Bashkir state medical university

Bashkir state medical university

Federal agency on public health services and social development

Faculty of propaedeutics of internal diseases with a course of physiotherapy

THE PATIENT INVESTIGATION AND THE HISTORY REPORT FORM

Guidlines

for the students of III year

UFA, 2009

Patient investigation and the case report design. - the guidline for the students of III year. / Authors.: staff of Chair of propaedeutics of internal diseases under the editorship of professor PhD Sh.Z. Zagidullin. - Ufa, BSMU, 1997-33p.

Is printed under the recommendation of coordination-methodical council on optimization of educational process of BSMU and the decision.

The guideline consists of 2 sections. In the first section classical elements of investigation of the patient and their sequence are submitted according to the unified form circuit of history of disease; the list of recommended laboratory methods of investigation is reflected; medical terminology in Latin language is also applicated. In the second section the methodical indications for students on registration of the case record with the examples are given. It is intended for self-preparation of students during nonlearning time and independent work practical occupations.

Reviewers:

Professor of Chair of neurology and medical genetics, PhD

Bashkir State Medical University,

L.R. Akhmadeeva

Chief of

PhD V.F. Shakirov

Introduction

On the Chair of propaedeutics of internal diseases the symptoms and attributes of disease, methods of their investigation are studied; student trains the logic of diagnosis construction. From the first days of clinical practice students should also acquire principles of medical ethics and a basis medical deonthology.

The knowledge of propaedeutics is necessary not only for the further studying therapy, but also for other clinical disciplines. The skills to distinguish symptoms of diseases, to know the basic diagnostic methods, to own methodology of the diagnosis should not only the therapist, but also the surgeon, the gynecologist, the neuropathologist, the stomatologist and all other clinical experts.

Federal State Educational Organization of ROSZDRAV

Bashkir State Medical University

Faculty of propaedeutics of internal illnesses with a rate of physiotherapy

Chef of the Chair

The teacher

THE CASE HISTORY

Family name, surname, fathers name of patient ________________________________

_______________________________________________________________________

The clinical diagnosis: ____________________________________________________

Main diagnosis: _________________________________________________________

______________________________________________________________________

Complications: __________________________________________________________

Accompanying diseases: ___________________________________________________

The curator - student ________________________ of year ________ group __________

_____________________________________________ faculty

The time of curation from ______________ till ________________

I. THE PASSPORT PART

1. A surname, a name, a patronymic.

2. Age.

3. A profession, a place of work (study), a post.

4. A constant residence.

5. Date of reception.

6. Date of curation.

II. COMPLAINTS

In this section the basic complaints of the patient showed by in the day of investigation will be worn out only with their detailed characteristic is resulted. To the basic complaints carry the disturbing sensations being a direct occasion for the reference {manipulation} of the patient to the doctor.

Variant of questions :

Ø What does the patient complain on?

Ø Exact localization (and irradiation) of the painful sensations.

Ø Occurrence time (in the afternoon, at night).

Ø The factors causing painful sensations (a physical or mental pressure{voltage}, food reception, etc.).

Ø Character of the painful phenomenon, for example, character of a pain:

Ø Compressing, колющий, burning, constant, приступообразный, etc. his{its} intensity and duration.

Ø What helps the painful to brake? Under the resulted provisional circuit of questions detailed elaboration of each basic complaint of the patient is carried out.

For example, the patient complains on the rise in temperature (fever).

Variant of questions:

Ø Character of a fever (constant, passing).

Ø How quick does the temperature raise?

Ø Whether rise of temperature is accompanied with fever?

Ø Range of temperature fluctuations during the day.

Ø Duration of the feverish period.

Ø What do patients feel during rise in temperature?

Ø What reduces temperature?

P.S. At absence of patient’s complaints at the moment of investigation students of III-IV year will registrate the complains with which the patient was accepted to the clinic.

III. THE HISTORY OF PRESENT DISEASE (anamnesis morbi)

In this section in detail, in chronological sequence occurrence, current and development of the present disease from its first displays till the moment of investigation by the curator is described.

Variant of questions:

1. What is the duration of disease?

2. The factors promoting the beginning of disease.

3. From what features does the disease manifested?

4. First physicains investigation, results of investigations, diagnosis, treatment during this period, its efficiency.

5. The subsequent development of disease:

а) Dynamics of initial symptoms, occurrence of new ones and the further development of all features of disease;

б) Frequency of aggravations, duration of remissions, complications of disease;

в) Used medical and diagnostic actions (stationary or out-patient investigation and treatment, drugs, physiotherapy, sanatorium treatment, etc. methods), results of diagnostic investigations (blood, urine, electrocardiogram analyses), efficiency of performed treatment therapy;

г) Labour capacity for the period of disease.

6. The detailed description of the present exacerbation of disease which has forced the patient to address to physicains.

