This document provides guidelines for writing a medical case report, including its typical structure and content. It describes the 7 main sections of a case report: 1) patient identification data, 2) medical history, 3) physical examination, 4) investigation data, 5) clinical diagnosis, 6) substantiation of the basic diagnosis, and 7) pathogenesis of symptoms and signs. Each section is explained in detail, outlining the key information that should be included about the patient's history, examination findings, test results, diagnosis, evidence supporting the diagnosis, and pathogenesis of observed signs and symptoms. The document aims to teach students the proper format for documenting a patient's medical case.
This document provides information on preoperative and postoperative physiotherapy assessment for pulmonary surgery patients. The preoperative assessment involves collecting subjective and objective information on the patient's medical history and functional status to create a treatment plan and reduce complications. The postoperative assessment examines the surgery details and any complications while monitoring pain, breathing, circulation, mobility and other factors to aid the patient's recovery. Physiotherapy focuses on regaining strength, mobility and functional independence through techniques like breathing exercises and range of motion.
A 43 year old male patient was transferred with an ambulance in the emergency department of the hospital with bleeding from right thigh after a motorcycle accident. He had become a trapped under the motorcycle.
Discuss the medical, surgical and anesthetic management of this patient.
The document provides guidelines for approaching critically ill patients, beginning with the primary survey of airway and cervical spine control, breathing and ventilation, circulation and hemorrhage control, disability, and exposure/environmental control. It then details assessments and interventions for each component. The secondary survey involves collecting subjective information from the patient, performing objective examinations, and creating a problem list and treatment plans. The approach emphasizes stabilizing life-threatening issues first before conducting full evaluations and treatments.
This document provides information about a course on basic clinical skills taught at the University of Gondar College of Medicine and Health Sciences in Ethiopia. The 3-sentence course is an 8-day, 3 ECTS course designed to teach students basic clinical skills including taking and recording vital signs, administering medications, performing procedures like IV cannulation and wound care, and maintaining medical records before going on clinical attachments. The course will be taught through lectures, demonstrations, assignments, tests, and a final exam.
This document outlines the objectives and assessments/interventions for the primary survey in emergency medical care. The objectives are to identify life-threatening conditions and interventions during the initial assessment. The primary survey focuses on the ABCDE approach - Airway, Breathing, Circulation, Disability, and Exposure. For each component, assessments are listed along with corresponding interventions to address any life-threatening issues identified.
This document provides an overview of the approach to treating emergency patients. It discusses conducting a primary survey following the ABCDE method to assess the airway, breathing, circulation, disability, and exposure. This is followed by taking a history, secondary survey, ordering relevant tests, providing treatment for life-threatening issues, and reevaluating the patient. Key areas covered include managing the airway, treating pneumothorax, hemorrhage control, head injury assessment, and the importance of spinal immobilization.
The document outlines the steps of a secondary survey performed on trauma patients after initial stabilization. The secondary survey is a thorough head-to-toe examination to identify all potential injuries and obtain relevant history. It involves examining the head and face, neck, chest, abdomen, genitals, extremities, skin, and performing a neurological exam. Key areas of focus include identifying signs of skull, cervical spine, rib, abdominal, urethral or rectal injuries. Sonography may also be used to identify internal injuries. The goal is to avoid missing injuries that could lead to morbidity if not identified.
This document provides an overview of respiratory and cardiac assessment techniques. It discusses the importance of obtaining an accurate assessment in order to develop an appropriate treatment plan. The document outlines the components of a problem-oriented medical system and problem-oriented medical records. It provides detailed descriptions of techniques for subjective and objective patient assessment, including gathering a history and examining the chest. Key areas of focus include breathing patterns, chest expansion, tracheal position, and tactile vocal fremitus.
