- •Vinnytsya National Medical University n.A. M.I. Pyrogov
- •Guide to case report writing, history taking and physical examination
- •Vinnytsia 2010
- •Passport part
- •1. Main complaints
- •2. Systems review
- •Life history (anamnesis vitae)
- •Morning exercises and physical training. Sport.
- •12.Trunsfusions.
- •Visual inspection of the chest
- •Visual examination of the precordial area
- •Investigation of the pulse and arterial pressure
- •Formulating suggested (primary) diagnosis.
- •Plan of the mandatory laboratory and instrumental examination
- •Cardiac system
- •Gastrointestinal system
- •Genitourinary system
- •Nervous system and sense organs
- •History of the present illness (anamnesis morbi)
- •Life history (anamnesis vitae)
- •Physical examination The general visual inspection
- •Examination of the respiratory system
- •Visual inspection of the chest
- •Examination of the cardiovascular system
- •Investigation of the pulse and arterial pressure
- •Examination of the Abdomen
- •Plan of the mandatory laboratory and instrumental examination
- •Results of the laboratory and instrumental examinations
- •Found and form clinical diagnosis according to classification.
- •Blood clinical chemistry биохимические показатели крови
- •Assessing of the ph-metry results (according to u. Linar) оценка ph-метрии ( по u. Linar)
- •Echocardiographic parameters основныe параметры эхокардиографии:
- •Ultrasonic examination of abdominal cavity organs ультразвуковое обследование органов брюшной полости
- •Further reading
Ultrasonic examination of abdominal cavity organs ультразвуковое обследование органов брюшной полости
Tests |
Показатели |
Reference range values |
Liver structure |
Структура печени |
Однородная, умеренной плотности, homogenous, moderate density |
Length of the right lobe of the liver |
Длина правой доли печени |
13,8±0,17 cm |
Thickness of the liver |
Толщина печени |
10,6±0,13 cm |
Length of the transversal size of the liver |
Длина печени в поперечном размере |
17,05±0,23 cm |
Diameter of the vena cava inferior |
Диаметр нижней полой вены |
1,4±0,021 cm |
Diameter of the portal vein |
Диаметр воротной вены |
11-13 mm |
Diameter of the spleen vein |
Диаметр селезеночной вены |
4,9±0,087 mm |
Longitudinal section of the spleen |
Продольный разрез селезенки |
9,5±0,07 cm |
Transversal section of the spleen |
Поперечный разрез селезенки |
4,1±0,04 cm |
Head of the pancreas |
Головка поджелудочной железы |
2,2-3,0 cm |
Body of the pancreas |
Тело поджелудочной железы |
1,1-2,2 cm |
Tail of the pancreas |
Хвост поджелудочной железы |
2,0-2,5 cm |
Internal diameter of the main pancreatic duct |
Внутренний диаметр главного панкреатического протока |
1,0 mm |
Thickness of the gall-bladder wall |
Толщина стенки желчного пузыря |
< 3,0 mm |
Further reading
РЕКОМЕНДУЕМАЯ ЛИТЕРАТУРА
Гребенев A.JI. Пропедевтика внутренних болезней: Учебник. 5-е изд., перераб. и доп. - М.: Медицина, 2001 г.- 592 с.
Ивашкин В. Т., Султанов В. К. Пропедевтика внутренних болезней. Практикум.- Издательство: Питер. - 2000 г. -384 с.
Мухин Н.А., Моисеев B.C. Пропедевтика внутренних болезней: Учебник для вузов. - М.: ГЭОТАР-МЕД, 2002. - 763 с.
Bickley L.S. Bate's Guide to Physical Examination and History Taking, Seventh Edition by Barbara Bates, published by Lippincott in 1999.
Clinical Medicine. A textbook for medical students and doctors / [edited by] Parveen Kumar and Michael Clark. - 6th ed., published by W.B. Saunders in 2005.
Coulehan's The Medical Interview, Third Edition , published by F. A. Davis in 1997.
Epstein O. et al. Clinical Examination, Third Edition , published by Mosby in 2003.
Grebenev A.L., Sheptulin A. A. Propaedeutics of Internal Diseases: Textbook, published by Medicina in 1987.
Ivashkin V.T., Ochlobystin A.V. Internal diseases propedeutics.-M.: GEOTAR-Media, 2005. - 176 p.
lO.Medicine / [edited by] Allen R. Myers. - 4th ed., published by Lippincott Williams & Wilkins in 2001.
1 l.STEDMAN'S Medical Dictionary, 27th Edition, published by Lippincott Williams & Wilkins in 2000.
12.Swash M. Hutchison's Clinical Methods, 21-th ed., publlished by W.B. Saunders in 2002.
13.Talley N. J., O'Kormor S. Clinical examination. A guide to Physical Diagnosis, published by Blackwell Scientific Publications in 1989.
14. Welsby Philip D. Clinical history taking and examination, published by Churchill Livingstone in 1999.