DEMO: AL-FARABI KAZAKH NATIONAL UNIVERSITY FACULTY OF MEDICINE AND HEALTHCARE HIGHER SCHOOL OF MEDICINE Guidelines for Writing a Medical History For 4th- and 5th-Year Students for the modules “Infectology, Infectious Diseases, and Tropical Diseases” Methodological Guide Almaty – 2026г Authors: G.M. Kurmanova, Doctor of Medical Sciences, Professor A.L. Shin, Acting Associate Professor. This publication was approved by the Academic Committee of the Faculty of Medicine and Healthcare on September 6, 2023 (Protocol No. 1). This methodological guide is intended for 4th- and 5th-year students enrolled in the General Medicine educational program. The guide provides comprehensive instructions on preparing an educational medical history in infectious diseases and tropical diseases, including examples of how to complete individual sections. Section I Patient’s Full Name (Surname, Given Name, Patronymic) Sex (Male/Female) Patient’s Age in Years and Months (Date of Birth – Numeric Format). For infants during the first year of life, age should be recorded in months and days (Date of Birth – Numeric Format). Marital Status If the Patient Is an Infant, Child, School-Aged Child, or Adolescent (0– 18 years) Patient’s Address: city (village), district, street, house number, apartment number (actual place of residence), contact telephone number. Occupation (Place of Work, Educational Institution, School, Kindergarten) Identification (Passport) Information The patient's surname, given name, and patronymic recorded in the medical history must correspond to official identification documents. This information must be specified because, in some ethnic groups, sex cannot always be determined from the surname or given name. The complete date of birth must be documented, and the patient's age at the time of presentation must be indicated. For infants during the first year of life, age should be recorded in months and days. Married / Single / Unmarried. Information about the parents, including their full names, contact information of legal guardians, occupations, and places of employment. Required for statistical (epidemiological and social) purposes and for diagnostic assessment when diseases associated with a specific geographical area are suspected (anthropozoonotic diseases, zoonotic diseases, etc.). Recorded to identify diseases associated with possible occupational hazards (occupational diseases). Date of Disease Onset (Outpatient Setting) Date of Completion of Treatment (Outpatient Setting) Diagnosis Provided by the Referring Institution (Outpatient/Emergency Referral) Admission Diagnosis (Preliminary Diagnosis) Date of onset of the acute illness or the most recent exacerbation of a chronic disease for which the patient sought medical attention at an outpatient clinic or medical center. Date when treatment at the outpatient clinic or medical center was completed. This section is completed if outpatient treatment ended with the patient's recovery. Completed by the physician of the day-care unit, inpatient department, or emergency department on the day of hospital admission. Completed when outpatient treatment was ineffective and the physician referred the patient for day-care treatment or inpatient hospitalization. Completed by the physician of the day-care unit, inpatient department, or emergency department on the day of admission. 1 2 3 4 5 6 7 8 9 10 11 Date of Hospital Admission. Specify the Mode of Admission (Emergency, Planned, Referred, Self-Referred). If Referred from an Outpatient Facility – Date of Referral for Hospitalization (Specify the Referring Institution). 12 13 14 15 16 17 18 19 20 Clinical Diagnosis (Date Established) Final Clinical Diagnosis (According to Classification): Primary Diagnosis Complications of the Primary Diagnosis Comorbid Conditions Outcome of the Disease (Recovery, Improvement, No Change, Death) Work Capacity (Preserved, Temporarily Lost, Requires a Medical Leave Certificate); for Children – School/Kindergarten Attendance and Exemption from Classes Date of Hospital Discharge Completed by the physician of the day-care unit, inpatient department, or emergency department on the day of discharge following completion of treatment. Example 1 Identification Information (Adults) Full Name: Ruslan Kamilovich Akhmetov Sex: Male Age: 52 years, Date of Birth: 12.04.1970 Marital Status: Married Home Address: 4 Tsentralnaya Street, Kok-Kainar Microdistrict, Alatau District, Almaty Contact Telephone Number: +7 XXX XXX XX XX Occupation (Place of Employment): Chief Specialist at a Trading Company Date of Disease Onset: 16.09.2022 Date of Completion of Outpatient Treatment: 17.09.2022 Date of Hospital Admission: 17.09.2022 Mode of Admission: Referred from an outpatient clinic Referring Institution: Outpatient Clinic No. 22, dated 17.09.2022 Diagnosis Provided by the Referring Institution: Community-acquired pneumonia Preliminary Diagnosis: Right-sided community-acquired pneumonia, Grade II respiratory failure Clinical Diagnosis: Community-acquired pneumonia of the right lower lobe, acute respiratory failure Grade II Final Clinical Diagnosis: Primary Diagnosis: Community-acquired pneumonia of the right lower lobe, severe course, unspecified etiology Complications: Acute respiratory failure Grade II Comorbid Conditions: Chronic obstructive pulmonary disease (COPD), bronchitic phenotype, moderate severity, GOLD Group B, remission Outcome: Recovery Work Capacity: Preserved Date of Discharge: 27.09.2022 Example 2 Identification Information (Pediatric Patient) Full Name: Amina Erlanovna Sadykova Sex: Female Age: 5 years, Date of Birth: 14.03.2021 Parents: Mother: Aigerim Nurlanovna Sadykova, teacher, telephone: __________ Father: Erlan Maratovich Sadykov, engineer Residential Address: 24 Zhandosov Street, Bostandyk District, Almaty Kindergarten: No. 145 Date of Disease Onset: 11.10.2025 Date of Completion of Outpatient Treatment: 13.10.2025 Date of Hospital Admission: 13.10.2025 Mode of Admission: Emergency admission Referring Institution: Municipal Polyclinic No. 12 Diagnosis Provided by the Referring Institution: Acute intestinal infection Preliminary Diagnosis: Acute gastroenteritis, moderate severity Clinical Diagnosis: Acute intestinal infection of viral etiology, gastroenteritic form, moderate severity Complications: Moderate dehydration Comorbid Conditions: Iron-deficiency anemia, Grade I Outcome: Improvement Kindergarten Attendance: Temporarily restricted Date of Discharge: 20.10.2025 Section II Chief Complaints at Disease Onset / Upon Hospital Admission Questions for Clarification Sections / Organ Systems During history taking, all subjective manifestations of the disease, as well as the specific clinical features of infectious and tropical diseases, should be assessed thoroughly and systematically. I. Chief complaints are the symptoms that prompted the patient to seek medical attention and are the most informative for establishing a diagnosis. For each complaint, the following characteristics should be specified: A detailed assessment of complaints includes: - Characteristics of the symptom or distressing manifestation (e.g., nature of cough: dry, productive, paroxysmal, persistent, etc.); - Exact or approximate localization and radiation of painful sensations, severity, intensity, precipitating factors, and measures providing relief; - Time of occurrence (daytime, nighttime) and duration of the symptom (minutes, hours, days, weeks, etc.); - Physical or psychological factors provoking the onset and/or exacerbation of the symptom; - Factors that relieve the symptom and the speed of symptom resolution II. Clarification of Secondary Complaints (General, Nonspecific Complaints): General weakness; fatigue; fever; pruritus; skin rash; sweating; weight changes; bleeding; and other complaints associated with functional disorders or chronic diseases. For Infectious Diseases, the Following Must Be Clarified: -Fever : Time of onset; Maximum recorded body temperature; Pattern of fever (continuous, undulating, intermittent/paroxysmal); Duration; Presence of chills and sweating; Effectiveness of antipyretic medications.. -Intoxication Syndrome: Weakness; Headache; Decreased appetite; Myalgia; Arthralgia; Sleep disturbances. -Rash: Time of appearance; Initial lesions and their localization; Stages and pattern of spread; Type of rash (macular, papular, vesicular, hemorrhagic, etc.); Color and size of lesions; Tendency to coalesce; Presence of pruritus or desquamation; Whether the rash blanches on pressure.. -Enanthem: Localization; Presence of hyperemia; Presence of plaques/exudates; Tenderness; Time of appearance.. -Diarrhea Time of onset; Stool frequency; Stool characteristics (watery, loose, “rice-water” stool); Color; Odor; Presence of mucus or blood; Presence of tenesmus; Relationship to food intake; Duration.. For children, signs of dehydration should additionally be assessed according to the IMCI (Integrated Management of Childhood Illness) guidelines.. -Vomiting: Time of onset; Relationship to food intake; Frequency; Volume; Characteristics of vomitus; Presence of pathological admixtures; Whether vomiting provides relief. -Abdominal Pain: Localization; Character; Intensity; Relationship to food intake and defecation; Association with diarrhea, vomiting, or flatulence. - Signs of Dehydration: Thirst; Dry mucous membranes; Decreased urination; Weakness. For children additionally: Sunken eyes; Decreased skin turgor; Absence of tears; Moderate or severe dehydration according to IMCI criteria. Example 1 Chief Complaints: Stabbing pain in the lower right hemithorax, persistent throughout the day and aggravated by coughing and deep breathing; persistent cough worsened by exposure to cold air, accompanied by difficult-to-expectorate whitish-yellow sputum in an amount of up to 15–20 mL/day; moderate mixed-type dyspnea occurring during physical exertion; fever up to 39.0°C accompanied by chills. Secondary Complaints: Weakness, sweating, headache, and decreased appetite. Example 2: Chief Complaints: Body temperature elevation up to 39.0°C, dry cough, rhinorrhea, conjunctival redness, photophobia, appearance of a maculopapular rash with staged progression—initially involving the face and postauricular areas, followed by the trunk and extremities; decreased appetite Secondary Complaints: General weakness, lethargy, restlessness, sleep disturbance, headache, and lacrimation. Respiratory System 1) Кашель  Duration (persistent, episodic, paroxysmal);  Character of the cough (soft, muffled, barking; infrequent or paroxysmal; dry or productive);  Triggering factors (dry weather, cold exposure, body position, strong odors, etc.);  Intensity of the cough (throat clearing, mild, moderate, severe);  Time of occurrence (morning, daytime, night);  Whether the cough is accompanied by wheezing, pain (in the chest or throat), dyspnea, etc..  For children, additionally assess: Presence of coughing fits; Relationship to feeding; Presence of cyanosis; Presence of inspiratory whoop (reprise).. 2) Sputum  Ease of expectoration (easily or with difficulty);  Time of expectoration (morning, daytime, night);  Color of sputum (yellowish, greenish, grayish, bright yellow, rusty, blood-stained);  Character (mucoid, glassy, frothy, mucopurulent, purulent, bloody);  Daily volume;  Odor (foul-smelling) and taste (unpleasant);  Consistency (thin or thick). 