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I. Inquiry (interview)
II. Objective examination (Status praesens)
1. General Inspection
2. Examination of the respiratory system
3. Examination of the cardiovascular system
4. Examination of the digestive system
5. Examination of the urinary system
6. Examination of the endocrine system
7. Examimation of the hematopoiesis system
8. Examimation of the nervous system
The order of each system examination:


III. Preliminary diagnosis and its argumentation.
IV. The plan of laboratory and instrumental explorations
V. Treatment sheet
VI. Diaries
VII. Final diagnosis
VIII. Epicrisis
I. Inquiry (interview)
1. General data.
a.) First name, family name
b.) Age
c.) Profession, occupation
d.) Race
e.) Address
f.) Data and time of hospitalization
2. Present complaints.
a.) main complaints (ex.: cough, chest pain, palpitations, dyspnea)
b.) changes in the general state (fever, loss of weight, weakness, headache)
3. History of the present disease (Anamnesis morbii).
a.) the time of the disease's onset (hours, days, years ago; it is an acute or chronic disease)
b.) the character of the first symptoms – describe them
c.) the probable course of the disease
d.) evolution of the symptoms - how they’ve changed in time
e.) previous instrumental or laboratory examinations and their results
f.) treatment, if any, and its efficiency

4. The past patient's history (Anamnesis vitae)
a.) General biographical information
- Birth place, number of the children in the family
- Patient’s health at birth, his physical and mental development
- Conditions of life, well-being, income
- Patient’s diet
- Physical activity (sports, exercises)
- Unfavorable labor conditions, industrial hazards (harmful dusts, radiation, cold, noise, vibration)
b.) Past illnesses. Ask about acute infections ( tbc, HIV, hepatitis), operations, trauma.
c.) Family history (health of parents, grand -, sisters, brothers; tbc, syphilis, hereditary diseases).
d.) Allergological anamnesis: ask about the type of allergy (rhinitis, nett1-rash, Quincke's edema,
anaphylactic shock) and the possible allergens (foods, medicines, perfumes, pollen).
e.) Sexual anamnesis (women's number of pregnancies and parturitions; duration and amount of
f.) Harmful habits - alcoholism; smoking, narcotics.

II. Objective examination (Status praesens)
1. General Inspection
1. General state (good, satisfactory, medium grave, grave, very grave)
2. Consciousness
- Clear -normal
- Stupor - patient can't orient himself to the surroundings, gives delayed answers,
- Sopor - unusually sleep from which the patient recovers for short periods of time;
- Coma - is a state of full loss of consciousness with almost complete absence of reflexes and deranged
functions (alcoholic, diabetic, hepatic, uraemic, epileptic coma)
3. Posture of the patient:
- Active (patient can change its posture himself)
- Passive (in unconscious patients, laying down, can’t serve himself)
- Forced (the patient is forced to take a position that can relieve his pain, dyspnea, cough)
4. Constitution
- hypersthenic
- normosthenic
- asthenic
5. Size and shape of the head
6. Specific facial expression (hippocratic, Parkinson's, mitral, nefrotic, mixedematous, Bazedov,
acromegalic, Corvizar, lyon type, sardonix etc. )
7. Eyes - eyelids, shape of pupils.
8. Size of nose
9. Mouth (color and moistening of tongue, gums, lips, oral mucous, and form of teeth)
10. Neck (pulsation, local enlargement)
11. Skin.
- Color (pallid, earth-like, yellowish, cyanosis)
- elasticity
- humidity, moistening (perspiration, dry)
- eruptions ( roseola, erythema, weals, nettle rush, urticaria)
- herpetic lesion
- scars

- desquamation
- abnormal growth of hair
- the size, form and pathological changes of the nails .
12. Visible mucosa
- Color (pallid, earth-like, yellowish, cyanosis)
- humidity (moisture)
- elasticity (turgor)
- eruptions
- ulcers
13. Subcutaneous fat
- type of location (male type, female type, pathological (in Kushing syndrome etc.).
- grade of the thickness of skin fold hold in inguinal region (female) or Traube region (male). Should be
normally 1-2,5 cm.
Grade of nutrition
Excessive (Obesity)
Satisfactory grade
Insufficient (Cachexia)

More than 2.0 cm
1.5 -2.0 cm
1.0 -1.5 cm
0.5 -1.0 cm
Less than 0.5 cm

More than 2.5 cm
2.0-2.5 cm
1.5 -2.0 cm
1.0 -1.5 cm
Less than 1.0 cm

14. Presence of peripheral edema. Edema is subcutaneous liquid accumulation due to heart or renal
failure. It could be appreciated by pressing the fingers over the region where the bones are placed close to
the skin.
15. Palpation of the lymph nodes. Should be appreciated:
- location,
- form,
- dimensions,
- consistence(elasticity),
- surface,
- mobility,
- painful or not,
- stick with surrounding tissues.
The order of lymph nodes palpation: occipital, postauricular, preauricular, submandibular,
mentonier, anterior-cervical,posterior-cervical, supraclavicular, subclavicular, axillary, cubital, femoral,
patellar ones.
16. Muscular system. Should be appreciated:
- Muscles development
- Local atrophy, hypertophy
- Strength (Tonus), symmetry of tonus for flexors and extensors; right and left)
16. Bones
- Defects
- Deformities
- Painful on palpation and percussion
17. Joints
The presence of inflammation signs:
- shape - edema (tumor)
- Tenderness (dolor)
- Red color