IV. LIFE HYSTORY (anamnesis vitae)

The brief biographic data:

Data of place of the birthplace, in what family was born, what child under the account as dews and developed. Education: incomplete or complete middle, special middle or the highest.

Mlitary service, stay at the war (if has been exempted or demobilized to specify, for what reason).

The family-sexual anamnesis:

For women - time of menses occurrence, duration of menstrual cycle, duration of menses, amount of blood. When was married. Pregnancy, роды and aborts (spontaneous and artificial), their number and complications.

Climax and its status. Time of menopause beginning. The marital status at the moment. Number of children.

The working anamnesis:

With what age, whom and where started to work. The further labour activity in chronological sequence with the indication of places of work and posts. Conditions and a mode of work. Professional harm (influence of toxic chemical compounds, пылей, radiation, physical and emotional loadings.

The household anamnesis:

Housing and sanitary-and-hygienic conditions of life (area of premises{rooms}, their characteristic, presence of convenience). Quantity{amount} of persons living on the given living space. Climatic conditions. Stay in zones of ecological disasters.

A feed{meal}:

Mode and regularity of a feed{meal}, character peep, its{her} variety, caloric content, etc.

Harmful habits:

Smoking, from what age, in what quantity{amount}. The use of alcohol, from what age, in what quantity{amount}. The use of drugs.

The transferred diseases:

In chronological sequence all transferred diseases, operations, wounds, traumas, contusions with the instruction{indication} of age of the patient, duration and weight of these diseases and their complications and carried out{spent} treatment are stated. Especially to specify the transferred infectious diseases, venereal illnesses, a tuberculosis, a jaundice. To note, whether blood or кровезаменители was poured earlier, and whether there were reactions to transfusion. To specify, whether it was carried out{it was spent} парентеральное introduction of medicines within last 6 months.

Аллергологический the anamnesis:

Intolerance of foodstuff, various medicines, vaccines and wheys. Presence of allergic reactions (вазомоторного a rhinitis, крапивницы, hypostasis Квинке), the reasons of these reactions, their seasonal prevalence.

The insurance anamnesis:

Duration of last hospital sheet, general duration of hospital sheets on the given disease for last calendar year. Physical inability (from what age, the reason, group of physical inability).

V. THE HEREDITY

Parents, brothers, sisters, children: a condition of their health, disease, the reason of death (to specify, at what age).

The burdened heredity:

Presence at close relatives malignant новообразований, cardiovascular (a heart attack of a myocardium, a stenocardia, an arterial hypertensia, insults), эндокринных (a diabetes, тиреотоксикоз, etc.) and mental diseases, геморрагических diathesises, алкоголизма. Presence in the anamnesis at close relatives of a tuberculosis.

VI. THE PRESENT{TRUE} CONDITION (status praesens)

THE GENERAL{COMMON} SURVEY (inspectio)

The general{common} condition of the patient:

Satisfactory, average, heavy.

Consciousness: clear, confused - a stupor, сопор, кома, delirium, hallucinations.

Position of the patient: active, passive, compelled (to specify - what).

Constitution: конституциональный type (нормостенический, hypersthenic, asthenic), growth, weight of a body. A bearing (a straight line, сутуловатая), gait (fast, slow, атактическзя, spastic, паретическая).

Body temperature:

Look:

Quiet, indifferent, маскообразное, melancholy, suffering, excited, tired, etc. Person Korvizara. fades feoris, facies nephritica, facies mitralis, facies Hyppocratica, facies Basedovica, etc.

Integuments:

Color (light pink, swarty, red, cyanotic, icteric, pale, earty). Pigmentation and депигментация (лейкодерма), their localization.

Высыпания: the form of a rash (розеола, папула, пустула, везикула, эритема, a stain, feverish высыпания - herpes); localization высыпаний, individual or plural (drain) высыпания.

Vascular changes: телеангиоэктазии, " vascular asterisks ", their localization and quantity{amount}.

Haemorrhages: localization, the size, quantity{amount}, expressiveness.

Рубцы: localization, color, the sizes, mobility, morbidity.

Trophic changes: ulcers, пролежни, their localization, the size, character of a surface, etc.

Seen tumours: a myoma, ангиома, атерома and others, their localization, the size.

Humidity of a leather{skin}. Тургор leather{skin}. Type оволосения.

Nails: the form (" hour glasses ", койлонихии, etc.), color (pink, cyanotic, pale); cross-section or longitudinal исчерченность, fragility of nails.

Seen mucous: color (pink, pale, cyanotic, icteric, red); высыпания on mucous (энантема), their localization and expressiveness; humidity mucous.

Hypodermic - fatty клетчатка:

Development (moderate, weak, excessive); places of the greatest adjournment of fat (on a stomach, hands, hips); hypostases (oedema); their localization (finitenesses, a waist, a stomach), prevalence (local or the general{common} - анасарка), expressiveness (пастозность, moderate or sharply expressed), a consistence of hypostases.

