Добавил:
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз: Предмет: Файл:

The scheme of medical history in the clinic of the internal diseases work book

..pdf
Скачиваний:
13
Добавлен:
15.11.2022
Размер:
414.63 Кб
Скачать

often appear on the forefront when there are diseases of cardiovascular system, of endocrine pathology, when there are diseases of blood formation system, or are included into a clinic picture of these diseases or in their after disease complication.

MUSCULOSKELETAL SYSTEM

Pains in limbs and movable joints: Their localization, nature (fugacity, relations with the change of weather, dependent on loads, occurrence in quietness or at night).

Arthroncus, redness of joints (which exactly);

Limitation of joint movement and in spinal column (in which joint there is “click” or “crackling”, in the morning there is constraint in movement, its continuance; in which part of the spinal column, irradiation of pains).

FEBRICULOSITY (FEVER)

An increase of body temperature, margins of its fluctuation during a day (feature of temperature curve). Fastness of temperature increase and duration of fever period; what reduces the temperature. If it is preceded by shivers and the intensiveness of sweating, if there are sweating at night.

COMPLAINTS OF GENERAL CHARACTER

Sickliness, weakness, tiredness, reduction of working efficiency.

III. Medical history (Anamnesis morbi)

In this section affects the onset of disease and its dynamics before examination by your doctor. First, it turns out the approximate date of onset of the disease and its first manifestation (year, month), under what circumstances it arose. The standard phrase in the movie history of the disease is "Patients consider themselves to be with ... when there were ..." At the same time ask for the opinion of the patient about the possible causes of the disease (though this view may be wrong). In the future trying to find out how the disease proceeded, changed over time is different symptoms: their appearance, increase or decrease the appearance of new symptoms are presented in chronological order.

You need to install when the patient first went to a doctor than treated (remember that the patient), which gave the effect of treatment. If, the patient was treated in hospital, to determine the length of stay in it. It should reflect the history of the known results of the patient held his laboratory and instrumental investigations, or extracts from the available medical records.

It is essential that all complaints made against admission have been agreed with certain moments of history, to be clear, when there was a particular pain. The history of the disease should be "brought" before the start of supervision,

11

regardless of the date of admission. Reading and the more up medical histories of students is unacceptable!

IV. Patient anamnesis (Anamnesis vitae)

This is short medical biography is characteristic in the moment of birth until to enter in the hospital. You must ask the patient by the next main pariods of his life. Babyhood:

The place of the birth, how many children in the family, how is progress the child birth, how is progress in the childhood. You must ask about life conditions, feeding.

Childhood:

Adoptive child”s infection, physical development, prophylactic immunization, vaccination.

School days:

What age is begin to study in the school, his ability, marks. What diseases was ill in that time.What kind of sport did he/she like?

Pubertal period:

When is bagin the pubescence; beginning the menses, duration, flooding, painfullness, regularity.

Juvenescence:

Education. When was begin to work, condition of the work, life; bad habbites, to observance of hygiene, diseases, military service (fores, reactors, propellant). Mature age:

Adoptive diseases, operations, traums, pay attention on the tuberculousis, syphilis, malignant neoplasms, disease of cardiovascular system, mental diseases, to disorder of metabolism.

Family history:

Ask about wife of husband, children. Ask about health of his/her family. Vita sexualis:

At the woman: when was began the menses, regularity? When was the last menses, to observe by gynecologist; quantity of pregnancy, abortions, labors, contraception. At the man: ask about of libido.

Housing:

Ask about the home, flat.

Character of nutrition: regularity or not.What food is more like? Working conditions: occupational, hazards; the place of the job;

Bad habits: how much to use the alcohol; Smoking (how many times, how use the sigarets in a day I S- smoker index), using a drugs or not; toxicomania (acetone, glue).

Allergic anamnesis:

After using which medicine, food, smells to appearance of skin rash, itch, to fall arterial pressure. Which hormone medicine is using ( corticosteroids, contraceptives, their doses, side effects)

Hemotransfusion:

12

Bloodgroubing, concentrated red cells, plasma, cryoprecipitate; the cause to pouring of blood.

Epidemiological anamnesis:

Adoptive infections, patient cooperation, stings, trips in another countries.

