MPH OF UKRAINE IVANO-FRANСIVSK NATIONAL MEDICAL UNIVERSITY Chair of Surger of !he De"!i#!r $e%ar!&e"! IFNMU The hea$ of !he 'hair( %rof) O)V) P%!iu* Tea'her( Tea'her( ++++++++++++++++++++ ++
CASE HISTORY OF THE INPATIENT(
Surname, first name, patronymic ---------------------------------Clinical diagnosis of a primary diseas.---------------------------Complication of a primary disease--------------------------------disease--------------------------------Diagnosis of an concomitant disease---------------disease--------------------------------------------An attending doctor: third year student---------------------------Beginning of treatment-----------------------_____(date) treatment-----------------------_____(date) Completion of treatment-----------------------____(date) treatment-----------------------____(date) ar!:______________________ "eacher#s signature:___________
Pa##%or! Da!a %. Surname, Surname, first name, patronymic__ patronymic_____ ______ ______ ______ ______ ______ _______ ____ &- Age-----------------------------------------______________,____ '. Se _______________________,__ _______________________,_______ ___________ ____________ ___________ _____ . *ationalit *ationality___ y_______ ________ ________ _________ _________ ________ _________ _________ ________ ____ +. ducation__ ducation________ ___________ __________ ___________ ___________ __________ ___________ ________ __ . rofession---------------rofession-------------------------------------------------_ --------------___/_ __/____ ______ ______ _____ __ 0. lace of 1or!----------------1or!--------------------------------._ ---------------.__._____________ _._______________ __ 2. 3ome address__ address_______ _________ ________ _________ _________ _________ __________ __________ _____ 4. 5amily status________________ status_________________________ __________________ _______________ ______ $6. Date of admission to a hospital_________________________ %%. Date of discharge discharge._____ .___________ ____________ _____________ _____________ ___________ _____ $&. Admission diagnosis___________________ diagnosis_____________________________ _______________ _____ $'.Basic diagnosis:_____________________________________ Clinical diagnosis of a primary disease________________ disease___________________ ___ Complication of a primary disease_______________________ Diagnosis of an concomitant disease__________________ disease_____________________ ___ $. Diagnosis on discharge_____________ discharge_______________________ ___________________ _________ $+. 7esult of treatment___________________________________ treatment___________________________________ 2) COMPLAINTS of the PATIENT PATIENT (QVERELLAE AEGROTI) 5irst of all it is necessary to count the complaints, concerning the disease 1ith, 1hich the patient has 8een hospitali9ed to a surgical cli nic . %t is necessary necessary to detail eery complaint. After that the secondary complaints, 1hich are caused 8y other reasons are ta!en into account. 2. ANAMNESIS of a DISEASE (Anamnesis mo!i) %n anamnesis anamnesis it is necessary necessary to 1rite do1n the deelopment deelopment and course of a gien disease in a chronological se;uence/ to pay attention
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to the 8asic stages of its deelopment, appearance of ne1 symptoms, methods of diagnostics and treatment 1hich 1ere used 8efore the patient#s admission to a hospital. I,a"o-Fra"i,#*. /01/
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". ANAMNESIS of LI#E (Anamnesis $itae) "his part of a medical card has a 8iographic character, 1hich deals 1ith different aspects of the patient#s life. %t is necessary to start it from the moment of
the patient#s 8irth, ta!ing into account the material conditions during his life, conditions of 1or!ing, family status, health of the 1ife (hus8and), children, condit condition ionss of famil family y life, life, mode mode of life. life. "ime "ime of pu8er pu8erty: ty: in the female female gynecologic anamnesis is (time of appearance of menstruations, their course, cyclicity, cyclicity, amount of p regnancies, la8ors, a8ortions). "he preious diseases (in particular a tu8erculosis, Bot!in#s disease, lues), operations (under 1hich anesthes anesthesia ia they 1ere carried carried out), use of hormones hormones,, serums, serums, al8umino al8uminous us preparations, hemotransfusions, immunodepressants in the treatment, complicati complications ons during during their application. application. Drug intoleranc intolerancee (due to 1hich drugs), the presence of other !inds of allergies. %t is necessary to find a possi8le connection of a disease 1ith heredity of the patient (diseases of his parents and relaties, the cause of their death), harmful ha8its <(smo!ing, a8use of alcohol, alcohol, narcotics, narcotics, etc.). etc.). =ou must find a possi8le possi8le connection connection 8et1een the receied data data and the cause of disease. %. GENERAL ANAMNESIS (Anamnesis &omm'nis) "he respiratory system. 7espiration through the nose natural, la8ored, impossi8le the patient (8reathes through the mouth). >hether there is the sensation of dryness in the nose. cretions cretions from the nose: amount (small, (small, moderate, moderate, large), large), character (thic!,li (thic!,li ;u id , diaphanous, diaphanous,purule purulent,sa nt,sanguinol nguinolent,1 ent,1ith ith an odor). odor). *ose - 8leeds (the cause of their occurrence,duration,; u a n t i t y of the 8lood). "he laryn. ain during conersation. A oice - sonorous,;uiet, hoarse, aphonia. ain in the region of the thora: a8sent, constant, constant, arises arises periodica periodically: lly: strengthens during motions, respiration, cough/ it can 8e of acute, dull, colic, shooting character, etc. Dyspnea (la8ored 8reathing): constant, during physical eertion, going up1ards, 1al!ing/ pronounced it and duration.