Morbidity at пальпации hypodermic - fatty клетчатки, presence крепитации (at air эмфиземе hypodermic клетчатки).

Lymph nodes:

Localization palpated лимфоузлов (occipital, околоушные, submaxillary, cervical, надключичные and подключичные, axillary, локтевые, паховые, popliteal). Their size, the form, a consistence, morbidity, mobility, сращения among themselves and with surrounding fabrics, a condition of a leather{skin} above лимфоузлами.

Muscles:

Degree of development (satisfactory, weak and-or atrophies, hypertrophies of muscles).

Tone: it is kept, reduced, raised{increased} (ригидность muscles). Force of muscles. Morbidity and condensation at ощупывании.

Bones:

The form of bones, presence of deformations, morbidities at ощупывании, поколачивании. A condition of trailer phalanxes of fingers of hands and legs{foots} (a symptom of " drum-type fingers " ).

Joints:

Configuration, swelling, morbidity at ощупывании, гиперемия and local temperature of skin above joints. Movements in joints: their morbidity, a crunch at movements, volume of active and passive movements in joints.

SYSTEM OF BODIES OF BREATH

Complaints:

Cough (tussis): its character (dry - unproductive or with allocation мокроты - productive), time of occurrence (in the afternoon, at night, in the morning), duration (constant, periodic, приступообразный), conditions of occurrence and knocking over of cough.

Мокрота (sputum): character, color and a consistence (serous, mucous, mucopurulent, purulent), the quantity{amount} мокроты is one-stage and for a day; impurity of blood; the position promoting best отхождению мокроты.

Кровохарканье (haemoptoe): quantity{amount} of blood (прожилки, clots or pure{clean} blood); color of blood (scarlet, dark, rusty or crimson color); conditions of occurrence кровохарканья.

Pain (dolor) in a thorax: localization, character of a pain (sharp, stupid{blunt}, колющие) intensity (weak, moderate, strong); duration (constants, приступообразные); communication{connection} be ill with respiratory movements; иррадиация pains.

Short wind (dyspnoe): conditions of occurrence (in rest, at physical loading, at cough, at change of position of a body, etc.); character of a short wind (инспираторная, экспираторная, mixed).

Asthma (asthma): time and conditions of occurrence, duration of attacks, their knocking over.

Fever (febrls): see. Complaints at a fever.

Survey

Nose: change of the form of a nose, breath through a nose (free, complicated). Separated from a nose, his{its} character and quantity{amount}. Носовые bleedings.

Throat: Deformation and a swelling in the field of a throat. A voice (loud, silent, hoarse), absence of a voice - афония.

Thorax:

The form of a thorax: нормостеническая, hypersthenic, asthenic: pathological forms (эмфизематозная, or бочкообразная, paralytic, ладьевидная, rachitic, funneled). Expressiveness above and подключичных ямок (are executed, sunk down, are involved); width of intercostal intervals (moderate, wide, narrow);

Size эпигастрального a corner (a straight line, sharp, stupid{blunt}); position лопаток and ключиц (do not act, act moderately, distinctly{clearly}, крыловидные лопатки); a parity{ratio} of the передне-back and lateral sizes of a thorax; symmetry of a thorax (increase or reduction of one of half, local выпячивания or западения).

Curvatures of a backbone: кифоз, лордоз, a scoliosis, кифосколиоз. A circle of a thorax, excursion of a thorax on a breath and an exhalation.

Breath: Type of breath (chest, belly, mixed). Symmetry of respiratory movements (backlog in the certificate{act} of breath of one half). Participation in breath of auxiliary muscles. Number дыханий in one minute. Depth of breath (superficial, deep, including breath Куссмауля). A rhythm of breath (rhythmical, arrhythmic, including breath Чейн-Стокса and Biothat). A parity{ratio} of a breath and an exhalation. Attributes of difficulty of a breath and-or an exhalation (инспираторная, экспираторная and the mixed short wind).

Пальпация

Definition of painful{unhealthy} sites, their localization. Definition of resistency (elasticity) of a thorax. Definition of voice trembling on symmetric sites (it is identical, усилено or is weakened on the one hand).

Перкуссия easy

Comparative перкуссия: character перкуторного a sound on symmetric sites of a thorax (a sound clear легочный, dulled, stupid{blunt}, box, тимпанический, dulled - тимпанический) with exact delimitation of each sound on edges and topographical lines.

Topographical перкуссия:

The top border easy: on the right at the left

Height of standing of tops in front......

Height of standing of tops behind......

The bottom border easy:

On околоградинной lines... неопредел.

On срединноключичной lines... неопредел.

On a forward axillary line......

On an average axillary line......

On a back axillary line......

On лопаточной lines......

On околопозвоночной lines......

