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FUNCTIONAL STATUS (Status functionalis)

Interview the patient on supposed changes (complaints) in all other organs and systems aimed to detect an evidence of complications.
General disorders: weakness, decrease or increase in body weight, fever, sweating, etc

Most often revealed neurological symptoms,

Changes in the psychic sphere.
Changes in motor activity.
Changes in basal metabolism.
Changes in secondary sexual characteristics.
Changes in skin and its appendages

Reproductive system

5. HISTORY OF LIFE (Anamnesis vitae)
Brief biographical information. Place of birth, social position, which account in childhood, the material conditions of life. Age of parents at the time of the birth of. From any account of pregnancy, maternal disease during pregnancy, childbirth. Character of feeding (natural, mixed, artificial).

Labor history.
Household history. Material and living, housing and sanitary conditions throughout of life. Family composition. Eating habits and lifestyle.

In chronological list indicate additional diseases, surgery, trauma, injury, hepatitis. What kind of drugs patient is taking constantly, their efficacy, doses, frequency rate of reception.
Gynecological and obstetrics history (females).

Allergological anamnesis.

Habits. Smoking. Alcohol.

6. CURRENT STATUS (Status praesens)
1. General examination
The general state of patient: satisfact, moderate,hard.
Consciousness: clear, stupor, sopor, coma, delirium, hallucinations. Smell of acetone in exhaled air.

Type of constitution: normosthenic, asthenic, hyperstenic.
Body weight (in kilograms). Height (in cm). Body mass index -BMI (kg/m2).Normal BMI 18,5 -24,9 kg/m2, overweight 25-29.9 kg/m2, obesity I 30-34,9 kg/m2, obesity II 35-39,9, obesity III - over 40 kg/m2. Waist size(cm), Femur size (cm), Waist/Femur relation.
Body temperature - in degrees by Celsius.
Facial expression.

Head: The pathological changes of shape, size, position, range of motion of the head, soft and bone tissues of the cranial vault on palpation, especially hair distribution.
Skin and mucous surfaces: color, humidity(normal, high, low), turgor (elasticity) of skin (normal, low), temperature: normal, hot and cold (with localization). Pathological changes of skin.
Subcutaneous fat tissue.

Edema. Localization and prevalence of edema (general - heart, kidney, mixed, local, regional, local and angioedema). Severity. Skin color and its density in areas of edema. Mucosal swelling of the skin and subcutaneous fat.
Lymphatic nodes. The sequence of study: occipital and parotid, submandibular and chin, neck front and back, over and subclavian, axillary, cubital, inguinal and popliteal. Characteristics of lymphatic nodes: the shape, size, density, tenderness, texture, mobility, cohesion lymph nodes between itself and the surrounding tissues, skin color changes over lymphatic nodes.
Musculature. Bone.
2. Respiratory system
Inspection of the nose: nose shape (regular, irregular), nasal breathing (free or impeded), wings of nose (involved or not involved in the act of breathing). Inspection and palpation of larynx: a form (correct or changed), position (normal, shift to one side), tenderness on palpation, mobility of larynx on palpation (normal, restricted).
Examination of chest
a) Static: shape.
b) Dynamic: participation of both halves of chest in act of breathing. Respiration rate. Respiratory rhythm.
Palpation of chest.
Percussion

Auscultation.
3. Cardio-vascular system
Inspection of neck vessels
Inspection and palpation of heart.

Arterial pulse and research vessels
Indicate the state of veins and signs of varicose enlargement or presence of thrombophlebitis.
Blood pressure: expressed. Results of three consecutive measurements on the right shoulder, compared with the corresponding values ​​of blood pressure on left arm, if necessary, compared with parameters of blood pressure, certain of the lower extremities. Pulse pressure (normal, increased, decreased).
Percussion of heart (detect absolute and relative heart flatness bound).
Auscultation of heart (detect arythmia – tachycardia, bradicardia, atrial fibrillation; heart murmurs with detection of localization –point of auscultation and relation to systole).
4. Gastro-intestinal system
Tongue
Teeths.
Inspection of abdomen.
Abdominal percussion
Palpation.
Percussion of liver: detect sizes by Kurlov.
Palpation of liver.
Spleen. Palpation of spleen..
Pancreas. Identification of palpation pain of the head, body and tail of the pancreas. Muscle protection symptom.
5. Genitourinary System
Inspection of lumbar region. Pasternatskii symptom (right, left side).To detect by palpation of kidney: size, shape, surface, texture, tenderness and mobility.

Primary and secondary sexual characteristics. Inspection and palpation of external genitalia.
6. Nervous system
Eye slits: the same, not identified, ptosis, nystagmus. Symmetry of face, tongue sticking out straight.

Muscle strength (decreased or not changed).

Coordination of movements is preserved, broken.
Pose Rehberg stable, unstable. Function of pelvic organs (disorderd, not disordered).
Reflexes. Pathological reflexes.
Receptor function (sencability: normal, decreased).

Autonomic function.
7. Endocrine System
Inspection: physical and mental development, age, sex.
Primary and secondary sexual characteristics

Distribution of body hair.
Face.
Eye symptoms

Palpation of thyroid gland. Detect the degree of enlargement of thyroid gland by WHO (0 degree – nondetected visually and by palpation, I degree – detected only by palpation, II degree – visual enlargement).
Hand tremor.

Basal metabolism according to Reed's formula: 0,75 (P 0.74 AP) - 72 = + / -10%, where P - pulse rate, PD - pulse pressure.

Trousseau's, Khvostek's symptoms (positive,negative).
Obesity (Weist/Femur relation)
General examination.

7. PRELIMINARY DIAGNOSIS
Main:
Complication:
Associated diseases:

8. PLAN OF ADDITIONAL EXAMINATION
List of additional laboratory and instrumental methods of examination, consultations of other specialists, indicated for patient. Results of additional examinations and their interpretation.

9. CLINICAL DIAGNOSIS AND ITS PROF
Main:
Complications:
Additional diseases:
Scheme justification diagnosis
Diagnosis __________ billed on the basis of:
Complaints _____________________________________________________,

10. DIFFERENTIATED DIAGNOSIS
Differentiate main disease with a 2-3 disease (Ex: patients with diabetes mellitus type 1 – differentiated diagnosis with type 2 and diabetes incipidus).

11. DIARY FOR THREE DAYS

Observation (except the first day)
Diary of observation includes the following:
1. Date.
2. Complaints of the patient.
3. Physical examination itself (briefly).
4. Interpretation of additional research methods at the day of curation.
5.Recommendations on treatment:
- Regimen
- Diet
- Medication and physiotherapy.

12. TREATMENT
1. Regimen(free, bed).
2. Diet. Menu.(diet № by Pevsner with discribtion of total caloricity and balance of carbohydrates, fats and proteins in %)
3. Drug treatmentwith prescription of 2 drugs (Rp.: …)
4. Physiotherapy.
5. Surgical treatment (if indicated). Indicate a type of operation.

13. PROGNOSIS for life and professional work.

14. USED ​​LITERATURE

СХЕМА ИСТОРИИ БОЛЕЗНИ (для стоматологического факультета)

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