This document provides information on preoperative and postoperative physiotherapy assessment for pulmonary surgery patients. The preoperative assessment involves collecting subjective and objective information on the patient's medical history and functional status to create a treatment plan and reduce complications. The postoperative assessment examines the surgery details and any complications while monitoring pain, breathing, circulation, mobility and other factors to aid the patient's recovery. Physiotherapy focuses on regaining strength, mobility and functional independence through techniques like breathing exercises and range of motion.
A 43 year old male patient was transferred with an ambulance in the emergency department of the hospital with bleeding from right thigh after a motorcycle accident. He had become a trapped under the motorcycle.
Discuss the medical, surgical and anesthetic management of this patient.
The document provides guidelines for approaching critically ill patients, beginning with the primary survey of airway and cervical spine control, breathing and ventilation, circulation and hemorrhage control, disability, and exposure/environmental control. It then details assessments and interventions for each component. The secondary survey involves collecting subjective information from the patient, performing objective examinations, and creating a problem list and treatment plans. The approach emphasizes stabilizing life-threatening issues first before conducting full evaluations and treatments.
This document provides information about a course on basic clinical skills taught at the University of Gondar College of Medicine and Health Sciences in Ethiopia. The 3-sentence course is an 8-day, 3 ECTS course designed to teach students basic clinical skills including taking and recording vital signs, administering medications, performing procedures like IV cannulation and wound care, and maintaining medical records before going on clinical attachments. The course will be taught through lectures, demonstrations, assignments, tests, and a final exam.
This document outlines the objectives and assessments/interventions for the primary survey in emergency medical care. The objectives are to identify life-threatening conditions and interventions during the initial assessment. The primary survey focuses on the ABCDE approach - Airway, Breathing, Circulation, Disability, and Exposure. For each component, assessments are listed along with corresponding interventions to address any life-threatening issues identified.
This document provides an overview of the approach to treating emergency patients. It discusses conducting a primary survey following the ABCDE method to assess the airway, breathing, circulation, disability, and exposure. This is followed by taking a history, secondary survey, ordering relevant tests, providing treatment for life-threatening issues, and reevaluating the patient. Key areas covered include managing the airway, treating pneumothorax, hemorrhage control, head injury assessment, and the importance of spinal immobilization.
The document outlines the steps of a secondary survey performed on trauma patients after initial stabilization. The secondary survey is a thorough head-to-toe examination to identify all potential injuries and obtain relevant history. It involves examining the head and face, neck, chest, abdomen, genitals, extremities, skin, and performing a neurological exam. Key areas of focus include identifying signs of skull, cervical spine, rib, abdominal, urethral or rectal injuries. Sonography may also be used to identify internal injuries. The goal is to avoid missing injuries that could lead to morbidity if not identified.
This document provides an overview of respiratory and cardiac assessment techniques. It discusses the importance of obtaining an accurate assessment in order to develop an appropriate treatment plan. The document outlines the components of a problem-oriented medical system and problem-oriented medical records. It provides detailed descriptions of techniques for subjective and objective patient assessment, including gathering a history and examining the chest. Key areas of focus include breathing patterns, chest expansion, tracheal position, and tactile vocal fremitus.
This document provides an overview of general surgery, including definitions, types, and procedures. It discusses:
- General surgery involves performing surgical procedures to treat health problems and diseases of the abdomen and related organs.
- Surgical procedures are classified based on urgency (elective, urgent, emergency), degree of risk (major, minor), and purpose (diagnostic, ablative, palliative, reconstructive, transplantation, constructive).
- Proper patient assessment and preparation is required before any surgery to ensure safety and success, including evaluating indication and contraindications, obtaining consent, optimizing medical conditions, and preparing logistically.
Physiotherapy plays an important role in the pre and postoperative care of patients undergoing abdominal surgery. In the preoperative stage, physiotherapy focuses on assessing respiratory and circulatory function, educating the patient on breathing and mobility exercises, and training the patient to prevent postoperative complications. Postoperatively, physiotherapy aims to prevent pulmonary and circulatory issues through techniques like breathing exercises, early ambulation, and limb movement. The overall goals are to enhance recovery and mobility and ensure patients regain independence.