Respiratory excursion of the bottom edge{territory} easy:

On a back axillary line........

Аускультация

The basic respiratory noise:

Character of the basic respiratory noise above symmetric departments easy (везикулярное, weakened, amplified{strengthened}, rigid, bronchial, амфорическое, absence of respiratory noise).

Collateral respiratory noise:

Rattles (dry or damp), крепитация, noise of friction of a pleura, their localization and the detailed characteristic.

Бронхофония: Definition бронхофонии above symmetric sites of a thorax (identical from both parties{sides}, усилена or it is weakened on the one hand).

Survey

Survey of a neck: an amplified{a strengthened} pulsation of carotids (" dancing каротид " ). Swelling of cervical veins. A seen pulsation of veins (presence negative or positive венного pulse).

Survey of area of heart: Выпячивание areas of heart (Gibbus cordis). Seen pulsations (a top push, an intimate push, эпигастральная a pulsation, атипичная a pulsation in the field of heart); their characteristic (localization, prevalence, force, the attitude{relation}, to phases of intimate activity).

Пальпация

Top push: his{its} localization (to specify межреберье and the attitude{relation} to left срединноключичной lines); force (normal, amplified{strengthened}, raising); the area (limited, разлитой).

Intimate push: his{its} localization, the area.

Эпигастральная a pulsation: its{her} character (communication{connection} with pulsations of a belly aorta, heart, a liver) force, prevalence (limited or разлитая).

Trembling in the field of heart: (fremitus): his{its} localization;

The attitude{relation} to phases of intimate activity (систолическое or диастолическое).

Definition пальпаторной morbidities and zones гиперестезии in прекордиальной areas.

Перкуссия

Relative dullness of heart:

Borders of relative dullness of heart:

Right.......

Left.......

Top.......

Diameter of relative dullness of heart (in sm)......

Width of a vascular bunch{beam} (in sm).......

Configuration of heart (normal, митральная, аортальная, etc.).

Absolute dullness of heart:

Borders of absolute dullness of heart:

Right.......

Left.......

Top.......

Аускультация

Tones: the Rhythm of intimate reductions (rhythmical or arrhythmic forms with the instruction{indication} аритмии - respiratory аритмия, vibrating аритмия, экстрасистолия, loss of intimate reductions). Number of intimate reductions.

The first tone, his{its} loudness (the normal sonority, weakened, amplified{strengthened}, clapping); splitting or bifurcation of the first tone.

The second tone, his{its} loudness (the normal sonority, weakened, amplified{strengthened} - stressed); splitting or bifurcation of the second tone.

Additional tones: пресистолический and-or протодиастолический a rhythm of gallop, a rhythm of a quail, систолический gallop, etc.

Noise: the Attitude{Relation} to bases of intimate activity (систолический, диастолический, пресистолический, протодиастолический, мезодиастолический, etc.).

Place of the best auscultation of noise. Carrying out of noise.

Character of noise (soft, blowing, скребущий, rough, etc.), his{its} timbre (high, low); loudness (silent, loud); duration (short, long), the form (increasing, нарастающе-decreasing - ромбовидный, decreasing, etc.).

Changes of noise depending on position of a body, a delay of breath on a breath and an exhalation and after physical loading.

Noise of friction of a pericardium: a place of the best auscultation, character of noise (rough both loud or silent and gentle).

Research of vessels

Research of arteries: Survey and пальпация temporal, sleepy, beam, popliteal arteries and arteries of rear stops; expressiveness of a pulsation, elasticity, smoothness of an arterial wall, извитость arteries. Definition of a pulsation of an aorta in яремной ямке. Auscultation sleepy, femoral, почечных arteries, a belly aorta (presence of vascular noise, double tone Траубе, double noise Виноградова-Дюрозье, etc.).

Arterial pulse: Arterial pulse on beam arteries: comparison of pulse on both hands (presence pulsus dificiens), a pulse rate, a rhythm (presence аритмий), filling; a pressure{voltage}; size; speed; the form of pulse. Presence of deficiency of pulse.

Arterial pressure (HELL): on humeral arteries in mm рт. An item (on Korotkov's method it is defined{determined} систолическое and диастолическое the HELL).

Research of veins: Survey and пальпация cervical veins, their swelling, a seen pulsation, presence negative or positive венного pulse.

Auscultation яремной veins (" noise of a top " ).

Presence of expansion вен* a thorax, a belly wall, finitenesses, with the instruction{indication} of a place and a degree of expansion.

Condensation and morbidity of veins with the instruction{indication} of a vein and extent of condensation or morbidity.

Complaints

Pains in a stomach: localization, иррадиация, intensity, duration, conditions of occurrence and communication{connection} with reception of food (early, late, hungry pains); character be ill (constant, схваткообразный, sharp, stupid{blunt}, whining); knocking over of a pain (independent or after reception of food, application of heat, a cold, medicines, after vomitting).