3) Hemoptysis  Amount of blood (estimated according to the patient's report);  Character (blood mixed with sputum, pure blood, blood clots, blood streaks, pink frothy sputum);  Color (bright red, dark, rusty, “raspberry jelly” appearance);  Circumstances of occurrence (during coughing, depending on body position);  Presence or absence of food particles;  Duration and frequency 4) Chest Pain  Localization;  Intensity;  Duration;  Triggering factors;  Character (sharp, stabbing, dull);  Radiation (to the left and/or right arm, abdomen);  Mode of onset (sudden or gradual);  Time of occurrence (daytime or night);  Circumstances of occurrence (association with breathing, changes in body position, or coughing);  Factors relieving pain (limiting the depth of breathing, assuming a forced position, taking medications) 5) Dyspnea  Type of dyspnea (inspiratory, expiratory, mixed, episodes of choking);  Duration (persistent or intermittent);  Intensity (mild or severe);  Mode of onset (sudden or gradual);  Circumstances of occurrence (morning, daytime, evening, night; during physical exertion; after meals; at rest; during conversation; during emotional stress);  Position that worsens symptoms (upright or supine);  Position that relieves symptoms.  For children, the following must additionally be assessed: Use of accessory respiratory muscles; Chest wall retractions; Noisy breathing; Stridor.. 6) Episodes of Choking (Asthma-Like Attacks)  Nature of the attack (typical or atypical);  Triggering factors;  Frequency;  Duration;  Intensity;  Time of occurrence;  Seasonality;  Relieving factors Cardiovascular System 1) Cardiac Pain  Localization (retrosternal region, cardiac apex area);  Radiation (to the neck, left scapula, arm, clavicle, lower jaw, most commonly to the left side; atypically to the right side);  Character (compressive, pressure-like, burning, dull, sharp, stabbing, aching, etc.);  Duration (minutes, hours, days);  Mode of onset (sudden or gradual);  Persistent or paroxysmal;  Intensity;  Causes and precipitating circumstances (physical exertion, emotional stress, rest, exposure to cold, after meals, or smoking);  Conditions under which pain subsides;  Patient’s behavior during pain episodes (“freezes,” becomes restless, stops activity);  Circumstances that relieve the pain or measures that alleviate it. 2) Palpitations  Circumstances of occurrence (during physical exertion, emotional stress, etc.);  Character (persistent, paroxysmal, intermittent, isolated episodes);  Duration of palpitation episodes;  Frequency (frequent or infrequent);  Intensity;  Time of occurrence (daytime or night);  Triggering factors (physical exertion, emotional stress, food intake, medications);  Circumstances under which they resolve or measures that alleviate them 3) Irregular Heartbeat (Cardiac Arrhythmias)  Circumstances and frequency of occurrence (persistent or intermittent);  Duration;  Triggering factors (physical exertion, food intake, medications, emotional stress, rest, sleep);  Circumstances under which they resolve or measures that alleviate them (rest, breath-holding, straining, antiarrhythmic medications, sedatives) 4) Dyspnea  Onset (sudden or gradual);  Circumstances of occurrence (during physical or emotional exertion, at rest, after meals);  Character (inspiratory, expiratory, mixed, episodes of choking);  Time of occurrence (daytime or night);  Duration (persistent or paroxysmal);  Whether the patient assumes a specific position to reduce dyspnea; relationship to exertion and its intensity;  Position assumed by the patient (free, supine, upright, orthopneic);  Relieving measures (forced position, oxygen inhalation, application of limb tourniquets, administration of cardiac medications or diuretics, etc.).  For children, additionally assess: Use of accessory respiratory muscles; Chest wall retractions; Cyanosis; Respiratory rate. 5) Edema  Localization (face, abdomen, extremities);  Character (soft, firm, symmetrical, asymmetrical);  Distribution (localized or generalized);  Severity;  Duration (persistent or transient);  Time of appearance or worsening (morning, evening, after exertion, body position, fluid intake);  Rate of progression (rapid or gradual);  Factors contributing to reduction or resolution of edema (fluid and salt restriction, diuretic therapy, etc.) Digestive System 1) Appetite  Degree of appetite (increased, decreased, absent);  Distorted appetite (pica);  Aversion to food (anorexia);  Fear of eating (sitophobia);  Association with other symptoms (nausea, belching, abdominal pain, weight loss)  For young children, additionally assess: Refusal of breastfeeding or formula feeding; Decreased feeding volume. 2) Thirst  Severity (amount of fluid consumed per day);  Frequency;  Duration;  Whether accompanied by dry mouth  For infectious diseases, thirst must be assessed as a possible sign of dehydration. 3) Excessive Salivation (Sialorrhea)  Time of onset;  Severity;  Relationship to food intake or pain during swallowing 4) Altered Taste Sensation  Character of taste perception (normal, sour, bitter, metallic, sweetish);  Presence or absence of taste sensation 5) Swallowing Difficulties (Dysphagia)  Character (painful, difficult, impossible);  Severity;  Frequency of occurrence;  Relationship to food consistency (solid, semi-solid, liquid);  Level at which food passage is perceived to sto  For infectious diseases, the presence of sore throat, plaques/exudates, and enanthem must be specifically assessed. 6) Heartburn  Intensity;  Duration;  Frequency;  Relationship to food intake (postprandial, fasting);  Relieving factors (food intake, antacids, water) 7) Belching  Character (air, regurgitated food);  Odor (e.g., rotten eggs);  Taste following belching (bitter, sour);  Frequency and duration;  Relationship to food intake and type of food consumed 8) Nausea  Frequency;  Duration;  Relationship to food intake and food characteristics;  Associated symptoms (vomiting, belching);  Relationship to body position 9) Vomiting  Circumstances of occurrence (fasting, after meals);  Associated symptoms (nausea, belching, heartburn);  Amount (copious or scant);  Odor (sour, putrid, foul-smelling);  Taste (sour, bitter, tasteless);  Characteristics of vomitus (food particles, bile, mucus, blood [bright red, dark, or “coffee-ground” appearance]);  Frequency (recurrent, persistent);  Whether vomiting relieves pain or nausea.  For children, additionally assess: Presence of regurgitation; Refusal to drink fluids; Signs of dehydration. 10) Abdominal Distension (Flatulence)  Circumstances under which it occurs;  Generalized or localized;  Passage of flatus (free, excessive, difficult);  Relationship to other symptoms (e.g., abdominal pain) 11) Bowel Movements (Stool)  Type of bowel habit (regular, constipation, diarrhea);  Frequency (number of bowel movements per day);  Duration of constipation (days);  Painful or painless defecation;  Factors provoking constipation (dietary factors or others);  Measures taken to facilitate bowel movements;  Stool volume;  Duration of diarrhea;  Presence of tenesmus;  Factors provoking diarrhea (association with emotional stress, food intake, time of day);  Stool consistency and shape (formed, sausage-shaped, ribbon- shaped, pellet-like, pencil-thin, loose, liquid, watery, rice- water stool);  Presence and nature of admixtures (mucus, blood, pus, undigested food particles, helminths);  Color (brown, dark, clay-colored, tarry, pale);  Odor (normal, sour, foul-smelling).  For infectious and tropical diseases, the following must be assessed: Watery stool; Rice-water stool; Presence of mucus or blood; Signs of intestinal syndrome; Frequency of defecation; Signs of dehydration..  For children, additionally assess: Reduced urine output; Thirst;Sunken eyes; Dry mucous membranes; Presence of moderate or severe dehydration according to IMCI criteria. 12) Abdominal Pain  Character (dull, aching, sharp, cutting, burning);  Localization (epigastric region, right or left hypochondrium, iliac regions, periumbilical region, etc.);  Radiation (to the back, shoulder, scapula, groin, leg, etc.);  Duration and intensity;  Frequency (persistent or paroxysmal/cramping);  Relationship to food intake (“early,” “late,” or “hunger” pain);  Relationship to the type of food consumed (coarse, spicy, sweet, acidic);  Relationship to physical exertion, straining, defecation, or flatulence;  Factors relieving pain (food intake, spontaneous resolution, antispasmodics, application of heat or cold, vomiting, defecation, or passage of flatus). 13) Jaundice  Localization;  Severity;  Intensity;  Shade (pale yellow, reddish-yellow, greenish-yellow);  Time and circumstances of onset  In neonates, the degree of jaundice is assessed using the Kramer scale.  For infectious diseases, additionally assess: Dark urine; Pale (acholic) stools; Pruritus; Hepatomegaly. Urinary System 1) Pain  Localization (lumbar region, suprapubic area, flanks);  Radiation (to the suprapubic region, groin, genital organs);  Character (aching, dull, sharp, severe, tearing);  Intensity;  Persistent or intermittent/paroxysmal;  Factors provoking pain (hypothermia, physical exertion, bumpy travel, brisk walking or running, alcohol consumption);  Associated symptoms (dysuria, nausea, fever);  Measures relieving symptoms (heating pad, hot bath, analgesic injections, body position, etc.).  For infectious diseases, additionally assess: Pain associated with fever; Changes in urine color; Reduced urine output; Signs of dehydration.. 2) Urination  Frequency (increased, decreased);  Volume (oliguria, polyuria, anuria);  Color (straw-yellow, dark, beer-colored, red, “meat-washing” color);  Time of occurrence (morning, daytime, evening, night);  Characteristics (normal, voluntary, difficult, painful);  False urge to urinate;  Changes in urinary stream (thin stream, intermittent stream, dribbling);  Pain during urination (cutting pain, burning sensation; at the beginning, end, or throughout urination);  Visible blood in the urine (gross hematuria).  For infectious diseases, additionally assess: Oliguria; Anuria; Dark urine; Beer-colored urine; Reduced urine output associated with dehydration.  For children, additionally assess: Frequency of urination; Number of wet diapers or diaper weight monitoring; Reduced urine output as a sign of dehydration. Nervous System 1) Headache  Localization (temporal, frontal, parietal, occipital region, etc.);  Intensity;  Character (throbbing, pressing, sharp, shooting, dull, aching, bursting);  Frequency (persistent, intermittent, episodic);  Time of occurrence (daytime, evening, night);  Triggering factors (physical exertion, emotional stress).  For infectious diseases, additionally assess: Severity of intoxication syndrome; Presence of vomiting; Photophobia; Meningeal signs; Altered consciousness.  For young children, additionally assess: Bulging anterior fontanelle; Monotonous crying; Irritability or lethargy; Seizures. 2) Sleep  Normal or disturbed (insomnia, difficulty falling asleep, restless sleep, vivid dreams, nightmares, daytime somnolence);  Duration of sleep.  For children, additionally assess: Irritability; Crying; Sleep disturbances associated with fever. 