VI. GENERAL INSPECTION (Status praesens, inspectio):

Phase II begins with a diagnostic search for a direct examination of the patient physical methods.

Initial evaluation of the severity of the patient is, above all, to assess the overall state of consciousness, of the patient in bed.

General principles for examination of the patient:

From simple to complex;

From general to specific;

The surface of the inside;

From top to bottom.

General condition: satisfactory, moderate, severe, extreme gravity, the terminal (in violation of the vital functions - breathing, circulation, consciousness).

Consciousness: clear (in fact sociable and well oriented in space, time, kept to his criticism of the state), depression, confusion, stupor, sopor, coma. Episodes of transient loss of consciousness - fainting (syncope).

Mental disorders.

Position the patient in bed: active, passive, involuntary (on which side, back, attracted to his knees on his stomach, Bozeman), orthopnea.

We describe a patient walking posture: straight, dull, bent. Gait is smooth, senile, "spastic", "Duck," "drunk".

Facial expression: a cheerful, quiet, suffering, apathetic, masklike, chorea, tic (twitching of facial muscles).

Person: age-appropriate and sex, youthful, old, like the moon, swollen, with a bright blush (one-color), red, bluish, Сorvisart, La Traviata, Hippocrates, etc.

Constitution: normostenic, asthenic, hypersthenic.

Body type: correct, incorrect (kyphoscoliosis, deformities of the chest, acromegaly). Height: medium, high, dwarf, giant.

Height- m, Body weightkg. BMI (body mass index). Fatness: average, good, excessive, low, cachexia. Obesity, fat deposition uniformity: android type (abdominal); ginekoidny type (femoral-gluteal), cushingoid type (moon face, "buffalo" hump).

Examination of the skin and mucous membranes. Skin: normal color, pigmented, pale, flushed, cyanotic, yellow, earthy, color, "coffee with milk", flexible, flabby, atrophied, moisture (sweating), dry, scaly, swollen in the legs, feet, waist, ascites , anasarca, expansion of the subcutaneous veins (to indicate their location). The presence of scars, rashes, hemorrhage, vascular "stars", vitiligo, telangiectasia, haemorrhages, nodular erythema, xanthoma, xanthelasma, trophic disorders

13

(ulcers, pressure sores). Dupuytren's contracture.

Visible mucous – pink and red, pale, bluish, yellow. Lips - pale, bluish, the presence of a bubble eruption. Sclera - the white, yellow, blue, with the presence of hemorrhage of deposits.

The development of hair: the head, face, armpits, pubic (by male or female type). Hypertrichosis, alopecia, hirsutism.

Lymphatic System: Lymph nodes were not palpable, palpable, (occipital, parotid, cervical, supra-, submandibular, axillary, elbow,, inguinal), size, single, multiple, elastic, hard, painful, painless, not spaennye or welded to each other and the surrounding tissues and the skin covered with intact, congested skin, suppurating fistulas, scars. Necessary to describe at least three groups of lymph nodes at different loci.

Musculoskeletal system: The amount of active and passive movements of the muscles - are well developed, fair, poor, atrophied, muscle tone is good, fair, poor, what is muscle strength. The presence of tenderness to palpation of muscles and effleurage.

Axial load on the spine - painful, painless. Kiforz, scoliosis, lordosis. Feeling, effleurage on spinous processes, paravertebral points - painful and painless.

Limbs - balanced, long, thick, lame, deformed. Shins - straight saber, raised, with varicose veins, trophic ulcers, scars.

Joints - the correct form, twisted, swollen, hyperemic, mobile, ankylosis (stiffness), fluctuation, crunch.

Brushes - regular, large, cold, bluish, distorted by the type of "fins" fingers in the form of "drumsticks", with lateral thickenings (heberden units), flickering, fading in the cold (a symptom of the "dead finger").

Feet - are proportional to, large, misshapen, flat, clumsy.

Nails - the usual form, pink, brittle, with the presence of longitudinal and transverse striations, prominent on the type of "time windows", transparent, opaque, shiny, matte, koilonychia, struck a fungus.

The temperature during the study: low-grade, febrile (numbers), prolonged fever, indicate the type (continuous, remittent, hectic, intermittent, wavy, return).

