nose: nature of discharges from the nose, nasal bleeding, pain (pain at the
root of the nose, in places of maxillary sinus and frontal sinus.
Larynx: dryness and rasping feeling in the throat.
Voice: sonorous, soundless, hoarse.
Cough: nature, constant, fit-like, severe, weak, sonorous, dry, with the discharge of
sputum. At what time of the day or season of the year it increases. Dependence of cough
on the position the body.
Sputum: nature, color (white, yellow, green, rusty color, contains blood), phlegm
(mucosal, mucopurulent). Consistency: dense, liquid, viscous, foamy. Volume of the
sputum daily (profuse, slight). At what time of the day the sputum appears.
Smell: putrid odor. Effect of the posture upon the sputum.
Blood-spiting (haemoptysis). Volume. Nature traces of the blood, clots of the blood,
blood, blood with sputum. Color. Time of appearance. Date of appearance. Precipitating
factors associated with the onset of haemoptysis: manual labor, overheating, cough.
Pain in the chest. Location. Irradiation. Character: sharp, dull, aching pain, stabbing pain.
Continuous. Intermittent. Duration of pain. Relation of a pain to respiration, coughing,
movement of the body, changes in posture (aggravating) on bending down to healthy or ill
side.
Shortness of breath (dyspnea). Time of its appearance (at rest, on slightest physical
exertion, when walking (distance in meters), ascending a staircase, when eating.).
Character of dyspnea fit (inspiratory, expiratory, mixed), intensity. Duration. Character of
development: suddenly or gradually. Symptoms which accompanying to dyspnea (cough
with sputum, etc.). Methods of the dyspnea relief.
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CARDIOVASCULAR SYSTEM
Shortness of breath. Palpitation. Constant of fit-like, duration, rate, cause (physical
exertion, movements, posture, changes, eating, alcohol, worrying, temperature changes).
With what it may be associated - dizziness (vertigo), unconsciousness, dyspnea.
Irregular heart beats: rate, duration, association with physical exertion or eating, or
smoking, or worrying and horizontal body position.
Pain or discomfort: location, character: (stabbing, squeezing), intensity, constant, fit-like,
radiation into the left arm, scapular, shoulder. Time of pain appearance. Rate. Duration.
Accompanying pain, other factors (feeling of fear, fear to move, palpitation and so on).
Causes: (worrying, physical exertion, movements, temperature changes etc. Pain relief
(cardiovascular drugs, narcotics).
Pulsation in the head, neck, right hypochondrium. Intermittent claudication. "Dead finger"
felling.
Edema: location (feet, skin, loin), relation to the time of the day (increasing in the
evening, disappearance in the morning). Duration. Causes (long walks, physical exertion
and etc.). Rate.

