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O.O.Bohomolets NATIONAL MEDICAL UNIVERSITY
Department of Internal Medicine № 2
Head of the department, professor______________________________
Lecturer, Associate Professor (assistant) ________________________
A CASE HISTORY
(surname, name and patronymic of the patient)
Complication of the main disease ____________________
Related disease ___________________________________
Curator - student_______________of the course
(surname, name, patronic)
Time of curation: from_________
Kyiv, The Year
I. ANAMNESIS (Interrogatio)
1. PASSPORT PART
Surname, name, patronic______________________________________
Education (primary, secondary, tertiary)
Place of employment_______________________
Date of admission to the hospital__________________________________
Diagnosis at the day of admission_________________________________
2. COMPLAINTS OF THE PATIENT (briefly)
Patients complaints on admission to the clinic and prior to the supervision are recsequently. First, describe the main feelings that were the reason for hospitalization of the patient, then - the secondary complaints of a minor nature. Then carefully characterized each of the complaints (in details).To define them is possible only when a doctor asks a patient additional questions. The review should be started from the main affected system. If the patient complains of pain indicate its localization, nature, time of occurrence, intensity, periodicity, duration, conditions for the appearance, relation to external factors, irradiation, etc.
It is necessary to find out what relieves the pain - taking medicine (which ones?), Heat, cold, and some (forced) status, etc., by what it is accompanied (by a feeling of fear, severe weakness, chills, vomiting, dispnoea, dizziness, etc. etc.).
In this chapter all other complaints of the patient should also be recorded.
3. HISTORY OF PRESENT ILLNESS (briefly)
Briefly described is the development and course of disease with the onset of initial signs of illness until the day of curing.
4. REVIEW OF ORGANS AND SYSTEMS
Characteristics of the general status: overall health, weakness, fever, weight loss, presence of edema (localization, time of appearance, etc.).
The review should be started from the system which desturbances predominated in the clinical manifestation of the disease.
Blood system (systema circulationis sanguinis). Pain (dolor) in pericardial zone: localization (behind the breastbone, the left of the sternum, in the apex), character (crushing, piercing, constricting, aching, etc.), intensity, irradiation, the duration ( continuously, periodically), the frequency of occurrence and the cause (physical stress normal or increased, excitement, etc.) by what is removed (nitroglycerin, analgin or other means); behavior during pain (decrease or increase in locomotor activity, forced position, rest); appearance during the pain of fear of death, depression, increased sweating, urination, dizziness, headache, shortness of breath, breathlessness (a detailed description of them), memory disturbances, vision.
Palpitation (palpitatio cordis): its nature (after what it appears or is intensified), the relationship with excitement or physical exertion, food intake, change in body position, lack of apparent reason, the frequency, duration, continuity, paroxysmal; is removed with drugs or drug-free means. Intermissions in cardiac activity: constant, periodic, connection with the load, food intake, change in body position.
Shortness of breath (dyspnoe): periodic, continuous, paroxysmal, inspiratory, expiratory, mixed; relationship with the load, emotional load (no reason), asthma, their nature, duration, cause, time of appearance than removed (nitroglycerin, hihteneo body position, antiasthmatic agents).
Edema (edema): localization in the shins, feet, abdomen, lumbar region, or face; time when there are (in the morning or evening), frequency, severity and duration, the impact of diuretics and other means.
Respiratory system (systema respiratorium). Breathing quality assessment (free, through the nose); dryness during respiration, scratching behind the breastbone.
Cough (tusis): dry, wet, permanent, periodical, fitlike, appears in the morning or at night; factors that remove or relieve cough.
Sputum (sputum): mucoid, purulent, mucopurulent, blood streaked, foam, evaluation of color, smell; time of appearance, the amount, in what condition; expectoration of sputum (is it heavy or easy).
Shortness of breath (dyspnoe) and suffocation (astma. asphyxia): conditions of its appearance occurrence, difficulty of inhaling and exhaling (expiratory, inspiratory, mixed); constant, fitlike, after what appears or gets worse, factors that remove.
Pain (dolor) in the chest: localization, character, intensity, irradiation, connection with cough, breathing, change in body position.
Hemoptysis (haemoptoe) (blood spitting): the amount of blood in the sputum, clean blood, blood clots; the blood is purple, dark, rusty, pink; the frequency and conditions of discharging blood, pulmonary hemorrhage.
Fever (febris), shivering, sweating, relation to cough, sputum discharge, duration and frequency of fever.
Voice: normal, hoarse, aphonia (no voice).
