The scheme of medical history in the clinic of the internal diseases work book
..pdfMINISTRY OF PUBLIC HEALTH OF KAZAKHSTAN REPUBLIC THE STATE MEDICAL UNIVERSITY IN KARAGANDA
S. D. NYRSULTANOVA, E. I. MIRZO, E. K. BEKOV, E. S. APPASOVA
THE SCHEME OF MEDICAL HISTORY IN THE CLINIC
OF THE INTERNAL DISEASES
WORK BOOK FOR STUDENTS
KARAGANDA 2012
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УДК 616.1/.4 ББК 54.1 ф 7 С 92
Reviewers:
G. M. Muldaeva- the head department of ambulatorry therapy of the state medical university in Karaganda, Doctor of Medicine.
V. B. Molotov-Luchansky - the head department of preliminary preparation of the state medical university in Karaganda, Doctor of Medicine.
V.A. Tkachev – the heand of department propedeutics of internal diseases AO
“The state medical university, Astana”, c.m.s.
С 92 THE SCHEME OF MEDICAL HISTORY IN THE CLINIC OF THE INTERNAL DISEASES:. - WORK BOOK.- Karaganda.- 2012.- 28c.
ББК 54.1 ф 7
In the work book to write the scheme of medical history and initial examination in the clinic. To describe the methods of question and inspection. The material to write in the logical sequence and can to use as hand book for right writing the educational case report.
The work book to intend for students, interns.
The work book to discuss and to approve on the meeting of methodological council KGMU. Record № at 09.12.2009 y.
This work is assert and recommend by publication of Academic Senate KGMU. Record № 9 at 25. 04 2012 y.
© S. D. NYRSULTANOVA, E. I. MIRZO, E. K. BEKOV, E. S. APPASOVA, 2012
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Nomenclature of abridgements
A P- arterial pressure
A G- arterial hypertension
I S- smoker index
IBWindex of body weight
VTvolume of thigh
WMwaist measurements
NRMnumber respiratory movements
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Contents |
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Introduction |
5 |
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1. |
Record data |
6 |
2. |
Complaints of patient |
7 |
3. |
The history of disease |
11 |
4. |
The history of life |
12 |
5. |
General examination |
13 |
6. |
Investigation of the patient by organs and systems |
14 |
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The respiratory system |
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The cardiovascular system |
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The digestive system |
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The urogenital system |
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The endocrine system |
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The central and peripheral nervous system |
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The hemotopoetic system |
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7. |
The provisional diagnosis, substantiation of diagnosis |
20 |
8. |
The plan of the additional inspection |
21 |
9. |
The final clinical diagnosis |
22 |
The list of the bibliography cited |
26 |
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INTRODUCTION
Filling histories is one of the most important elements of medical work, during which a physician records his observations and medical activities as a result of creative thinking at the bedside to ensure the continuity of diagnostic and therapeutic measures and facilitating the establishment of correct diagnosis and treatment. The value of medical history in clinical medicine can not be overestimated. This document is of great medical and legal importance. Based on the history of the disease studied the dynamics of the disease, and labor performed a forensic examination. The history of the disease is a major indicator of the quality of hospital treatment which reflects the nature of the disease and treatment efficacy. The high quality of this important medical document should be viewed as sensitivity to the patient and care about its future.
Therefore, the writing of history teaching students is an important component of learning. For the first time a student attempts to generalize their own own clinical observations. Medical history should be written carefully, in detail, with the release of all sections of the standard form provided by the history of the disease - p. № 003 \ y (inpatient medical records). Writing histories requires the student to actively explore the literature on this and similar illness. The results of his observations of the patient it should compile in epicrisis. In this case the student secures their skills in a comprehensive and systematic study of the patient, logical presentation of the data. You should carefully, thoroughly and carefully examine the patient. In the process of communication with the patient should strictly observe the principles of ethics.
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Medical History Sheet
A medical history sheet should be written thoroughly, without any abbreviations and corrections, and with main articles in bold:
-title sheet, passport data,
-patient’s complaints,
-anamnesis morbi,
-anamnesis vitae,
-status praesens of a patient with docimasy of organs and systems.
-graphologic structure of clinical picture of a patient’s illness with justification and separation of a leading syndrome
-preliminary diagnosis and its justification
-plan of assessment
-data of laboratory-tool methods of working-up and specialists’ consultations
-final diagnosis and its justification on every fragment of statement. Formulations of the clinical diagnosis in comply with commonly accepted classification and a code according to MKB-10 (МКБ-10).
1.Treatment and its justification
2.Prediction
3.Prophylaxes
4.Diary of follow-up of patient
5.Body temperature sheet
6.Epicrisis
7.List of literature used
The medical history report is finished with the statement of a preliminary diagnosis and with the plan of additional researches.
Clinical diagnoses of main and co-occurring illnesses, complications on the basis of made analysis with laboratory – tool data included, has to be submitted not later than in three days after an admission of the patient to hospital.