DIGESTIVE SYSTEM
Appetite it's upset: lack of appetite (anorexia), poor appetite, good appetite,
excessive appetite (hyperrhexia), gargantuan appetite, limosis (bulimia). Good appetite,
but eats little because of fear of pain after meal cytofobia. Perverted appetite
(parorexia). Appetite (attraction to spicy, salty and other food and attraction to inedible
things (pica). Feeling of disgust to some food as for example to meat, fat, milk. Feeling of
satiety after meals (normal, rapid, slow, constant feeling of starvation).
Distinguish the taste of food (unpleasant, bitter, sour, sweet, and metallic, of taste
absence.
Feeling of dryness, burning in the mouth and salivation.
Thirst: volume of liquid.
Chewing of food: good, bad.
Swallowing: easy, difficult, painful, choke over the food. Swallowing appears suddenly
or gradually; continuous or intermittent.
Passage of food: easy, difficult, painful (dysphagia), impossible. Is it difficult to swallow
solid or liquid food?
Belching (eructation): gaseous, sour, putrefied eructation, regurgitation (belching of
food). Belching soundless or loud (noisy). Dependence of belching on the kind of food
and body position.
Heartburn: the time of it's appearance. Dependence on the time and kind of meals and on
the position of the body. Duration of heartburn. Rate. Methods and means of relieving
heartburn (soda, acid (hydrochloric acid)).
Nausea (sickness): time of appearance: empty stomach, before meals, after meals.
Dependence on kind of food, headache, change of the position of the body. Rate.
Duration.
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Vomiting (emesis). Time of appearance (on an empty stomach, after meals (at what
time?). Dependence on the kind of food, drugs. Rate. If it is accompanied by nausea. The
amount of vomiting, its taste (insipid, sour, bitter). Composition (undigested food, food
eaten not long ago or day before; liquid, mucous, bile, feces vomiting). Odor. Color
(yellowish, green, grounds-like). Soreness of mouth; does vomiting relieve pain?
Stomach-bleeding. Rate. Amount of blood.
Pain in the abdomen: Location. Constant or fit-like, time of appearance (on an empty
stomach, after meals, at night). Dependence of the time of meal, amount and kind of food
(rough, spicy, fatty). Effect of sharp movements, and body shaking. Character of pain
(dull, aching, sharp, stabbing, squeezing, spastic). Intensity of pain, radiation (into the
back, lumber, scapular, shoulder). Duration. Relief (heat, cold, meals, sweet water, milk,
soda, change of body position, gas pass, stool).
Flatulence - time of appearance, constant or intermittent. Dependence of kind of food,
easy gases pass.
Collywobbles: time of appearance (on an empty stomach, after meals). Dependence on
the kind of food.
Stool: Rate (daily, i.e. once a day, how many times a day?). Sense of incomplete
emptying.
In cases of constipation - necessity to use an enema or laxatives. Presence of piles (rectal
hemorrhoid), bleeding, painful defecation. Anus itching.
In cases of diarrhea - dependence of kind of food (milk). Time of appearance (a.m.
/p.m.), association with meals, wearying. False urge. Diarrhea alternating with
constipation. Spontaneous defecation. Proctoptosis (falling of the straight intestine).
Feces (Stools): form, consistency (a) shaped stool ribbon stool, scybalous ("sheep's")
stool; b) shapeless stool ointment-like feces, porridge-like (spinach); hard stool, watery
feces, loose stool (liquid as water, as rice water, foamy); color of stool: light or dark
brown, yellow, whitish, colored, colorless (acholic stool), tarry stool. Presence of mucous
(much, little, mixed with feces, on the feces). Presence of blood (amount). Undigested
foods, worms (helminthes).

LIVER, GALL BLADDER

Pain in the right hypochondrial region, constant or fit-like, rate, character, intensity,
radiation of pain. Causes for pain (fatty food, exertion, worrying). What is pain associated
with: high temperature, flatulence, vomiting, heartaches, yellowish skin or eyes, changes
in the color of urine and feces and skin.

SPLEEN
Pain in the left hypochondrial region constant or fit-like pains, character, intensity,
duration, radiation and cause for pains.

URINARY SYSTEM
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Pain: location on the lumber and pubic region, constant or fit-like pains. Intensity,
character, duration. Effect of body shaking on pain.
Edema - face, legs, body, rapidity of appearance, relation to the time of the day
(increasing in the morning on the face and disappearance in the evening).
Urination: rate, number of the urinations in the day-time and at night (nicturia). Diurnal
urine excretion. Urination: easy, normal flow, narrowing of the stream, stream dribble
(stranguria), interruption of the flow. Abnormal sensations during urination (pain in the end
or at the beginning of urination, burning sensation). Involuntary urination. Urination at
night sleep (enuresis).
Color of urine: straw-yellow, light, beer-colored, color of meat-water, red urine. Urine
transparent or turbid.

GENITAL SYSTEM
Functional upset. About women - menses (menstruation): at what age did the menses
begin? Regular, intermenstrual period, duration, amount of menstruation, painful in the
hypogastric region (region below the navel). The date of last menses. Pain during
menstruation, character. Vaginal discharge (leucorrhea do the whites).

SKIN
Itching, intensity, location, time of appearance. Rashes, ulcers. Sweat, intensity, time and
causes of appearance.

LYMPH NODES
Enlarge in size, pain, presence of fistulas.

OSTEOMUSCULAR SYSTEM
Pain in bones: Location. Character. Intensity, relation to the time of the day (at which
time it's increasing).
Pain in joints. Location. Pain appears at rest or in motion. Mobility of joints. Swelling of
joints.
Muscle pains (myalgia, muscular ache). Kind of groups. Myalgia independents or in
motion. Weakness of muscles. Trembling of hands, fingers. Convulsions, especially in crus
muscles feet, change of gait.