3) Dizziness  Mode of onset (sudden or gradual);  Circumstances of occurrence (during physical activity, changes in body or head position, etc.);  Frequency (persistent, intermittent, episodic);  Time of occurrence (daytime, evening, night);  Associated symptoms (tinnitus, nausea, etc.);  Measures relieving symptoms (opening the eyes, widening the stance, vomiting, etc.) Endocrine System 1) Neurological Complaints: (Headache, dizziness, seizures, tremor, sleep disturbances, emotional disorders).  Character;  Severity;  Time and cause of onset;  Localization;  Frequency;  Measures relieving symptoms 2) Changes in Appearance: (Central obesity, weight loss/cachexia, skin discoloration, changes in growth, physical development, facial appearance, or edema-related changes)  Character;  Severity;  Time and cause of onset;  Localization;  Frequency;  Measures relieving symptoms.  For children, additionally assess: Height; Body weight; Age- appropriate physical development. 3) Sexual Disorders: (Menstrual disorders in women, impotence in men, infertility, changes in libido)  Character (for menstrual disorders);  Quantity/amount (for menstrual disorders);  Severity (for menstrual disorders);  Time and cause of onset (menstrual disorders, impotence, changes in libido) 4) Disorders of Drive and Appetite: (Thirst, appetite disturbances, increased hunger, altered taste perception).  Severity;  Frequency;  Time and cause of onset;  Measures relieving symptoms. 5) Asthenovegetative Disorders: Weakness, fatigue, asthenia, reduced work capacity, apathy, mood lability, excessive sweating, etc..  Severity;  Frequency;  Intensity;  Time and cause of onset;  Measures relieving symptoms Musculoskeletal System Joints 1) Pain Syndrome  Localization;  Symmetry;  Intensity (0–3 scale or Visual Analogue Scale [VAS] 0–10);  Duration (minutes, hours, days);  Time pattern (worsening toward the end of the day and during physical activity, improving with rest and in the morning);  Character (aching, boring, throbbing, dull, sharp, migratory);  Persistent or intermittent;  Relationship to movement;  Factors provoking pain (movement, physical exertion);  Dependence on time of day;  Factors and medications relieving pain.  For infectious diseases, additionally assess: Myalgia; Arthralgia; Relationship of pain to fever and intoxication syndrome. 2) Stiffness  Localization (affected joints);  Symmetry;  Intensity (0–3 scale);  Duration (minutes, hours, days);  Time of occurrence (morning, daytime, evening);  Factors and medications relieving stiffness. 3) Limitation of Mobility  Localization (affected joints);  Symmetry;  Intensity (0–3 scale);  Duration (minutes, hours, days);  Time of occurrence (morning, daytime, evening);  Factors and medications relieving symptoms 4) Deformity  Localization (affected joints);  Symmetry;  Severity Spine 1) Pain  Localization (spinal region);  Intensity (0–3 scale or VAS 0–10);  Duration (minutes, hours, days);  Time pattern (worsening toward the end of the day and during physical activity, improving with rest and in the morning);  Character (aching, boring, throbbing, dull, sharp, migratory);  Persistent or intermittent;  Relationship to movement;  Factors provoking pain (movement, physical activity, rest);  Dependence on time of day;  Factors and medications relieving pain 2) Stiffness  Localization (spinal region);  Intensity (0–3 scale);  Duration (minutes, hours, days);  Persistent or intermittent;  Time of occurrence (morning, daytime, evening);  Factors and medications relieving stiffness. 3) Limitation of Mobility  Localization (spinal region);  Intensity (0–3 scale);  Duration (minutes, hours, days; persistent);  Persistent or intermittent;  Time of occurrence (morning, daytime, evening);  Factors and medications relieving symptoms Muscles 1) Muscle Weakness  Localization (specific muscle, muscle group, or limb);  Symmetry;  Intensity;  Duration (persistent or intermittent);  Time of occurrence (morning, daytime, evening);  Factors and medications relieving symptoms.  For infectious diseases, muscle weakness should be assessed as a manifestation of intoxication syndrome. 2) Seizures  Localization (specific muscle, muscle group, or limb);  Symmetry;  Intensity;  Duration (persistent or intermittent);  Time of occurrence (morning, daytime, evening).  For children, additionally assess: Presence of febrile seizures;  Relationship to elevated body temperature; Duration of seizure episodes; Loss of consciousness. Sensory Organs 1) Vision: Visual impairment, blindness, lacrimation, photophobia, eye pain, burning sensation, floaters)  Severity;  Duration;  Time of onset;  Symmetry;  Factors and medications that relieve symptoms.  For infectious diseases, additionally assess: Conjunctivitis; Scleral injection; Photophobia; Pain during eye movements. 2) Hearing: Hearing loss, ear pain, tinnitus, ear fullness, ear discharge.  Hearing status (normal, impaired, deafness);  Character of ear discharge (purulent, serosanguineous, serous);  Localization and radiation of pain;  Frequency;  Duration;  Time and circumstances of onset;  Factors and medications that relieve symptoms 3) Taste and Smell:  Character of disturbance (loss of taste and smell, altered taste perception);  Severity;  Time and circumstances of onset;  Clinical course.  For infectious diseases, additionally assess: Association of symptoms with a viral infection. Example 1 Chief Complaints at Disease Onset / Upon Hospital Admission Date of Admission: 17.09.2022 (Emergency Department) The patient complains of a persistent cough aggravated by exposure to cold air, accompanied by difficult-to-expectorate whitish-yellow sputum in an amount of approximately 15–20 mL per day; moderate mixed-type dyspnea occurring during physical exertion; fever up to 39.0°C accompanied by chills; weakness, excessive sweating, headache, and decreased appetite. Follow-Up Assessment Date: 18.09.2022 (Inpatient Department) The patient continues to complain of a persistent cough aggravated by exposure to cold air, accompanied by difficult-to-expectorate whitish-yellow sputum in an amount of approximately 15–20 mL per day; moderate mixed-type dyspnea occurring during physical exertion; weakness and excessive sweating. Body temperature has decreased to 37.9°C, appetite has improved, and headaches have become less severe . Example 2 Chief Complaints at Disease Onset / Upon Hospital Admission Date of Admission: 11.10.2025 (Emergency Department) According to the mother, the child presented with fever up to 38.8°C, watery diarrhea up to six times per day, vomiting up to three times per day, abdominal pain, decreased appetite, thirst, general weakness, and lethargy. Follow-Up Assessment Date: 12.10.2025 (Inpatient Department) Positive clinical dynamics have been observed during treatment: body temperature has decreased to 37.5°C, the frequency of vomiting and diarrhea has decreased (stool frequency up to three times per day), the child has become more active, and appetite has partially recovered. Signs of moderate dehydration persist . Section III Анамнез заболевания (anamnesis morbi): 1. History of Present Illness (Anamnesis Morbi): Determine the onset of the present illness (when the patient became ill, the initial manifestations, the sequence of symptom development) and its duration (if the disease is chronic). 2. 3. Identify the presumed cause of the illness (what the patient associates the onset of the disease with). Clarify the course of the illness (symptom progression and the appearance of new symptoms). 4. Obtain information regarding previous diagnostic evaluations (consultations with specialists, established diagnoses). 5. Obtain information regarding previous treatment (home treatment, outpatient treatment; for chronic diseases, the most recent hospitalization, the most recent exacerbation, and the duration of remission). 6. Determine the reasons for deterioration of the patient's condition (ineffectiveness of outpatient treatment, worsening of symptoms, emergency medical service call, self-referral, or planned hospitalization). 7. In infectious diseases, the following must be specifically assessed: Contact with individuals suffering from infectious diseases; Time of fever onset; Staged appearance and progression of rash; Presence of diarrhea and vomiting; Signs of dehydration; Epidemiological history; Travel to endemic areas; Insect bites; Seasonality of the disease. Example 1 History of Present Illness (Anamnesis Morbi) The patient considers himself ill since 13.09.2022, when, following exposure to cold and heavy rain, he developed a dry cough and general malaise the next day. Initially, he did not attach significant importance to these symptoms. On 14.09.2022, the cough became more frequent and severe, and retrosternal pain occurred during coughing. He self-administered paracetamol with minimal effect. By the evening of the same day, he developed chills, and his body temperature increased to 37.8°C. He continued taking paracetamol and drinking hot tea with lemon and raspberry. On the morning of 15.09.2022, he felt somewhat better; however, a small amount of light-colored sputum appeared, and retrosternal pain during coughing persisted. By the evening, his condition worsened, body temperature increased to 38.5°C, right- sided chest pain developed, and mild dyspnea at rest appeared. He again took paracetamol before bedtime. Throughout the night, he was troubled by coughing associated with right-sided chest pain. The sputum became more viscous and acquired a whitish-yellow color. On the morning of 16.09.2022, he attended an outpatient clinic, where he was examined by a physician and referred for laboratory blood tests and chest radiography. On 17.09.2022, based on the results of the outpatient evaluation, he was referred for inpatient treatment. . Example 2 History of Present Illness (Anamnesis Morbi)) The child developed an acute illness on 10.10.2025, when body temperature increased to 38.5°C and lethargy and decreased appetite appeared. Several hours later, watery diarrhea developed with a frequency of up to six episodes per day, accompanied by vomiting up to three times daily.According to the mother, the illness was associated with the consumption of homemade dairy products. The child received antipyretic medications and oral rehydration therapy at home, with minimal clinical improvement. On the following day, fever, diarrhea, and vomiting persisted. Increased thirst and decreased urine output subsequently developed. The child was examined by a primary care pediatrician and referred for inpatient treatment because of signs of moderate dehydration and a persistent intoxication syndrome . Section IV Past Medical History (Anamnesis Vitae) 1. Childhood and Adolescence (Health status and development during childhood, childhood infectious diseases, and features of physical and psychomotor development. For children, additionally assess: Maternal pregnancy and delivery history; Gestational age at birth; Birth weight and length; Type of feeding (breastfeeding, formula feeding, mixed feeding); Vaccination history; Previous infectious diseases. 2. Adulthood (Living conditions, occupational history, profession, place of employment, previous and chronic illnesses, surgeries, and injuries in chronological order (year, type of surgery, possible complications). The presence of rheumatic diseases and chronic tonsillitis should also be clarified. 