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).

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