Examination sick on organ and system

The respiratory system

Local inspection.The nose: you must determine the condition a mucous membrane of nose, about character of secrete, herpetic eruptions, the type of breath (the breath of nose, mouth, free or shortness of breath), accessory sinuses of nosethe patient to have the pain by palpation or not, the secret from noseto scanty, profuse, mucous, purulent, bloody.

The larynx: voice - hoarseness, aphonia.

The chest: the form of the thorax - regular form (normosthenic, hypersthenic, asthenic), pathological changes (barrel - emphysematous, paralytic, rickets, funnelshaped).

The characteristic of epigastric corner. The characteristic of above and

14

subclavian fossa.

Asimmetry of the chest, protrusion or confluence. The width of intercostals. The direction of the ribs. The position of the scapulas: theirs symmetry, scapula alata. The movement of the chest by breath: uniform motion or to lag one of the side by breath. You must to inspection the skin: varicose vein, capillaries, different rash, subcutaneous hemorrhage.

The type of the breath: thoracal, abdominal, mixed.

The depth and rhythm of the breathing: superficial, deep, rhythmic, arrhythmic ( the type of arrhythmia). The number of the respiratory movements (NRM).

The dyspnea: inspiratory, expiratory, mixed; high-grade of the dyspnea. Palpation: resistance of the chest. Palpatory tenderness of the chest, determine

the localisation, edema. To determine the vocal tremor ( normal, increase, weakening, to absent). The localisation of alteration. You must determine by palpation the pleural fremitus; to determine the chest circumference on the 4 intercostal: by quiet breathing, by deep breath and expiration ( to determine the rate of excursion). You must determine by palpation the thickening of ribs, crackle of the ribs by fracture, subcutaneous emphysema..

Percussion of the lungs: The results by comparative percussion: the character of percussion sound above different regions of the chest ( the area of the apex to behind and in front, anterior, lateral, scapular and subscapular). What character of percussion soundlight sound above the surface of lung, dullness, bandbox, tympanic. Topographic percussion: to determine the altitude apex of the lungs in front and behind, the width area of Krenig, to determine the lower borders of the lungs by lines, to determine the mobility of the lower side of the lungs ( in cm) by lin.mediaclavicularis, by lin. axillaris media and lin. scapularis on the both sides. By detection of percussion sound (for example, dullness, blunt), you must characteristic the boders by vertical line and intercostal. The results by percussion of lungs you must wrire in tne table.(table 1).

Topographic percussion of lungs

 

 

 

 

 

 

 

The boders of lungs

 

on the right

 

on the left

 

 

 

 

 

 

 

superior

 

 

 

 

 

 

 

 

 

 

 

at the frontспереди ( the apex of the

 

 

 

 

 

lungs)

 

 

 

 

 

 

 

 

 

 

 

behind (the apex of the lungs)

 

 

 

 

 

 

 

 

 

 

 

the width of Krenig”s areas

 

 

 

 

 

 

 

 

 

 

 

inferior

 

 

 

 

 

 

 

 

 

 

 

Lin. parasternalis

 

 

 

Not determine

 

 

 

 

 

 

 

Lin. mediaclavicularis

 

 

 

Not determine

 

 

 

 

 

 

 

Lin. axillaris anterior

 

 

 

 

 

 

 

 

 

 

 

Lin. axillaris media

 

 

 

 

 

 

 

 

 

 

 

Lin. Axillaris posterir

 

 

 

 

 

 

 

 

 

 

 

Lin. scapularis

 

 

 

 

 

 

 

 

 

 

 

Lin. paravertebralis

 

 

 

 

 

 

15

 

 

The mobility boders of lungs

Lin. mediaclavicularis

Lin. axillaris media

Lin. scapularis

Auscultation of the lungs: the auscultation of the lungs the same that comporative percussion. You must determine the character of the main respiratory sounds ( normal vesicular or pathologicdiminished breath sounds, amplify, hard, bronchial, bronchovesicular, amphoric, saccadic, longer expiration, «silent lung»).

