Beruflich Dokumente
Kultur Dokumente
a) Basic information: first name, surname, title, address, post code, telephone number,
admitted to the Clinic of Internal Medicine of Motol Teaching Hospital on (date)….
at (hour, min.)
b) Cause of admission: brief accurate information on the reason for admission (e.g.
protracted retrosternal pain accompanied by dyspnoea).
c) In repeated hospitalisations, the date of the last hospitalisation.
COMPLAINTS
(Describe complaints, which disturbed patient at the 1 -st day of examination by
student). Complaints preceding hospital admission, their origin, circumstances and
development, must first indicate the main complaints (specific) for the disease with which the
patient is treated in a hospital than nonspecific.
SH - Social History:
a) Marital status - married, divorced, lives alone, etc.
b) Accommodation arrangements - which floor, elevator, up the hill, etc.
c) Occupation - physically demanding, stress, pollutants, risk at workplace, etc.
d) Retired - old age pensioner, disabled, reason for the disability pension, since when.
PA - Pharmacological Anamnesis:
List of permanently taken medications including their dosing.
AA - Allergic Anamnesis
a) Drug allergy – kind and type of allergic reaction (exanthema, allergic oedema,
anaphylactic shock), when the reaction occurred.
b) Hay fever (pollinosis), allergy to dust, pollen, mites.
c) Food allergy.
d) Allergy to adhesive plaster etc.
e) Allergy to contrast media.
GA - Gynaecological Anamnesis
a) Menstruation – from - to, regular, irregular, date of the latest menstruation.
b) Menopause - at what age, hormone replacement therapy.
c) Number of children, number of spontaneous miscarriages or abortions.
d) Gynaecological surgeries.
e) Hormone contraceptives.
EH – Epidemiologic History
a) Chronological list of illnesses from childhood up to present date (dates to be given either
in the form of the year or the age of the patient – should not be mixed, definitely not in
the form of how many years ago)
b) Children's infectious diseases (rubella, mumps, chicken-pox, scarlet fever, diphtheria),
repeated tonsillitis, rheumatic fever (protracted febrile disease in childhood accompanied
with joint swelling, or resulting in heart murmur).
PH - Personal History
a) Operations.
b) Habits: smokes from - to, how many cigarettes a day, how long, date of giving up.
alcohol – beer, wine, spirits, how much per day on average, regularity of consumption
coffee – how many cups per day other habits.
c) Ask about diseases of all body systems such as coronary heart disease (CHD) chest pain
myocardial infarction orcerebral stroke in the past. Treated for hypertension – for how
long, what type of treatment.
d) Diabetes mellitus (DM) Type 1or 2 , what type of treatment, other metabolic and
endocrine diseases (thyreopathy etc.).
e) Digestive disorders - i.e. gastroduodenal ulcer, gallbladder problems, cholecystolithiasis,
biliary colic, icterus, infectious hepatitis, intestinal problems – diarrhoea, obstipation,
body weight stable, unstable, weight gain or loss (how many kilograms and in what time
course), reason – anorexia, bad eating habits, vomiting, slimming diet, stress etc. Stools
regular, irregular, pathological substances in the faeces – blood, mucus, melena.
f) Urological problems - dysuria, pollakisuria, cystolithiasis, renal colic, haematuria.
g) Diseases of lower extremities: – claudication, venous – varicose veins, state after deep
vein thrombosis, chronic venous insufficiency, varicosel ulcer, joint problems, state after
injuries, fractures.
h) Briefly neurological diseases.
10.Auscultation:
vesicular breathing, hard breathing, weakened, strengthened, puerile, bronchial
breathing (amforyc, metal). The weakening or absence of respiratory noise, indicate
localization.
11. Breath sounds: not auscultated.
If auscultated additional respiratory sounds then specify the following:
a) Dry rales (whistling, squeaking, buzzing, humming) indicate localization.
b) Moist rales (small, medium, large bubble), their sonority, place of hearing;
crackling (indicate localization).
c) Pleural rub, indicat localization.
d) Bronhofoniya (weakened, the same on both sides, reinforced).