Диспепсические the phenomena: Difficulty of swallowing or passage of food on a gullet (dysphagia), a nausea (nausea), vomitting (vomitus), an eructation, a heartburn (pyrosis), a swelling of a stomach (meteorismus). The detailed characteristic, a degree of expressiveness of these phenomena, the attitude{relation} to reception of food, its{her} quality and quantity{amount}, than are stoped диспепсические the phenomena.

Appetite: it is kept, lowered, raised{increased} (polyphagia), completely is absent (anorexia), it is perverted. Disgust for food (fat, meat).

Chair: Frequency for a day, quantity{amount} (plentiful, moderate, small), a consistence of a chair (made out, liquid, кашицеобразный, firm, " sheep" ), color кала (brown, yellowy-brown, yellow, gray-white, дегтеобразный).

Bleedings: Attributes пищеводного, gastric, intestinal and геморроидального bleedings - vomitting by blood, a coffee grounds{thick}, black дегтеобразный a chair (melena); fresh blood in кале.

Survey

Oral cavity: Language (painting, humidity, a condition сосочкового a layer, presence of strikes, cracks, ulcers).

Condition of a teeth. Desna, the soft and firm sky (painting, strikes, геморрагии, изъязвления).

Pharunx (painting, a redness, a swelling, strikes). Миндалины (size, a redness, a swelling, strikes).

Stomach: the form of a stomach, his{its} symmetry, participation in the certificate{act} of the breath, seen перистальтика a stomach and an intestines, venous коплатерали. A condition пупка.

Circle of a stomach at a level пупка.

Перкуссия

Character перкуторного a sound. Presence free or осумкованной liquids in a belly cavity.

Пальпация

Superficial rough пальпация: painful{unhealthy} areas, a pressure{voltage} of muscles of a belly wall (muscular protection - defance musculaire), a divergence of direct muscles of a stomach and presence of hernias, presence superficially located опухолевидных formations{educations}. Перитонеальные symptoms (symptom Щеткина-Блюмберга, etc.). Mendel's symptom.

Methodical deep sliding пальпация on Образцову-Стражвско : Definition of localization, morbidity, the sizes, the form, a consistence, character of a surface, mobility and rumbling сигмовидной, a blind gut, cross-section - ободочной, ascending, descending ободочной guts, the big curvature of a stomach, the gatekeeper (with preliminary definition of the bottom border of a stomach by a method перкуссии, перкуторной пальпации - definition of noise of splash, and a method аускультаторной перкуссии).*

At presence of tumoral formations{educations} their sizes, a consistence, morbidity, смещаемость, localization and possible{probable} communication{connection} with that or other body of a belly cavity are described also.

Аускультация

The characteristic listened перистальтики intestines. Noise of friction брюшины..

LIVER AND BILIOUS BUBBLE

Complaints

Pain in the right подреберье: Character be ill (приступообразные or constants, sharp, stupid{blunt}, whining, feeling of weight in the field of right подреберья); иррадиация pains; conditions of occurrence (dependence on reception of food, on change of position of a body, on physical loading и.т.д.); than pains are stoped.

Диспепсические the phenomena: the Nausea, vomitting (character of emetic weights, them колличество), an eructation. Conditions of occurrence диспепсических the phenomena, communication{connection} with reception of food, than are stoped.

Fever: see. Complaints at a fever.

Survey

Borders of a liver on Курлову:

The top border абсоллютной dullness of a liver:

On right среднеключичной lines. (to specify, on what edge)

The bottom border of absolute dullness of a liver:

On right среднеключичной lines

On a forward median line

On the left costal arch

Поколачивание on the right costal arch: Presence of symptom Ортнера.

Пальпация

Liver: Specification of the bottom borders of a liver on срединно-ключичной and a forward median line.

The characteristic of edge{territory} of a liver (sharp or rounded, soft or dense, painful{unhealthy} or painless).

The characteristic of a surface of a liver (at its{her} increase): a surface smooth, granular, бугристая.

The sizes of a liver on Курлову:

On right среднеключичной lines (in sm)

On a forward median line (in sm)

On the left costal arch (in sm)

Bilious bubble: the Characteristic of a bilious bubble, it{him} прощупываемостй, morbidities, the sizes, and also presence of symptoms

Кера, Курвуазье, a френикус-symptom.

Аускультация

Presence of noise of friction брюшины in the field of a liver.

PANCREAS

Complaints

Pain : Localization (in the top half of stomach), иррадиация (surrounding pains), character be ill (sharp, stupid{blunt}, constant, приступообразные), conditions of occurrence (communication{connection} with reception of food, alcohol, physical loading, etc.), than are stoped.

Диспепсические the phenomena: nausea, vomitting, meteorism, diarrheas, locks and their detailed characteristic.

Palpation

Presence of morbidity, increase and condensation of pancreas.