Interrogation (Interrogatio)
I. PASSPORT DATA
Surname, name, patronymic name Age of patient (date of birth) Nationality
Date of admission
Profession, position (disability, unemployed) Work place, position
Home address (street, house number) Name of hospital
Who the patient was directed by Directed diagnosis
Clinical diagnosis
Clinical final diagnosis (conclusive)
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___________________ main illness
___________________ complications
___________________ co-occurring diseases
II. PATIENT’S COMPLAINTS
Interrogation about painful senses of a patient is a very important link in the first stage of diagnostic search. In number of cases it can be such that a preliminary diagnostic conception of the patient’s illness may be formed; in case there are pathognomonic complaints it is quite possible. On the other hand while clarifying of patient’s complaints the idea may appear that there is a quite number of similar diseases or the idea of affection of the whole certain organ or the system of a body. At the moment of admission to hospital it is necessary to provide a detailed description of patient’s complaint. The interrogation of painful senses of a patient should be: “What troubles you currently?”, "What made you to address to the doctor?" Complaints may be as very variable and numerous so on the contrary very scant. The explanation of complaints often depends on the patient’s culture, or his/her nerve system, awareness of medical matters, medical terminology. Complaints are subdivided into main, dominating, connected with the basic illness of a patient, and characterizing the severity of patient’s condition ones, and additional ones, connected with co-occurring diseases. Patient may not mention some of the illness’s symptoms thinking they are not so essential, that is why it is valuable to find out the main and the additional complaints by using interrogation on organs and systems maximum detailing of each complaint. Apart from that it is reasonable to separate complaints when admitted and on the date of followingup reflecting its dynamics.
One has to keep in mind that only the complaint described in detail is useful for recognition of illness.
No need to overload the medical history by listing of missing complaints (for example: appetite is in norm, no coughing, etc.).
List of complaints the most frequently met if separate systems are ill and their specification.
Respiratory system
Cough: continuous or attack-like, dry or wet – with phlegm. Conditions that affect its occurrence, intensification and reduction, time of its appearance (in the morning, at night), and cough nature (loud, strong, barking, soundless).
Pains in thoracic cage: localization, intensiveness, duration, nature of pain (sharp, dull, stinging, dull ache), relation to breathing, cough, position of a body, what strengthen or releases the pain.
Dyspnoea (chest-foundering): expiratory or inspiratory one, its evidence, what its attacks are connected with, symptoms accompanying the dyspnoea, affects of smells, when in quiet state, when worried, during conversation, behavior of patient at attack moment, in what condition the chest – foundering reduces or by means of what medicines (inhalations) it is stopped.
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Phlegm: quantity (per a day and at one time), how it draws off (easily, with difficulty), dependence of drawing off on position of a body, consistency, color, smell, whether a patient feels better after the drawing off of phlegm (reduction of chest - foundering, and pains).
Bloody expectoration: intensiveness (quantity) and color, poppy red or dark, with clots or liquid blood.
Cardiovascular system:
Dispnoea: intensiveness, time of occurrence (at what time of the day), nature (continuous, attack-like), related to physical tensions (walking on the stairs), in relief, when worried, during conversation, in what position it reduces (vertical - sitting, in horizontal – on the left or right side, on the back).
Pain: localization (in area of heart or behind the breast bone), time and condition of occurrence (if quiet, under physical tension, when worried, in cold), nature and intensiveness, irradiation, duration, accompanying of pains with feeling of depression, fear of death, weakness, cold sweat, giddiness; by means of what the pain is stopped (Validol, nitroglycerine, nitrosorbide, relief without medicine), frequency of painful attacks.
Feelings of heartbeats, intermission: continuous, attack-like, intensiveness, duration, frequency, conditions for occurrence (under physical tension, if quiet, if worried, after eating, in horizontal position, under the change of outside temperature, how is stopped (by change of body position, holding of breath, vomits (sickness), etc).
Edemas: localization, intensiveness, continuous or disappearing, time of occurrence (tonight, in the morning), relation to physical tension, eating of salted food, or liquid; feeling of heaviness or pain in the right area below the ribs, growth of belly.
Feeling of pulsation: intermitted lameness, feeling of a “dead” finger.
Digestive system
Appetite: good, hyperorexia, hyporexia, anorexia (to what food), dysorexia (willing to eat unusual food, uneatable).
Satiation: normal, fast, continuous feeling of hunger, pseudo diabetic trilogy (hunger feeling, with polyphagia, atrophy, heavy urination).
Taste sense in the mouth: acidy, bitter, metallic, sweet, dry mouth, taste perversion, burning mouth syndrome (glossodynia).
Thirst: how much of liquid a patient drinks in a day.
Salivation: attack-like salivation. Reduction or lack of salivation.
Eructation: by what, time of occurrence, loudness (attention to be paid to aftertaste: acidy, bitter, putrid, "rotten egg"). Whether it is a result of ate food and its types.
Hiccup: after food, does not depend on the food.
