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

VIII. The plan of supplementary investigation The period of diagnostic seeking.

The provisional diagnosis is tentative, expectable diagnosis, it”s require in specification. For specification of provisional diagnosis,the doctor must do it the plan of accessory investigations and after this the doctor is formulation a final diagnosis with next directions:

- fundamental disease,

-complicationof the fundamental disease, - associated diseases.

The complementary diagnostic investigations include laboratory-instrumental methods.

The plan of investigation to patient consist from some parts: 1.There are mandatory investigations do it all patients.

2.The another investigations it is necessary for differential diagnosis and specification of diagnosis.

3. Professional consultations (ophthalmologist, urologist and another).

The obligatory investigations is include:

General blood analysis.General urine analysis.General feces analysis.

Biochemical analysis of bloodgeneral protein, glucose, cholesterol, bilirubin, creatinine.

Wassermann reaction.Electrocardiography.

X-ray organs of the thorax.

Volume of the additional studies is defined in each concrete diagnostic situation. The final clinical diagnosis is formed through the syndromic approach. This is a creative work of the doctor, which leads to a medical report on the health of the patient's illness. Identifying symptoms (subjective, objective, paraclinical), you can group them into syndromes - a relatively stable set of symptoms, united by a common pathogenesis.

Thus, a physician in the diagnostic process goes through three phases of creative work: 1) the search for symptoms, 2) the grouping of symptoms in syndromes, 3) the search for links between the syndromes and the construction of the diagnosis.

The first phase of the most complex and largely determines the success of the second and third phases.

By definition, the famous Russian scientist, Academician of RAMS V.H.Vasilenko clinician, diagnostic prerequisites are:

-Knowledge of the symptoms of clinical entities.

-Good knowledge of methods and techniques of direct clinical research.

-An understanding of the pathogenesis of each symptom.

-Ability and desire to find a mutual relationship of symptoms.

-Accounting for genetic and acquired characteristics of the patient.

-Knowledge of the diagnostic value of additional methods of clinical research. Master the basics of the methods of examination and diagnosis of the doctor starts

medical school in the early stages of learning, then learning and improved life.

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The test questions

1. Choose the correct variant of sequence of question of patient

A.complaints, history of life, history of the real disease

B.it is history of the real disease, history of life of patient, complaints

C.complaints, hospital chart, history of life

D.examination, hospital chart, history of life

E.nothing of transferred

2. A basic ethic rule at taking the history of disease is?

A.it is critical attitude toward previous diagnoses

B.it is an accent on sufferet colleagues errors

C.it is ignoring of results of the researches conducted before D.respectful attitude toward opinion of the colleagues

E.it is a concealment of the noticed errors in tactics of conduct of patient

3.You will define, what from the transferred methods of research, behave to physical?

A.it is taking the history

B.it is sciagraphy

C.it is inquiring for the complaints of patient

D.it is a spirography

E.it is palpation

4.Mark among prominent clinicians that, who developed the method of anamnesis to the degree of art

A.S.P.Botkin

B.Laenek

C.М. I.Мudrov

D.Zaharin

E.Paracels

5.What is the name of stupor?

A.are excitations

B.apathy

C.stunned

D.emotional лабильности

E.alcoholic psychosis

6.What term is designate the loss of memory, loss of remembrances about one or another events?

A.it is apraxia ;

B.anakusis;

C.it is analgesia ;

D.amnesia;

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E.it is agnosia.

7.What does it mean a receptor?

A.the unpleasant feeling, arising up without causing of irritation;

B.it is a pain syndrome because of defeat of separate peripheral nerve or nerves;

C.it is a return reaction on an irritation, carried out by the nervous system;

D.specialized nervous education, percipient irritation;

E.it is an involuntary rhythmic twitch of eyeballs at a look in parties or upwards.

8.What does it mean a syncope?

A.brief loss of consciousness because of sharp hypoxia of cerebrum

B.it is disorder of consciousness at which a patient is quite apathetic to surrounding, on questions does not answer, but reflexes are yet stored, at the repeated loud appeals can open eyes;

C.it is a stupor, complete immobility;

D.it is sudden, strong and long, involuntary reduction of certain muscle or muscular group, related to the increase of her tone;

E.it is a syndrome of heavy defeat of cerebrum, one of main clinical displays of which is a loss of consciousness.

9.Caused by the actions of doctor a disease is named

A.basic;

B.secondary;

C.paratherapeutic;

D.somatic;

E.psychogenic.

10.The estimation of position of patient in space belongs to:

A.to anamnesis of life;

B.to the exposure of complaints of patient;

C.histories of the real disease;

D.to general examination;

E.to additional research.

11.From the facts of anamnesis of life mark that which can take place only for a woman?

A.it is epidemic parotitis in childhood;

B.it is an osteoporosis;

C.it is the eclampsia carried by a mother in luing-ins;

D.gestosis;

E.alcohol abuse

12.Name the name of doctor, describing a next "mask" : the scared or angry mien, unwinking look, expansion of eye cracks, hyperemia of cheeks, brilliance of eyes?

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A.Коrvizar;

B.it is Hippocrates;

C.Bazedov;

D.Brayt;

E.Parcinson.

13.At examination of patient you paid attention to violation of posture. What from the methods of inspection is it necessary to set these violations in about reasons of causing?