3. Social History and Harmful Habits: Smoking (Number of cigarettes smoked per day; Duration of smoking history), Alcohol Consumption Considering that patients may underreport alcohol use, the CAGE questionnaire may be used to identify potential alcohol-related problems): The CAGE test is considered positive if there are: Two or more positive responses in men; One or more positive responses in women.. Необходимо спросить следующие вопросы и получить ответы «да»/ «нет». 1. Have you ever felt that you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?The following should also be specified: Quantity of alcohol consumed; Frequency of consumption (times per day, week, month, etc.) 4. Allergic History (Drug, food, and environmental allergies; allergic diseases in parents and siblings; type of allergic reaction (urticaria, anaphylactic shock, etc.); name of the medication or allergen responsible for the reaction. 5. Family History : Diseases affecting parents and other close relatives, causes of death and age at death; presence of psychiatric disorders, chronic diseases, and hereditary/genetic conditions. 6. Epidemiological History: for the purpose of identifying the possible source of infection, the mechanism and route of transmission, risk factors for infection, exposure to an epidemic focus, as well as determining the probable association of the disease with occupational, household, foodborne, waterborne, contact, vector-borne, and natural focal factors.. The following should be clarified: Contact with infectious patients: presence of contact with infected individuals in the family, childcare facilities, educational institutions, workplace, and healthcare facilities; presence of similar symptoms among surrounding individuals. Previous infectious diseases: tuberculosis, viral hepatitis, HIV infection, intestinal infections, measles, rubella, varicella, mumps, scarlet fever, meningococcal infection, parasitic diseases, and other infectious diseases. Vaccination history: receipt of preventive immunizations according to the National Immunization Schedule; vaccination against measles, rubella, mumps, hepatitis B, tuberculosis, diphtheria, pertussis, tetanus, poliomyelitis, influenza, COVID-19, and other infections; presence of medical exemptions from vaccination or refusal of vaccination. Food history: consumption of spoiled or contaminated food products, homemade dairy products, raw milk, inadequately cooked meat, fish, eggs, seafood, canned foods, and street food; meals consumed in cafés, cafeterias, or at social events; presence of similar symptoms among individuals who consumed the same food. Water exposure: consumption of untreated water, water from wells, springs, or open water sources; swimming in natural bodies of water; accidental ingestion of water while swimming. Animal exposure: presence of household pets; contact with cats, dogs, rodents, birds, and farm animals; animal bites, scratches, and animal care activities; consumption of animal-derived products. Occupational exposure: employment in healthcare facilities, laboratories, livestock farming, slaughterhouses, veterinary services, agriculture, or the food industry; contact with blood, biological fluids, animals, or animal-derived raw materials. Vector-borne exposure: bites from mosquitoes, ticks, sandflies, fleas, lice, tsetse flies, and other vectors; seasonal occurrence of bites; exposure in forests, steppes, rural areas, jungles, or near bodies of water. Parenteral risk factors: blood transfusions, injections, surgical procedures, dental procedures, tattoos, piercings, manicure procedures, cosmetic procedures, and hemodialysis. Sexual history: history of unprotected sexual contact; history of sexually transmitted infections (STIs). Travel and geographic history: travel outside the city, region, or country; stay in endemic areas; dates of departure and return; living conditions, dietary habits, swimming activities, and exposure to animals and insects during travel. For tropical diseases, it is mandatory to clarify: travel to countries in Africa, Southeast Asia, South America, India, the Middle East, and other endemic regions; use of malaria chemoprophylaxis; bites from mosquitoes, sandflies, and tsetse flies; swimming in freshwater bodies; walking barefoot; consumption of untreated water, exotic foods, raw fish, or undercooked meat; occurrence of fever after returning from travel. Sanitary and living conditions: housing conditions, overcrowding, presence of insects and rodents, personal hygiene practices, access to safe drinking water, and sanitation. Infection focus: presence of ill individuals in the family, workplace, dormitory, school, kindergarten, or other organized groups; date of onset of the first cases; number of affected individuals; association of the disease with a common source of food, water, or contact. For children, additionally clarify: attendance at kindergarten, school, or extracurricular activities; presence of quarantine measures in organized groups; contact with sick children; age-appropriate vaccination status; presence of ill family members. 7. Immunization History: vaccination according to the National Immunization Schedule; vaccinated according to age; vaccination records unavailable; vaccination incomplete. Additionally, it is necessary to clarify vaccination against: varicella; rotavirus infection; meningococcal infection; pneumococcal infection; human papillomavirus (HPV); influenza; COVID-19; tick-borne encephalitis; hepatitis A; typhoid fever; yellow fever; and other infections, particularly before travel to endemic regions. 8. Diabetes Mellitus (presence or absence of diabetes mellitus.) 9. Gynecological History in Women (age at menarche; regularity and pain associated with menstruation; date of the last menstrual period; menstrual cycle disorders; number of pregnancies and deliveries and their outcomes (medical or elective abortions, miscarriage [spontaneous abortion], live births); complications during pregnancy and delivery; gynecological diseases; gynecological surgeries; menopause (onset, course, and use of medications). 10. Medication History: medications and dietary supplements currently taken (names, dosages, duration of use, frequency of administration, route of administration, and effectiveness) Example 1 Past Medical History (Anamnesis Vitae) According to his parents, the patient had mumps and varicella during childhood. He underwent an appendectomy at the age of 15 years. He has a higher education degree in economics. Working conditions are satisfactory. Chronic obstructive pulmonary disease (COPD) was diagnosed 6 years ago. He has smoked one pack of cigarettes daily for 25 years and does not abuse alcohol (provide the results of the CAGE questionnaire if performed). No history of allergic reactions. Family history is unremarkable. The patient denies a history of tuberculosis, sexually transmitted diseases, viral hepatitis, and HIV infection, and reports no known exposure to these diseases. Diabetes mellitus is denied. He has not received influenza or COVID-19 vaccination. Example 2 Past Medical History (Anamnesis Vitae) The child was born from the mother's second pregnancy and second full-term delivery. The pregnancy was uneventful. The child was born at term with a birth weight of 3400 g and a birth length of 52 cm. Breastfed until 1 year of age. Physical and psychomotor development were age-appropriate. Previous illnesses included acute respiratory viral infections and varicella. Chronic diseases are denied. Allergy history is unremarkable. Family history is non-contributory. Contact with infectious patients: according to the mother, cases of acute intestinal infection have been reported in the kindergarten attended by the child. The child attends kindergarten. Vaccination has been administered according to the National Immunization Schedule. Tuberculosis, viral hepatitis, and HIV infection in family members are denied. The child does not take any medications on a regular basis . Section V Status praesens (Physical Examination, Present Condition of the Patient) Sections / Organ Systems Points for Assessment Attention! Examination methods highlighted in bold are mandatory and must be performed and documented in the medical history regardless of the organ system involved. All other examination methods and symptoms should be documented only if pathological findings involving the corresponding organ system are identified. Present Condition of the Patient (to be described in detail in the presence of pathology of any organ system) General condition: satisfactory, moderately severe, severe (specify). Consciousness: clear, confused; stupor, sopor, coma, delirium, hallucinations (specify). Patient’s position: active, passive, forced (specify). Body habitus: constitutional type (normosthenic, hypersthenic, asthenic), height, body weight. Posture (straight, stooped), gait (rapid, slow, ataxic, spastic, paretic). Body temperature: subfebrile, febrile, hyperfebrile; type of temperature curve — febris continua, febris remittens, febris intermittens, febris hectica, febris recurrens, febris undulans. Facial expression: calm, indifferent, mask-like, melancholic, suffering, agitated, fatigued, etc. (Corvisart facies, facies febris, facies nephritica, facies mitralis, facies Hippocratica, facies Basedowica, etc.). Skin, nails, and visible mucous membranes: color (pale pink, red, cyanotic, icteric, pale, earthy, dark). Pigmentation and depigmentation (leukoderma), their localization. Rashes: in the presence of an exanthem, the following must be described: time of appearance; localization of the first elements; staged spread; character of the rash (roseolar, papular, macular, vesicular, hemorrhagic, urticarial, etc.); size of elements; color; clarity of borders; tendency to merge; presence of itching and desquamation; disappearance on pressure; presence of residual pigmentation. Vascular changes: telangiectasias, “spider angiomas,” their localization and number. Hemorrhages: localization, size, number, severity. Scars: localization, color, size, mobility, tenderness. Trophic changes: ulcers, pressure sores, their localization, size, surface characteristics, etc. Skin moisture, skin turgor. Hair distribution pattern. Nails: shape (“watch-glass” nails, koilonychia, etc.), color (pink, cyanotic, pale), transverse or longitudinal ridging, nail brittleness. Visible mucous membranes: color (pink, pale, cyanotic, icteric, hyperemic), mucosal eruptions (enanthema), their localization and severity, moisture of the mucous membranes. For infectious diseases, the following must be assessed: presence of enanthem; Belsky– Filatov–Koplik spots, herpetic eruptions; hemorrhagic elements. Subcutaneous adipose tissue: degree of development (moderate, reduced, excessive), predominant areas of fat deposition (abdomen, arms, thighs), edema (oedema), its localization (extremities, lumbar region, abdomen), extent (localized or anasarca), severity (pastosity, moderate or marked), consistency of edema and its symmetry. Tenderness on palpation of the subcutaneous adipose tissue, presence of crepitus (in subcutaneous emphysema). Lymph nodes: localization of palpable lymph nodes (occipital, posterior cervical, parotid, anterior cervical, submandibular, submental, supraclavicular and infraclavicular, axillary, epitrochlear, inguinal, popliteal). Their size, shape, consistency, surface characteristics, tenderness, mobility, adhesion to each other and to surrounding tissues, and condition