This document outlines the guidelines for assessing and managing multiply injured patients. It discusses conducting a primary survey to identify life-threatening issues and provide resuscitation. Next is a secondary survey with a full physical exam and patient history. Ongoing monitoring and reevaluation is important to detect any deterioration and provide definitive care through consultation, surgery or transfer.
This document provides an outline for the care of critically ill patients. It begins with definitions and notes that critically ill patients require intense nursing care and monitoring of medical and surgical treatment. It describes the anatomy, etiologies, signs/symptoms, investigations and management considerations for treating critically ill patients. Specific conditions that may require intensive care such as acute respiratory failure, sepsis, and congestive heart failure are also discussed. The treatment section emphasizes multisystem support and monitoring to stabilize the patient until the underlying condition can be addressed.
This document discusses the components and objectives of a preanesthesia evaluation (PAC). The PAC involves taking a medical history, conducting a physical exam including airway assessment, ordering relevant investigations, and obtaining informed consent. The goals are to identify any medical conditions or risks that could impact anesthesia, develop an anesthetic plan, and educate the patient. Key parts of the evaluation involve assessing the respiratory, cardiovascular and neurological systems, as well as the airway. Common investigations include blood tests, ECG, and chest x-ray.
Surgical operations and Interventions. Pre and Post-operative procedures (gen...ShivangiSingh280
This document provides an overview of general surgery, including pre-operative, intra-operative, and post-operative procedures. It defines surgery and discusses its history, classifications based on urgency, risk, and purpose. The pre-operative stage involves diagnosis, assessments, consent, and preparation. The intra-operative stage is the surgery. The post-operative stage focuses on recovery and can involve complications. Overall, the document covers the key aspects and stages of general surgical operations and interventions.
This document discusses the initial assessment and management of trauma patients based on ATLS guidelines. It covers the primary and secondary surveys, with a focus on airway management, breathing, circulation, disability, and exposure. Specific injuries such as tension pneumothorax, cardiac tamponade, and hemorrhagic shock are reviewed. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are described as emergency procedures for trauma patients in shock. The document emphasizes treating the greatest threats to life first in trauma resuscitation.
Early recognition and stabilisation of ill patientsTonyGATEREGA
This document provides information on the ABCDE approach for assessing and stabilizing critically ill patients. It describes the ABCDE assessment method which breaks the assessment into Airway, Breathing, Circulation, Disability, and Exposure. For each component, it outlines how to assess problems, common causes, signs to look for, and initial treatment approaches. The goal of the ABCDE approach is to systematically assess and treat life-threatening problems in a clear and organized manner to stabilize the patient.
Bronchial hygiene therapy involves noninvasive techniques to clear secretions and improve lung function. It includes techniques like positioning, coughing, breathing exercises, and chest manipulation. The goals are to prevent accumulation and promote removal of secretions to improve respiratory status. Indications are excessive sputum production and ineffective cough. Contraindications include conditions that increase risk of aspiration or compromise hemodynamics.
polytrauma lecture prepare by three medical student in Kerbala university / college of medicine department of surgery to presented as seminar
for download as ppt
https://drive.google.com/open?id=1bc3HMEeJyhrOwag-AvTFMmPVKi12O1PU
This document discusses chest x-ray findings and physiotherapy treatment for several pulmonary diseases. It describes Adult Respiratory Distress Syndrome (ARDS) characterized by increased vascular permeability and pulmonary infiltrates on x-ray. Physiotherapy may include manual hyperinflation if secretions are present but is otherwise contraindicated in severe hypoxia. Pulmonary edema, pneumonia, pleural effusion, and atelectasis are also discussed along with their characteristic x-ray findings and appropriate physiotherapy treatments such as breathing exercises, postural drainage, and incentive spirometry.