SPLEEN

Complaint

Pain in left costal archподреберье : Character be ill (constants or приступообразные, sharp or stupid{blunt} whining), intensity of a pain, its{her} duration, иррадиация, conditions of occurrence (communication{connection} with change of position of a body, physical loading, etc.).

Survey

Presence limited выпячивания in the field of left подреберья, restriction of this area in breath.

Перкуссия

Definition of the longitudinal and cross-section size of a spleen in see.

Пальпация

Прощупываемость spleens in a prone position on one side and on a back. The characteristic of the bottom edge{territory} of a spleen (sharp or rounded, painful{unhealthy} or painless). The characteristic of a surface of a spleen (at its{her} substantial growth): a surface smooth or бугристая, painful{unhealthy} or painless.

Аускультация

Presence of noise of friction брюшины in the field of a spleen.

Complaints

Pain: its{her} localization (in lumbar area, in the bottom of a stomach, on a course мочеточника); иррадиация; character of a pain (sharp or stupid{blunt}, constant or приступообразная); duration of a pain; conditions of occurrence of a pain (physical loading, change of position of a body, reception of a spicy food, alcohol, water loading, etc.), than are stoped to a pain.

Мочеиспускание: Quantity{Amount} wet for a day (presence полиурии, олигурии, анурии or delays of urine - ишурии).

Дизурические frustration: complicated мочеиспускание (a thin jet, drops, faltering): presence involuntary мочеиспускания; false desires on мочеиспускание; резь, burning, pains during time мочеиспускания (in the beginning, in the end or during the certificate{act} мочеиспускания): учащенное мочеиспускание (поллакиурия); night мочеиспускание (никтурия).

Urine: Color wet (straw-coloured, is sated yellow, dark, color of " beer", red, colors " meat помоев ", etc.); a transparency wet. Presence of an impurity of blood in urine (in the beginning or in the end мочеиспускания, in all portions).

Hypostases: localization; time of occurrence (in the morning, in the evening, during day); conditions of occurrence or amplification{strengthening} of hypostases (drinking loading, superfluous reception salt, etc.); speed of increase of hypostases;

The factors promoting reduction or disappearance of hypostases.

Survey

Lumbar area: presence гиперемии leather{skin}, swellings, smoothings of contours of lumbar area.

Надлобковая area: presence limited выбухания in надлобковой areas.

Перкуссия

Lumbar area: definition of symptom Пастернацкого.

Надлобковая area: character перкуторного a sound above лобком; at increase in a bladder - a level of an arrangement of a bottom of a bladder.

Пальпация

Kidneys: пальпируемость kidneys in a prone position and costing{standing}; at increase in kidneys - their morbidity, a consistence, size, the form, mobility, presence of a symptom of balloting.

Bladder: пальпируемость a bladder; at increase in a bladder - a level of an arrangement of a bottom of a bladder, morbidity at пальпации.

Painful points: presence of morbidity at пальпации in реберно-позвоночной to a point and on a course мочеточников (мочеточниковые points).

SYSTEM OF GENITALS

Complaints

Pain: presence be ill in the bottom of a stomach, in a groin, a waist, крестце, мошонке, in the field of external genitals. Character be ill, localization, иррадиация, conditions of occurrence, than are copied.

Менструальный a cycle: a regularity; duration менструального a cycle; duration менструаций, quantity{amount} менструальных branches, morbidity. Маточные bleedings, others of allocation (бели).

Sexual function: normal, it is raised{increased}, reduced, no.

Survey and пальпация

Secondary sexual attributes: type оволосения (man's, female), a scalp in axillary hollows, on the person, on a stomach, in лобковой areas. Presence гинекомастии. A voice (high, low). Attributes гирсутизма, евнухоидизма, вирилизма, feminism.

Dairy железы (at women) and chest железы (at men):

Degree of development, condition of integuments, pigmentation, local hypostasis as " citric корки ", втяжения. Symmetry желез. The form сосков, presence of erosion and ulcers, deformation желез. Condensation, тяжистость and tumoral formations{educations} at пальпации желез.

External genitals (at men): the size мошонки, яичек, a hypostasis мошонки, morbidity at пальпации яичек, presence of tumoral formations{educations}. Недоразвитие яичек (anarchism, крипторхизм). Erosion and ulcers of a sexual member. Anomalies and uglinesses of a sexual member.

Предстательная iron (at men): the size, a consistence, пальлаторная morbidity предстательной железы at ректальном research.

Gynecologic research (at women) ': a condition ка-ружных genitals, a vagina, a uterus, appendages at survey in mirrors and бимануапьной пальпации.

ЭНДОКРИННАЯ SYSTEM

Complaints

Infringement of growth, constitution, increase in weight of a body, похудание, thirst, feeling of famine, constant sensation heat, потливость, ознобы, spasmes, muscular weakness, rise in temperature of a body. The detailed characteristic of these complaints.