Epigastric burning: frequency, dependence on eating, its nature, position of a
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body, intensiveness, duration, with what it is stopped or relieved (sodophagia). Sickness: dependence on eating, its nature, time of occurrence, (after food, on an empty stomach, related to food smell), when body convulsed, at inclined position. Emesis: on an empty stomach or right after the eating – right after or after a while, frequency, relief of well-being after the emesis, nature of emesis masses – as eaten food, as bile, blood presence (light, or the type of “coffee grouts”), smell (putrid, acidy), without any smell, color.
Ingestion and passing through of food: painful, painless, with difficulty, what food does not pass.
Pain in the belly: localization and irradiation, when and under what circumstances they occur, before food, after food, after a while, whether it is as a result of the nature of the eaten food, at night, "hunger" pains, related to physical load, what relieves the pain (position of a body, eating of food, alkali, with taking of medicines, by use of heat, emesis), intensiveness, nature of pain, rhythm (during a day), periodicity (during a year - seasonality), duration of pains, availability of attacks, with what are they accompanied (emesis, sickness, stool retention or quickening of stool, increase of temperature, abdominal distention, if yellow sickness appear, change of urine and fecal masses color, passage of flatus).
Urination system
Pains in lumbar area: continuous, attack-like, from one side or from both sides, dull pain, acute pains and their irradiation, circumstances, under which they occur and weaken.
Urination: frequency, colic availability, burnings, difficulties under it, false imperative feelings, intermittent flow of urine.
Urine: quantity per a day, color (normal, dark, like "meat slops"), turbidity, blood occurrence in urine (at the beginning of urination or at the end of it).
Endocrine system:
It is necessary to orient not on separate symptoms when questioning patients with given pathology but on the symptomatic complexes. Neurological semiotics is very often found out. There are complaints on pains at the side of cardiovascular system and organs of digestion.
Changes from the psychic sphere: irritability and impatience, increased excitability, insomnia, and fearfulness are specific for hyper thyroidism; and on the contrary, such symptoms as flabbiness, apathy, adynamy, and weakening of memory are specific for hypothyroidism.
Changes of motional activity: weakness of muscles, spasms, change of walk, pains in muscles, spontaneous breaks are specific for illnesses of parathyroid glands.
Changes of basic metabolism: increase of motional activity, intensified peristalsis, tachycardia, temperate fever, excessive sweet, increased appetite, with tendency to diarrhea, and malnutrition are specific for hyper thyroids; and reduction of basic metabolism with hypothermia, excessive weight, and edemas are evidence of hypothyroidism.
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Obesity (fatness): crescent-shaped face, increased fattiness of skin, thick body, thin arms and legs, high blood pressure, hyperglycemia, hirsutism, amenorrhea, impotence, reduced resistance against infections are typical symptomatic complexes for primary or secondary hyper corticism when there is a hypothalamic syndrome.
Change of secondary genital characters: hyper trichauxis, masculinization of women if there is a tumor of adrenal gland, eunochoid state, feminization when there is a hypogonadia.
Weight loss – It is even up to cachexy, if there is a Simmonds – Sheehan syndrome. The characteristics are as follows: rare and miserable monthly menstrual flux or amenorrhea, agenesis, hyper trichauxis, tendency to fatness – if there is Stein-Leventhal syndrome (SDO - sclerocystic disease of the ovary).
Gigantism, is characterized as the occurrences of acromegalia (Marie’s disease): enlargement of brows, nose, jaws, heavy chin, gapping of teeth, enlargement of wrists and footsteps that are evident of pituitary disease (hypophysis).
Dwarfism, mental retardation (oligophrenia), bradycardia, and constipations are characteristics of genuine hyper thyroids, and goiter.
Hard skin pigmentation, loss of weight, weakness, anorexia, diarrhea, hypotension, hypoglycemia – if there is adrenal inefficiency.
Skin itch, excessive appetite, and thirst, very frequent and heavy urination are characteristics of pancreatic diabetes.
NERVOUS SYSTEM, SENSORY ORGANS, MENTAL STATE
While clearing up of complaints it is important to pay attention to self features and behavior of a patient whether he/she is calm, equable, quick-tempered, querulous, sociable or of shut-in personality.
Sleep: normal or troubled (worrying, disrupted, insomnia or sleepiness. Headaches: their nature, intensiveness, frequency, duration, localization; causes of the headaches occurrence or of increase of these aches, with what these aches are accompanied, by means of what they are relieved, whether there is a relation to meteorological conditions.
Faintness (swimming of the head): frequency, intensiveness, duration, "blinking of flies", insensibility, and what they are caused by.
Psychic sphere: memory, suspiciousness, mood, availability of obtrusive ideas, hallucinations.
Sense of sight: weakening, nearsightedness, far-sightedness. Sense of hearing: weakened, deafness, noise in the ears. Sense of smell: weakening, lack of any changes.
Abnormality of sensibility and movements: violation of usual cold sensation, sensation of heat, a feeling of “creeps’ crawling”, numbness, violation of walk, spasms of muscles, not-willed movements, and a change of handwriting.
Finding out of specific complaints in this section of interrogation does not always evidence of self neurological pathology by no means. Neurological symptoms very
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