5 Part I. Scheme of student's case history




Название5 Part I. Scheme of student's case history
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Part II. Recommendations for student’s case history writing

The Student’s Case History (SCH) is the part of the curriculum designated for out-of-class work. It means that after primary examination and supervision of a patient in dynamics the student has to write the SCH according to the scheme proposed by the Department.

This scheme includes the basic elements of doctor’s diagnostic and curative actions during his professional activities: history taking, examination, diagnosis, differential diagnosis, treatment, prevention of disease, analyses of effectiveness, prognosis, keeping medical documents, etc.

For a fourth year student the task is to produce these actions in a written form. Thus it would be possible to objectively evaluate the student’s level of clinical training and theoretical knowledge. The student has to answer all the questions of the Scheme. If there is no proper information for some questions the student would answer adequately naming all the points. For example "Operation - there were no operations"; "Accidents and injuries - there were no ones", "Gastrointestinal tract - there were no vomiting, diarrhea, constipation, etc."

Working with the SCH under the guidance of his teacher the student receives from him the recommendations about the list of the diseases to be considered during differential diagnosis and consulting the students in the process of taking history, examination, prescribing the treatment, making the SCH.

In section "Present Illness" it is necessary to describe the course of the patient's disease from its onset till the initial examination by the student.

For sec. "Provisional Diagnosis" the student has to name all the symptoms, which would be the ground for diagnosis, complaints and results of the physical examination.

For VII sec. "Plan..." the student has to name all the investigations, which are necessary for confirmation of the provisional diagnosis.

For IX sec. "Diary" it is necessary to give quite brief information about the patient's state on the day of the examination. Obligatory data: Complaints. General Condition (mild, moderate, severe, unconsciousness, comatose, critical, etc.). Temperature. Pulse. Respiration rate. Skin. Throat. Breathing. Heart (Sounds). Abdomen. Liver. Spleen. Stool. Urination.

If there are any disturbances in the organs and systems the details of them have to be described.

The description of the status depends on the age of the patient. In infants more attention has to be paid to peculiarities of feeding, weight, and stool.

The structure of the status changes according to the nature of the disease. In patients with neurological pathology, neurological status has to be dynamically described; for gastrointestinal disorders stool and defecation are substantial, and so on.

The instructions concerning these aspects are to be obtained from the teacher.

In X sec. "Differential diagnosis" the student first reveals the patient’s symptoms, which are common both the supposed disease and for others. Then for every considered disease the student proves why the latter is denied.

In XI sec. "Final Diagnosis" means the summary in diagnosing.

In XII sec. "Treatment…" it is necessary to write prescriptions.
Part III. Short vocabulary for using in the clinic

^ I. ANATOMICAL TERMS АНАТОМИЧЕСКИЕ ТЕРМИНЫ

HEAD

ГОЛОВА

Hair

Волосы

Scalp

Скальп (волосистая часть головы)

Forehead

Лоб

Eye

Глаз

Eyebrow

Бровь

Eyelid

Веко

Eyelash

Ресница

Nose

Hoc

Nostrils

Ноздри

Cheek

Щека

Mouth

Рот

Tooth

Зуб

Canine tooth

Зуб-клык

Incisor tooth

Зуб-резец

Premolar tooth

Премоляр, малый коренной зуб

Molar tooth

Моляр, большой коренной зуб

Gum

Десна

Tongue

Язык

Palate

Нёбо

Lip

Губа

Jaw

Челюсть

Chin

Подбородок

Salivary gland

Слюнная железа

Thyroid gland

Щитовидная железа

Face

Лицо

Tonsils

Миндалины

Nape of neck

Задняя часть шеи

Fontanelle

Родничок

^ THORAX AND ABDOMEN

ГРУДЬ И ЖИВОТ

Chest Mediastinum

Средостение

Manubrium

Рукоятка

Sternum

Грудина

Main bronchus

Главный бронх

Bronchiole

Бронхиола

Alveolus

Альвеола

Breast (mammary gland)

Молочная железа, грудь

Nipple

Сосок

Areola

Ареола

Back

Спина

Abdominal wall

Брюшная стенка

Umbilicus

Пупок

Loin

Поясница

Iliac fossa

Подвздошная ямка

Waist

Талия

Groin

Пах, паховая область

Gut

Кишка

Peritoneal Cavity

Брюшная полость

Small intestine (bowel)

Тонкая кишка

Large intestine (bowel)

Толстая кишка

Lesser omentum

Малый сальник

Greater omentum

Большой сальник

Aorta

Аорта

Inferior vena cava

Нижняя полая вена

^ UPPER LIMBS

ВЕРХНИЕ КОНЕЧНОСТИ

Shoulder

Плечо (верхний участок грудной клетки сбоку от шеи)

Axilla

Подмышечная ямка

Upper arm

Плечо (часть конечности от туловища до локтя)

Forearm

Предплечье

Wrist

Запястье

Hand

Кисть руки

Thumb

Большой палец кисти

Finger

Палец кисти

Palm of the hand

Ладонь

Knuckle

Сустав пальца

Finger nail

Ноготь пальца кисти

^ LOWER LIMBS

НИЖНИЕ КОНЕЧНОСТИ

Leg

Нога

Buttock

Ягодица

Thigh

Бедро

Shin

Голень

Calf

Икра, задняя часть голени

Ankle

Голеностопный сустав, лодыжка

Heel

Пятка

Foot

Стопа

Sole of foot

Подошва стопы

Toe

Палец стопы

Big toe

Большой палец стопы

Toe nail

Ноготь пальца стопы
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