NERVOUS SYSTEM (NEUROLOGY SYSTEM)

Feeling. Sleep (rapidity of falling, asleep, awakening; duration; sleep soundly, sleep
fitfully, frightening dreams (nightmare) a nap in the middle of the day.
Headache. Location. Character. Time of appearance. Cause-relation to intellectual work,
reading, nervousness.
Dizziness (Vertigo). Character. Time of appearance. Loss of consciousness of for a short
time. Syncope.
Memory (good, bad).
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Parastesia (creeping sensation). Sensation of the numbness, fever, cold, prickling, burring
off color or blush of face in emotional state. Sensation of the cold in the limbs.

ORGANS OF SENSE
Eyesight, hearing, sense of smell, taste, touch.

OTHER DATA ABOUT STATE OF PATIENT

Weakness, loss of weight, efficiency, fatigability. Ferber, high temperature (time of
appearance).

III. PRESENT ILLNESS

First symptoms of the disease, onset of the disease: its characteristics (date, has it
developed rapidly or gradually). Causes.
Development of the disease: describe the progress of the disease (since the moment
of first symptoms to the present moment). State the time of the appearance of new
symptoms and give their characteristics in progress.
Previous investigations data. Previous treatment and its efficiency. In cases of lingering
chronic illnesses give details of acute periods, their causes, peculiarities of progress, loss
of ability to work caused by this illness. Regular treatment.
State of the patient in remission.
What has brought the patient to the physician at present moment?

IV. LIFE HISTORY (PERSONAL HISTORY)

1. Childhood and Youth. Place of birth and life in early childhood. Growing up and
development. Health, family conditions, financial circumstances. Studies: When did he
(she) begin to study? Was it difficult to study or not?
2. Occupation. Since what age working carrier began. Name all kinds of jobs he (she)
has had. Length of service. Changes in work caused by illness. Conditions of work.
Working room (dry, wet, dusty, wooden floor, stone floor, warm, cold, neat, and
ventilation). Is work connected with cold, wet clothes and shoes? Hazards: abnormal
body position, dust, noice, high temperature, industrial intoxication.
Military service. For how long has he served in the army? Taking part in military actions.
Discharged in time or because of some illness.
3. Financial Status.
4. Living conditions.
5. Clothes. How is he (she) dressed? Is he (she) dressed according to the season? Are feet
often wet?
6. Meals (Nutrition habits): Where does he (she) have meals? How many times a day? Is
it regular and sufficient? Kinds of foods preferable. Keeping to diet.
7. Body Hygiene.
8. Marital Status. Married. Single. Divorsed. Widowed. Children.
9. Family History. Parents' state of health. Close relations (brothers, sisters,
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grandparents). Pay attention to tuberculosis, venereal diseases, cancers, endocrine system

diseases, mental impairments, alcoholism and sock. If his (her) relatives died, ask why and
when.
10. Past illnesses: infections (viral hepatitis, tuberculosis, measles, scarlet fever,
diphtheria, malaria, typhus); venereal diseases (syphilis, gonorrhea, chlamydiosis, etc.);
pneumonia, pleurisy, rheumatism, sores throat; respiratory diseases, cardiovascular
diseases, gastrointestinal diseases, liver troubles, genitourinary troubles, illness of
nervous system, etc. Effect of past illnesses treatment. Wounds and contuses. Traumas
and injuries. Psychoemotional conflicts.
11. Habits: alcohol, how often and how much (daily, periodically, from time to time,
before dinner, in good company). For how long does he (she) take alcohol? Smoking
how many cigarettes a day. Narcotics (which, how often).
12. Allergy (to drugs, to foods, to any pollens, etc.).
13. Blood transfusion: what components where administered, complications.
14. Hormones, poisoning, toxic and strong medicines treatment.

B. OBIJECTIVE EXAMINATION

GENERAL INSPECTION
1. General condition (satisfactory condition, middle-grave condition, grave condition,
agonal state, terminal state).
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2. Show, conformity of appearance and age.