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Cough: if there there is any, insignificant, insignificant, 1hooping, strong, constant, and attac!-li!e. Sputum: the ;uantity .1hether it depends on the time of ecretion and a position of the 8od y of the patient/ character (slimy, purulent, s limy-purulent), an odor. 3emoptysi 3emoptysiss (epector (epectoration ation of the 8lood): 8lood): time of appearanc appearance, e, intensity intensity (8leeding, 8lood-stained sputum), the color of the 8lood (red, dar!). "he cardioascular system. 3eart8eating - attac!s, constant/ its dependence on ecitement, physical eertion, a position of the 8ody. %rregularity. A feeling of pulsation in d ifferent parts of the 8ody. ain in the region of the heart, 8ehind the 8reast8one 8reast8one - their irradia irradiatio tion, n, force, duration, dependence on locomotions, physical eertion, eertion, ecitement. ec itement. demas (locali9ation, regularitu of their appearance). ?rgans ?rgans of digestio digestion. n. Appeti Appetite te - good, good, satisfac satisfactory tory,, 8ad, hyperor hyperoreia eia (8ulimia). Disgust to this or that food. "aste "aste - a8sent, unpleasant (8itter, acidic, @metal@). Dryness in the mouth, thirst, hypersaliation. "he ;uantity of drun! li;uid during & hours. Che1ing of food, the presence of a pain during it, tiredness. S1allo1ing of solid and li;uid foods (meals), causal pass of it into the trachea. ass assag agee of soli solid d and and li; uid food food alon along g the the esop esopha hagu guss (fre (free, e,la la8o 8ore red, d, impossi8le, painful). Dyspeptics phenomena. Belching (regurgitation) its fre;uency, the cause and time of occurrence/ character (8y air, ta!en food, stomachic contents)/ taste (8itter, s1eet, acidic)/ an odor (inodorous, of rotten eggs, fecal). 3eart8urn, nausea (intensity, for ho1 long (duration), after 1hich food). omiting - 1ithout a cause, on an empty stomach, after a meal, 1hat food causes it %n 1hat period of time does it occur omiting matters (eaten food). "he ;uantity of the omits, taste (of ta!en 8efore food, acidic, 8itter), an odor (inodorous, (inodorous, of rotten rotten eggs, fecal), color (yello1, (yello1, 8loody, 8loody, dar!-8ro1n) dar!-8ro1n),, the omiting of fecal matter (in the presence of gastrocolic fistulas). --
ain in the a8domen, its locali9ation (the epigastric, the right and left su8 costal regions, in the region of the um8ilicus/ the iliac, inguinal regions/ along the course of the small intestine, colon/ a8oe the pu8is). %rradiation of a pain - into the thora, the 8ac!, loins, etc. %ts character constant, colic, sudden, arises gradually, acute, cutting, shooting, @!nife-li!e@, @!nife-li!e@, etc. Connected Connected 1ith ta!ing of food, 1hat !ind of food, at 1hich, through 1hat time after that Depends on a position of the 8ody. Agents that alleiate (reliee pain). *ight pains. assage of flatus - is free, in an ecessie amount, retentioned. Defecation (easy (normal), daily, some times per day/ 1ith the help of an enema or purgatie drugs), influence of food. crem crements ents:: formed, formed,soli solid,li; d,li; ui d, @sheep@ @sheep@ feces. feces. Color: Color: usual,cl usual,clay ay,, dar!, coal coal-t -tar ar-l -li! i!ee (mel (melen ena) a),, fece fecess 1ith 1ith admi admit tur ures es of the the 8loo 8lood d (on (on a surface,inside),slime (in a small,large ;uantity),purulent discharges. %nef %neffe fect ctua uall impul impulse ses: s: tene tenesm smus us and and impe impera rati tie e impul impulse ses, s, feca fecall incontinence. A pain in the region of anal orifice during defecation. rolapse of the nodes, the mucous mem8rane, and the rectum. "he urinary system. ain in the region of the loins - constant, sudden: its duration and intensity, 1hen it strengthens, its irradiation (to the 8ac!, iliac regions, femur, eternal genitals). ain a8oe the pu8is, its character and reasons factors, 1hich cause, strengthen and reduce it. rination rination - effortle effortless, ss, la8ored, la8ored, painless, painful (at the 8eginning of urination, during urination, at the end of it), at night, inoluntary urination, constant drop-li!e ecretion of the urine in men, character of the urinary stream. ain in the region of the testicles, its appearance, intensity, irradiation. %n 1omen - pain in the region of the eternal genital organs, ecretions from the agina. ocomotorium. ain in muscles, @intermittent claudication@. ain in the Eoints, 8ones, column (in a state of rest, in the afternoon, at night, at locomotions). A muscular muscular force, 1ea!ening - 1hether for a long time "he nerou nerouss system system and sense sense organs organs.. Finds Finds of charac character ter:: calm, calm, 8alanced, and irrita8le. emory can 8e: good, 1ea!ened, and lost. Dream: deep,;uiet (calm),alarming. Sleeplessness (insomnia). Sight, hearing, smell, touch (changes, for ho1 long, decrease, loss)-+-
. O*ECTIVE E+AMINATION E+AMINATION (Stat's ,aesens o!-e&ti$'s) The patient's status at the moment of examination "he general condition condition of th e patient: patient: good, satisfact satisfactory ory,, moderate seere, seere, difficult, etremely serious, an agony. Consciousness: clear, mental confusion, clouding of consciousness, 1ithout consciousness. ositions: actie, passie, forced. pression of the face: usual, mas!-li!e face (ar!inson#s face), 1hether it epresses epresses sufferin suffering, g, 8oredom, 8oredom, fright, fright, anger, anger, ecitemen ecitement, t, miedemato miedematous,the us,the Basedo1#s face.3ippocratic face,etc. Saddle nose. Gorner#s sign. Constitution of the 8ody: normosthenic, asthenic, hypersthenic. Body height, 1eight. Body temperature. Examination of the patient by systems "he s!in. %ts color: pale-pin!, pale-pin!, pale, cyanotic, cyanotic, earthy, yello1ish, yello1ish, yello1, 8ron 9e). "he presence of seams, their locali9ation and the si9e/ the presence of eruption, tumors, hemorrhages. 3air 3air integu integumen ment: t: deelo deeloped ped accor accordin ding g to the @male, @male, a female female type@, type@, hypertrichosis. oisture of the s!in: usual, increased (in 1hat places). "he s!in is dry. "he s!in elasticity. *ails (appearance, color, elasticity).