Digestive System (systema apparatus digestorii). Pain: its localization, intensity, nature (acute, constant, periodical, fitlike, belting, dull, aching, stabbing, etc.); duration; irradiation; relation to food intake (immediately after 1,5-2 hours night, "hungry"); relation of pain to dification (feces); removing or relieving factors.
Appetite (orexis): violation of appetite and its absence (anorexia), increase (polyphagia), perversion, disgust, and saturation.
Diarrheal effects: nausea (nausea), vomiting (vomitus), eructation (eructatio), heartburn (pyrosis). Dysphagia (dysphagia) - a violation of the act of swallowing, the feeling of delay of food in the esophagus. The degree of dyspeptic and disfagiac phenomena, their relation to food intake. The nature of vomit, its amount, impurities of bile, blood (unmodified, type of coffee grounds), odor, deterioration or improvement of feeling well after vomiting. Abdominal bloating (metcorismus).
Excrements (liming) (feces), regularity, intake of laxatives, enemas. Constipation (obstipatio), diarrhoea (diarrhoea). The nature and amount of feces, stool liquid, solid, "sheep", watery, frothy, and others; the color (brown, yellow, black, gray, clay); the smell, the presence of mucus, pus, undigested food, blood, discharge of worms. Itching in the anus, pain during defecation, the presence of hemorrhoid, rectal prolapse.
Urinary system (systema urinaria). Pain: in the lumbar zone, iliac zones, of over the pubis, below abdomen, in the urine channel, character, the provoking and relieving factors; irradiation; constant, paroxysmal, sharp, dull; connection with physical exercise, change of posture, food, water, alcohol intake, etc.; nature of urination: the frequency, daily volume of urine (polyuria, anuria, oliguria); dysuric phenomena: frequent, interrupted, involuntary urination, pain when urinating, frequency of urination per night; colour of urine : straw-yellow, saturated yellow, the color of beer, dark meat mud, red), urine clear, turbid, the presence of blood in the sediment; assessment of urine smell; edema (detailed description).
Sexual system (for women).
Pain: localization (lower abdomen, in the groin area, in the sacrum, in the external genitalia); character; irradiation; conditions of appearing; relieving factors.
Menstruation: regularity, duration, periodicity, number of menstrual discharge, pain, menopause. Features of climacteric flow.
Pregnancy, childbirth, abortion.
Nervous system (systema nervosa) and the senses. Headache: localization, nature, duration, frequency, removing factors. Dizziness: association with physical exercise, change in body position, frequency, duration, tinnitus, nausea, vomiting with vertigo. Loss of consciousness: the frequency, duration, cause, periodicity. Memory. The mood, job satisfaction, aggression, hostility, depression, and indifference. Breach of skin sensitivity, itchy skin, assessment of vision, smell, taste, hearing.
Musculoskeletal system. The pain in the joints (in detail), bones, limbs, spine, muscles, feet; frequency, removing factors; change of gait, stiffness in the joints, morning stiffness in movements, tremor of limbs, convulsions.
5. PATIENT'S LIFE
The main data about patients life should be presented in a short form: the place of birth, family, living conditions and nutrition in childhood, education and work, military service, the nature and working conditions, occupational hazard, sanitation and hygiene in the workplace.
Present social conditions, the nature of work.
II. DIRECT PATIENT EXAMINATION
(Status praesens objectivus)
Overall condition: satisfactory, moderate, heavy, very heavy, moribund.
General appearence of the patient: age, respectively.
Consciousness: clear, vague (torpor (stupor), stupor (semisopor), syncope (coma), delirium (hallucinations)), the possibility of contact with the patient.
Body position in bed: active, passive, stimulated (what?).
Facial expression: normal, calm, excited, indifferent, agonizing, immovable characteristic of fear, anger. The symmetry of factures, flatness of nasolabial folds, cheeks, the presence of "a butterfly's wings", signs of acromegaly, myxedema, Korvisar's face.
Gait: slow, spastic, paretic, ataxic, fast, etc.
Posture: direct, stooping, arrogant.
Body type: type (normostenic, hiperstenic, asthenic), height, weight, waist circumference.