3. Consciousness and stages (alert, clouded, stupor, sopor (an unnaturally deep sleep),
coma, agitation, delirium, hallucinations).
4. Posture (active, passive, forced). Gate.
5. Lock at the face.
6. Weight, height, constitution (normosthenic, asthenic, hypersthenic), nutritional state
(well nourished, poorly, nourished, cacheksia, obese, emaciated). State of development:
flabby, muscular, asymmetrical.
7. Skin: Color of the skin and mucous membrane (mucous coat): normal, pale, red,
cyanotic, icteric, bronze. Skin eruptions (rashes), subcutaneous hemorrhages, ulcerations,
desquamation, pigmentation, depigmentation. Skin scars (cicatrices), turgor, dry, moist,
flabby, wrinkleless of the skin.
Nails: configuration, lesions, brittleness.
Hair: changes in hair growth, baldness, grey hair, brittleness.
8. Subcutaneous fat (development normal, moderate, superfluous. Places of the best
deposit of fat.
Edema general (anasarca) or local. Location, density (compact, soft). Expressed:
pronounced, insignificant (small). Mobility. Displacement. Subcutaneous emphysema.
9. Lymphatic System: location of palpable nodes, size, color of the skin above the
nodes, consistency, single /"packet group"; tenderness, shifting.
10. Muscular system: Degree of development (good, weak, symmetrical). Muscular
tension: normal, stiff, increased, decreased. Tenderness. Convulsions (clonic convulsions,
tonic convulsions, tetanic convulsions). Tremor. Muscular strength.
11. Bones. Location of pathological changes. Curvatures, deformations, shortenings,
tenderness; periostisis, clubbing of fingers.
12. Joints: form, size, changes of skin, temperature, tenderness in palpation, fluctuation,
crackles, movements (active, passive), tenderness in movements, changes of mobility
joints, immovable (ankylosis). Changes in joints size in cases of deformation (changes in
joints circumference).
13. Vertebral column: Inspection: shape, curvatures (normal, pathological). Palpation of
paravertebral points, percussion of the spinous processes of vertebrae.
14. Head: size and form (configuration) of the skull, scars, tremor.
Nose: form (shape), septum deviation, taking part of wing of nose (nostrils) in respiration.
Herpes. Polyposis.
Eyes: color of the sclera coat; brightness. Cornea state. Endophthalmus. Exophtalmus.
Lids: edema, ptosis, width of palpebral fissures. Sclera: jaundice, hemorrhage.
Conjunctiva: pallor, injection, petechiae. Cornea: scars, ulceration, arcus senilis. Pupils:
size, shape, equality of reaction to light and accommodation. Vision: acuity, visual fields
by confrontation. Ophthalmoscopy: optic disks, vessels, exudate, hemorrhage.
Lips: form, color, lesions, scars, fissures.
15. Neck, thyroid gland: enlarged, nodular, bruit, consistency, surface.
16. Body temperature.
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RESPIRATORY SYSTEM

INSPECTION OF THE CHEST.

Form of chest. Symmetry of the chest. Deformities of the chest wall. Equality of
expansion of the chest halves during respiration (presence of the chest half lagging). State
of intercostal spaces. Type of respiration: 1) Upper thoracic (thoracic respiration,
thoracic breathing); 2) low thoracic (lower rib) (abdominal respiration); 3) Mixed.
Respiration rate (per minute): tachypnoe, bradypnoe. Respiration rhythm (normal,
irregular). Respiration depth (moderately deep, shallow (superficial), excessively deep).
Pathological types of respiration (Biot's respiration (meningitic), Kussmauls
respiration (deep, rare, noisy breathing), Cheyne-Stockss respiration (tidal, or periodic).
Short breath. Objective dyspnea and its characteristics: inspiratory dyspnea, expiratory
dyspnea, mixed dyspnea. Measuring of the chest circumference during quiet breathing,
deep inhalation and deep expiration.

PALPATION OF THE CHEST.