of the skin over the lymph nodes. For infectious and tropical diseases, the presence of generalized lymphadenopathy must be assessed Respiratory System (to be described in detail only in the presence of pathology involving this organ system) Nose: changes in the shape of the nose; nasal breathing (unobstructed or obstructed). Nasal discharge, its character and amount. Epistaxis. Oropharynx (soft palate, base of the tongue, palatine arches, posterior pharyngeal wall): color, edema, plaques/exudates. Tonsils: size, color, edema, plaques/exudates. Larynx: position, deformity, and edema in the laryngeal region. Voice: loud, soft, clear, hoarse; absence of voice (aphonia). Chest: Chest shape: normosthenic, hypersthenic, asthenic; pathological forms (emphysematous, barrel-shaped, paralytic, scaphoid, rachitic, funnel chest). Prominence of the supraclavicular and infraclavicular fossae (bulging, filled, sunken, retracted), width of the intercostal spaces (normal, wide, narrow), size of the epigastric angle (right, acute, obtuse), position of the scapulae and clavicles (not prominent, moderately prominent, markedly prominent, winged scapulae), anteroposterior and transverse dimensions of the chest, symmetry of the chest (enlargement or reduction of one hemithorax, localized bulging or retraction). For children, additionally assess: chest wall retractions; nasal flaring; grunting respiration. Respiration: type of breathing (thoracic, abdominal, mixed). Symmetry of respiratory movements of both sides of the chest (lagging of one side during respiration). Use of accessory respiratory muscles. Respiratory rate per minute. Depth of respiration (superficial, deep, including Kussmaul respiration). Respiratory rhythm (regular, irregular, including Cheyne–Stokes and Biot respiration). Palpation: identification of tender areas and their localization. Assessment of chest wall resistance (elasticity). Assessment of vocal fremitus over symmetrical areas (equal bilaterally, increased or decreased on one side). Comparative percussion: character of the percussion note over symmetrical areas of the chest (clear pulmonary, impaired resonance, dull, hyperresonant/box-like, tympanic, dull- tympanic) with precise determination of the borders of each percussion note according to ribs and topographic lines. Upper lung borders: height of the lung apices anteriorly, height of the lung apices posteriorly, width of Krenig's fields. Lower lung borders: along the parasternal line, midclavicular line, anterior axillary line, midaxillary line, posterior axillary line, scapular line, and paravertebral line. Respiratory excursion of the lower lung borders: along the midclavicular line, midaxillary line, and scapular line. Auscultation. Primary breath sounds: character of the primary breath sounds over symmetrical areas of the chest (vesicular, diminished, increased, harsh, mixed, bronchial, amphoric, absence of primary breath sounds). Adventitious breath sounds: wheezes (dry or moist), crepitations, pleural friction rub, pleuropericardial friction rub, their localization and characteristics. Forced expiration and coughing test. Bronchophony: assessment of bronchophony over symmetrical areas of the chest (equal on both sides, increased or decreased on one side). Cardiovascular System (to be described in detail only in the presence of pathology involving this organ system) Inspection of the neck: condition of the external jugular veins and carotid arteries of the neck, and any pathological changes. Inspection of the precordial area: bulging of the cardiac region (gibbus cordis). Visible pulsations (apical impulse, cardiac impulse, epigastric pulsation, atypical pulsations in the cardiac region), their characteristics (localization, extent, intensity, and relationship to the phases of the cardiac cycle). Apical impulse: its localization (specify the intercostal space and its relationship to the left midclavicular line), intensity (weakened or increased), area (localized or diffuse), amplitude (high- amplitude/heaving or low-amplitude), and resistance. Cardiac impulse: its localization and area. Epigastric pulsation: its character (whether related to the pulsation of the abdominal aorta, heart, or liver), extent (localized or diffuse). Precordial thrill (fremitus): its localization and relationship to the phases of the cardiac cycle (systolic or diastolic). Assessment of tenderness on palpation and areas of hyperesthesia. Cardiac configuration: normal, mitral, aortic, etc. Percussion. Borders of relative cardiac dullness: right, left, and upper borders. Borders of absolute cardiac dullness: right, left, and upper borders. Auscultation. Heart sounds: rhythm of cardiac contractions (regular or irregular, specifying the type of arrhythmia — respiratory arrhythmia, atrial fibrillation, extrasystoles, dropped beats, embryocardia). Heart rate. First heart sound: intensity (diminished, accentuated, loud/snapping), splitting or duplication of the first heart sound. Second heart sound: intensity (diminished, accentuated), splitting or duplication of the second heart sound. Additional heart sounds: presystolic, protodiastolic, or summation gallop rhythm, “quail rhythm,” systolic gallop. Murmurs: relationship to the phases of the cardiac cycle (systolic, diastolic, presystolic, protodiastolic, mesodiastolic, etc.). Point of maximal intensity of the murmur. Radiation of the murmur. Characteristics of the murmur (soft, blowing, scratching, harsh, etc.), pitch (high or low), intensity (soft or loud), duration (short or prolonged), and changes in intensity over time (crescendo, decrescendo, etc.). Changes in the murmur depending on body position, breath-holding during inspiration and expiration, and after physical exertion. Pericardial friction rub: point of maximal intensity, character of the sound (harsh and loud, soft, delicate). Arterial pulse: arterial pulse in the radial arteries, comparison of the pulse in both arms (pulsus differens), rate, rhythm (presence of arrhythmias and pulse deficit), volume, tension, amplitude, velocity, and contour of the pulse. Arterial blood pressure (BP): measured on the brachial arteries in mmHg. For infectious diseases, the following must additionally be assessed: tachycardia; relative bradycardia; signs of infectious-toxic involvement of the cardiovascular system; hemodynamic disturbances Digestive System (to be described in detail only in the presence of pathology involving this organ system) Oral cavity: examination of the tongue (color, moisture, condition of the papillae, presence of coating, fissures, ulcers), condition of the teeth, gums, soft and hard palate, presence of halitosis. For infectious diseases, the following must be assessed: “raspberry tongue” in scarlet fever; “varnished tongue”; coated tongue; papillary hypertrophy; dry tongue; aphthae; enanthem; Belsky–Filatov–Koplik spots; herpetic eruptions; plaques/exudates on the tonsils and mucous membranes. Abdomen: shape of the abdomen, its symmetry, participation in respiration, visible gastric and intestinal peristalsis, venous collaterals. Abdominal circumference measured at the level of the umbilicus. Percussion: character of the percussion note. Presence of free or loculated fluid in the abdominal cavity. Dimensions of the abdominal organs. Palpation: tender areas; abdominal wall muscle tension (muscular guarding — défense musculaire); diastasis of the rectus abdominis muscles and the presence of a linea alba hernia or umbilical hernia; peritoneal signs (Shchetkin–Blumberg sign, etc.). Mendel’s sign. Presence of superficially located mass lesions. Systematic deep sliding palpation according to Obraztsov–Strazhesko of the sigmoid colon, cecum, ascending colon, descending colon, greater curvature of the stomach (following preliminary determination of the lower border of the stomach by percussion, percussion-palpation with assessment of the succussion splash, and auscultatory percussion), pylorus, and transverse colon. The localization, tenderness, size, shape, consistency, surface characteristics, mobility, and borborygmi of various segments of the intestine and stomach are assessed. In the presence of mass lesions, their size, consistency, tenderness, mobility, localization, and possible relationship to a specific abdominal organ should be described. For infectious diseases, the following must additionally be assessed: borborygmi; flatulence; spastic abdominal pain; signs of enteritis and colitis. Liver: determination of the lower liver borders along the right midclavicular and anterior median lines. Characteristics of the liver edge on palpation (soft or firm, tender or non-tender, sharp, smooth, granular, or nodular). Characteristics of the liver surface (if enlarged): smooth, granular, or nodular. Liver dimensions according to Kurlov: along the right midclavicular line, anterior median line, and left costal arch (when percussion boundaries are determined according to the Obraztsov–Strazhesko method, liver dimensions are measured along the right anterior axillary, midclavicular, parasternal, and anterior median lines). Gallbladder: characteristics of the gallbladder, its palpability, tenderness, and size. Presence of Kera’s sign and Mussi–Georgievsky (phrenic) sign. Spleen: palpability of the spleen in the lateral and supine positions. Characteristics of the lower splenic border (sharp or rounded, tender or non-tender, smooth or nodular). Characteristics of the splenic surface (in cases of marked enlargement): smooth or nodular, tender or non-tender. Presence of tenderness in the area of pancreatic projection on the anterior abdominal wall, as well as enlargement and induration of the pancreas. For infectious and tropical diseases, the following must be assessed: hepatomegaly; splenomegaly; hepatosplenomegaly. Auscultation: presence of a peritoneal friction rub Urinary System (to be described in detail only in the presence of pathology involving this organ system) Urine: urine color (straw-yellow, deep yellow, dark, “beer-colored,” red, “meat-washing” color, etc.), urine clarity, urine odor. Presence of blood in the urine (at the beginning, at the end, or throughout urination). Edema: localization, time of appearance (morning, evening, throughout the day), conditions associated with the onset or worsening of edema (fluid overload, excessive salt intake, etc.), rate of progression, and factors contributing to the reduction or resolution of edema. Inspection Lumbar region: presence of skin hyperemia, swelling, and loss of the normal contours of the lumbar region. Suprapubic region: presence of localized bulging in the suprapubic area. Percussion Lumbar region: assessment of costovertebral angle tenderness (kidney punch tenderness). Suprapubic region: character of the percussion note over the pubic region; in cases of bladder enlargement, determination of the level of the bladder fundus. Palpation Kidneys: palpability of the kidneys in the supine and standing positions; if enlarged, assessment of tenderness, consistency, size, shape, surface characteristics, mobility, and the presence of ballottement. Urinary bladder: palpability of the urinary bladder; in cases of bladder enlargement, determination of the level of the bladder fundus and tenderness on palpation. Tender points: presence of tenderness on palpation at the costovertebral angle and along the course of the