Section 3. SAMPLE OF CASE HISTORY

VIII. EXAMPLE OF CASE HISTORY WRITING

1. IDENTIFICATION DATA

1. Name: Ivan Ivanov.

2. Age: 35 years old.

3. Gender: male.

4. Place of work: Kazan motor company number 5.

5. Occupation: mechanic.

6. Position at present: motor mechanic.

7. Home address: Kazan, E. Telman str., 45, Apt. 5.

8. Date of admission: February 20, 2015.

2. MEDICAL HISTORY

1. Complaints (at admission to the hospital)

The main complaints: a sudden rise in body temperature up to 40 °C, stunning chills, headache, severe pain of stabbing character in the left chest, radiating to the epigastric region, aggravated by deep breathing and bending to a healthy side, constant during the day, cough with moderate amounts of rusty-colored, odorless sputum and the constant shortness of breath of a mixed nature.

Secondary complaints: general weakness, loss of appetite.

2. History of present illness

Development of the disease the patient connects with a history of emotional stress - the death of his father, after which he drank alcohol for 3 days (from 14 to 16 February). On February 16, intoxicated patient fell asleep at a bus stop and got hypothermia. In 2 days (February 18 at 13.00), he had sudden rise of the body temperature to 40 °C, a terrific chills and severe headache developed. His wife said he had episodes of impaired consciousness (delirium). On February 19 the patient developed a dry, hacking cough, he was troubled by pain in the left side of chest while coughing and breathing (with a deep breath.). He took paracetamol and cough syrup without any improvement - the temperature remained until 40.2 °C, there was shortness of breath at rest, cough became productive, with rusty sputum, there appeared general weakness. February 20 (the third day of illness) ambulance was called and the patient was admitted to the therapeutic department of the hospital.