Surface palpation of chest, ribs, breast-bone, intercostal. Vocal fremitus (pectoral fremitus)
palpation (intensified, weak, normal, is absent). Elasticity of the chest (normal, decreased
(rigid chest)). Position of the trachea.
PERCUSSION.
Comparative percussion of the lungs (along the parasternal, midclavicular, anterior
axillary, mid axillary, posterior axillary, scapular, paravertebral lines). The character of
percussion sound (lung resonant, tympanic resonance, dull sound, bandbox sound,
dull-tympanic sound). In the presence of pathologic sound in the local region, show the
actual lines. Use for orientation the ribs and topographic lines. Damoiseaus curve (in
presence of the pleural cavity fluid), Grocco's triangle, Garland's triangle.
Topographic percussion of the lungs. Determination of the upper borders (apexes)
position (anterior and posterior chest surfaces). Kroenigs isthmus (comparatively in
symmetrical areas). Position of the lower borders of lungs (according to all of topographic
lines). Determination of the respiratory excursion of lower lungs borders (along mid-
clavicular, mid axillary, and scapular lines). Determination of the Traube's space borders
(semilunar space).
AUSCULTATION OF THE LUNGS (comparative in symmetrical areas). Character and
intensity of breathing sounds, relative duration of inspiration and expiration. Character of
breathing sounds: vesicular respiration (normal, decreased, intensified, harsh breathing
(rough respiration); cogwheel (or intermittent) breathing); bronchovesicular respiration;
bronchial respiration (tubular respiration), amphoric respiration. Absence (lack) of
respiration (atelectatic silence). Rales: location, character (dry rales (high-sibilant rales, or
whistling rales), low-pitch, or sonorous rales; moist rales (large bubbling rales, medium
bubbling rales, fine bubbling rales; consonating rales (sonorous, ringing) and
nonconsonating) rales. Crepitation sounds, their amount and intensity; influence of cough
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on their appearance and intensification. Pleural friction rub (location). Splashing sound
(succussion sound) sign. Bronchophony (intensifying, decreased, normal). Spirometry.

CARDIOVASCULAR SYSTEM
INSPECTION
Region of heart. Cardiac humpback. Point of maximal impulse (apex beat). Cardiac beat.
Abnormal pulsations: aorta pulsation, pulmonary trunk pulsation, ventricular aneurysm
(postinfarctive cardiac aneurysm).
Region of neck. Aortic arch pulsation, carotid arteries pulsation ("carotid shudder")
engorgement of jugular veins. Undulation (waving) of neck veins. Jugular venous pulse
negative, positive).
Peripheral arteries pulsation. Capillary pulse (nail pulse, Quince's sign). Crimp of
arteries ("worm sign").
Epigastric pulsation. Hepatic pulsation. Plesh's sign" - jugular pulse while pressing on
enlarged liver. Pulsation of right ventricle of the heart. Abdominal aorta pulsation.
Phlebiectasia of subcutaneous chest, abdominal veins. Varicose phlebiectasia of lower
extremities and changes of vascular walls.
PALPATION. Apex beat (maximal impulse). Location. Character (area dilated, limited).
Strength and intensity (normal, intensified, raised, dome-like, weakened). Systolic
retraction of heart region. Systolic and presystolic thrills ("cat purr") location.
Aortic arch palpation. Oliver-Kardarelli's symptom - (trachea shifting during systole).
Aorta palpation to the right of the sternum. Pulmonary artery pulsation to the left of the
breastbone.
Epigastric pulsation (right ventricle pulsation, hepatic pulsation).
Peripheral arteries pulsation (density of radial, brachial, temporal artery walls,
beading-like). Radial artery pulse: rate, rhythm (normal, abnormal, full, tense, deficient,
form, high/low). Pulse change on exertion. In cases of arrhythmia its character
(extrasystolic, fluttering / fibrillation, etc.). Pulse deficit. Foof arterie palpation.
PERCUSSION. Retromanubrial dullness relative cardiac dullness and superficial cardiac
dullness - right, left upper borders of heart. Configuration of heart (configuration of
relative cardiac dullness). Heart shape: normal, pendul (hanging heart), mitral, aortal,
pulmonary greatly hypertrophied (cor bovinum).
Transversal diameter of heart (in centimeters) measuring into both side from median linea.
Transversal diameter of vascular bundle (aorta and pulmonary artery in the second
intercostal space).
AUSCULTATION. First heart sound (sonorous, flag, flapping, weak, dull, bifid,
splitting), second heart sound (intensified, prominent, weak, bifid, splitting) in all of
auscultation points: timbre tone (normal, flapping, metallic).
Systole rate. Rhythm. Gallop rhythm (cantering rhythm). Embriocardia.
Murmur: systolic, diastolic (presystolic murmur, protodiastolic murmur, mesodiastolic
murmur). Character of murmur: blowing, soft-musical, whistling, scratching harsh.
Strength (harsh, weak). Timbre: high, low. Duration: long, short, increasing, decreasing.
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Places of best murmur auscultation changes (effect body position and physical exertion).
Pericardial friction rub, location.
Auscultation of vessels: Durozier's double murmur; Troube's double tone. Nun's murmur
(venous hum in the neck).
Arterial and venous pressure.