- Higher temperature over them
- Active and passive movement (functio laesae)

2. Examination of the respiratory system
1. General configuration of the thorax (position of the clavicles, supra- and subclavicular fossae,
2. Form of the chest (Normosthenic, hypersthenic, asthenic, emphysematous, rathitic, paralytic,
funnel, foveated)
3. Deformation of spine (Scoliosis, Kyphosis, Lordosis)
4. Type of breathing (thoracic, abdominal, mixed)
5. Rhythm of breathing (normal, pathological)
6. Frequency of breathing
7. Involvement of the accessory respiratory muscles in the breathing
(sternocleidomastoideus,.trapezius, pectoralis major et minor)
1. Identification of thoracic elasticity.
2. Identification of tender, pain areas.
3. Assessment of the observed abnormalities.
4. Assessment of tactile fremitus.
1. Comparative percussion - to appreciate percussion note over the lungs (resonance, dullness, slight
dullness, tympanic, hyperresonance)
2. Topographic percussion
a.) Determination of the upper borders of the lungs:
- superior anterior ( over the clavicles 3-4 cm )
- superior posterior ( at the level of the VIIth cervical vertebra)
- Kroenig's area (perpendicular to m. trapezius)
b) Determination of the lower borders of the lungs
Parastermal line
Midclavicular line
Anterior axillary line
Midaxillary line
Posterior axillary line
Scapular line
Paravertebral line



c) Determination of the respiratory mobility of the lower pulmonary border
Auscultation – main respiratory sound: Vesicular breathing, bronchial breathing.
Adventitious respiratory sounds: Presence of adventitious sounds: rales (wheezes, crackles), crepitation,
pleural friction.

3. Examination of the cardiovascular system
1 Inspection of Neck area
а) inspection of Carotid artery (excessive (patological) ripple «carotid saltation (fling)»)
b) inspection of cervical veines (swelling, pulsations)
c) jugular venous pulsations (negative venous pulsation)
d) neck, face, shoulder girdle oedema (the collar of Stokes)

2 Inspection of Heart and Vessels area
а) inspection of the heart region ( cardiac ”humpback”)
b) inspection of apical impulse (location, sistolic retraction in apical post)
c) ventricular movements (cardiac beat of right ventrical)
d) inspection of atipical pulsation in pericardiac region (jugular fossa, II interspace (right , left),
1 Palpation of apical impulse, its characteristics
- location,
- intensity,
- amplitude,
- diameter (surface),
- resistence;
diastolic cat purring .
So, in the hypertrophy of the left ventricle we'll have a diffuse, high, forced and resistant apex beat.
2 Palpation of right ventricular area (cardiac impulse) (presence, intensity).
So-called cardiac beat, due to contractions of the enlarged right ventricle.
3 Atipical pulsation in pericardiac region ( jugular fossa, II interspace (right , left
(systolic fremitus)), epigastric (subxiphoid) area.
Is used to determine: the size, position and the shape of the heart; the length of vascular bundle.
Determinate the heart’s borders.
1 borders of relative cardiac dullness (-right, -left, -upper)
2 borders of vascular bundle (in 2-nd inerspace)
3 cardiac configuration (in interspaces).



Right edge of the sternum

Left edge of the sternum

Right edge of the sternum

Left edge of the sternum

Right edge of the sternum

Left parasterbal line

1 cm laterally of the right edge of sternum 3-4 cm medially left midclavicular line


1- 2 cm medially left midclavicular line

Configuration of the heart
a.) Aortal configuration - in the dilation of left ventricle;
b.) Mitral configuration - in the dilation of the left atrium.
Heart sounds, their intensity in each of 5 points of auscultation. Heart murmurs.
Areas of the valves auscultation are the following:
1. point - the area of the apex beat for the mitral valve;
2. point - in the second interspace, to the right of the sternum - the aortal valve;
3. point - in the second interspace, to the left of the sternum - the valve of the pulmonary trunk;
4. point - the lower part of the sternum near its junction with the xiphoid process - for tricuspid valve;
5. point - the additional point - point of Erb - at the left of the sternum between 3rd and 4th costal
6. carotic arterys.


2 3

Twisting and pulsating temporal arteries
Pulsation of the carotid, subclavian, and peripheral arteries
Determination of the peripheral pulse at the radial artery
Palpation of the pulse on peripherial arteries (aa.femoralis, poplitea, tibialis posterior, dorsalis pedis)
Auscultation systolic murmur on the carotid arteries
Listening Traube double tone and dual noise-Vinogoradov- Duroziez on femoral

4. Examination of the digestive system

Inspection of the abdomen;
Auscultation of the abdomen
Percussion of the abdomen;
Superficial and deep palpation of the abdomen;
Percussion and palpation of the liver. Note liver dimensions (3);
Percussion and palpation of the spleen. Appreciate spleen dimensions (2);
Blumberg symptom (Positive? Negative?)

5. Examination of the urinary system

Inspection of the lumbar and bladder region
Giordano symptom (Positive? Negative?)
Palpation of the kidneys,
Percussion and palpation of bladder


Thyroid gland inspection
Thyroid gland palpation
Thyroid gland auscultation

6. Examination of the endocrine system

9. Examination of the hematopoiesis system
10.Examination of the nervous system


III. Preliminary diagnosis and its argumentation.
IV. The plan of laboratory and instrumental explorations and what can we find using
that paraclinical methods
V. Treatment sheet
VI. Diaries
VII. Final diagnosis
VIII. Epicrisis
IX. Forecast