The Endocrine system
Complaints (yes, no)
The thyroid gland, it’s size and consistence, painfulness (if there is an enlargement to indicate what part (lobe) is enlarged)
The condition of sexual characters (the secondary and primary phenomena of histurism, eunuchoidism, virilism, feminism)
Menses: regular, irregular, missing. Pains in the time of menstruation and without it, pain
Skin condition (humadity, thinning or ossification striae of hyperpigmentation)
Eye symptoms: Grefe, Mobius, exopthalmus, abnormality visual acuity and field
Abnormality of growth, constitution and proportionality of separate bodyparts
Examination, obesity (the degree of manifestation, predominant locating)
The Sense organs
Complaints (yes, no)
Vision (normal, night blindness, weakening, temporary or persistent loss of vision, exophthalmos, nystagmus, pupils)
Hearing organs – pains, tinnitus, suppuration
A provisional diagnosis: the main complaints are enumerated in short: medical history and life history, objective data with the substantiation of diagnosis.
An initial diagnosis:
Physical, physiological. Healthy (yes, no)
Disease
The Laboratory investigations
The data of blood, urine, feces, gastric juice, sputum, etc. analyses.
The Tool methods of examination
The data of the X-ray examination and other special examinations (spirometry, pneumotachometry, electrocardiography, radioisotopic diagnosing, sigmoidescopy and others).
CLINICAL DIAGNOSIS:
The main diagnosis:
Accompanying:
Complications:
TREATMENT:
Treatment is prescribed indicating aetiologie, pathogenic, symptomatic, supporting and so on, treatment separately according to prescriptions.
Diaries are written for the period of curation of “pp” (for the 3-4 days of admission and before the discharge from the hospital for comparison). Additional complaints on the day of admission, complaints in dynamics, sleep, appetite, patients response to this or that treatment (physiotherapeutic, medication) must be noted.
Further condition of inner organs according to the systems (respiratory, cardiovascular, digestive, urogenital) must be described. Pulse rate, respiratory rate, temperature must be written daily. Arterial pressure, AD, diuresis stood. Temperature chart must be filled in daily. Student must fill in temperature and pulse chart (if it is necessary to give the chart of pulse deficiency as well as the chart of AP in dynamics)
Signature of attending doctor.
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