DANYLO HALYTS’KYI LVIV NATIONAL MEDICAL UNIVERSITY
Department of Propaedeutic Pediatrics
Head of the Department: _______________________________
Supervisor: ________________________________
PATIENT’S RECORD
Name______________________________________________________________________
Age___________________
Clinical syndromes___________________________________________________________
Examinator: student of Medical Faculty,
______ year of study, group No _______,
___________________________________
___________________________________
20__- 20__ study year.
1
PASSPORT PROFILE.
Name______________________________________________________________________
Birth date (age)_______________________________________________________________
Home address________________________________________________________________
Date of the admission to the hospital______________________________________________
Date of the 1-st examination of the patient by student________________________________
Diagnosis at admission to the hospital_____________________________________________
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COMPLAINTS.
(to describe complaints, which disturbed patient at the 1-st day of examination by student)
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ANAMNESIS MORBI – HISTORY OF ILLNESS.
(to describe all details bearing directly on the complaints: chronological account of the
symptoms, investigations in the past and their results, treatment in the past and its efficiency)
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2
ANAMNESIS VITAE – PERSONAL HISTORY.
1. Past History:
number of pregnancies______, mother’s health during pragnancy_______________________
mother’s living conditions________________, mother’s nutrition______________________
mother’s exposure to drugs or substance abuse______________________________________
mother’s exposure to ionizing radiation during pragnancy_____________________________
events of labor and delivery_____________________________________________________
first baby’s cry______________, scores according to Apgar scoring system______________
birth weight_________, birth height_______, first baby’s sucking movements_____________
day when umbilical cord segment fell off_____, healing of the umbilical wound___________
physiologic weight-loss_________%, physiologic jaundice: no, yes: onset________________
_____________________duration_______________________________________________
cronologic account of growth and development_____________________________________
___________________________________________________________________________
first teeth___________________________________________________________________
language development_________________________________________________________
motor and social skills: held head erect at_________mo, sat without support at________mo,
stood without support at_________mo, started to walk at ____________mo,
other skills__________________________________________________________________
mental development___________________________________________________________
behaviour of the child among relatives and other children_____________________________
______________________________hobby________________________________________
sleeping and rest___________________________, habits_____________________________
feeding history:
 during infancy – breast-feeding untill__________mo, formula-feeding because of______
_________________________________________________(formula__________________)
mixed-feeding from___________mo; introducing of juces (___________________________)
at_____________mo, introducing of fruit puree at_________________mo, introducing of egg
yolk at________________mo, introducing of complementary foods: 1-st (_______________)
at________mo, 2-nd (______________________) at_________mo, 3-rd (_______________)
at________mo; weaning process_________________________________________________
 afterward: at home____________________________________, at the kindergarten_____
______________________________, at school_____________________________________
past medical history (chronological account of events):
 previous illnesses (exept those of infection origin)________________________________
___________________________________________________________________________

previous hospitalizations____________________________________________________

surgeries________________________________________________________________
3
2. Family History:
mother: age___________, medical condition_______________________________________
father: age____________, medical condition_______________________________________
pedigree illustration:
3. Social History:
environmental circumstances____________________________________________________
living conditions______________________________________________________________
social status of parents_________________________________________________________
4. Allergologic History:
 allergic responce to: medications_____________________________________________
foods_______________________________________________________________________
animals______________________, insects______________________, dust______________
cosmetics__________________________, chemicals________________________________
 manifestation of allergic responce: skin manifestation____________________________,
conjuctivitis, respiratory manifestation____________________________________________,
anaphylaxis in the past_________________________________________________________
5. Epidemiologic History:
immunization________________________________________________________________
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tuberculin skin test: negative, positive (date)______________, preventive treatment : no, yes
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past infectious diseases (chronological account of events)_____________________________
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contact with infectious patient within 21 day before admission to the hospital: no, yes (date of
contact, kind of disease)________________________________________________________
4
REVIEW OF SYSTEMS.
1. General state:
condition of patient: very severe, severe, moderate, mild, satisfactory;
consciousness: present, confused, unconsciousness;
position: active, passive__________________, compelled_____________________________
2. Assessment of physical development:
weight_________________(N____________), height_______________(N_____________),
head circumfarence __________(N_________), chest circumfarence _________(N________)
conclusion__________________________________________________________________
3. Assessment of mental level:
appearance_________________________, behaviour________________________________,
attantion span_________________________, mood_________________________________,
speech______________________, ability to cooperate with examinator__________________
conclusion__________________________________________________________________
4. Nervous system:
 fatigue____________________, irritability_________________, head ache___________
_______________, dizziness__________________, weakness_________________________;
 motor examination: voluntary movements______________________________________,
involuntary movements________________________________________________________,
motor coordination tests_______________________________________________________;
 examination of reflexes: tendon__________________, pathological_________________,
reflexes of neonates (for young infants)___________________________________________;