"he mucous mem8ranes mem8ranes of the mouth and eyelids (color, pigmentation, pigmentation, reddening, eruption, ulcers, leu!opla!ia). A state of the gingia (gums): color, density, hemorrhages. "he tongue - 1et, dry, ery dry/ s1ollen, thic!ly coated 1ith 1ith 1hite, 1hite, grey, grey, earthy earthy layer/ layer/ its color color - pin!, pin!, crimso crimson, n, arnis arnish-l h-li!e i!e// the presence of fissures, ulcers. "he teeth - the dental formula. "he tonsils - si9e, color, edema. 5auces. "he high palate. An odor from the mouth: a8sent, purulent, smells li!e urine, acetone). 3ypodermi 3ypodermicc 8asis: 8asis: thic!ness thic!ness of the su8cutaneous su8cutaneous fat (the s!in fold on the leel of the -% ri8s along the 8ac! aillary line), character of its locali9ation. "he presence of edemas, their locali9ation. "he mammary glands. Symmetry, their dimensions, form, a state of the s!in. "he papilla and peripapillary circle. %n a ertical and hori9ontal position of the patient on palpation of the mammary glands - -
the doctor determines determines the deelopment deelopment of a cellular cellular tissue, character character of glandular lo8es, the presence of consolidations and tumors, their dimensions, locali9ation on ;uadrants, mo8ility, adnation 1ith the surrounding tissues, painfulness. cretions from the papilla papilla (serous, hemorrhagic, slimy, slimy, etc. ymph ymph nodes: nodes: su8men su8mental tal,, su8ma su8maill illary ary,, along along the course course of the sternocleidomastoid muscle, supraclaicular and su8claial, aillaries, along the eternal edge of the mammary gland, ulnar, inguinal, femoral. "heir si9e, solidity solidity,, adnation adnation 1ith each other 1ith the surrounding surrounding tissues, mo8ility, mo8ility, painfulness. uscles. uscles. General General deelopme deelopment: nt: (good, (good, satisfac satisfactory tory,, unsatisf unsatisfacto actory), ry), tonus tonus:: (usua (usual, l, reduc reduced ed,, incr increa ease sed) d).. "he "he pres presen ence ce of pain painfu fuln lnes ess, s, consolidat consolidations, ions, tumors, atrophies, atrophies, hypertrophies hypertrophies - may 8e determined determined on palpation. "he thyroid thyroid gland. gland. Si9e: Si9e: is (6,$, (6,$, %%, %%%, %, %, degree) degree).. "he form of enlargemen enlargement: t: (diffuse, (diffuse, nodal, mied). mied). %ts consistence, consistence, surface, surface, painfulness painfulness on palpation, shift during s1allo1ing, adnation 1ith the surrounding tissues. "he thyroid gland#s 8orders. "he presence of sounds on auscultation. Grefe#s, e8ius, Shtelag#s, lline!#s, Dalrymple#s signs. Bones. Symmetry of the 8ones of the lim8s, the form of the s!ull, the presence of deformations of the column, the thora (!yphosis, lordosis, scoliosi scoliosis), s), of the pelis, pelis, of the 8ones 8ones of the etrem etremitie itiess (defec (defects ts of the deelopment due to trauma). ainfulness on palpation, percussion and loading on an ais. Hoints. Hoints. Changes Changes of configurat configuration: ion: (thic!ening, (thic!ening, edema, edema, the presence of dierti dierticulum culums, s, fluctuat fluctuation) ion).. o8ility o8ility actie, actie, and passie: passie: (usual, (usual, limited, limited, ecessie). ain at locomotions, on palpation. Sensation of crunch in the Eoints at passie locomotions. ?rgans ?rgans of the respirato respiratory ry system. system. "he form of the thora: are (conic, (conic, 8arrel-shaped, 8arrel-shaped, cylindrical, cylindrical, funnel-shaped, funnel-shaped, etc.). A position position of the scapulae: (if they adEoin to the thora). "ype of respiration: (thoracic, (thoracic, a8dominal, mied). articipation of 8oth hales of the thora in the act of respiration-A respiratory rhythm,fre;uency per $ minute,depth. Cheyne-Sto!es, Fussmaul, Biot#s respiration. State of the intercostal intercostal spaces spaces during during deep respiration: respiration: (retracti (retraction, on, a dierticulum). -0-
alpat alpation ion of the thora thora (painf (painful ul places places,, an edema, edema, consol consolida idatio tion). n). oice trem8ling: (not changed, 1ea!ened, strengthened). Comparatie percussion. percussion. A sound: (pulmonary, 1ooden (8o), dull, tympanic). 