Skin: color - flesh, pale, pale pink, red, yellow (sharp, weak), earthy-gray, bronze, cyanotic (specify where there is the most pronounced cyanosis), hyperpigmentation, depigmentation, humidity (normal, dry, wet), humidity of palms, sweating general or local anesthesia (indicate the degree (mild, strong) and time of appearance), rash (exanthema)-rose rash, petechiae, papules, vesicles, pustules, urticaria, hemorrhage, erythema, hemorrhage; scratches, teleangioektazii, vascular "stars", angioma (point location with a detailed description of them)," blood drops ", post-traumatic and postoperative scarring, bed sores, ulcers (their localization and expression); skin turgor (saved, increase, decrease).
Visible mucous: color - pale pink, cyanotic, pale, jaundiced, congested; rash on the mucous membranes (enanthema).
Skin appendages: the type of body hair, hair loss and graying hair, hypertrichosis, hirsutism, shape of nails ( "hour glass slides", celonychia), brittleness, color, striped.
The hypodermic cellulose: the degree of development (moderate, weak, overweight), evenness of division, skinfold thickness in the area of the abdominal wall and the rib area of the arc, general obesity, emaciation, cachexia.
Edema: general, local, their localization (in the lumbar area, legs, face, general edema); consistency, puffiness; mucous (myxedema).
Head: shape, size, presence of asymmetry.
Eyes: a form of eye slits, exo-or endophthalmitis, strabismus, color of sclera hemorrhage; the size of the pupils, their symmetry, deformation, narrow, expanded, reaction to light, the state age, presence of edema, Xanthi, xanthelasma.
Nose: size, shape (saddle-shaped, duck, enlarged); color, presence of cyanosis, the blood vessels. The nature of breathing (nose, mouth) is complicated, free, participation of the wings of the nose in breathing.
Neck: size, shape, symmetry, presence of goiter, a swelling of the neck veins, the nature of the pulse of arterial and venous vessels of the neck, swelling, edema, asymmetry in the area of the larynx and trachea.
Lymph nodes: submandibular, cervical, occipital, axillary, elbow, inguinal, other location; their size (in centimeters), shape, texture, tenderness, mobility, unity with the surrounding tissues, among themselves, as well as with the skin.
The muscular system: the general degree of development (satisfactory, moderate, weak), tone (retained, reduced, increased - rigidity), local degeneration, atrophy, compaction, pain (self-dependent, during the movements, while probing).
Bone system: proportionality of parts of the skeleton, examination of bones of the skull, spine, chest, pelvis and extremities (distortion, thickening of the distal phalanxes in the shape of drumsticks, deformation, softening of bones), pain (involuntary or by probing and percussion of the sternum, ribs, tubular bones, the spine).
Joints: configuration change (swelling, thickening), condition of skin above the joints, pain, its character and strength, a change in local temperature, swelling, volume of active and passive movements (presence of pain, cracking, fluctuations, contractures and ankylosis), change of the diameter of afflicted joints (in centimeters) and evaluation of range of motion (in degrees).
SURVEY ON ORGANS AND SYSTEMS
1. Respiratory system
Examination of the chest.
1. Static inspection. The shape of the chest: normal (normostenic, astenic, hyperstenic), pathological (emphysematous (barrel), cylindrical, paralytic, rachitic, lordotic, kyphotic, scoliotic). The symmetry of both halves of the chest and over-and subclavian space ( inflow or protrusion); position of collarbone and shoulder blade (a tight seal or gap), the deformation of the chest (the presence of a diverticulum and the confluence, the deformations resulting from curvature of the spine). Features of intercostal intervals.
2. Dynamic examination. Symmetric motion of both halves of the chest in breathing, retardation of one half with a deep breath, the involvement of accessory muscles, the number of respiratory movements per minute; type of breathing (thoracic, abdominal, combined), depth (superficial, deep); rhythm (rhythmic or arrhythmic - Biota, Cheyne-Stokes equations, a large noisy breathing of Kusmaulya).
Shortness of breath: the degree of severity, nature (expiratory, inspiratory, mixed); measuring the girdle of the chest at the angles of blades and the fourth intercostal space in the front at a height of inhalation and exhalation.
Palpation of the chest: resistance, pain, swelling in different parts of the chest along the ribs, intercostal intervals, in the intercostal nerve exit points (points of Valais). Determination of friction to touch the pleura. Voice trembling at symmetric areas: the same, invariable, strengthened, weakened (accurately indicated localization).
Percussion of the chest: comparative (the sound is clear - pulmonary; dull-to-tympani dull shortered, obtuse, bund-box, tympanic) with the precise boundaries of the detected change; topographic (elevation standing tops of light in front and behind, Kernig’s area width to the left and right, lower border of right and left lung on all orientation lines, left of parasternal and midclavicular line indeterminate); size of passive and active excursion of the lower lung border (along the right midclavicular line, mid-axial and miscapular line on both sides) Traube semilunar space (size, base width and height).