sensory examination_______________________________________________________;

examination of cranial nerves_______________________________________________;
 meningeal signs: stiff neck__________________, Kerning sign____________________,
Brudzinskyi signs____________________________________________________________;
 vegetative nervous system__________________________________________________
___________________________________________________________________________;

visual acuity________________________, hearing ability_________________________
5. Skin, mucosa and subcutaneous tissue:
 skin: color__________________, lesions______________________________________,
___________________________________________________________________________,
texture_____________________, moisture_________________,elasticity_______________,
5
temperature_________________________________________________________________;
 nails: shape_______________, color________________, lesions____________________
_____________________________texture________________________________________;

hair: appearance__________________, texture_________________________________;
 mucosa of the lips, gums, conjuctiva: color_____________________________________,
lesions_____________________________________________________________________,
_________________________________moisture___________________________________;
 subcutaneous tissue: general development______________________________________,
thickness of the fold__________________________________________________________,
edema_____________________________________________________________________,
6. Lymphnodes:
(to describe number, sizes, consistency, tenderness, motility of palpable limphnodes)
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7. Musculoskeletal system:

head: shape of the skull____________________________________________________,
*for infants: frontal fontanell – sizes_____________, bulging, depressive, on the level of
the skull bones; occipital fontanell (sizes)_______________; craniotabes: no, yes; sutures
condition:_______________________________________________________________

neck: short (no, yes), torticollis (no, yes);
 chest: shape_____________________, deformities: no, yes________________________,
rachitic rosary (no, yes), Harrison groove (no, yes);
 spine: posture__________________________, lordosis and kyphosis (to note the
segment of the vertebral column): physiologic______________________________________
____________________________________, pathologic_____________________________,
scoliosis no, yes (to note the segment of the vertebral column)_________________________;
 extremities: abnormalities: no, yes_______________________________, deformities:
no, yes_____________________________________________________________________,
muscles: strength____________________________, tone____________________________;
 joints (to note the name of the altered joint): swelling: no, yes______________________,
deformities: no, yes____________________________, motility: of full value, hypermotility,
limited_____________________________________________________________________;

musculature: general development____________________________________________
6
8. Respiratory system:

nose breathing___________________________, voice___________________________,

throat__________________________, tonsils__________________________________;
 respiration: rate________/ min (N - _______/min), dyspnea: no, yes________________,
rhythm___________________, type__________________, depth______________________;
 thorax: obvious effort of the accessory muscles during respiration (no, yes), symmetry of
expansion____________________________, pain due to palpation: no, yes______________,
resistence___________________________________________________________________,
vocal fremitus_______________________________________________________________,
comparative percussion________________________________________________________
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___________________________________________________________________________,
topographical percussion:
- lower borders of the lungs
Lung
l. medioclavicularis
l. axillaris
medialis
l. scapularis
l. paravertebralis
Excursion of the
diaphragm
Right
Left
- apex of the lungs (sizes)
right____________________________________, left_______________________________;
Korani’s sign: neg., posit._______________, Arkavin’s sign: neg., posit.________________;
auscultation: breath sounds_____________________________________________________
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adventitious sounds___________________________________________________________
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voice sounds_________________________________________________________________
d’Espine’s sign: neg, posit._____________________________________________________
9. Cardiovascular system:

visible pulsation of the neck vessels: no, yes____________________________________;
 prominence of the precordial chest wall: no, yes_________________________________,
hyperdynamic precordium: no, yes; thrills: no, yes__________________________________,
apical impulse: ______________________________________________________________;
 pulse: synchronous on the symmetrical arteries – yes, no__________________________,
rate________/ min (N - _______/min), rhythm________________, tension______________;
7

blood pressure (BP):
Patient’s BP
Extremity
systolic
Ranges of normal BP
diastolic
systolic
diastolic
Upper
Lower