3eight of locali9ation of the pulmonary apees a8oe the claicle in the front and relatiely to the spinous process of the %% cerical spondyle at the 8ac! (Frenig#s fields). "he inferior 8order of the lungs along the lines at 8oth sides. o8ility of the pulmonary edge (along 1hat line). Comparati Comparatiee auscultati auscultation. on. 7espiration 7espiration:: esicular esicular,, 8ronchial, 8ronchial, amphori amphoric, c, mied, etc. 7ales: are dry or 1et, their locali9ation. A pleural friction sound, its character. ?rgans of the circulatory system. "o determine a pulse comparatiely at t1o sides the arteries arteries:: the radial, radial, temporal, temporal, carotid, humeral, humeral, femoral, femoral, popliteal, posterior ti8ial arteries, the dorsal arteries of the foot. Characteristics of pulse: (rate (rate per $ minute, minute, rhythm, rhythm, intensity) intensity).. Characte Characteristi risticc of the arterial arterial trun!s (density of the 1alls, the presence of the dilatings, a isi8le pulsation). "he arterial pressure (maimal (systolic), (systolic), minimal (diastolic), (diastolic), pulse). "he presence of the aricose distended eins on the thora, for1ard a8dominal 1all, etremities. "he degree of distension. "roEano-"redele8urg#s, "roEano-"redele8urg#s, Del8e ertes#, ayo - ratt#s signs. amination of the region of the heart. "he presence of a dierticulum in the region of the heart. "he ape 8eat, its force, locali9ation. ?n palpation of the region of the heart the place of the ape 8eat and its force force (not (not streng strengthe thened ned,, streng strengthe thened ned , sha!in sha!ing, g, rising rising)) should should 8e also also determined. ulsation in the epigastric region (the heart, aorta, lier), in the Eugular fossa (the aorta, carotid arteries, eins). By percussion the 8orders of relatie and a8solute cardiac dullness (the right, upper and left) are determined. Auscultation. Cardiac sounds (clear, dull, stressed, splitting, dou8ling, dropping - out). Cardiac murmurs, their attitude to a phase of the cardiac actiity (systolic, diastolic, presystolic). "heir force (sharp, 1ea!), duration (long, short). Change of the character of murmur in a postural change of the 8ody. A friction murmur of the pericardium. -2-
5uncti 5unctiona onall tests: tests: orthos orthostat tatic, ic, 1ith 1ith physic physical al eerti eertion, on, retent retention ion of respiration (Stange#s test). "he gastrointestinal tract. "he form of the a8domen (spherical, oal, retracte retracted, d, een distended, dierticulums dierticulums of separate separate regions, regions, the @frog@ @frog@ 8elly). isi8le isi8le peristalsis. peristalsis. articipation articipation of the anterior anterior a8dominal 1all in the act of respiration, a pain during respiration or cough. Superficial comparatie palpation. uscle#s protection (defense musculaire), partial on palpation, 1hether constant (@8oard-li!e a8domen@), a8domen@), painfulness, painfulness, the presen presence ce of Shchot Shchot!in!in- Blum8erg Blum8erg symptom. symptom. State of the um8ilical, um8ilical, inguinal, and femoral rings. Diarication of the rectus muscles (diastasis re ct i) , cough impulse symptom. symptom. enetrating, enetrating, methodical, methodical, sliding palpation palpation according to ..?8ra9tso, .?.Stra9hes!o method. "he sigmoi sigmoid d colon: colon: its locali locali9at 9ation ion,, form, form, consis consisten tence, ce, mo8ili mo8ility ty,, painfulness, and murmur. "he caecum, the same data. ermiform appendi. "he ascending, descending transerse colon (dimensions, painfulness, mo8ility, consistence, and murmur. "he presence of tumors. "he stomach (entricul (entriculus). us). %ts inferior inferior 8order 8order determine determined d (8y palpation, palpation, percussion, percussion-auscultatie, splashing sound sign). ainfulness (circum (circumscri scri8ed, 8ed, unlimited) unlimited),, isi8le isi8le peristal peristalsis sis on palpation. palpation. "he lier. lier. eculiarities of the lier margin: (acute, 8lunt, rounded, solid, soft, tu8erous, een). %ts 8orders: the upper is determined 8y percussion, the inferior - 8y palpation. "he gall8ladder - 1hether it is palpa8le. ainfulness in Fer#s point. "he gall8l gall8ladd adder er - is palpat palpated, ed, is locali locali9ed 9ed,, its si9e, si9e, mo8ili mo8ility ty,, consis consisten tence, ce, painfulness. "he pancreas (painfulness, the presence of infiltrate, cyst, tumor). "he lien. %ts si9e, si9e, 8orders, 8orders, consistenc consistencee (soft, (soft, dense), dense), its surface surface (een, (een, tu8erous) tu8erous),, painfulness. Determining Determining of its 8orders 8y percussion. Determining Determining the presence of fl u i d in the a8dominal caity on percussion. ?n percussion 1e can determine dullness in the presence of tumors, fluids/ thympanitis - in the presence free gas in the a8dominal caity, in distended loops of the intestines. Auscultation helps to determine the presence of the intestinal murmurs (sounds) (amount, locali9ation, intensity), colonic, small intestinal. - 4 I