To determine the localization of change breathing. The concurrent respiratory sounds: dry ( on the breath and expiration) or bubbling [moist] rales (sonority, caliber), crepitation (sonorous, quiet), pleural friction rub, pleuropericardial sound. The concurrent respiratory sounds after cough. The bronchophony on the both sides of the thorax (weakening, enchancement, anacoustic).

Of the circulatory system

The study of the cervical arteries and veins visible pulsation of the arteries of the carotid, the jugular fossa arteries. State of the neck veins (visible swelling and throbbing). Venous pulse: is not expressed, the positive and negative. Listening to the jugular vein (the noise of the top). Arterial pulse - a comparison of the pulse in both radial arteries (there is no asymmetry, no pulse), the rhythm, frequency, voltage, filling, pulse deficits, the state of the vascular wall is the pulse wave, the study of the temporal, brachial and carotid arteries, the pulse on the back side of the foot . Listening to the carotid and femoral artery - a double tone Traube, Duroziez –Vinogradov`s dual noise. Blood pressure in the upper and lower extremities.

Inspection and palpation of the heart: protrusion of the heart - a heart hump. The visible pulse: in the heart, in other areas. Apical impulse: localization, the nature (positive or negative), area (limited or diffuse), height (high, low), power (normal, impaired, ascending, a dome-shaped), displaceability when the body positions studied. Cardiac impulse. Trembling of the heart ("cat purring"), the localization, in which phase of the heart is determined. The sensitivity of the skin over the area of the heart, in the intercostal spaces.

Percussion: the limits of the relative and absolute cardiac dullness. Determination of left and right borders of the relative cardiac dullness is over all intercostal space, the definition of the upper limit of the left parasternal line.

Arrange the data in tabular form:

border

 

absolute dullness

 

relative dullness

 

 

 

 

 

on the right

on the left

from above

relative (left) the right

edge of

 

from the edge of the sternum in

the sternum

 

 

the intercostal space IY … cm

in relation to the the left mid- from the mid-clavicular line clavicular line medially, laterally intercostal

space in the Y

to parasternal line

 

to parasternal line

 

 

 

16

Vascular bundle does not act, in favor of the sternum, its width in cm

The width of the vascular bundle (in cm). Determination of the configuration of the heart (not modified, mitral, aortic, cardiomegaly).

Auscultation: listening to the heart of the mandatory five points. When listening to each point (apex - in the apical impulse, the base of the heart - the aorta, the pulmonary artery, in 3-leaflet valve, at Botkin-Erb).

Describe the auscultatory pattern, answering the following questions: the rhythm of the heart - the correct, incorrect (premature beats, atrial fibrillation), but audible tones, two, one, three? What the tone is stronger - I or II, there are no split tones, there are no noise if so, what is their tone, the ratio of the phases of cardiac function (systolic, diastolic - the proto-, meso-, presystolic), where they are the best listening and holding. Change in their strength and sonority, depending on the position of the patient (standing, lying on his right side, on the left side), after exercise, the breath, exhale when lifting the arms up (SirotininKukoverov`s symptom). Pericardial rub, place of best hearing.

Of the digestive system

Examination of the oral cavity: the language - the quantity, color, moisture, cracks, scabs, sores, the severity of papillae ("cardinal's language," "geographic tongue" hanterovsky glossitis), presence of plaque, the prints of teeth, bad breath. Gums - paint, diarrhea, bleeding, swelling of the presence of inflamed gingival hyperemia, necrosis, pain. Soft and hard palate - paint, raids, hemorrhage. The rear wall of the pharynx, tonsils - size, color, texture, state of the gaps.

Investigation of the stomach: inspection (in the vertical and horizontal), the usual configuration, there is a protrusion (even, uneven, the symmetry of the abdomen, sunken belly, saggy, the presence of hernias (umbilical, inguinal) the state of the midline abdominal pigmentation, the presence of stretch marks, traces of scratching, scarring, the severity of subcutaneous veins (location, direction of blood flow), the involvement of the abdominal wall in the respiratory movements. navel - the presence of a diverticulum, inflammation, soak, changing the color of the navel and the umbilical region, a symptom of "Medusa head", a symptom of Cullen, epigastric pulsation.

Abdominal circumference at the navel.

