- •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)
Patient anamnesis
(Anamnesis Vitae)
Represents the patient’s medical biography stated consistently in such order:
Childhood: the date of birth and the birth place, what child under the account in family, material - conditions of life, physical development, when began walking and talking, when has gone to school, school results. Past children's diseases (rickets, dyspepsia, infections).
Adolescence: physical development, go in for sport, study, family material - conditions of life, feature of the sex maturity: girls — menstruation occurrence, when they were established, their cycle.
Maturity: the beginning of labor activity, military service, occupation (its changes), carried out work now, its features; occupational hazard, invalidism (disability) (when received, what group, what occasion (disease)), the pensioner. Family status: married, structure of family, number of children, their age; women — number of pregnancies, parturition, miscarriage (on what month), abortions, mortinatality.
Social history at this time: the budget, apartment, municipal services, feeding (regular, chaotic, to eat food dry, propensity to sharp food. Rest (time to sleep, the way in which the patient spends his leisure time: weekend, holiday), personal interest, habits, additional works in-home, frequent business trips.
Harmful habits: smoking (how long time smokes, how many cigarettes in a day, smokes at night, on an empty stomach). Drug or alcohol abuse (in what quantity, frequently, how long time); predilection for strong tea, coffee, to tranquilizers.
Previous illnesses; describe with a chronological account illness, operations, accidence, specifying at what age has passed different disease, if sick was hardly, if was hospitalized, consequences. Is necessary to find out from each patient this diseases: rheumatism, tuberculosis, venereal diseases, viral hepatitis, HIV.
Family history: the health and age of the members of family (the wife, the husband, children) and near relatives of the patient (father and mother, brothers and sisters, the uncles and the aunts, grandparents) — if they are sick it is need to detailed disease, if died it is need to detailed course and in what age.
Residence or travel abroad: where, prophylactic medication.
Allergological anamnesis: allergic reactions to various food (strawberry, eggs etc.), medical preparations (novocaine, analgin etc.), perfumes, pollen etc.
PAST MEDICAL HISTORY (Anamnesis vitae) |
|
Date of birth |
When were you born? |
Place of birth |
Where were you born? |
Life's condition in childhood |
What life's condition did you have in your childhood? |
Education |
What education have you received? |
Beginning of work |
At what age did you begin to work? |
Occupation |
What is your occupation? |
Past diseases in childhood |
What childhood diseases were you ill with? What were you ill with before? |
Adult |
At what age were you ill with this disease? Were you ill with tuberculosis? Were you ill with a venereal disease? (gonorrhoea, syphilis) |
Operations, traumas |
Have you undergone an operation, which one? Did you have any wounds (contusions, traumas)? |
Chronic poisoning |
Do you smoke? Do you smoke much? How many cigarettes a day do you smoke? Do you use narcotics, which ones? Since when have you been taking opium (heroin, hashish)? |
Drinking habits |
Do you drink? Are you addicted to drink? Do you drink every day or just on social occasions? How much do you drink on an average every day? Do you think your drinking causes any problems? |
Relatives |
Do you have relatives? How many relatives do you have? How many of you are there in your family? Are your parents alive? Is your father (mother) well? What diseases did he (she) has? At what age did he (she) dye? What caused his (her) death? Are you children healthy? What diseases have they got? Do you have brothers, sisters? How many brothers, sisters do you have? Are they well? What diseases do they have? Were your relatives ill with tuberculosis, venereal, malignant (tumor), mental, endocrine diseases? |
Material status |
Are you single? Are you widowed? Are you divorced? Are you married? How long have you been married? |
Obstetric history |