"he rectum and anus. "he presence of the eternal eternal hemorrhoid hemorrhoid nodes, nodes, prolapse of the mucous mem8rane, mem8rane, condylomas, condylomas, fistulas, fistulas, fissures fissures are seen on eamin eaminati ation. on. Digita Digitall palpat palpation ion (tone (tone of a sphinc sphincter ter,, the presen presence ce of the throm8osed hemorrhoid nodes, infiltrate, tumors, accumulation of feces). "he urinary system. "he !idneys: !idneys: si9e, locali9ation, locali9ation, mo8ility, mo8ility, surface surface (een, tu8erous), painfulness. asternats!y#s sign. alpatio alpation n of the urinary urinary 8ladder. 8ladder. Digital Digital palpatio palpation n of the prostati prostaticc gland throug through h a rectum rectum , its si9e, si9e, consis consisten tence, ce, the presen presence ce of consol consolida idatio tions, ns, fluctuation. "he nerous system. upillary, corneal, !nee, Achilles tendon, cremasteric reflees, muscular rigidity rigidity of the 8ac! of the head, Fernig#s sign. Sensitiity Sensitiity to a pain, tactile, tactile, temperatu temperature re sensitien sensitieness. ess. 3ypo-esthe 3ypo-esthesia, sia, hyperesthesia. aresis, paralysis, hyper!inesia. Dermographism (red, 1hite, 1hen does it appear and disappear). . LOCATION of DISEASE (Lo&'s mo!i) Carrying out detailed inspection of the place of the main surgical disease it is necessary to adhere to the same se;uencers during eamination of the patient ta!ing into account account anatomica anatomicall locali9at locali9ation ion (the locomotorium locomotorium,, endocrin endocrinee system, etc.)/ the eamination, palpation, percussion, auscultation. %f necessary special methods of eamination can 8e used. 3) INITIAL 3) INITIAL DIAGNOSIS DIAGNOSIS (Dia/nosis ,'e0iminais) a!ing a!ing of in iti al diagnos diagnosis is is 8ased 8ased on the main main data data of the patien patient#s t#s complaints, complaints, determining of anamnesis and o8Eectie inspection, inspection, at this stage &-' diagnoses may 8e made. cept for it, it is necessary to specify the character of disease (acute, chronic, recurrent). %n order to specify a diagnosis it is necessary to generali9e typical attri8utes of the disease. Example. ?n the 8asis of: - Complaints of the patient (of a peculiar, constant pain, the presence of tumortumor-li! li!ee forma formatio tions ns in the region region of the right right mamma mammary ry gland, gland, eleation of 8ody temperature up to '2JC, rigor, general 1ea!ness)/
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- "he data data of the case case history history (is ill during during one 1ee!, 1ee!, sudden sudden onset, onset, of the organ or system, or diagnosis 8y eclusion (diagnostic search). A student since appearanc appearancee of painful consolidation in the region of the right must sho1 all his !no1ledge concerning the ;uestion,not 8eing limited to the mammary gland, eleation of 8ody temperature up to '2JC/ methods, 1hich 1ere gien (stated) in the hospital medical card. - Self - treatment treatment of the patient: use of analgesics, aspirin, doing massage . +3RA4 +3RA4 E+AMINAT E+AMINATION ION of the mamma, applying of hot compresses)/ ulti-aial roentgenoscopy of the chest, K-ray of the chest in t1o standard - "he data data of anamne anamnesis sis of lif e (three (three 1ee!s 1ee!s ago ago she gae 8irth 8irth to a healthy, mature infant, the period of pregnancy 1as complicated 8y proEections, roentgenography of the heart in t1o slanting positions, roentgeno!ymography, 8ronchography, pneumomediastino-grap pneumomediastino-graphy, hy, tomography tomography,, anemia, la8or 1as complicated 8y 8leeding)/ diagnostic pneumothora, pneumopericardiography, esophagography, contrast study - "he data of o8Eectie o8Eectie inspection inspection (temperatur (temperaturee - '2,JC, '2,JC, the presence of of the gastrointestinal tract, parietography, retrograde contrast study of colon (the sharply sharply painful infiltrate infiltrate $62 cm of dimensions dimensions in the region region of the irrigoscopy), pneumoperitoneum, retropneumoperitoneum, cholecystocholangioupper - lateral lateral ;uadrant ;uadrant of the right mammary mammary gland, !he s!in in the phle8ography, aortography, aortog raphy, region of consolidation is hyperemic, edematous, adhesion 1ith the graphy, urography (general, ecretory), cystography, phle8ography, lymphography, fistulography. surrou surroundi nding ng tissue tissues. s. "he retrac retracted ted nipple nipple,a ,a fissur fissuree 6,06, 6,06,' ' cm INSTR7MENTAL AL E+AMINAT E+AMINATION ION dimens dimension ionss in the cente center, r,coa coated ted 1ith 1ith fi8rin fi8rinopur opurule ulent nt layers layers.. By 56. INSTR7MENT palpation - is fluctuation determined in the center center of infiltrate. Cathete Catheteri9a ri9ation tion of the 8ladder, 8ladder, urethras urethras,, cystoscopy cystoscopy,, chromocy chromocystos-co stos-copy, py, %t is possi8le to ma!e an initial diagnosis - of acute suppuratie right- 8ronchoscopy, esophagogastroscopy, a8dominal paracentesis, laparoscopy laparoscopy hand lactational mastitis. (perit (peritone oneosc oscopy opy), ), 8ronch 8ronchosc oscopy opy,, thorac thoracosc oscopy opy,, rector rectoroma omano-sc no-scopy opy,, fi8ro fi8ro colonoscopy, endoscopic 8iopsy and others. 