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
complex health disease reflection lisa trippLisa Tripp
This document provides an overview of traumatic tension pneumothorax, including its pathophysiology, diagnosis, treatment, and implications for nursing care. Traumatic tension pneumothorax occurs when air enters the pleural space due to a chest wall injury and becomes trapped during expiration, increasing pressure on the lungs and heart. Immediate treatment involves needle decompression followed by chest tube placement to relieve pressure and allow lung re-inflation. Nurses play a key role in assisting with procedures, monitoring drainage systems, managing pain and anxiety, and supporting patients through the physical and psychological impacts of this life-threatening condition.
Role of physiotherapy in covid 19 patientsHina Vaish
Physiotherapy plays an important role in managing both the respiratory complications and other issues arising from COVID-19. It can [1] improve ventilation and circulation, help deal with complications, and prevent deconditioning. Physiotherapy assessments screen for readiness to mobilize safely. Interventions include positioning, breathing exercises, airway clearance, early passive mobilization progressed to active based on tolerance, and managing complications. Physiotherapy is needed both during acute infection and long-term rehabilitation following discharge to fully recover from COVID-19.
This document outlines the initial assessment and management of multiply injured patients according to ATLS guidelines. It describes conducting a primary survey to address life threats and establish stability, including airway, breathing, circulation, disability, and exposure. Adjuncts aid the primary survey. Next is a full secondary survey with patient history and head-to-toe examination. Special diagnostic tests, reevaluation, and definitive care such as transfer to a higher level of care follow. Key steps include rapid assessment and treatment of vital functions, prevention of missed injuries, and thorough documentation.
The document provides guidance on performing an initial assessment of a trauma patient using the ABCDE approach and mnemonics to evaluate the patient's airway, breathing, circulation, disability, exposure, vital signs, comfort, history, and injuries. It emphasizes stabilizing life-threatening problems, providing ongoing monitoring, and evaluating multiple body systems.
The document provides a summary and detailed outline of the topics and weighting that may be covered on the Certified Patient Care Technician/Assistant (CPCT/A) certification exam. The 100 item exam is divided into 5 domains: Patient Care (45 items), Compliance, Safety, and Professional Responsibility (20 items), Infection Control (11 items), Phlebotomy (14 items), and EKG (10 items). The detailed outline lists the tasks and knowledge statements in each domain that candidates should know to properly perform the duties of a CPCT/A.
The document discusses physiologic monitoring of critically ill patients. It describes four categories of patients that require monitoring, including those with unstable regulatory systems, suspected life-threatening conditions, at high risk of developing complications, and in a critical state. Common monitoring parameters are discussed for these patients such as pulse oximetry, blood pressure, ECG, temperature, urine output, and arterial blood gases. Specific monitoring techniques are also described for conditions like increased intracranial pressure, brain function, anesthesia depth, mixed venous oxygen saturation, and more.
2018 ATLS PROTOCOL
FOCUSING ON THE PRIMORDIAL MANAGEMENT OF PT IN THE APPROACH OF IMPROVING TRAUMA PT MANAGEMENT AND REDUCING MORTALITY OF TRAUMA PT AT OUR RESPECTIVE HEALTH FACILITIES AS DOCTORS AND CLINICIANS WORKING IN THE EMERGENCY DEPARTMENT.
GIVEN THE NECESSARY EQUIPMENT AND FAVOURABLE AMBIENT WORKING ENVIRONMENT WE SHOULD BE ABLE TO OFFER OUR HUMANITY RACE QUALITY SERVICES BEARING IN MIND THAT LIFE COME FIRST AND ALL THE OTHER ATTRIBUTES IN LIFE FOLLOWS
The document discusses a seminar presentation about history collection and physical assessment. It covers key terminology, the importance and components of collecting a patient history, and the definition, principles, preparation, techniques, and components involved in performing a physical assessment. The presentation provides an overview of best practices for nurses to obtain comprehensive information about a patient's health status through thorough history collection and physical examination.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document provides an overview of general surgery, including definitions, types, and procedures. It discusses:
- General surgery involves performing surgical procedures to treat health problems and diseases of the abdomen and related organs.