ureters (ureteric points). For infectious diseases, the following must additionally be assessed: oliguria; anuria; signs of dehydration; “beer-colored” urine; hemorrhagic syndrome. Nervous System (to be described in detail only in the presence of pathology involving this organ system) Mental status: level of consciousness; orientation to place, time, and situation. Intellectual function: appropriate or inappropriate for the developmental level. Impairment of intellectual functions (reduced attention, memory impairment, impaired judgment, narrowing of interests). Patient's behavior in the hospital, degree of sociability, emotional stability, fussiness, and psychomotor agitation. Cranial nerve examination: visual acuity, diplopia, ptosis, range of eye movements, pupillary response to light. Symmetry of the nasolabial folds during smiling or baring the teeth. Swallowing Endocrine System (Described in detail only when pathology of this organ system is present) Musculoskeletal System (Described in detail only when pathology of this organ system is present) Sense Organs (Described in detail only when pathology disorders. Dysphonia. Position of the tongue upon protrusion. Meningeal signs: nuchal rigidity, Kernig's sign, and Brudzinski's sign. For young children, additionally assess: bulging anterior fontanelle; monotonous crying; seizures; impaired consciousness; Lesage's sign. Motor function: gait pattern with eyes open and closed (normal, ataxic, paretic, or other types). Stability while standing with eyes open and closed (Romberg test). Finger-to-nose and heel-to-knee tests (coordination tests). Seizures: clonic and tonic seizures, fasciculations, tremor, and other involuntary movements. Muscle contractures: localization. Range of motion and muscle strength in the extremities. Sensory function: tenderness on palpation along the course of peripheral nerves and nerve roots. Range of motion and muscle strength in the extremities. Reflexes: corneal and pharyngeal reflexes. Deep tendon reflexes: patellar and Achilles reflexes. Pathological reflexes: Babinski's sign and Rossolimo's sign. Speech: aphasia (motor or sensory), dysarthria. Autonomic nervous system: ocular findings: width of the palpebral fissure, pupil size, exophthalmos, enophthalmos. Horner's syndrome. For infectious diseases, the following must additionally be assessed: signs of neurotoxicosis; manifestations of encephalitis; seizure syndrome. Skin: type of dermographism, temperature asymmetry, hypertrichosis, alopecia, trophic ulcers, and sweating disturbances. Assessment includes abnormalities of growth, body habitus, and proportionality of individual body parts. Obesity: degree of severity and predominant distribution of adipose tissue. Weight loss and cachexia. Assessment of the skin: moisture, thinning or thickening of the skin, hyperpigmentation of the skin and skin folds (specify localization), presence of striae, abnormal hair distribution (hirsutism), and moon facies. Enlargement of the tongue, nose, jaws, auricles, hands, and feet. Thyroid gland palpation: location, size, consistency, tenderness, and mobility. Muscles: degree of development (well developed, underdeveloped, muscle atrophy, or muscle hypertrophy). Muscle tone: symmetry; normal, decreased, or increased (muscle rigidity). Muscle strength. Tenderness and areas of induration on palpation. Bones: bone shape, presence of deformities, tenderness on palpation or percussion, and assessment of the terminal phalanges of the fingers and toes (digital clubbing). Joints: configuration, swelling, tenderness on palpation, hyperemia, and local skin temperature over the joints. Joint movements: pain during movement, crepitus, and range of active and passive motion. For infectious diseases, additional assessment includes: arthralgia, myalgia, and reactive arthritis. Vision: hyperopia, normal vision, myopia, and lacrimation. Hearing: normal, decreased, and presence of discharge from the external auditory canal. of this organ system is present) Olfaction: absent, decreased, or distorted. Taste: absent, decreased, or distorted. Tactile sensation: absent, decreased, or preserved. For infectious diseases, additional assessment includes: anosmia, ageusia, conjunctivitis, and photophobia. Example 1 Status Praesens (Physical Examination, Present Condition of the Patient) The patient is in a moderately severe condition. Consciousness is clear. The patient is active and has a normosthenic body habitus. Height: 168 cm; weight: 75 kg. Body temperature: 38.9°C. The skin is warm to the touch with mild facial flushing. Visible mucous membranes are pink. Subcutaneous fat tissue is moderately developed. Lymph nodes are not palpable. There is no peripheral edema. Dyspnea is present at rest. The oropharynx is mildly hyperemic. The chest is normosthenic in shape. Slight lagging of the right hemithorax during respiration is noted. Respiratory rate: 21 breaths/min. Chest palpation is painless. Reduced movement of the right side of the chest during respiration is observed. Vocal fremitus is increased over the lower right lung fields. Comparative percussion reveals a clear pulmonary sound with dullness below the angle of the right scapula. Topographic percussion: excursion of the lower lung border along the midaxillary line is 4 cm on the right and 6 cm on the left. On auscultation, scattered dry crackles are heard throughout both lungs. In the lower right lung fields, diminished vesicular breath sounds are noted, accompanied by slightly increased bronchophony and fine inspiratory crackles. Pulse oximetry (SpO₂): 92%. No visible precordial pulsations are present. The apical impulse is palpated in the 5th intercostal space, 1 cm medial to the left midclavicular line; it is not displaced, of moderate intensity and resistance. Cardiac borders are within normal limits. Heart sounds are clear and rhythmic; no murmurs are heard. Heart rate: 82 beats/min. Blood pressure: 130/85 mmHg. The pulse is palpable over both radial arteries and is of moderate volume and tension. The abdomen is of normal shape and symmetrical; no visible peristalsis is observed. Percussion reveals tympany over the intestinal loops. On superficial palpation, the abdomen is soft and non-tender, without guarding or abdominal wall rigidity. The lower border of the liver along the right midclavicular line is at the level of the costal margin. On palpation, the lower edge of the liver is smooth, sharp, and non- tender. The spleen is not palpable. The lumbar and suprapubic regions are unremarkable. Costovertebral angle tenderness is absent bilaterally. Physiological functions are normal.. Example 2 Status Praesens (Physical Examination, Present Condition of the Patient) The patient is in a moderately severe condition due to intoxication syndrome and fever. Consciousness is clear. The child is lethargic but cooperative. The position is active. Body build is appropriate for age. Body temperature: 38.7°C. The skin is clean, warm to the touch, and moderately moist. Visible mucous membranes are mildly hyperemic. No rash is present. Subcutaneous fat tissue is moderately developed. Skin turgor is preserved. There is no peripheral edema. Submandibular and cervical lymph nodes measuring 0.5–0.7 cm are palpable; they are elastic, mobile, and non-tender. Nasal breathing is impaired due to mucous discharge. The oropharynx is hyperemic. The tonsils are enlarged to grade II without exudates. The tongue is moist and coated with a white plaque. The chest is of normal shape. Both hemithoraces participate equally in respiration. Respiratory rate: 24 breaths/min. Breath sounds are puerile and are heard throughout all lung fields. No adventitious sounds are present. Percussion reveals a clear pulmonary sound. Pulse oximetry (SpO₂): 97%. The precordial area shows no visible abnormalities. Heart sounds are clear and rhythmic. Heart rate: 108 beats/min. No murmurs are heard. Blood pressure: 100/60 mmHg. The pulse is of satisfactory volume and tension. The abdomen is soft and accessible to deep palpation, with mild tenderness in the periumbilical region. There are no signs of peritoneal irritation. The liver extends 1 cm below the costal margin; it is soft and non-tender. The spleen is not palpable. The stool is loose and contains no pathological impurities. Diuresis is moderately decreased. The lumbar region is unremarkable. Costovertebral angle tenderness is absent bilaterally. Meningeal signs are negative. There are no focal neurological deficits . Section VI Justification of the Preliminary Diagnosis and Differential Diagnosis. After obtaining the medical history and performing the physical examination, students must formulate a justified preliminary diagnosis. This should include a clear explanation based on the patient's complaints, history of present illness, epidemiological history, and findings of the objective physical examination, with identification of the relevant clinical syndrome(s). Students should also identify diseases that require differential diagnosis, specify comorbid conditions, and prepare a patient problem list. When completing a student case history, the justification of the preliminary diagnosis and the differential diagnosis plan must be written in full text, as demonstrated in the examples below. Example 1 Justification of the Preliminary Diagnosis. Based on the patient's complaints of gradually progressive dyspnea, productive cough with mucopurulent sputum, and fever up to 39°C that developed after exposure to cold; the identified syndrome of pulmonary consolidation (restricted movement of the right hemithorax during respiration, increased vocal fremitus, dullness to percussion, diminished vesicular breath sounds, increased bronchophony, and fine inspiratory crackles below the angle of the right scapula); and signs of grade II respiratory failure (pulse oximetry 92%, respiratory rate above 20 breaths/min), the following preliminary diagnosis is established: Community-acquired pneumonia of the right lower lobe, moderate severity. Leading syndromes: Pulmonary consolidation syndrome, Respiratory failure syndrome, Fever. Example 2 Justification of the Preliminary Diagnosis. Based on complaints of fever up to 38.8°C, watery diarrhea up to six times per day, vomiting up to three times per day, abdominal pain, thirst, and decreased appetite; the history of acute disease onset following consumption of homemade dairy products; the identified gastroenteritis syndrome (diarrhea, vomiting, abdominal pain), intoxication syndrome (fever, weakness, lethargy, decreased appetite), and signs of moderate dehydration (dry mucous membranes, thirst, and decreased urine output), the following preliminary diagnosis is established:: Acute intestinal infection, gastroenteritis form, moderate severity. Moderate dehydration. Leading syndromes: Gastroenteritis syndrome, Intoxication syndrome, Dehydration syndrome. Differential diagnosis is the analysis of other possible diseases that share partially similar clinical manifestations. However, in order to exclude or confirm these conditions, additional investigations may be required, or the physician may need to re-evaluate the patient and obtain missing information from both the history of present illness and the past medical history. This information should be incorporated into the patient's problem list. A problem list is a list of the most important health-related issues affecting the patient, including non-communicable diseases, previous illnesses, injuries sustained by the patient, and any other conditions that have influenced the patient's health in the past or continue to affect the patient at present (https://www.techtarget.com/searchhealthit/definition/problem-list). There may be several differential diagnoses (two, three, four, or more). Medical textbooks usually provide a list of differential diagnoses for each disease at the end of every chapter. Therefore, this section should never be omitted. Students are strongly encouraged to record this information in their notebooks and review it regularly, paying particular attention to the specific similarities and differences between diseases.. . Example 3 Differential Diagnosis (Pulmonary Consolidation Syndrome) 1. Infiltrative or focal pulmonary tuberculosis – if the epidemiological history reveals contact with individuals who have had a prolonged, poorly productive cough lasting more than two months and accompanied by hemoptysis, or if the patient has symptoms such as prolonged low-grade fever, weight loss, and night sweats. 