At what age did you begin to menstruate? When did your periods first start? Are the menses regular (irregular)? Is your menstrual cycle regular? How often do you have your periods? How long do they last? Are the menses abundant (moderate, painful)? Are you still having your periods? When did you have your last menses? How many pregnancies have you had? Have you had abortion (miscarriages, still-born)? Was it an induced or spontaneous abortion? Did you have any trouble during pregnancy, such as raised blood pressure? Did you have any complications at delivery? Which ones? Did you have a normal delivery? How many children have you? How old are they? |
Profession and living conditions |
What are the conditions of your work? What harm is there at your enterprise? Do you work with lead, mercury, acids, alkalis, nickel, radioactive substances? What are your living conditions? Allergic history |
Allergic history |
Have you got allergic reaction? |
COMPREHENSION |
Free from pain, painless. |
Pain Aches |
Aches are used in compound words: backache, earache, headache, stomachache, toothache. |
For the other parts of the body we say: "I have a pain in my shoulder". |
The word "ache" can also be used as a verb: "My leg aches after walking two miles". |
The word "hurt" is another verb used to express injury and pain: "My chest hurt when I cough", "My neck hurts when I turn my head". |
“like being in a vice”, “like an iron band round the chest”, |
Detailed description "Pain". |
Aching |
Biting |
Boating |
Burning |
Colicky (abdominal disease) |
Crampy |
Cutting (rectal disease) |
Deep – diffuse aching sensation |
Dragging |
Drawing |
Dull (headache, tumour) |
Excruciating |
Gnawing (tumour), pronounced gnawing |
Grinding |
Gripping (as in angina pectoris) |
Heavy (as premenstrual) |
Knife-like |
Numb (lack of sensation) |
Piercing (angina pectoris) |
Pinching, pinch |
Pressing |
Prickling (like pins and needles in inflamed eyes, conjunctivitis) |
Scalding (cystitis) |
Severe - gip, 'It gives me the gip' |
Sharp |
Shooting (toothache) |
Sickening |
Smarting (burns) |
Sore |
Stabbing (indigestion) |
Steady |
Stinging (Guts, stings) |
Stitch (spasm in side due to excessive exercise) |
Straining |
Sudden |
Tearing |
Tender |
Throbbing (headache) |
Tingling (return of circulation to extremities) |
Twinge (sudden, sharp) |
Wasp |
Other words to describe pain: |
acute/subacute/chronic; constant/inter-mitten; localized/diffuse, radiating, spreading; mild/severe; superficial/deep-seated; constricting; convulsive, spasmodic; darting, fleeting; intense, very severe, violent, agonising, excruciating; persistent, obstinate, stubborn. |
RESPIRATORY SYSTEM |
Breathing. |
Medical words: respiration, expiration, inspiration Colloquial words: breathing, breathing out, breathing in Descriptive words: breathing, shortness of breathing, deep breathing, weak breathing, noisy breathing, quick breathing, rapid breathing, wheezing breathing, laboured breathing, shallow breathing |
Cough |
Descriptive words: |
Character: dry, productive, explosive, suppressed, postural spasmodic, persistent, moist |
Tone: barking, brassy, hacking, hawking (catarrhal and chronic sinusitis) wheezing (bronchitis) loud, strong, voiceless |
Sputum |
Medical words: sputum, to expectorate |
Colloquial words: phlegm (flem), to bring up phlegm; |
Descriptive words: |
Quality: clear, frothy, glassy, jelly-like |
Colour: black-gray, blood-stained, brown, dark-red, green, red, pinkish, rusty-brown, yellow |
Odour, foetid, putrid, nauseating |
DIGESTIVE SYSTEM |
Vomiting |
Medical words: to vomit |
Colloquial words: to be sick, to bring up food |
Descriptive words: |
Character, residues of food, watery |
Colour: black, blood, coffee-ground, green |
Bowels |
Medical words: faces, stools, to defecate |
Colloquial words: motion, to have a bowels opened, to do to stool |
Descriptive words: |
Colour: black, brown, like rice-water (cholera), green, gray, pale, pea-soup-like, porridge-like (steatorrhea), white, yellow |
Form and consistency: bloody, dry, fatty, hard, purulent (with pus), slimy (excess of mucus), soft, watery, well-formed |
URINARY SYSTEM |
Urination |
Medical words: to micturate, to urinate |
Colloquial words: to pass water |
Descriptive words: |
Character: clear, cloudy, flecked, milky, muddy, thick, slimy, smoky |
Colour: amber, black, brown, blood-streaked, blue-green (as result of drugs for back and kidney), orange, pink, red, redish-brown, straw-colored (normal), yellow |
Odour: ammoncical, foetid, fruity and sweet (diabetes) |