Estimated palpation of the abdomen (vertical, horizontal position of the patient). Compliance with the principles V.P.Obraztsov (palpation of the bottom up, from left to right): the degree of tension of the abdominal wall, location, condition of skin, tenderness, peritoneal symptom Shchetkin-Blumberg, a zone of hyperesthesia, the difference recti, the presence of a hernia, a symptom of Mendel, the presence of pain appendicular symptoms Mc Burney, Lanz, Abrazhanov, Rozanov, Gubergrits, Rovzing, Sitkovskiy, Kocher, Razdolsky.

These percussion and auscultation of the abdomen: the presence of abdominal tenderness on palpation, a place of maximum tenderness, the direction, scope of pain, definition of fluid buildup in the abdomen, changing boundaries deadened tone of sitting and standing, lying down, in sloping areas abdomen, the presence of unusual colors in the tympanic region (in the lungs, liver), whether it is limited to a

17

particular constant region or spreads throughout the abdomen, splashing (in the terminal segment of the ileum - a symptom of Strazhesko, right epigastric empty stomach - a symptom Vasilenko).

Deep palpation (in the horizontal position of the patient) in the presence of any entity defined by its location, size, shape, surface texture, tenderness, communication with the surrounding tissues and organs, the mobility, the detection of pain, if it is limited to a small area, you can use one palpation finger.

Palpation of the intestine - localization, shape, mobility, tenderness, texture, rumbling, the surface of all departments (sigmoid, descending and ascending colon, transverse colon, in some cases - the cecum).

Definition of epigastric pain points around the navel, near the spine - Herbst, Boas, Openhovsky, the definition of the boundaries of the stomach (auskultopalpation).

Definition of pain in the area of chauffeur (pain points Gubergrits, May-Robson, Desjardins, Kach).

Palpation of the liver - the properties of edges, surfaces, tenderness, texture, degree of protrusion from the right costal arch (cm). In cases of ascites, the use of "running for palpation."

Determination of the upper and lower boundaries of percussion (the size of M.G.Kurlov - on the right mid-clavicular line at the front of the midline of the body, the left costal arch, 14/9/6 cm).

Palpation of the gallbladder - pain, proschupyvaemost, a symptom of Ker, Musso, Ortner, Murphy, Courvoisier.

Palpation of the spleen - is held in the supine position and on the right side (the method of Sali).

Pay attention to: 1) location, 2) form, and 3) the presence of clippings, and 4) consistency, and 5) the mobility of 6) by palpation tenderness, and 7) the nature of the surface.

Determine the degree of enlargement of the spleen: 1 - the spleen is out of the left costal arch at the I cross fingers 2 - spleen reaches midway between the navel and the left upper quadrant, and 3 - the spleen reaches the median line of the abdomen (it takes the left half of the abdomen), 4 - Spleen is not only the left half of the abdomen, but also goes into the right half and the pelvic area.

Percussion of the spleen - definition of longitudinal and transverse dimensions of the body: in the middle axillary line-width (6cm m \ y IX and XI rib), the X on the left edge - lengthly spleen (8 cm m \ at the front and back of axillary lines) in the form of (6х8).

Auscultation of the intestine (peristalsis listening, noise, friction of the peritoneum). Inspection of the anus (fissures, hemorrhoids). Research through the rectum, if necessary, through the vagina ("acute abdomen", a suspicion of intraabdominal bleeding, intestinal obstruction, malignant tumor).

The urogenital system

The checkup of the lumbar area: smoothing sidebar, red skins, increas kidney area.

18

Palpation the bud (vertical and horizontal position sick): determination of their form, localization, nature to surfaces, pain, degree to mobilities.

The Determination pain urea points: 1) rib-vertebral (in the corner, formed by spine and XII rib); 2) rib-lumbar (in the corner between XII rib and lumbar muscle); 3) подреберная (beside front end X rib); 4) upper urea point (on umbilical line on three fingers or left of bellybutton, beside medicine to be taken externally of the edge of the direct muscle of the belly); 5) average urea point (on horysontal, connecting both middle-upper area iliaca of the bones, on place her(its) crisscross; rechristen with vertical line, passing on butting internal and two medicine to be taken externallies third ligaments).