2. Atypical pneumonia (viral, Legionella, Mycoplasma, or Chlamydia pneumonia) – if there is a corresponding epidemiological history and limited physical examination findings 3. Acute bronchitis – if physical examination findings are minimal 4. Lung cancer – if the patient presents with symptoms such as chronic cough with hemoptysis, weight loss, a long history of smoking, a significant family history of malignancy (not limited to lung cancer), or occupational exposure to harmful factors 5. Acute exacerbation of chronic obstructive pulmonary disease (COPD) – in the presence of signs of emphysema, a long smoking history, and advanced age. Comorbidities (Concomitant, usually chronic diseases) –examples: Ischemic heart disease (IHD), Arterial hypertension, Diabetes mellitus. Suspected HIV disease (B20) Patient Problem List The patient smokes one pack of cigarettes per day. The patient has not received influenza or COVID-19 vaccination. Example 4 Дифференциальный диагноз (по синдрому уплотнения легочной ткани) 1. Rotavirus infection – in the presence of a pronounced gastroenteritis syndrome, watery diarrhea, vomiting, fever, catarrhal symptoms, seasonal occurrence of the disease, and contact with infected children.. 2. Salmonellosis – following consumption of contaminated dairy products, meat, or eggs, with severe intoxication syndrome, prolonged fever, repeated vomiting, and frequent greenish diarrhea. 3. Shigellosis – in the presence of symptoms of colitis, tenesmus, pain in the left iliac region, and scant stools containing mucus and blood. 4. Foodborne toxic infection – if several individuals become ill after consuming the same food, with predominant vomiting and a short incubation period. 5. Acute appendicitis – in the presence of severe pain in the right iliac region, signs of peritoneal irritation, and the absence of pronounced diarrhea. 6. Intestinal intussusception – in young children presenting with intermittent abdominal pain, vomiting, irritability, and stools resembling “red currant jelly”. Comorbidities : Iron deficiency anemia, Atopic dermatitis, Protein-energy malnutrition, Frequently ill child. Patient Problem List: Attendance at an organized childcare facility. Incomplete vaccination status or lack of rotavirus vaccination (if applicable) Section VII Diagnostic Workup Plan To Confirm the Preliminary Diagnosis and to Exclude (less commonly, to Confirm) Differential Diagnoses. When completing student case histories, the diagnostic workup plan should be presented in the same tabular format as shown in the examples Diagnostic Workup Plan You must clearly understand the purpose of every investigation you order. Investigations should never be ordered arbitrarily or “for the sake of ordering tests.” Investigations are ordered for specific clinical purposes: To confirm the diagnosis – For example, in a patient presenting with burning chest pain radiating to the left arm, an electrocardiogram (ECG) and cardiac troponin levels must be obtained because they provide objective evidence supporting the diagnosis. In infectious and tropical diseases, the diagnostic workup plan should include: general clinical investigations; biochemical tests; specific laboratory diagnostics; bacteriological, virological, and parasitological methods; instrumental investigations when indicated; investigations required for differential diagnosis. It is important to indicate, first and foremost, the investigation that directly confirms your preliminary diagnosis. As shown in the example, a patient with community-acquired pneumonia requires a chest radiograph to confirm the diagnosis. If atypical pneumonia is suspected, computed tomography (CT) is necessary because radiographic changes may not be visible in patients with atypical pneumonia or in immunocompromised patients. 1. To determine disease severity For example, in patients with infectious diseases, indicators of inflammatory severity include a complete blood count (CBC), C-reactive protein (CRP), procalcitonin, blood electrolytes, acid-base status, liver and kidney function tests, signs of dehydration, and non- specific inflammatory markers, depending on the disease. In patients with suspected asthma, the degree of airway obstruction should be assessed using peak flowmetry or spirometry. For patients with suspected anemia, hemoglobin levels must be determined because the severity of anemia is classified according to hemoglobin concentration, and treatment decisions also depend on hemoglobin levels. Severe anemia may require blood transfusion, whereas mild and moderate anemia are usually treated with oral iron supplementation. In addition, erythrocyte indices help determine the etiology of anemia; remember the classification into microcytic or macrocytic, and hypochromic or hyperchromic anemia. For patients with jaundice, it is particularly important to determine alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels because they directly reflect the extent of liver injury. 2. To identify complications of the primary disease. For example, a patient with diabetes mellitus should undergo urinalysis because one of the most common yet asymptomatic complications of diabetes is diabetic nephropathy. To detect nephropathy, urinalysis should be performed to determine urinary protein or albumin levels. Serum creatinine should also be measured in order to calculate the glomerular filtration rate (GFR). Fundoscopic examination should be performed because another common complication of diabetes mellitus is diabetic retinopathy 3. To identify complications of the primary disease. For example, a patient with diabetes mellitus should undergo urinalysis because one of the most common yet asymptomatic complications of diabetes is diabetic nephropathy. To detect nephropathy, urinalysis should be performed to determine urinary protein or albumin levels. Serum creatinine should also be measured in order to calculate the glomerular filtration rate (GFR). Fundoscopic examination should be performed because another common complication of diabetes mellitus is diabetic retinopathy. 4. To identify comorbid conditions, as mentioned in the example above, such as screening for B20 (HIV disease), among others. 5. To perform screening for possible occult diseases (HBsAg, anti-HCV, HIV, syphilis screening [RW], blood glucose testing, pregnancy testing in women of reproductive age, etc.). 6. In suspected tropical diseases, the epidemiological history must always be clarified, and investigations should be selected according to the patient's stay in endemic regions. Additional investigations may include rapid diagnostic tests; thick and thin blood smears for malaria; parasitological examination of blood, stool, and urine; serological tests; PCR assays for tropical infections; and investigations for leishmaniasis, trypanosomiasis, dengue fever, yellow fever, and other tropical diseases. The following epidemiological factors must always be assessed: travel abroad, insect bites, swimming in freshwater bodies, contact with animals, and the use of malaria chemoprophylaxis. It is very important that, when ordering investigations to confirm a preliminary diagnosis, you clearly understand which specific laboratory or instrumental findings are expected to confirm the diagnosis. In other words, you must know the anticipated abnormalities. First and foremost, indicate the investigation that directly confirms your preliminary diagnosis (for example, an ECG and cardiac troponin levels in acute coronary syndrome [ACS]).. In textbooks and other medical resources, a list of investigations for each disease is usually provided in the “Diagnostics” section. Therefore, this section should also be studied very carefully, with a clear understanding of why a particular test is ordered and why specific results are expected. This is directly related to the pathophysiology of disease development. If you have a good understanding of the pathophysiology of a disease, understanding its diagnostic workup will not be difficult. In clinical practice, physicians order investigations according to national clinical practice guidelines. In Kazakhstan, these are the clinical protocols of the Ministry of Health of the Republic of Kazakhstan, which can be found on websites such as: https://diseases.medelement.com/?searched_data=diseases&q=&mq=&tq=&diseases_filter_type=list&dise ases_content_type=4&section_medicine=0&category_mkb=0&parent_category_mkb=0. However, if a patient's condition does not fit within the framework of the national protocol, or if the physician determines that a more extensive diagnostic workup is required and a more complex or rare diagnosis is being considered, the diagnostic and treatment plans may and should be based on international recommendations and clinical guidelines. Ideally, such decisions should be made not by a single physician, but by a multidisciplinary team of physicians (medical board/consilium). When ordering investigations, indications, contraindications, availability, and cost must always be taken into consideration. For example, pregnant women should not undergo X-ray examinations or computed tomography (CT) scans. Patients with metallic implants, previous bone fixation hardware, very old metallic dental fillings, or old tattoos containing metallic pigments should not undergo magnetic resonance imaging (MRI), because MRI uses a strong magnetic field. If the patient is paying for medical services out of pocket, their financial capabilities must be taken into account and discussed with the patient. If the patient's healthcare expenses are covered by an insurance company, every requested investigation must be clearly and specifically justified: what is being ordered, why it is necessary, and for what purpose. Example 9: Name of Investigation Purpose of the Investigation Interpretation 1. Chest X-ray (CXR) 1. To confirm the primary diagnosis and identify pulmonary infiltrates 2. For differential diagnosis with other infiltrative processes, such as tuberculosis and malignancy 3. For differential diagnosis with bronchitis and atypical pneumonia. 1. Homogeneous opacity of the right lower lobe with well-defined borders and increased pulmonary markings. 