- •A system of case recording and clinical examination of patients
- •Guidelines for students
- •Complaints (presents illness)
- •The general anamnesis
- •Enquiry about a functional condition of all the organs and systems.
- •Nervous system
- •Locomotor system
- •Respiratory system
- •Cardiovascular (blood-circulation) system
- •Alimentary Gastro-intestinal system
- •Urinary organs
- •Sexual function
- •Hematosis system
- •(Anamnesis morbi)
- •Patient anamnesis
- •Physical examination (Objective examination) (Status praesens)
- •General assessment
- •Respiratory system
- •Comparative percussion of lungs
- •Auscultation of lung
- •Cardiovascular system
- •Percussion of heart
- •Auscultation of hearts
- •Alimentary (Digestive) system
- •Inspection of the abdomen in vertical position.
- •Light (superficial, tentative) palpation.
- •The analysis of the data of enquiry and Objective examination of the patient (substantiation of the provisional diagnosis)
The analysis of the data of enquiry and Objective examination of the patient (substantiation of the provisional diagnosis)
1. Determine features of the present disease beginning (sudden, gradual) and its further current (acute, chronic — stable, progressing, calming down; paroxysmal (attack-like), recurrent, cyclic).
The symptoms that revealed during enquiry and objective examination, group according to each system — in the individual syndromes which are representing characteristic combination of symptoms, connected with general pathogenesis (syndrome of liquid accumulation in pleural cavity, bronchospastic, cardiac insufficiency, left, right ventricular, total; coronary, hypertension, dyspeptic, a portal hypertensia, edematic, uric, etc.); specify diagnostic value of them.
In clinical presentation of the given disease allocate the principal (dominating, prevailing) syndrome which is representing the main abnormality. Specify, what symptoms (syndromes) on the other part of bodies and systems are the components of the principal syndrome.
4. Determine the most probable character of a pathology, which based in conducting syndrome in this case (anatomic changes, inflammation, infection, blood supply disturbance of organ, metabolism, intoxication, tumors, functional disorder of the regulatory mechanisms etc.).
What circumstances could promote occurrence and development of disease in the current patient? (nervous or physical overloads, overcooling, infection, malnutrition, alcohol abuse, hereditary predisposition etc.).
Formulate are provisional (presumable) diagnosis: syndromic, and if it possibility — nosological diagnosis.
The signature of the student