A.in inquiring for complaints;

B.in anamnesis of life;

C.at examination;

D.at an acquaintance with passport data;

E.at palpation.

14.A patient is delivered in the unconscious state. At examination there is breathing noisy deep, cutaneous covering dry, in an expirate smell of rotten apples. About coma of what genesis is it possible to suppose for a patient?

A.diabetic;

B.alcoholic;

C.traumatic;

D.uremic;

E.hypoglycemia;

15. What specialist was Syndrome of Icenco-Kushihg described by?

A.endocrinologist B.cardiologist

C.by a neurologist;

D.pulmonologist E.gastroenterologist

16.What method of instrumental diagnostics does allow to visualize the structure of pancreas and channels?

A.FGDS;

B.endoscopic retrograde pancretocholangiografhy

C.it is the duodenal sounding;

D.fibrocolonoscopy

E.coprology

17.What method of instrumental diagnostics does allow to visualize the structure of pancreas and channels?

A.FGDS ;

B.ULTRASONIC;

C.it is the duodenal sounding; D. fibrocolonoscopy

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E.coprology

18.What can be defined by superficial, reference by palpation of stomach?

A.large curvature of stomach

B.sigmoid bowel

C.blind gut

D.muscular defence (defanse muskulere)

E.topography of spleen

19.What disease is characteristic a creatorrhea and steatorrhea?

A.gastritis

B.hepatitis

C.pancreatitis;

D.colitis

E.ulcerous illness.

20.What can you determine by palpation?

A.Cardial beat

B.Configuration of the heart is change

C.Arterial hypertension

D.Prolapsed of the mitral valve

E.The border of the heart is change

The right answer:

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Литература

1.Богатырев В.Г. Основы медицинской диагностики внутренних болезней.- М.: Эксмо, 2008.-208с.- (Медицинское образование).

2.Василенко В.Х. Введение в клинику внутренних болезней. – М., «Медицина», 1985.

3.Гребенев А.Л. Пропедевтика внутренних болезней. – М., «Медицина», 2005.

4.Клинические классификации и основные синдромы внутренних болезней /Под ред Т.З. Мейсембекова и М.Н. Пака.-Астана.-2001.-230с.

5.Померанцев В.П. Стратегия диагностического обследования в клинике внутренних болезней //Клиническая медицина. – 1991. – N1. – С.108114.

6.Практикум по пропедевтике внутренних болезней: учебное пособие/ Под ред. Ж.Д. Кобалава, В.С. Моисеева.-М.: ГЭОТАР-Медицина,2008.-

208с.

7.Тетенев Ф.Ф. Для чего нужна теория диагностики //Клиническая медицина. – 1996. – N3. – C.73-74.

8.Умбеталина Н.С. Современные принципы диагностики и формулирования диагноза. /Учебно-метод.рек., Караганда.-1996.-с.23.

9.Черноруцкий М.В. Диагностика и лечение внутренних болезней. – М.,

Медгиз, 1947.

10.Шамов И.А. Поропедевтика внутренних болезней: учеб.пособие. /изд. 6-е, прераб. И доп.- Ростов н/Д: Феникс, 2007.-447с.- (Медицина).

11.Шульцев Г.П. Клиническое значение осмотра больного //Клиническая медицина. – 1973г. – N 2. – С. 65-74.

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Appendix 1

The state medical university in Karaganda

The department of propedeutica internal diseases

The head of department-

The teacher-

The history of the disease

The last name, name, patronymic

Compartment, the number of the room

Diagnosis

Curator: the student of 3 course

«General medicine»

The last name, name, patronymic The date of observation

Karaganda - 2012

Appendix 2

The structure of the medical history 3 rd year students

The structure of the educational history of the disease

1.The patient's complaints

2.History of present illness

3.History of the patient's life

4.The objective status

5.Graphological structure of the syndromes (symptoms)

6.The preliminary diagnosis (isolation syndrome leading to 3rd year students)

7.The plan further study

8.Rationale for the clinical diagnosis (justification syndrome leading to 3rd year students)

9.Used literary sources

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Appendix 3

The structure of the medical history students 4-6 courses

The structure of the medical history

. The structure of the curriculum reflects the continuity of the history of the study of therapeutic disciplines. It consists of the following sections:

1.Passport part: full name the patient, his profession, occupation, place of residence

2.Diagnosis at admission

3.patient's complaints

4.History of present illness

5.History of the patient's life

6.objective status

7.Graphological structure of symptoms and syndromes

8.I-th stage of the differential diagnosis

9.The preliminary diagnosis

10.Plan Survey

11.Additional studies and their results

12.II-nd stage of the differential diagnosis

13.Rationale for the clinical diagnosis

14.Blogs observation

15.Principles of treatment

16.epicrisis

17.Used literary sources

Appendix 4

CRITERIES FOR EVALUATION OF CLINICAL HISTORY

1.The completeness of the collection of information from patient complaints and medical history.

2.Completeness of data collection, obtained in the patient's physical examination.

3.Consistency and validity of the statement of the preliminary diagnosis (syndrome).

4.Consistency and validity of a plan of the laboratory-instrumetalnogo additional examination of the patient.

5.Consistency and literacy study the final diagnosis (syndrome) with a clinical interpretation of laboratory instrumentation and other research methods.

6.Use additional literature.

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