2. Localized focal lesions typical of pulmonary tuberculosis, usually involving the upper lobes. Localized focal lesions suggestive of lung malignancy 3. Absence of infiltrative or focal changes. 2. Complete blood count (CBC) To determine the severity of the inflammatory process and to differentiate between bacterial and viral inflammation. Leukocytosis with neutrophilia or leukopenia, accompanied by markedly elevated ESR, suggests bacterial inflammation. Leukocytosis with lymphocytosis and moderately elevated ESR suggests a viral etiology. 3. Biochemical blood tests: non- specific inflammatory markers (CRP, procalcitonin, LDH); prognostic indicators and markers indicating the need for hospitalization (urea, creatinine, To determine the severity of the inflammatory process. Elevated CRP is important for differentiating bacterial from viral inflammation. Changes over time (i.e., decreasing CRP and procalcitonin levels) indicate the effectiveness of antibacterial therapy. Elevated LDH levels indicate pulmonary tissue destruction and therefore suggest complicated pneumonia. Blood urea level is one of the components of the CURB-65 score and is necessary for determining the appropriate treatment strategy and AST, ALT) setting of care. Newly elevated creatinine and blood urea nitrogen (BUN) levels are also associated with a poor prognosis and often indicate the need for hospitalization. These findings, together with abnormal liver function tests, may also be signs of sepsis and require immediate additional investigations (blood cultures and sputum culture with antimicrobial susceptibility testing) and prompt treatment. Section VIII Justification of the Clinical Diagnosis. The clinical diagnosis is established after all investigations have been completed, when the diagnosis has been confirmed, conditions included in the differential diagnosis have been excluded, disease severity has been determined, comorbidities have been identified, and all relevant clinical information has been obtained. Continuing with the example of a patient diagnosed with community-acquired pneumonia. On the chest X-ray, as expected, homogeneous opacification of the lower lobe of the lung is identified, with no other abnormalities detected. The complete blood count (CBC) demonstrates leukocytosis with neutrophilia and a left shift, an elevated erythrocyte sedimentation rate (ESR), and increased levels of C-reactive protein (CRP) and procalcitonin, while lactate dehydrogenase (LDH), urea, creatinine, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) remain within normal limits. At this stage, based on the previously established justification of the preliminary diagnosis (patient complaints, progression of symptoms, and physical examination findings), together with the results of laboratory and instrumental investigations, the clinical diagnosis can be established When completing student case histories, you will be required to write the justification of the clinical diagnosis in full text, as shown in the example below Example Clinical Diagnosis Justification: Based on the identified syndrome of inflammatory consolidation of the lung tissue in the lower right lung fields, fever, and signs of grade II respiratory failure, as well as the results of laboratory and instrumental investigations (homogeneous opacification of the right lower lobe on chest X-ray, neutrophilic leukocytosis with a left shift on CBC, elevated ESR, and increased CRP levels on biochemical blood analysis), the following clinical diagnosis is established: Community-acquired pneumonia of the right lower lobe, moderate severity. 10 Section IX Treatment Plan Non-pharmacological Treatment. Prescription Types Indications for This Patient Activity regimen I – Strict bed rest II – Bed rest III – Ward regimen IV – General regimen Indicate which type of activity regimen is appropriate for the patient and justify your choice. Diet The attending physician's dietary recommendations for the patient. Specify which foods are allowed and which are contraindicated Rehabilitation measures - (Stage 1 – inpatient care: physiotherapy and therapeutic exercise; Stage 2 – outpatient care: spa and sanatorium treatment) Indicate the goals of physiotherapy, therapeutic exercise, and spa/sanatorium treatment for this patient, if indicated Prescribe these interventions when necessary. Indicate which type of rehabilitation should be recommended for the patient What additional non- pharmacological treatment methods can you suggest? Describe their mechanism of action Indicate the clinical indications Pharmacological Treatment*** . (All tables in this section must be completed independently by the student using relevant literature sources). Example Table 1. Pharmacodynamics and Pharmacokinetics of the Prescribed Medications. 11 № Drug Group* Pharmacodynamics of the Drug and Route of Administration** Rationale for Selecting This Drug Group and Route of Administration, Taking Its Pharmacokinetic Properties into Account 1. Primary treatment – etiotropic therapy: Broad- spectrum antibiotic – cephalosporins Cephalosporins exert a bactericidal effect. Their mechanism of action is associated with damage to the bacterial cell wall (inhibition of peptidoglycan synthesis) in actively dividing bacteria and the subsequent release of autolytic enzymes, resulting in bacterial cell death. Up to 70% of all cases of pneumonia are caused by Streptococcus pneumoniae 2 Pathogenetic treatment: Mucolytic and expectorant agent Mucolytic and expectorant agents have secretomotor, secretolytic, and expectorant effects. They stimulate the serous cells of the bronchial mucosa, increase ciliary epithelial activity, enhance endogenous surfactant production, increase the proportion of the serous component of bronchial secretions, improve mucus structure, reduce sputum viscosity, promote mucociliary clearance, and facilitate sputum elimination from the bronchial tree Necessary to liquefy and remove sputum in order to relieve cough * - International nonproprietary name (INN) of the drug group ** - Specify the pharmacodynamic properties for which the medication is prescribed in this particular case Table 2. Adverse Effects of Medications and Their Management № Drug Group Adverse Effects Management 1. Cephalosporins Allergic reactions: urticaria, chills or fever, rash, pruritus, serum sickness, anaphylactic shock. Gastrointestinal effects: nausea, vomiting, Symptomatic treatment or discontinuation/substitution of the medication diarrhea or constipation, flatulence, dysbiosis. Hematologic effects: anemia, leukopenia, leukocytosis, neutropenia, granulocytopenia, lymphopenia, thrombocytosis, thrombocytopenia, hemolytic anemia. Renal effects: impaired renal function (azotemia, elevated blood urea levels, hypercreatininemia, glycosuria, cylindruria, hematuria), oliguria, anuria. Other: headache, dizziness, epistaxis, candidiasis, superinfection 2 Mucolytic and expectorant agent Allergic reactions: rare – skin rash, urticaria, exanthema, facial edema, dyspnea, pruritus, fever; frequency unknown – anaphylactic reactions, including anaphylactic shock, angioedema, pruritus, allergic contact dermatitis. Gastrointestinal effects: common – nausea; uncommon – vomiting, diarrhea, dyspepsia, abdominal pain. Nervous system effects: common – dysgeusia. Skin and subcutaneous tissue disorders: very rare – toxic epidermal necrolysis (Lyell syndrome), Stevens–Johnson syndrome; frequency unknown – acute generalized exanthematous pustulosis. Respiratory system effects: common – reduced sensitivity in the oral cavity or pharynx; rare – dryness of the respiratory tract mucosa, rhinorrhea; isolated cases – dryness of the pharyngeal mucosa. Symptomatic treatment or discontinuation/substitution of the medication Table 3. Monitoring the Effectiveness of Medications № Drug Group Monitoring Parameters for Drug Effectiveness* Indicators of Drug Effectiveness* 1. Cephalosporins Assess 2–3 days after the The patient's body temperature first dose decreases, and symptoms improve (if present): general weakness, body aches, myalgia, headache, and nausea diminish. 2 Mucolytic and expectorant agent Assess 1–2 days after initiation of treatment The patient's cough improves due to reduced sputum viscosity and enhanced sputum clearance. * - Specify which parameters should be monitored ** - Specify which changes and within what timeframe indicate that the medication is effective *** - Students receive additional credit if they justify the choice of a specific medication from an evidence- based medicine perspective More information and examples of how to write medical records can be found in the following electronic resources: 1. https://www.wolterskluwer.com/en/expert-insights/what-are-soap-notes 2. https://www.ncbi.nlm.nih.gov/books/NBK482263/ 3. https://geekymedics.com/document-patient-assessment-soap/ 4. https://www.carepatron.com/blog/what-is-a-soap-note-how-to-write-them-examples#chapter-one Use all the information very best way as you can and analyse this data. And make appropriately using the following data. Create a realistic else data as needed and make a case history of 2 year old baby named turikhan son of (any Kazakh name) having dry cough and high fever, reportedly reaching 39–40 °C, beginning early in the morning on the day of admission. Reduced appetite was also reported. The student observed shortness of breath and mild wheezing. A blue coating on the tongue was observed/reported; the exact description and clinical significance require confirmation on examination. The mother reports that the illness began acutely in the early morning of 2 October 2026 with fever and dry cough. The maximum reported temperature was 39–40 °C. Reduced appetite was reported. Shortness of breath and mild wheezing were observed by the student. The mother reports no medication was administered at home before admission. The mother does not know which medicines were administered in hospital. The child was reportedly improving by the fourth day of illness; the exact dates, temperature trend, treatment received, and objective evidence of improvement are not available and must be checked against the inpatient chart. 4.2 Allergy history The mother reports an antibiotic allergy in the child and also reports an antibiotic allergy in herself. The specific antibiotic, reaction, timing, severity, and whether the child’s allergy is documented in the medical record are unknown. This must be clarified before any medication is prescribed. Do not infer a particular antibiotic or reaction. 4.3 Family history According to the information supplied, the father and siblings are healthy and have no similar symptoms or reported allergies. Other hereditary, chronic, infectious, or relevant family conditions were not provided. Make it as realistic as you can . Consider you self as dr sai kiran and you are taking case history and you have all the data. Now give me legit case history. Dont forget final diagnosis, hypothetical interpretation of labs which should look REAL and don’t forget dosages at treatment Don’t mention anything about illustrative information, not provided, check this that, hypothetically, so on such kind of terms this is a home work and complete it as a real student work in the whole history Keep the data accordingly

Quick answer

Create a polished DOCX case history for submission

Quick answer

Create the polished DOCX case history now