- Surgical procedures are classified based on urgency (elective, urgent, emergency), degree of risk (major, minor), and purpose (diagnostic, ablative, palliative, reconstructive, transplantation, constructive).
- Proper patient assessment and preparation is required before any surgery to ensure safety and success, including evaluating indication and contraindications, obtaining consent, optimizing medical conditions, and preparing logistically.
Physiotherapy plays an important role in the pre and postoperative care of patients undergoing abdominal surgery. In the preoperative stage, physiotherapy focuses on assessing respiratory and circulatory function, educating the patient on breathing and mobility exercises, and training the patient to prevent postoperative complications. Postoperatively, physiotherapy aims to prevent pulmonary and circulatory issues through techniques like breathing exercises, early ambulation, and limb movement. The overall goals are to enhance recovery and mobility and ensure patients regain independence.
This document outlines the guidelines for assessing and managing multiply injured patients. It discusses conducting a primary survey to identify life-threatening issues and provide resuscitation. Next is a secondary survey with a full physical exam and patient history. Ongoing monitoring and reevaluation is important to detect any deterioration and provide definitive care through consultation, surgery or transfer.
This document provides an outline for the care of critically ill patients. It begins with definitions and notes that critically ill patients require intense nursing care and monitoring of medical and surgical treatment. It describes the anatomy, etiologies, signs/symptoms, investigations and management considerations for treating critically ill patients. Specific conditions that may require intensive care such as acute respiratory failure, sepsis, and congestive heart failure are also discussed. The treatment section emphasizes multisystem support and monitoring to stabilize the patient until the underlying condition can be addressed.
This document discusses the components and objectives of a preanesthesia evaluation (PAC). The PAC involves taking a medical history, conducting a physical exam including airway assessment, ordering relevant investigations, and obtaining informed consent. The goals are to identify any medical conditions or risks that could impact anesthesia, develop an anesthetic plan, and educate the patient. Key parts of the evaluation involve assessing the respiratory, cardiovascular and neurological systems, as well as the airway. Common investigations include blood tests, ECG, and chest x-ray.
Surgical operations and Interventions. Pre and Post-operative procedures (gen...ShivangiSingh280
This document provides an overview of general surgery, including pre-operative, intra-operative, and post-operative procedures. It defines surgery and discusses its history, classifications based on urgency, risk, and purpose. The pre-operative stage involves diagnosis, assessments, consent, and preparation. The intra-operative stage is the surgery. The post-operative stage focuses on recovery and can involve complications. Overall, the document covers the key aspects and stages of general surgical operations and interventions.
This document discusses the initial assessment and management of trauma patients based on ATLS guidelines. It covers the primary and secondary surveys, with a focus on airway management, breathing, circulation, disability, and exposure. Specific injuries such as tension pneumothorax, cardiac tamponade, and hemorrhagic shock are reviewed. Resuscitative endovascular balloon occlusion of the aorta and resuscitative thoracotomy are described as emergency procedures for trauma patients in shock. The document emphasizes treating the greatest threats to life first in trauma resuscitation.
Early recognition and stabilisation of ill patientsTonyGATEREGA
This document provides information on the ABCDE approach for assessing and stabilizing critically ill patients. It describes the ABCDE assessment method which breaks the assessment into Airway, Breathing, Circulation, Disability, and Exposure. For each component, it outlines how to assess problems, common causes, signs to look for, and initial treatment approaches. The goal of the ABCDE approach is to systematically assess and treat life-threatening problems in a clear and organized manner to stabilize the patient.