1. PLAN of E+AMINATION E+AMINATION a!in a!ing g an initia initiall (prei (preious ous)) diagnos diagnosis is the doctor doctor should should proe proe the 22) APPARA 22) APPARAT7S T7S INSPECTION correctness correctness of his conclusions conclusions 8y use of modern modern methods of diagnostics, diagnostics, from ltrasonic eamination of the thyroid gland, heart, lier and 8iliary ducts, the common to comple. !idneys, !idneys, uterus uterus and adnea uteri, computer computer tomography tomography,, nuclear-m nuclear-magneti agneticc%t is necessary to 8egin eamination of eery patient from the o8ligatory resonance and others. program, 1hich includes: 52. LAORATOR4 LAORATOR4 RESEARC8ES $. General General 8lood test. test. I! is necessary to hae general notions concerning the purposes of clinical, clinical, &. General test test of the urine. 8iochemic 8iochemical, al, and 8acteriolo 8acteriologica gical, l, serologic, serologic, pathomorp pathomorphologi hologicc and isotope '. amination of feces for eggs eggs of intestinal parasites. la8or la8orat ator ories ies.. =ou shoul should d remem remem8er 8er,, that that la8or la8orat atory ory analy analyses ses should should 8e . Analysis Analysis of the urine urine for #ugar (in the ;uantity of the urine, ecreted accompanied 8y clinical thin!ing (intellection), as results of la8oratory tests do per & hours). not proide eact, ready diagnosis. diagnosis. 5inally 5inally,, 1hile prescri8ing prescri8ing analyses analyses it is +. Blood test for sugar. sugar. necessary to ta!e into account not only their diagnostic alue. a8oratory tests . >assermann#s >assermann#s test. are methods of eamination of the ital organs and systems in a surgical surgical clinic, 0. hotoroentgenography (fluorography). 1hen 1hen the determine determined d data are necessary necessary for correction correction of the disorders, 1hich 2. Blood group and rhesus - distinguishing. occur in patients in the preoperatie period, during operation, and at the postSpecial methods of eamination should 8e prescri8ed ta!ing into account operatie stage. the initial (preious) diagnosis 8y 1ay of direct eamination -$$-
-$&-
5". #7NCTIONA #7NCTIONAL L E+AMINATION E+AMINATIONS S "here are: electrocardiography electrocardiography,, phonocardiography, phonocardiography, 8allistocardiography, cardiac catheteri9ation, measuring of central enous pressure 8y aldman#s appara apparatus tus,, eamin eaminati ation on of etern eternal al respir respirati ation, on, 8ronch 8roncho-s o-spi piro rome metr try y, capill capillar arosc oscopy opy,, enceph encephalo alogra graphy phy,, rheoa rheoasog sograp raphy hy,, plethy plethysmogr smograph aphy, y, determini determining ng of the regional regional 8lood flo1, flo1, olume of the circulatory circulatory 8lood and others. :i: *ote. Data of a special eamination of the gien patient are to 8e 1ritten 1ritten do1n after after the plan of eamination eamination 1ith o8ligatory o8ligatory interpreti interpreting ng of norm and pathology in the corresponding se;uence. "o sho1 their diagnostic alue concerning the disease, 1hich is studied. 5%. CLINICAL DIAGNOSIS (DIAGNOSIS CLINICA) "he c lin ica l diagnos diagnosis is should should 8e descri descri8ed 8ed distinctl distinctly, y, shortly shortly and conincingly, on the 8asis of synthesis of the receied data (on the 8asis of the preious diagnosis and ...), including additional methods of eamination. "he concomitant concomitant diseases diseases and complicati complication, on, 1hich 1hich 1ere reealed reealed in the gien patient should 8e mentioned and descri8ed here. 5. ETIOLOG4 an9 the PAT PAT8OGENESIS 8OGENESIS of DETERMINED DISEASE odern concepts a8out etiology and pathogenesis are 8riefly mentioned. %t is necess necessary ary to sho1 sho1 connec connectio tion n of the ie1s, ie1s, 1hich 1hich eist eist concern concerning ing etiology and pathogenesis of the gien patient. >hat data confirm or o8Eect the standard notions a8out the determined disease. 5. TREAT TREATMEN MENT T "o sho1 modern methods of treatment concerning the gien
disease: a) Conseratie treatment (specific, (specific, pathogenetic, symptomatic)/ 8) Surgical (indications, a preparation for an operation, choice of the method of anesthesia,the description of the operation,the characteristic of macro-preparation). macro-preparation). %t is necessary to descri8e the general principles of treatment of the gien pathology, and then to detail detail all the methods concerning the gien patient.