Lung auscultation: assessment of strength and pattern of primary respiratory sounds over symmetric sections of the right and left lung: vesicular respiration (normal, exaggerated, diminished, harsh, saccaded), bronchial (cavernous, combined, indeterminate), absence of primary respiratory sounds. Precise indication of location of each respiratory sound alteration needed. Additional respiratory sound rattling – dry (low-tone – bass, high-tone – discant, sibilant); wet – (small, medium and large vesicular, subcrepitant); consonant and non-consonant; crepitation, pleural membrane friction murmur. Broncophony in symmetric chest sections.
2. CARDIOVASCULAR SYSTEM
(systema circulationis sanguinis)
Overview: cardiac hump, apex beat (intercostal space where it is located is identified, pulse), pulse under apex, under the collar bone and in the 2nd intercostal space on the left and the right side of the chest, altered large neck vessels (carotid flutter, jugular vein bulging and pulsation).
Arterial pulse: similar or different on the right and the left hand; rhythm (regular, irregular); frequency, deficiency, strength and intensity, pulse size and shape; large blood vessels auscultation (whether there is double Traube tone, double Vinogradov-Durosier murmur in pelvic arteries and nun’s murmur in jugular veins); determination of the arterial blood pressure under the Korotkov method (maximum, minimum, sphygmic); capillary and vein pulse examination.
Palpation: apex beat (area, localization, strength, height and resistance); cardiac impulse; flutter (systolic, diastolic, “cat purr”) in the heart area (localization, cardiac phase in which it is determined); beat in the upper-abdominal section (differentiation of aortic pulse, right heart ventricle and liver) and suprasternal notch.
Percussion of heart: determination of the right, upper and left borders with respect to cardiac dullness; vascular bundle diameter (determined in centimeters in the 2nd intercostal space); borders of absolute cardiac dullness (right, upper, left).
Auscultation: performed consistently on the top (bicuspid valve) next to the base of the ensisternum (tricuspid valve), in the 2nd right (aortic valve) and left (pulmonary trunk valve) intercostal space and in the 5th auxiliary point of Botkin-Erb (3rd intercostal space to the left from the chest border).
Tone character and sonority: first tone (normal sonority, suppressed, intense, split, bifurcate), “quail” rhythm (additional tone of bicuspid valve opening - clicking); second tone (normal, emphasized, split, bifurcate), tripartite galloping rhythm (protodiastoic, mesodiastolic, presistolic); pendulous rhythm, embryocardia; number of cardiac contractions per minute (tachycardia, bradycardia); cardiac contractions rhythm (regular, irregular, - extrasystole, flickering arrhythmia).
Murmurs: relation to cardiac phases – systolic, diastolic (protodiastoic, mesodiastolic, presistolic), pattern (blowing, scratching etc.), intensiveness (strong, faint), timbre (soft, harsh, high, low), duration (long, short, rising, falling); areas of better hearing of murmurs, changes in murmur pattern depending on the respiratory phase and the patient’s position (from vertical to horizontal and vice versa), hearing of murmurs on the left side, Sirotinin-Kukoverov symptom (systolic, intensifies when the patient raises hands and places them on back of the head), pericardium friction rub, pleuropericardial friction rub, aorta abdominal region hearing.
3. DIGESTIVE SYSTEM
(systema apparatus digestorii)
Mouth cavity: mucus coat of the inner surface of lips and cheeks, hard and soft palate; color, pigmentation, erosion, leukoplacia, aphthaes; breath, teeth (dental formula, tooth decay, looseness, false teeth); gums (color pattern, tenderness, angiostaxis, gray stripe etc.); tongue (size, color pattern, moisture, mammillar layer evidence, fur – localization, color, thickness), crimson, varnished, scalloped tongue; tonsils (size, color, tenderness, fur, lacunes).
Stomach examination: examination in the patient’s upright and lying position; shape (configuration) – normal, retracted, enlarged, protruding (proportional, disproportional, symmetric, asymmetric), sunken, diastalsis visible through abdominal layers; scarring, pigmentation, pronounced collaterals on the front and the side walls of stomach (“jellyfish head”), herniae ; participation of the frontal abdominal wall in the breathing (regular, irregular breathing, does not participate).
Stomach percussion: percutory sound in different areas of stomach; free or incapsulated fluid in the abdominal cavity (differentiate by changing the patient’s position appropriately); fluctuation symptoms (check if the stomach is strongly enlarged).