percussion:
Borders
Heart dullness:
relative
patient’s
absolute
normal
patient’s
normal
Left
Right
Upper
width of the heart dullness: according to the ralative dullness_________cm (N_________cm),
according to the absolute dullness________cm (N_________cm),
 auscultation: heart sounds: intensity S1_________________________, S2____________
______________________, quality S1___________________, S2_____________________;
murmurs: no, yes – point of maximal intensity_____________________________________,
timing______________________ duration_________________, intensity_______________,
quality__________________________________, pitch______________________________,
irradiation___________________________________________________________________
10. Digestive system:
 oral cavity: odor: no, yes_________________, tongue____________________________,
teeth_______________________________________________________________________;
 abdomen: shape_______________________, symmetry__________________________,
umbilicus__________________________, visible peristalsis (no, yes), dilated veins (no, yes);

anus: sphincter tone and control________________, lesions_______________________;
 palpation: superficial______________________________________________________,
deep (to note size, shape, consistency, tenderness, mobility of palpable structures): sigmoid
flexure_____________________________________________________________________,
caecum_______________________________________, colon transversal_______________
________________________________________________, colon ascending_____________,
______________________________colon descending_______________________________,
liver (lower border)___________________________________________________________,
pancreas__________________________, spleen___________________________________,
8
 percussion: percussion note over abdomen_____________________________________,
spleen sizes: upper border__________, lower border___________, length х width_________,
liver sizes: I_________ (N_______), II__________, (N______), III_________ (N________);
 points and signs of digestive system diseases (to note whether the following points are
painful or not, are the following signs positive or negative): Mayo-Robson’s point_________,
Katsch’s point_______, Desjardin’s point__________, Chauffard’s zone______________,
Mendel’s sign____________, Openhovskyi’s points______________, Boas’s points_______,
Kehr’s sign______________, Murphy’s sign_______________, Ortner’s sign____________,
de Mussey’s sign_____________, McBurney’s point____________, Rovsing’s sign_______,
obturator sign __________, psoas sign _____________, Blumberg’s sign________________;

auscultation (peristalsis)____________________________________________________,

stool____________________________________________________________________
11. Urinary system: urination___________________________________________________,
enuresis (yes, no), daily fluid intake_________, daily diuresis_____________(N_________),
palpation of the kidneys_______________________________________________________,
painfull ureteral points: no, yes__________, Pasternatskyi’s sign: neg., posit.____________;
12. Endocrine system: thyroid gland______________________________________________,
secondary sexual signs (A P V L Ma Me)_________________________________________,
mensis (for females)___________________________________________________________
INITIAL DIAGNOSTIC CONCLUSION.
(to make a dignostic conclusion, based on complaints, anamnesis information and results of
physical examination, to distinguish initial clinical syndromes)
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PLAN OF INVESTIGATIONS.
(to note diagnostic tests which are necessary for establishing a final diagnostic conclusion)
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9
DATA OF DIAGNOSTIC TESTS.
1. Lab studies (to note normal values in brackets):
 CBC with differential (date_________): _______________________________________
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 Blood chemistry (date_________): ___________________________________________
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 Urinalysis (date_________): ________________________________________________
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 Netchyporenko (or Addis) test (date_________): ________________________________
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
Urine culture (date_________): ______________________________________________

Stool culture (date_________): ______________________________________________
 Stool for: ova and parasites (date___________): pH__________,fat_________________,
Er__________________, Le_______________,other________________________________
 Others__________________________________________________________________
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2. Instrumental studies:
 ECG (date___________):___________________________________________________
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 Ultrasound invesigation (date____________):___________________________________
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10
 Endoscopic investigation (date___________): __________________________________
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 pH test (date________):____________________________________________________
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 Radiographic studies (date_________):________________________________________
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 Others__________________________________________________________________
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DAILY CUMULATIVE REPORT.
Status objectivus
Date
Management
11
Date
GRAPHIC OBSERVATION RECORD.
Date
Hospital day
Examination day
Pulse
Respiration
Blood pressure
T˚
140
45
130
130
40
120
41
120
35
110
40
110
30
100
39
100
25
90
38
90
20
80
37
80
18
70
36
70
16
60
35
60
15
50
34
Bowel movement
Daily diuresis
12
FINAL DIAGNOSTIC CONCLUSION (CLINICAL SYNDROMES).
(to emphasize, analize and confirm each syndrome that was distinguished)
Student signature__________________________________