- •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)
Locomotor system
Joints: pain — localization, intensity, character (aching, drilling, cause to burst etc.), constant, periodic, amplifying at movements, by the end of day, at night, in the morning, during cold diseases, at weather changing, "volatility" (migration pains from one joint on another). Mobility: stiffness (restriction of movement), enhancement (excessive, pathological, not peculiar to the given joint), morning constraint of movements, duration; swelling, reddening, feeling crunch at movements.
Muscles: pain — localization, intensity, character, weakness, undue fatiguability; swelling, reddening, change of gait.
Bones: pain — localization (vertebral column, extremity, breast bone, ribs etc.), intensity, constant, periodic (at movements, at night), swelling.
LOCOMOTOR SYSTEM |
Have you pain in any joints? |
What joints are affected? |
Have you noticed a swelling (reddening of the skin) in the region of the joints? |
Are the movements of the joints limited? |
Do you notice hindered movements? |
Is it worse in the morning or in the evening? |
Have you noticed a deformation of joints? |
Has the disease of joint begun after the trauma or without any apparent cause? |
Have you pain in your spine? |
Have you pain in your neck? |
Are the movements of the spine limited? |
Do you have pain in the muscles? |
Do you have muscular spasms? |
Do you have muscular weakness (hypotonic)? |
Respiratory system
Breathing through nose: free, difficult (nasal obstruction). A cold: frequency, causative agents (supercooling, hypersensitization to smells etc.). Nasal discharge: quantity, character (thick, liquid, serous, mucoid, purulent, sanious, bloody, with an unpleasant smell, without smell). Nasal bleeding: frequency, intensity, duration, connection with high arterial blood pressure. Olfaction: usual, impairment, be absent.
Voice: usual, hoarse, absent (aphonia), feeling of dryness, scratch in a throat.
Chest Pain: localization, character (sharp, dull, shooting, aching), intensity (mild, moderate, intense), its connection with respiratory movements, cough and the posture, radiation, the position relief pain.
Cough: intensity (insignificant, moderate, intense), permanent, periodic (in the morning, in the afternoon, at night), paroxysmal (paroxysmal (attack-like)), dry (unproductive, without sputum), moist (with sputum, productive). Sputum: amount of sputum expectorated during one spit or during entire day (large or small), expectoration freely or difficultly, the time of the day mainly (in the morning, in the afternoon, at night), dependence sputum expectoration from patient posture (in what position of the body better), character (serous, mucous, mucopurulent, purulent, putrefactive), odour, color.
Expectoration of blood (haemoptysis): frequency, degree (blood-streaked sputum, blood-stained sputum, diffuse colouration of the sputum, frank haemoptysis, rusty sputum), duration, color (scarlet, fresh, rusty, dark, pink), foamy.
Breathlessness (shortness of breath, dyspnoea): with difficulty of inhalation, an exhalation, mixed; at rest, at walking (usual, fast). Attacks of asthma (onset of breathlessness): with difficulty of a inhalation, an exhalation, time of occurrence (at night, in the morning, during the day), intensity, duration, frequency, accompanied by cough, filling of wheeze in a chest, the reason of occurrence (smells, a dust, a tobacco smoke, supercoolings, excitements etc.), the position alleviate breathing during an attack, the medicaments that patient take for alleviation the condition.
RESPIRATORY SYSTEM |
|
Sneeze |
Do you have sneeze? |
Voice |
Have you noticed any change of your voice? Have you noticed that you had begun to speak hoarsely? Have you noticed that you had begun to speak in a low voice? |
Pain in the chest |
Do you have a. pain in the chest? |
Dyspnoea {short of breathing) |
Have you had any difficulty with your breathing? Do you have short of breathing? Do you suffer from short of breathing? Is the dispnoea constant or does it appear from time to time? What causes your shortness of breathing? Do the fits occur at night (in the morning, in the evening, in the daytime)? Do you get short of breathing when you run or climb up stairs? Do you have dyspnoea on inspiration (expiration)? How long does a fit of dyspnoea last? Does the dyspnoea disappear after a rest? What drugs relieve a fit of dyspnoea? |
Asthma |
Do you suffer from asthma? What causes your asthmatic fit? Do you often have fits of asthma? How long does a fit of asthma last? Is it difficult to inhale or exhale? Does the asthma appear suddenly or develop gradually? Are you forced to sit in a bed during the fit? What drugs relieve a fit of asthma? Does adrenaline (...) relieve a fit of asthma? Is the fit of asthma accompanied by cyanosis of the face (pain in the chest, sensation of fear)? What sensation do you feel after the fit of asthma (cough, discharge of sputum)? |
Cough |
Do you have cough? Does the cough trouble you? Do you cough? What kind of cough is it? When do you get it? For how long have you been coughing? Is your cough constant (fit-like)? Is your cough with discharge of sputum? Does any position make it worse (better)? Do you have a pain in your chest when you cough? What drugs relieve the cough? |
Sputum (phlegm) |
Do you discharge a sputum during cough? Is there much (little) sputum? How much is there? How much sputum a day do you discharge? Do you have sputum only in the morning (evening)? What colour is it? What is the smell of your sputum? Of what consistency is the sputum? Is there blood in your sputum? Does it contain cats, clots, pus, mucus? |
Haemoptysis (spitting blood, bloody expectoration) |
Have you noticed any blood in your sputum? Does the sputum contain any blood? Is there blood in your sputum? Do you have a blood-spitting (haemoptysis)? Do you have expectoration of blood? Haven't you ever had blood in your sputum? Is there much blood in your sputum? Are there traces of blood in your sputum? Are there clots of blood in your sputum? How many times did you have blood in your sputum? |