Survey and пальпация

Infringements of growth, constitution and proportionality of separate parts of a body.

Adiposity: a degree of expressiveness, primary localization of fat. Исхудание, кахексия.

Condition of integuments: humidity, истончение or огрубение; hyperpigmentation of a leather{skin}, skin складок (localization), presence стрий; атиличное оволосение; лунообразное the person.

Increase in the sizes of language, nose, челюстей, auricles, brushes of hands and stop.

Пальпация a thyroid gland: localization, size and a consistence, morbidity, mobility.

Complaints

Headache: localization, intensity, periodicity, character of a headache, time and the reason of occurrence, than is stoped.

Dizziness: character of dizziness, a condition of his{its} occurrence (at walking, at change of position of a body and a head, etc.). The accompanying phenomena.

Condition of mentality: Serviceability, memory, attention, dream, his{its} depth, duration, a sleeplessness.

Emotional - strong-willed sphere: mood, features of the character, the raised{increased} irritability, slackness, apathy, disturbing suspiciousness, depression, euphoria. Suicide ideas and moods.

Impellent sphere: Weakness in finitenesses, trembling, spasmes, other involuntary movements.

Sensitive sphere: Infringements of skin sensitivity (гипестезии, гиперестезии, парестезии), pains on a course of nervous trunks, корешковые pains. Sight, taste, sense of smell, hearing.

Survey

Condition of mentality: Consciousness. Orientation in a place, time and a situation.

Intelligence: Easing of intellectual functions (easing, attention, decrease{reduction} in memory, infringement of criticism, decrease{reduction} in a circle of interests) corresponds{meets} or does not correspond{meet} to a level of development.

Behaviour of the patient in clinic, a degree of sociability, steadiness, fussiness, impellent anxiety.

Research of craniocereberal nerves: Visual acuity, doubling in eyes (диплопия); птоз, volume of movements of eyeballs, reaction of pupils to light. Symmetry носогубных складок at a grin of a teeth. Frustration of swallowing. Дисфония. Position of language at высовывании.

Менингеальные symptoms: ригидность occipital muscles, symptoms Кернига and Брудзинского.

Impellent sphere: character of gait with the open and closed eyes (usual, атактическая, паретическая, other forms).

Stability at standing with the open and closed eyes (test Ромберга).

Finger - носовая and коленно-calcaneal tests.

Spasmes: клонические and tonic, фибриллярные twitchings, trembling (tremor), etc. involuntary movements. Контрактуры muscles (localization). Volume of movements and force in finitenesses.

Sensitive sphere: Пальпаторная morbidity on a course of nervous trunks and корешков. Infringements of skin and deep sensitivity (localization). Symptoms of a tension, symptom Лассега.

Reflexes: Corneal, pharyngeal.

Сухожильные reflexes: knee, ахиллов.

Pathological reflexes: symptoms Бабинского and Россолимо. Speech: афазия (motor or touch), дизартрия.

Vegetative nervous system:

Eye symptoms: width of an eye crack, width of a pupil, экзофтальм or анофтальм. Symptom Горнера.

Leather{Skin}: a kind дермографизма, temperature asymmetry, гипертрихоз, облысение, trophic ulcers, infringement потоотделения.

VII. THE DIAGNOSIS (PRELIMINARY) AND HIS{ITS} SUBSTANTIATION

The preliminary diagnosis is formulated right after the terminations{endings} of interrogation and objective research of the patient on the basis of the analysis of complaints, анамнестических the data and results objective физи-кального researches of the patient.

In the formulation of the preliminary diagnosis should be allocated:

а) The diagnosis of the basic disease;

б) The diagnosis of complications of the basic disease;

в) The diagnosis of accompanying disease.

Further the brief substantiation of the preliminary diagnosis is resulted:

1) Listing{Transferring} and analyzing the basic complaints of the patient, it is expedient to make the conclusion about primary defeat of this or that body or system;

2) On the basis of the analysis of all available clinical data it is necessary to allocate the basic pathological symptoms and syndromes, to give their characteristic and to describe features of displays at the given patient;

3) Analyzing pathogenetic interrelation of separate pathological symptoms and syndromes to make the conclusion about their possible{probable} unity and an accessory{a belonging} to this or that disease (i.e. to furnish proofs нозологического the diagnosis);

4) According to the accepted classifications it is necessary to prove whenever possible the individual diagnosis, namely to furnish proofs:

а) The clinical, клинико-morphological or pathogenetic form of disease,

б) Character of current (sharp, подострое, chronic, рецидивирующее, long, slowly progressing, quickly progressing, etc.),

в) Stages, phases, degrees of activity of pathological process,

г) Presence of complications,

д) Degrees (stage) of functional frustration and-or weights of disease.

5) Briefly, by transfer of the basic symptoms to prove the diagnosis of accompanying diseases if those are available.