5:. The DAIR4 Date Course of a disease
rescription (treatment of the $. Gene Genera rall state state of the the pati patient ent,, $. 7egi 7egim men of of dream, eercise. appe ppetit tite. "he sta state of the &. Diet Dietar ary y regim regimen en.. cardioas '. rescri rescription ptionss of cular, cular, respira respiratory tory systems systems and medi organs cinal preparations of the the gast gastro roen ente teri ricc trac tract. t. (gie hysiolo some prescriptions). gic eacuation. . hysiother hysiotherapeut apeutic ic &. A dressing dressing:: state state of a 8andage 8andage,, procedures. ;uan Additional tity and and char haracte acterr of the the eamina discharges tions, etc. (on the from from a 1oun 1ound. d. Stat Statee of the the day
"he signature of the attending doctor 51. GRAP8I GRAP8IC C REPRES REPRESENT ENTAT ATION ION of the TEMPER TEMPERAT AT7RE 7RE C7RVE; C7RVE; P7LSE; ARTERIAL PRESS7RE (en&0ose9 on a se,aate sheet) sheet) 5. PROP84LA+IS PROP84LA+IS of of DISEASES DISEASES 26. PROGNOSIS PROGNOSIS CONCERNIN CONCERNING< G<
- life (prognosis (prognosis ;uo ad itam)/ itam)/ - health health (prognosis (prognosis ;uo ad ad alitudinem alitudinem)/ )/ - 1or!ing capacities capacities (a8ility (a8ility to 1or!) (prognosis (prognosis ;uo ad la8orem)/ la8orem)/ "he record should 8e 1ritten in 8rief (faora8le, unfaora8le, dou8tful). 25. The COND7CT; the RECOMMENDED to #ROM a 8OSPITAL
REGIMEN; an9 DIET; the PATIENT PATIENT on
-$'-$-
=8IC8 a e DISC8ARGE
22. EPICRISIS EPICRISIS (E,i&isis) (E,i&isis) "he patien patient#s t#s surnam surname, e, name, name, patron patronym ymic, ic, his age. age. "ime "ime and cause cause of V)ENUMERATION OF NORMALVALUES OF THE THE 4ASIC 4ASIC LA4OR LA4ORATORY ATORY hospitali9ation. A diagnosis. Data of the o8Eectie eamination, 1hich helped to UNITS ma!e a diagnosis. Special methods of eaminations. "he course course of disease. "reatment (conseratie, operatie). Date and type of the operation. Anesthesia. Genea0 !0oo9 test "he postoperatie diagno diagnosis sis.. athoh athohist istolo ologic gic concl conclusi usion. on. "he "he course course of the postop postoper erati atie e perio period d , complic complicatio ations. ns. 3eal 3ealing ing of of the postoper postoperati atie e 1ound. 1ound. Adice Adicess I"$e5 Nor& for further treatment in a place of residence, life and 1or!. r throc tes en: 66 -+ 6 L %6#0l >o >omen: ' 44 - %6#0l Dispensary o8seration. 3emo lo8in 38 en $'+-$26 M$ >o >omen : $ &6 &6-$6 rognosis, prophylais. Color inde C% C% 6 2+ 2 +-$ $+ $+ 7 e t i c u l o c t e s & $ 6 N 2". RE# RE#ERE ERENC NCES ES "hrom8oc tes $26 66 -'&6 6 $60$ 2%. DATE> SIGNAT7RE SIGNAT7RE of the ATTENDING ATTENDING DOCTOR eucoc tes ,6-4,6 io0l Baso hils 6-6 6 6+ $60$ 66-$N osino hils 6 6& 6&-6 '6 '6 $60$ 6 +-+ 6N 6N Band neutro hils 6 6-6 '6 $60$ $-N Se mente ented d ne neutro utro hil hils & 6-+ 6-+ +6 $60 $60$ $ 0-0 0-0&N &N onoc tes 6 64 64-6 6 6 $60$ '' -$$N m hoc tes $ &&- ' 6 $60$ $4 $ 4-'0N rythrocyte en: &-$6 mmMh, >omen: &-$+
3ematocrit 3ct en : 6- 2N 2N > om omen : ' - -&N Biochemical !0oo9 test
$+
"otal 8lood rotein Scrum al8umins SA Serum lo8ulins SG Al8umen- lo8ulin ra ti o %mmuno %mmuno lo8uli lo8ulins: ns: % D % G % % A %
6-6 $+ M$ +6- $$&.+ uolMl 6 -&.+ uolMl + -&2 $ uolMl 6 '-'6 nolMl
"otal 8lood 8iliru8in
2,+- &6.+ uolMl
Com8 Com8in ined ed direc direct, t, con con u ated ated
+ - 2+ M$ '+ - +6 M$ +& +&-+N &'-'+ M$ '+-2N $ &&-& 6
6,2+ 6,2+-+ -+.$ .$ uol uolMl Ml $
Coagulogram Bloo Blood d li ids ids the ener eneral al cont conten ents ts Scrum tri l cerides "otal cholesterol i o ro te teins : er lo1 lo1 dens densit it re 8eta 8eta o1 densit 8eta li o roteins 3i h-densit al ha - li o roteins Ch lomicrons
