- •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)
Sexual function
Sexual desire (libido); normal, lack of libido, missing, potency (normal, reduced).
Menstruation: regularity (regular, irregular), frequency, duration, blood loss (small (hypomenorrhea), normal, excessive); painful (in the bottom of abdomen, in sacrum area); menopause, how long time.
Hematosis system
Pains in left hypochondrium: character (sharp, dull, aching, constant, periodic, amplifying at breathing, cough), intensity, duration, radiation (in the left shoulder, scapula).
Bleedings; nasal, gum, gastric, uterine (frequency, intensity), bruise on a skin (spontaneous, connection with a trauma).
Lymph nodes increase, localization, tenderness.
Pains in bones: flat, cortical (tubular), spontaneous, at movement, night pains.
Skin
Itch skin: strong or slight; their duration.
Scattered skin, rash skin: is it itching.
Itch skin |
Do you have itch? Is the itch strong or slight? When does the itch become stronger? |
Scattered skin Rash skin |
Do you have rash skin? Is the rash itching? Have you had a skin rash? |
HISTORY OF THE PRESENT DISEASE
(Anamnesis morbi)
The history of the presence disease at each concrete patient is always individual, at the same time it correct finding-out has the greatest diagnostic value. Enquiry and a statement is necessary make in detail and consistently in the following order.
What time of the onset of the disease?
At the same time it is necessary to specify, how the patient felt oneself till this time (day, month) as quite often it appears, that considers the occurrence of the disease beginning and the expressed symptoms. Whereas actually number of other "unimportant" phenomena with vital diagnostic importance preceded them.
How began disease, the characters of the first symptoms: suddenly, gradually, from what signs (symptoms), what developed sequence, character’s change, expressiveness, etc.
What the reason of this disease in patient’s opinion? The patient can’t usually specify true reason of disease, but at enquiry often informs very essential circumstances which preceded and could promote development of disease (supercooling, an infection, overfatigue, conflict situation, an error in a eatten, a way of life disturbance and etc.).
The course of the disease, before patient receipt to the clinic proceeded: continuously, cyclically, paroxysmal (attack-like); dynamics of initial manifestation (amplification, easing, disappearance). Proceed with a chronological account of the mode of onset and course of patient illness.
In parallel with it describe treatment carried out earlier stage by stage (out-patient, stationary, sanatorium), its efficiency, results of laboratory – instrumental researches if the patient remembers of them or represents corresponding documents.
Course of the disease in clinic: improvement, deterioration — in exactly, carry out treatment.
The basic contents of this anamnesis unit — dynamics of disease development clinical presentations. For each symptom is necessary to find out: time of occurrence, speed of development, a causal connection, a constancy or periodicity, qualitative character, expressiveness degree, sequence of development with other symptoms.
HISTORY OF PRESENT DISEASE (Anamnesis morbi) |
|
The date of the onset of the disease |
When did you fall ill? Since when have you been ill? How long have you been ill? When did the changes of health appear? When did you notice these disturbances? When did your .... hurt you for the first time? For how long have you been suffering from...? How long do you have a...? How long has it been bothering you? When were you last well? When did symptoms first develop, and what were they? |
The, first signs of the disease |
How did the disease begin? How did the disease manifest itself in the beginning? What were the first signs of the disease? What was the first thing you felt wrong? What symptoms did the disease begin with? |
The cause, of the onset |
What are the causes of the onset? |
Visiting a doctor |
Did you call in a doctor? Did the doctor visit you at home? Did you consult a doctor on your diseases? What doctor did you consult? |
Examination |
What examination did you undergo? Did you have your blood analysis (sputum, faeces, urine discharge, pus, gastric juice, spinal fluid analyses) taken? Have you had your electrocardiogram made? Have you had your chest (skull, stomach, bones, kidneys) examined? |
The preliminary diagnosis |
What was your diagnosis? |
Treatment |
Were you treated before? Did you take (have) any treatment before? Where did you undertake treatment? By what doctor were you treated? What doctor did you consult? What treatment have you been given? What drugs have you taken? How many times a day do you take this medicine? When (in what year) were you treated in an in-patient department? Were you hospitalized for....? In what hospital were you treated? Have you been given an injection? Have you been given intramuscular (intravenous, subcutaneous) injection, intravenous infusions? Were you given a puncture? Have you been given an X-ray treatment? Have you finished your course of treatment? Do you feel better after taking medicine? Did you have any improvement after the treatment? How long have you been treated in a hospital? What was you diagnosis on entering and discharging? |
The development of disease |
Was the disease relapsing? Was the disease subsiding? Are the relapses (attacks) frequent or rare? Do the relapses depend on the season, weather, food? Do you have any improvement? Are they long? After what do you fed better (worse)? Do you notice exacerbation (improvement) of the disease in winter(summer. spring, autumn)? |
Last exacerbation |
When did the last exacerbation appear? What do you think is the cause of the exacerbation? Did you consult a doctor"? Did you take any treatment? What treatment have you taken? What is the aim of your hospitalization? |