II. Cardiovascular system.
1. Apex beat: in 5th intercostal space by 1 cm to the middle on the left midclavicular line.
2. Pulse rate per minute
a) rhythm (rhythmic, arrhythmic, which arrhythmia),
b) tension (hard, soft, medium);
c) filling.
3. Blood pressure mm Hg (left hand, right hand)
4. Border of relative cardiac dullness:
a) Right - 1 cm from the right edge of the sternum in the 4th intercostal space
b) Left – 1 cm medially from the left mid-clavicular line in the 5th intercostal space
c) Upper – lower edge of the 3rd rib
5. Border of absolute cardiac dullness:
a) Right - left edge of the sternum in 4th intercostal space
b) Left – coincides with the relative cardiac dullness
c) Upper - lower edge of the 4th rib
6. Auscultation: Tones (heart sounds) their sonority, at all points of auscultation
(sonorous, rhythmic)
In the case of pathological changes should indicate:
a) Accents, splitting, split tones, additional tones (rhythm "gallop" rhythm
"quail"), auscultatory phenomena.
b) Murmurs their relation to the phases of cardiac activity, localization, maximum
intensity, conductivity, character, strength, timbre duration. Changes depending
on the phase noise of breathing, position the patient load.
c) Pericardial friction, its location, duration.
III. Digestive system
1. Oral cavity (needs sanitation, sanation not require)
2. Tongue:
a) color (red, pale, cyanotic, crimson, black, lacquered)
b) humidity (wet, dry)
c) presence of plaque, ulcers, fractures, tooth prints
3. Inspection abdomen:
a) size (increased, not increased)
b) form (oval, "frog", involved, fallen, flaccid)
4. Palpation (not painful, painful during the palpation)
5. Percussion:
a) percussion sound (tympanic, dull – indicate where)
b) fluctuation symptom (present, not present)
6. Auscultation:
peristaltic sounds (auscultated, does not auscultated)
7. Liver dimensions by Kurlov (indicate dimensions - 9×8×7 cm)
a) by the right midclavicular line – 7 cm
b) by the median line – 8 cm
c) by the left costal arch – 9 cm
8. The lower edge of the liver (does not appears from the costal arch, appears out of the
costal arch on __ cm)
9. Spleen (indicate dimensions - 3×4 cm)
10.Gall bladder (not palpable, area of palpation not painful)
11.Pancreas (not palpable, area of palpation not painful)
12.Bowel movements ________day.
IV. Urinary system
1. Area of kidney
a) swelling (no, yes)
b) congestion (no, yes)
2. Palpation of the kidneys (not palpable, palpable – specify size, density, elasticity,
soreness, mobility)
3. Pasternatsky symptom (negative, positive – on the left side, on the right side, on both
sides)
4. Edema ( no), pastosity ( no)
a) If we see presence of edema or pastosity we indicate their localization (lower
limbs, back, face, anasarca), prevalence, texture.
5. Dysuric signs (no, yes)
6. Daily diuresis __liters per day (1,5 – 2)
V. Osteoarticular system
1. The joints
a) swollen (no, yes - indicat localization)
b) painful (no, yes - indicat localization)
c) deformed (no, yes - indicat localization)
2. Range of movements (full, limited – indicat localization)
PREVIOUS DIAGNOSIS
On the basis of the received information (Complaints, Anamnesis morbid – history of the
illnes, Anamnesis vitae – personal history, Review of system) form a previous diagnosis.
PLAN OF EXAMINATION
Basic tests that are performed always:
a) complete blood count
b) urinalysis
c) blood chemistry (must specify the indicators you want to define)
d) ECG
TREATMENT PLAN
a) Regime (stringent bed, expanded bed, ward semi bed, free)
b) Dietary table