+-0 +-0 Ml 6 +4 +4- l 00 00molMl & 40 40 - 2 04 04 molM$
Blood lucose Gl cos lled hemo lo8in
' '-+ + molM$ -0N
Blood serum iron Scrum ot otassium Serum sodium Scrum calcium Scrum ma nesium Serum hos horus inor anic Blood chlorides
2 +' +'-&2 6 6 uolMl ' 2 - + & molM$ $'2-&$0 molM$ 6 0+ - & + molM$ 6 02 02-6 4$ 4$ molM$ 6 - $ &4& molM$ 40-$62 molM$
Blood Blood urea urea nitro nitro en not Scrum urea Blood creatinine Creatine
$ &2-&+ molM$ molM$ ' ''-2 '& molM$ +'- $6 $ uolMl en: $+,&+-+,0+ uolMl/ en: 6,$&-6,'2 uolMl/ -
Blood uric acid
$+-&6 '- + M$ $ &+- + 6 6+ M$
M$ 6 '-64 '-64 ' 6-' $ molM$ M$ $ $'-$ $+ 6-6 $ molM$
actate deh dro enase DG O 0 molM houi-Ml Aldolase 6 &-l &molM hourMl Blood al ha am lase di diastase $&-'& M hourM$ As artat rtatee am aminot inotra rans nsfferas erasee AS" 6 $-6 $-6 + mol molMM hour hourMl Ml Alani lanine ne amin aminot otra rasf sfeerase ase A" A" 6 $-6 $-6 2 mol molMM hour hourMl Ml Cholincstcrase $6-'6molM ho h ourMl Al!aline ho hos hatase 6 ++ -$ ' uolM hourMl Creatine !inase 6 $+ $+& - 6 '6 '6+ molM ho h ourMl Scrum creatine hos ho!inase to $ & mol i ase 6 - '6 molM hourMl -$0-
rothrom8in inde "ime of scr scrum reca recalc lciifica ficattion ion "hrom8otest 5i8rino en en 5i8rino en B 5i8rinolytic actiity Coagul Coagulat ation ion time time of of 8loo 8lood d 8y 8y iiBleedin duration 8 D u! u! 7etraction of of 8lood clot Indexes of an acid-base balance 3 the arterial 8lood 3 the enous 8lood Strain Strain of car8on car8on dioide dioide C6&: Arterial 8lood enous 8lood Strain Strain of o en, 6&, the arte arteria riall Sur lus deficienc of 8ases "he enera enerall 8uffe 8ufferr 8ases 8ases of 8lood 8lood Standard Standard 8icar8onat 8icar8onatee B : Arterial 8lood enous 8lood ?ri inal 8icar8onate Other blood units
26-$66N 6-$ 6-$&6 &6 sec sec. % I de re ree + 4-$$ 0 uolMl *e atie $2'-&' minutes. I + - $6 minu minutes tes.. to minutes. I + N (retraction 0 0 '+ 6 mm 3 . mm 3 . 0+-$6+ 0+-$6+ mm 3 . P& ' molM$ + - +6 molM$ molM$ & molM$ & molM$ &0 molM$
Serum h drocortisone Serum ar a rath roid hormone Somatotro ic hormone "hyroid-stimulati "hyroid-stimulating ng hormone,
&'6-0+6nolMl & P4 '$ o olM$ 6-$$2 olMl $&2P&2nolMl
"h roine " " Serum "riiodoth ronine "' " ' Serum 5erritin, Serum
+-$++nolMl $ 00-& ' nolM$ . en: 4 P 0,' ugM$/ Q
-$2-
A$ I seromucoid "h mol tu tur8idit test Sialine test C - reactie rotein CC-7 Antistre tol sin-6 AS AS-? Antis tr tre toh aluron id idase AS3 ?smolarit Serum Urine units
$& 0 0-'$ 0+ 0+ uolMl to + nits ++6 - 046 m M$ M$ *e atie &+6 nits &+6 nits &0+ - &4+ mosolM!
7elatie de densit of the ur urine $ 6$-$ 6&& 5ormed elements of the urine: Acco Accord rdin in to *ech *echii oren oren!o !o eucoc tes to $6#0$ r throc tes to $ $6#l rotein eneral + 6 - 0+ 6 m M er & hours otassium '2-00 molM cr & hours Calcium & + - 0 + molM er er & hours Creatinine clearance en: 40 I $'0 ric acid $ 2- ' uolMl Sodium Chan es es de en endin on on a diet ?alates 46-+ uolMl Chlorides $ - $' 0 uolM er e r & hours $0-!etosteroids en: &0,0 - 04,0 uolMper & hours/ >omen: $0-o corticosteroids rinar a l ha-am lase diastase rinary creatinine
6 $$ $ $ -6 00 0 0 uolM er & hours &2- $6 hourM$ en: ,2- $0, molMper & hours/ >omen:
rin rinar ar sedi sedime ment nt eam eamin inat atio ion n ace ace eucoc te tes r throc tes C linders
ordi ordin n to Fa!o Fa!os! s! -Add -Addis is to t o & $6# cr c r & hours to $ x $6# $6# er & & hour hourss to & $6M er & hour hourss
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