Percussion behind in the field of bud: determination болезненности herewith with one or with both sides (the knock symptom on lumbar area - SPPO).

Percussion and palpation of the urinary bubble. Diurez. The Edemas. Auscultation: noise kidney artery (is listened to,is not listened to Sexual system The Mammary glands and breast ferrics of the mans: degree of the development, condition skin cover, pigmentation, containers, local edema in the manner of

"lemon crust", втяжение. Simmetrichnosti ferrics in size. The Form nipple, presence erosion and cankers on ареолах, deforming the ferrics. The Compactions,

тяжистость and tumors at пальпации.

Palpation bottom of the belly beside women (womb and her(its) apurtenance)

.

The endocrine system

Inspection: the physical and intellectual extension must to correspond of age, sex. Primary and secondary sexual characters: to presence of virilism, eunuchoidism, feminism. Growth disorder ( gigantism, nanism), proportionality of body. Complexion: hyperpigmentation, thinning, roughening, humidity, vitiligo.

Hair cover:

Face – expression, changes to side of eyes, exophthalmos can be sharp or moderate.

Eye symptoms: the symtoms of Grefe, Koher, Mebius, Elinek, Dalrimpel, Rozenbah, Shtelvag.

Palpation of the thyroid: normal size or to increase, to corresponding 2-5 stage by Nikolaev or 1-2 stage by World Health Organization: by palption you must determine the form, consistency (nodosity), painfulness.

Hand tremor. Basal metabolism can to determine by Rids formula: 0,75 (P+0,74 PP)-72=+-10%, P is characterize the pulse rate, PP-pulse pressure. The symptom of Trusso, Hvostek ( in the norm not determine).

Obesity: general, degree of manifestation, waist measurements (WM), volume of thighs (VT), correlation of WM/VT.

The central and peripheral nervous system.

Higher nervous activity: the mood-quet, to excite, depressed. Movement function: active and passive movements.

Palpebral fissure: identical or not identical, ptosis, nystagmus. Symetry of the face, position of the tongue, straight or defect in the side. The speech is free,

19

scanning speech, aphasia, dysarthria, the voice is loud or quiet. The movements in the upper and lower extremities is restriction or not. The power of muscles is equally or reduce.The coordination of movements to pressure or disbalance.

The Romberg”s pose: stable or not stable. The functions of pelvic organs is disturb or not.

The reflex function: the pupils of the eyes identical or not identical; reaction on the light is rapid or retard. The tendon reflexes are stronger or weakend. The pathologic reflexes to determine or not.

The receptor function: vision, hearing, olfaction to keep, weakened or to absent. The painful perceptibility to increase, dicrease, where? You must to determine the stiff neck.

The autonomic function: red, white dermographism to increase or dicrease. The hyperhidrosis is default or expressed. Salivation. You must to determine the pulse rate in horizontal and plantigrade position (orthostatic tachycardia).

The system of blood

Inspection.

Features of skin color - "marbling", reticulation - "livedo", paleness, ikterics, "waxy" color, cherry-red color.

The presence of haemorrhagic rash, change the language ("painted" red, cracked, flattening of papillae). Necrotic and gangrenous lesions in the mouth - a condition of the tonsils, the gums. The presence of asymmetry of the abdomen, the left half of the increase due to the spleen, the condition of the joints, the musculoskeletal system.

Palpation:

State of the lymphatic system, bone tenderness, liver, spleen, and to characterize the surface texture.

percussion:

Determination of the liver and spleen Kurlov. Percussion of the long tubular bones of the sternum, ribs - the presence of pain, symptom testing harness, pinch.

VII. the preliminary diagnosis, his(its) motivation and wording.

The General and local check up and available given laboratory and instrumental studies help to reveal the leadinging syndrome (-y) and approach to wording of the preliminary diagnosis.

The Preliminary diagnosis and his(its) motivation to write after completion writing the given objective study and question. The Diagnosis is formulated in accordance with existing categorization. The Motivation of the diagnosis - a writing the short move of the discourses and conclusions about having disease beside given sick. The main facts happen to In motivation got when questioning and objective study, confirming supposed disease ( the preliminary diagnosis). The Motivation practically is a reflection of the move of the clinical thinking of the physician, it must be an logical and full.

20