GASTROINTESTINAL SYSTEM
INSPECTION OF ORAL CAVITY:
Smell (normal, fetor, putrefactive (saprogenic), urine acetone, apple).
Teeth. How main teeth are absent? Number of carious teeth and parodontosis teeth.
Dental deposits. Artificial teeth.
Gums (gingiva): color. Bleeding (stomatorrhagia), ulceration, suppuration (pyosis), grey
edge.
Mucous membrane of the oral cavity hard palate, soft palate. Color, pigmentation,
ulceration, cicatrices, cleft, palate (palatum fissum uranoschisis).
Tongue: size, color, clean, coated (furred) tongue: character of fur. Tongue dry, humid
(moist); dark red, strawberry tongue, with smooth, papillae. Ulceration cracks, scars.
Difficult to put out of tongue and deviation of tongue during.
Throat. Mucous membrane: color: normal, red, dry, smooth or granular surface.
Tonsils: size, color. Patch (area, color, easily (difficulty with removed), pus in lacunes.
ABDOMEN. Inspection in upright and lying position. Size. Configuration: normal,
navicular abdomen (scaphoid abdomen), diverticulum, pendulous abdomen, retracted
belly in upper region of abdomen; "frog" belly. Adiposis (obesity). Symmetrical and
asymmetrical diverticulum. Participation in breathing. Venous network. Visible gastric and
intestinal peristalsis. Stria. Pigmentation. Scars (location). Divarication of rectal
abdominal muscles. Umbilicus (navel), state. The abdomen circumference (in cm).
Surface abdominal palpation tenderness, muscle tension (muscle protection -
show the place of location). Palpation of hernia openings. White line. Blumberg
Schetkin's symptom. Tenderness in McBurney's point and other painful points.
In cases of tumor define the location, size, consistency, configuration, flexibility and
shifting while breathing. Free liquid in abdomen (with the help fluctuation and
percussion).
Stomach: determination of the lower border, great curvature of the stomach (its
determination with the deep sliding palpation by Obraztsov's method); percussion;
succusion and auscultopercussion after stating the left border of the stomach). Splashing
sound in pathology.
Intestine: palpation of certain areas of intestine according to Obraztsov and Strazhesko
method. Sigmoid colon, coecum, ascending colon, transverse colon, descending colon
(location, size, tension, surface, shifting, splashing sound, tenderness).
Anus inspection, hemorrhoid.
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LIVER AND GALL BLADDER.

INSPECTION.
PERCUSSION: by Obraztsovs (determination of the upper border of liver with the help
of percussion along the following lines: mid clavicular, anterior axillary and right
parasternal) method. Sizes of the liver (according to Kurlov's) along the following lines:
mid clavicular, median and along the margin of the left costal arch.
PALPATION of the lower border of liver along the following lines: right mid clavicular,
median and left parasternal. Liver border characteristic (sharp, round, even, uneven),
tenderness, consistency (normal, soft, dense, cartilaginous), surface (smooth, nodular,
granular).
Liver determination with the help of balloting palpation.
Gallbladder palpation (form, size, shifting, consistency, tenderness). Determination of
painfull zones. Diaphragm painful point.

SPLEEN.
INSPECTION.
PERCUSSION. Upper and lower margins: determination along medic axillary line.
PALPATION of the lower margin (consistency, surface, tenderness). Size: longitudinal
and transverse (in centimeters).

URINARY SYSTEM.
INSPECTION of lumber area (region): red skin, swelling, edema.
PERCUSSION (Pasternatsky's symptom).
PALPATION. Painful points. Deep, bimanual palpation in horizontal and vertical
position. Determination of the kidney displacement (I, II, III degree), size of the kidney,
its form, character of the surface, consistency, tenderness.
Determination of the upper margin of the urinary bladder above the pubic symphysis by
means of palpation and percussion.
Genitals - external examination.

C. MAIN CLINICAL SYNDROMES

1.
2.
3.

D. PLAN OF ADDITIONAL EXAMINATION AND SUGGESTED RESULTES

EXAMINATION SUGGESTED RESULTES

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1
2
3
4
5
6
7
8
9
10
11
12

E. PROVISIONAL DIAGNOSIS

A. MAIN DIAGNOSIS
B. COMPLICATIONS
C. CONCURRENT DIAGNOSIS

F. PLAN OF THE TREATMENT

1. REGIMEN
2. DIET
3. PHARMACOTHERAPY (groups of medicines):
A)
B)
C)