ДНЕВНИК
Студента _____________________________________________________
(ФИО студента)
________ курса_____ группы, лечебного факультета
Сроки практики: ____________________________________
База практики _________________________________________________
Вид практики: Производственная практика
тип: клиническая практика
(помощник врача амбулаторно-поликлинического учреждения)
Руководитель практики от базы практики ______________________________________________________________
(указать Ф.И.О., должность)
Руководитель практики от Университета: доцент Якубовская А.Г., ассистент Дашкевич О.В., кафедра поликлинической терапии и профилактической медицины.
If you go home: 1st page
Ryazan State Medical University
Diary
Student_______________________ (your name)
_________grade _________group general medicine faculty
Date of practice: __________________________
Place of practice_________________ (name of the hospital)
Type of practice: Occupational clinical practical: assistant of the out-patient doctor
The head of practical from the hospital ____________ (full name and position of the person who is responsible for you in the hospital)
The head of practical from the University: assistant professor Iakubovskaia A.G., lecturer Dashkevich O.V.
2nd page of the diary: If you stay in Ryazan, you write it in Russian
ЛИСТОК учета вводного инструктажа по охране труда,
Пожарной безопасности, технике безопасности,
Правилам внутреннего трудового распорядка
| Дата инст-руктажа | Наименование подразделения, в которое направляется инструктируемый | Инструктаж провел: ФИО и должность инструктирующего | Подпись | |
| Инструктирующего | Студента/ Инструктаж усвоил | |||
| The name of an out-patient clinic |
Place for a stamp
If you go home:
Instructional advice on accident prevention:
| Date | The department name where the student works | Full name, position of the instructor | Signature | |
| Instructor | Student | |||
| Out-patient clinic |
Records from emergency room: you record every patient who came to emergency room in detail (complaints, anamnesis morbi, physical exam, diagnosis, results of analysis, results of investigations done in emergency room, treatment (before admission), if the patient was admitted and in what department). If you saw too many patients, then you record only 10 of them. At the end of the day – brief report, the signature of your doctor and a stamp (if possible).
Records from ambulance: you record all patients you saw(complaints, anamnesis morbi, physical exam, diagnosis, results of analysis, results of investigations done by ambulance, treatment (before admission), if the patient was admitted and in what department). At the end of the day – brief report, the signature of your doctor and a stamp (if possible).
- Records from an out-patient department: on the first day you should write about the structure of polyclinics, the amount of population treated, the amount of doctor’s districts, and so on.
Every day you write:
1. The brief report: how many patients you saw (name and diagnosis of everyone), how many patients were visited at home,
Ø what documents were filled by the student or when a student took part in filling of the document (ambulatory cards, receipts, dispensary cards, referral to MSE), so on – amount of every position.
Ø results of what analysis and instrumental investigations were analysed by a student - amount
Ø in what procedures the student took part (ECG, presence on US and X-ray investigations, endoscopy, consulting with another doctor, clinical conference and so on)
Example of a brief report:
Ø Patients treated – 21
Ø Patients treated in polyclinic – 19
Ø Patients treated at home – 2
Ø Receipts filled – 5
Ø Referrals to hospital filled – 1
Ø Presence on US investigation – 1.
Ø ECG analysis – 5.
2. 2-3 patients a day should be recorded in detail (complaints, brief anamnesis morbi, physical exam, diagnosis according to all classifications – the main and accompanying diagnosis, prescribed treatment including regime and diet). The drugs are written in concrete doses.
Example of detailed patient report:
Smith A., 23 y.o., male.
Complaints: pain in throat which increases during swallowing, increase of temperature up to 38,7 С.
Anamnesis: He is ill for the second day. The symptoms appeared after he ate an ice cream. He took strepsils without a significant result.
On examination: General condition is normal. The body temperature is 37,9 С.
The back wall of throat is not changed, the tonsils are enlarged, over the archs, hyperemic, there is pus in lacunae.
Lungs: vesicular breathing, no rales. Heart tones are well heard, rhythm is normal, no murmurs. Abdomen is soft, not painful. Urination and defecation are normal.
Diagnosis: Lacunar tonsillitis.
Prescriptions: Bed rest.
Drink a lot.
Amoxycillin 1 g BD per os during 7 days.
Mouth gargling with furacillin
A smear from throat and nose for BL
General blood count, urine analysis.
Johnson Р., 66 y.o., male.
Complaints: pressing retrosternal pain while walking over 100m, climbing 1 flight, dyspnea on mild physical exertion, legs edema, headache in occipital region, fatigue.
Anamnesis: BP increases during last 10 years up to 180/110 mm Hg. He suffers from pressing retrosternal pain for 5 years. He experienced a myocardial infarction with ST elevation a year ago (02.09.2014г.). Legs edema appeared a month ago. He takes acetylsalicylic acid 100 mg/d, atorvastatin 20 mg/d, perindopril 4 mg/d, bisoprolol 2.5 mg/d.
There is a pathological Q in I, aVL, V5, V6 leads on ECG
On examination: general condition is satisfactory. Consciousness is clear.
Lungs: vesicular breathing, moist rales in basal regions. RR – 20 per min.
Heart: diminished sounds, rhythmic, acsent of the 2-nd tone over aorta, no murmurs. HR – 86 per min. BP – 150/95 mmHg.
Abdomen is soft, painful in right hypochondrium. Liver is enlarged, +2 cm lower the right rib arc, dense, painful on palpation.
Edema of feet and the lower third of shin.
Defecation is once in 2 days. Urination is easy, not painful.
Ds: CAD: stenocardia of effort, FC 3. Postinfarctious cardiosclerosis (02.09.2014г).
Arterial hypertension 3 stage, 3 grade, risk 4.
Chronic heart failure 2B, 3 FC.
Prescriptions: Perindopril 4 mg OD
Bisoprolol 5 mg OD in the morning
Spironolactone 100 mg OD in the morning.
Torasemide 10 mg OD in the morning.
Atorvastatine 20 mg OD in the evening.
Acetylsalicylic acid 100 mg OD in the evening.
Biochemical blood analysis: lipid profile, glucose, creatinine, urea, brain natriuretic peptide.
Echocardiography.
ATTENTION! The patient's complaints, examination results, diagnosis and treatment should match!
E.g.: If a patient has acute respiratory viral infection, the throat should be examined.
Such a description is unacceptable:
Complaints: back pain.
On examination: Lungs: vesicular breathing, no rales. Heart: tones are rhythmic, well heard, no murmurs. Abdomen is soft, not painful. (No information about the back).
Ds: Acute respiratory viral infection (doesn't match with the complaints, no information about the throat).
Treatment should be prescribed according to international guidelines.
3. At the end of every day – signature and the stamp of the doctor you work with.
ИНДИВИДУАЛЬНОЕ ЗАДАНИЕ (Individual task)
(made on a list А4) If you stay in Ryazan, it should be in Russian
студента _____ курса ________ группы ____ факультета ______________
student____________course______group________faculty_____________