- •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)
Cardiovascular (blood-circulation) system
Pains:
Localization (main site of pain) (precordial area, retrosternal — diffusive, localised).
Character (aching, shooting, stabbing, pinprick, sharp, dull, constricting (tight, heavy, crushing, pressing, like a weight, compressing, squeezing), burning, cutting, pinch, wasp, boring (gnawing), accompanying with a shiver, amplified hyperhidrosis, rapid imperative excessive urination, dyspnoea, sensation of melancholy, accompany by a sense of impending death, feeling of tightness, palpitation, intermissions, weakness, trembling in the body, cramps, filing of air deficit, dizziness).
Origin: gradually, in a moment, paroxysmal (attack-like).
Intensity (severity): mild, moderate, severe.
Duration (it may range from less than a second to several minutes, hours, days - steady).
Frequency (pain every day, several times a day (to indicate how many times), every week, seldom).
Periodicity (steady (constant), fluctuant, intermittent, transitory, attacks of pain); regular or irregular (pain-free) intervals of day, month.
Special time of occurrence
Radiation (to left shoulder, left arm, left shoulder-blade, left supraclavicular and infraclavicular region, the back, interscapular region, the left of the neck, lower jaw, the epigastric region, the right half of the chest).
Aggravating factors (provocation, the reason of occurrence,) (during insignificant physical exertion - during walk: quick, ordinary, slow; ascending the stairs, walking uphill (go upstairs), the other exercise stress (in considerable physical loading), excitement (emotional factors), frosty day, cold wind, excessive meal, after alcohol use, smoking, without visible cause).
Behaviour of the patient in pain (relieving conditions) subside spontaneously (stops: how many meters of way before stop, on what floor; how many minutes stand; lay in bed, rises, physical or emotional exertion, talking, try sitting, standing or walking; better itself feels in movement, changing position, etc.).
Relieving factors (relief with medication): the analgetic effect after intake of nitroglycerine (how many minutes pain persisting), how many tablets intakes a day, pain relieved at once, in few seconds, in few minutes; tolerance (well, noise in head).
Associated phenomena: pallor, sweating, vomiting.
Breathlessness (shortness of breath, dyspnoea): character (with difficulty of inhalation, an exhalation, mixed), intensity (dyspnoea on effort, go upstairs, fast walking, slow walking on plane surface, in rest). Onset of breathlessness (paroxysmal dyspnoea, asthmatic fit): in the afternoon after exercise stress, at night, duration, frequency, accompanied by the cough, bubbling breathing, discharge liquid pinkish foamy sputum, the position facilitating breathing during an attack.
Palpitations: awareness of the heart beat, unusual them frequency, begin gradually, suddenly, duration (how many minutes, hours), accompanied with a shiver, amplified hyperhidrosis, with rapid imperative urination; the reasons of occurrence (at exercise stress, fast change of position, excitement, in food intake, "causeless"), frequency of attacks, what stop they (reflex way, what medicine intake, call emergency)
Intermissions (escaped beats): periodic, constant, regular alternating (through 1-2, etc. of normal beat), chaotic, the reasons of occurrence (exercise stress, excitement, in food intake, lying position etc.).
Filling of a pulsation of neck vessels, head, top extremity etc., cold extremity, attacks numbness and paleness of hands and foots fingers, (symptom «dead fingers») on a cold.
Pains in gastrocnemius muscles at walking («an alternating lameness»), how many meters of way stops, how many minutes stand.
Oedema (swelling): localization (of feet, on the ankles, other parts of a body), degree of expressiveness (small, moderate, significant), changes within day (appear or increase by the end of day, decrease or disappear to the morning, do not change).
CARDIOVASCULAR SYSTEM |
|
Pain in the heart |
Do you feel a pain in the heart? Do you have a pain in the heart? What's the pain like? What kind of pain is it? Does the pain in the heart spread any where else in the body? Does the pain radiate to the back (the shoul-derblade, the arm, the neck)? Have you the attacks of pain? With what do you connect the onset of your pain? How did it start? Does the pain occur more commonly when you are sitting in a chair or when you are walking? Does the position make any difference to your pain? Does the pain increase (become more acute) on physical exertion (heavy work), waking for a long time? Are there any other symptoms that you notice when you have the pain? Have you ever got pain at night (daytime)? How long does the pain last? How often does the attacks of pain come on? Is there anything that makes it better/worse? If I wanted to see you with the pain, what could you do to bring it on? What do you do when you get your painз (stop walk, take a tablet ...)? Does the pain disappear (subside, calm) after taking tablet of? If you take the tablet of.... how soon does it help to relieve the pain? |
Pain in the sternal region |
The same questions |
Breathlessness (shortness of breath, dyspnoea) |
When you are walking, can you talk at the sane time? Do you have dyspnoea? What does your dyspnoea cause? Does the dyspnoea occur at rest? Does a slight physical exertion cause dyspnoea? How far can you walk? How many flights of stairs can you climb? Can you walk as far as you could five years ago? Does anything make it better/worse? |
Asthma (cardiac) |
Do you suffer from attacks of asthma? How did it start? What sensation do you have before the fit of asthma? Have you noticed any causes of the onset of asthma? Does the asthma appear at night (in the evening, in the daytime)? Do you wake up from asthma at night? Are you forced to sit in a bed during the fit? How often does the fit of asthma come on? Does the asthma disappear after change of a position of the body? What drugs relieve a fit of asthma? Is the asthma accompanied by cyanosis of the face (pain in the heart region, cough, scharge of sputum)? |
Palpitation |
Have you ever had palpitation? What does your palpitation cause? Does the palpitation appear when you are excited, (when ascending a stair case); when you carry something heavy? If you have palpitation can you describe the sequence of events leading up to it? Does the palpitation appear without any apparent cause? Does it come on suddenly, or gradually or in some other way? How often does the attack of palpitation come on? How long does the palpitation last? Are there any symptoms that you notice when you have palpitation? Do you feel a painful sensation at the palpitation of heart? Is the palpitation accompanied by fainting fits, pain in the heart? What drugs relieve a fit of palpitation? |
Intermissions (escaped beats) |
Do you fed you heart beating? When you heart is beating fast can you tell whether it is beating regularly or irregularly? Can you note the circumstances under which intermission develops? After what do you feel heart beating (emotional stress, physical exertion)? Do the escaped beats occur in a state of rest? Is your heart beating constant or periodic? How many hours (days) do the attack last? What is the frequency of attacks? Do the fits happen often or rarely? Do you feel giddy at the heart beating? Do you lose consciousness at the heart beating? What drugs help you? Is there anything that makes it better (worse)? |
Oedema |
Do you have oedema? Do your hands (legs, eyelids) become periodically swollen? Does oedema develop quickly or gradually? When does oedema appear? Did you notice the appearance of oedema in the evening? What part of the body (hands, legs, face) swells first in the morning? Does the oedema disappear by the morning (after a rest)? Does the oedema increase after walking? Have you already taken diuretics? |