Surface (light-touch) palpation: pain, tension of muscles in the frontal abdominal wall, presence of hypodermal tumor-like growth, exploration of weak areas (umbilical and abdominal ring and the white line); Shchotkin-Blumberg and Mengele symptoms.
Deep methodical sliding palpation according to Obraztsov: characteristics of the palpated intestinal tract sections (sigmoid colon, blind intestine, appendicitis, final section of the ileum, ascending and descending large bowel and transverse colon); absence or presence of pain, displaceability, texture (firm, elastic), diameter, surface (smooth and shiny, bumpy), borborygmus.
Determination of the stomach’s lower border: palpation of the greater curvature of the stomach and its pyloric section; pathologic symptoms, splashing sounds on an empty stomach.
Liver: determination of the upper and lower border by percussion and palpation; size according to Kurlov; by how many centimeters it bulges over liver, what shape it is (even, pointy, round); texture, pain, surface type (smooth and shiny, bumpy); throbbing (true, annexal), peritoneal murmur.
Gall bladder: protruding, fixation during respiration; pain in the projection area (unconditional, during breathing, during palpation); shape, size, displaceability, texture, symptoms according to: Kehr, Murphy, Mussy-Georgiyevskiy, Zakharyin, Obraztsov, Ortner.
Pancreas: pain in the upper left stomach section, its pattern, irradiation; pain during palpation in the pancreas projection area and indicative areas (Schofer area, Mayo-Robson area etc.) induration and growth (tumors, cysts).
Spleen: palpation with the patient lying on the back and on the right side (according to Sally); degree of enlargement, pain, border, texture (firm, soft), surface, displaceability; percussion (size in centimeters).
Stomach Auscultation: murmuring in intestines and blood vessels, borborygmus (rubbling); peritoneal murmur.
4. UROGENITAL SYSTEM
Lumbar area examination: smoothed edges, protruding, swelling in the lumbar section, dermahemia.
Kidney palpation in the patient’s lying and upright position; localization, size, pain, displaceability, Pasternatskiy symptom (on both sides); palpation along the renal ducts (detection of points of pain); palpation and percussion of the suprapubic section (bladder).
Lacteal glands: for women – level of development, scarring, fistulas, visible and palpated tumors, mastopathy; for men – gynecomasty.
5. NERVOUS AND ENDOCRINE SYSTEM
(systema nervosa et endocrinica)
Patient’s personality evaluation. Maintenance of orientation in space, time and specific situations. Communication skills, consistence and accuracy of speech. Interpersonal relations, attitude towards work and difficult experiences; adaptability to changes in circumstances. Susceptibility to influence and induction. Attitude towards own sickness. Psychological and physiological trauma and conflicts. Temper, its persistence and pattern (calm, aggravated, anxious, euphoric etc.). Attention span, memory, intelligence, character pattern.
Endocrine system: thyroid gland, its swelling (with indication of degree of swelling), texture, surface, pain during palpation; thyroid dysfunction symptoms (Greffe, Moebius, Kocher, Schtelvag etc.) and other endocrine glands (obesity, trichauxis, polyuria etc.).
III. PRELIMINARY DIAGNOSIS
Diagnostic conclusion is formed based on the analysis of complaints, case history and results of objective research (examination, palpation, percussion and auscultation). A follow-up patient examination plan is formed with indication results acquired from laboratory and instrumental research methods necessary for specification and subsequent detailed justification of diagnostic report.
1. ADDITIONAL RESEARCH METHODS DATA
Presentation of results acquired from laboratory and instrumental research methods and consultative conclusion.
2. Forming of final diagnosis.
Nosological principle is primary in forming of a diagnosis, according to which the diagnosis must contain the name of a specific disease determinable by a term, established classification and nomenclature.
Clinical diagnosis is formed under the following scheme:
Once the diagnosis has been formed and treatment has been prescribed, its adequacy is reviewed in the course of the subsequent monitoring of the run of the disease and the effectiveness of treatment. Accordingly, clinical, laboratory and instrumental data confirm, challenge or disprove the diagnosis.
Definition (stratification) of risk of the patient with cardiovascular disease.
This section contains methods of the patient’s treatment (individualized treatment) based on the evidentiary medicine.
Presented in the following order:
Disease expectancy is established based on the primary disease diagnosis and the presence of complications and associated diseases with the consideration of treatment results.
Indicate recovery expectancy considering medical, psychological and social rehabilitation.
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