XIV. THE DIARY

The diary reflects results of daily survey of the patient with the attending physician. The special attention addresses on dynamics{changes} of all displays of illness, and also efficiency of treatment and attributes of possible{probable} undesirable (collateral) action of medicines.

In the beginning in a diary the estimation of a condition of the patient is given, complaints for the expired day, including quantity{amount} and character of episodes of illness (attacks of pains, an asthma, faults in work of heart are described, etc.), dream, appetite, a chair, мочеиспускание is estimated. Then cited the brief objective data on bodies under condition of their change in dynamics{changes}. The data of measurements (number of intimate reductions, pulse, number of respiratory movements, the HELL, диурез) are born{taken out} in a temperature sheet (a sheet of the basic parameters of a condition of the patient), and various medical purposes{assignments} - in a sheet of purposes{assignments}.

In a diary it is necessary to reflect medical interpretation of new clinical symptoms and results of additional methods of research, and also change in tactics of treatment.

Each 10 days of stay of the patient in a hospital, and also in case of sharp change in a condition of the patient or at revealing the new diagnostic attributes essentially changing representations of the doctor about the clinical diagnosis, it is made out этапный эпикриз. In it{him} the brief conclusion of the doctor about the clinical diagnosis concerning which the patient is in a hospital, about features of current of disease and presence of complications is resulted. The list of the medical means used at the given stage of treatment of the patient is resulted also. Dynamics{changes} of the basic attributes of disease, including dynamics{changes} of results of laboratory and tool research of the patient with the instruction{indication} conducting{leading} laboratory, электрокардиографических, the radiological and other parameters revealed at the patient for past period is especially in detail described. All by-effects of therapy used at the given stage having a place are described. On this basis it is judged adequacy of the appointed therapy and its{her} efficiency. The plan of the further treatment and inspection of the patient is proved.

In case of deterioration of a condition of the patient reasons of the doctor about the possible{probable} reasons of such deterioration (infringement of a diet, a mode, progressing of the basic disease, an inefficiency or inadequacy of the appointed therapy, etc.) are resulted. At not clear diagnosis, it is especial at occurrence of new symptoms of illness, it is necessary to plan the plan of the further inspection of the patient, and also the plan of the further treatment.

XVI. THE FORECAST

The forecast is proved by the data received at research of the patient during time of curation. It includes:

а) The health forecast (whether recovery or deterioration is possible at chronic disease and under what conditions);

б) The life forecast (whether disease of a life of the patient threatens);

в) The work forecast (degree of restriction of work capacity, physical inability - time or constant).

XVIII. EPICRIS

Final эпикриз (выписной, translation, posthumous) the final clinical diagnosis is made out in the same cases, as. It{he} represents the brief description of the case record and includes the following sections:

1. A surname, a name, a patronymic of the patient, date (if necessary - time) receipts and extracts (or death). The final clinical diagnosis.

2. The basic complaints at receipt (it is brief).

3. The basic анамнестические the data (briefly), giving representation about prescription, character and features of current of disease and his{its} complications, and also data on transferred other diseases.

4. The basic pathological data on bodies.

5. The data of laboratory and tool methods of research (at receipt and at an extract or death): clinical analyses of blood, urine, кала, мокроты, an electrocardiogram, results of radiological research, biochemistry of blood, the data of other methods of research, and also the conclusion of experts - advisers.

6. The treatment lead{carried out} by a hospital: a mode, a diet, medicamentous means (their dosage and duration of reception), physical methods of treatment, operation, etc.

7. An estimation of results of treatment in a hospital on the basis of dynamics{changes} of the basic displays of illness. A condition of the patient at an extract.

8. The conclusion of a hospital: leaves for work (the mode of work, restriction), in a polyclinic, is translated in other hospital, goes on долечивание to sanatorium, goes on МСЭК.

9. Recommendations concerning a mode, diets, operating conditions and a way of life, secondary preventive maintenance, medicamentous (the name of a preparation, a doze, ways of reception, duration of treatment) or other methods of treatment. Sanatorium treatment.

XIX. LIST ЛИТЕРАТУРЫ*

The list of the domestic and foreign literature used by the curator at a spelling of the given case record is resulted.

The signature of the curator. ________________ Date. __________________

THE APPENDIX №1

Arterial hypertension.

1. Nechiporenko analysis.

2. Radioisotope renography.

3. Kidneys scanning.

4. Intravenous urography

5. Skull X-ray (a turkish saddle).

6. Epinephrine and nonepinephrine blood and urine investigation.

7. Research 17-ketosteroids investigation.

8. Blood electrolits investigation.

9. Zimnizkiy test.

10. Creatinine in blood and urea.

11. Lipip exchange parameters.

12. Eye bottom investigation.

13. Kidneys and adrenal glands ultrasound investigation.

Bashkir state medical university

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