Bronchial hygiene therapy involves noninvasive techniques to clear secretions and improve lung function. It includes techniques like positioning, coughing, breathing exercises, and chest manipulation. The goals are to prevent accumulation and promote removal of secretions to improve respiratory status. Indications are excessive sputum production and ineffective cough. Contraindications include conditions that increase risk of aspiration or compromise hemodynamics.
polytrauma lecture prepare by three medical student in Kerbala university / college of medicine department of surgery to presented as seminar
for download as ppt
https://drive.google.com/open?id=1bc3HMEeJyhrOwag-AvTFMmPVKi12O1PU
This document discusses chest x-ray findings and physiotherapy treatment for several pulmonary diseases. It describes Adult Respiratory Distress Syndrome (ARDS) characterized by increased vascular permeability and pulmonary infiltrates on x-ray. Physiotherapy may include manual hyperinflation if secretions are present but is otherwise contraindicated in severe hypoxia. Pulmonary edema, pneumonia, pleural effusion, and atelectasis are also discussed along with their characteristic x-ray findings and appropriate physiotherapy treatments such as breathing exercises, postural drainage, and incentive spirometry.
د/ماجد الوراقي
Structured approach for critically ill patient
المحاضرة التي قدمت يوم الاربعاء 9 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
complex health disease reflection lisa trippLisa Tripp
This document provides an overview of traumatic tension pneumothorax, including its pathophysiology, diagnosis, treatment, and implications for nursing care. Traumatic tension pneumothorax occurs when air enters the pleural space due to a chest wall injury and becomes trapped during expiration, increasing pressure on the lungs and heart. Immediate treatment involves needle decompression followed by chest tube placement to relieve pressure and allow lung re-inflation. Nurses play a key role in assisting with procedures, monitoring drainage systems, managing pain and anxiety, and supporting patients through the physical and psychological impacts of this life-threatening condition.
Role of physiotherapy in covid 19 patientsHina Vaish
Physiotherapy plays an important role in managing both the respiratory complications and other issues arising from COVID-19. It can [1] improve ventilation and circulation, help deal with complications, and prevent deconditioning. Physiotherapy assessments screen for readiness to mobilize safely. Interventions include positioning, breathing exercises, airway clearance, early passive mobilization progressed to active based on tolerance, and managing complications. Physiotherapy is needed both during acute infection and long-term rehabilitation following discharge to fully recover from COVID-19.
This document outlines the initial assessment and management of multiply injured patients according to ATLS guidelines. It describes conducting a primary survey to address life threats and establish stability, including airway, breathing, circulation, disability, and exposure. Adjuncts aid the primary survey. Next is a full secondary survey with patient history and head-to-toe examination. Special diagnostic tests, reevaluation, and definitive care such as transfer to a higher level of care follow. Key steps include rapid assessment and treatment of vital functions, prevention of missed injuries, and thorough documentation.
The document provides guidance on performing an initial assessment of a trauma patient using the ABCDE approach and mnemonics to evaluate the patient's airway, breathing, circulation, disability, exposure, vital signs, comfort, history, and injuries. It emphasizes stabilizing life-threatening problems, providing ongoing monitoring, and evaluating multiple body systems.
The document provides a summary and detailed outline of the topics and weighting that may be covered on the Certified Patient Care Technician/Assistant (CPCT/A) certification exam. The 100 item exam is divided into 5 domains: Patient Care (45 items), Compliance, Safety, and Professional Responsibility (20 items), Infection Control (11 items), Phlebotomy (14 items), and EKG (10 items). The detailed outline lists the tasks and knowledge statements in each domain that candidates should know to properly perform the duties of a CPCT/A.
The document discusses physiologic monitoring of critically ill patients. It describes four categories of patients that require monitoring, including those with unstable regulatory systems, suspected life-threatening conditions, at high risk of developing complications, and in a critical state. Common monitoring parameters are discussed for these patients such as pulse oximetry, blood pressure, ECG, temperature, urine output, and arterial blood gases. Specific monitoring techniques are also described for conditions like increased intracranial pressure, brain function, anesthesia depth, mixed venous oxygen saturation, and more.
2018 ATLS PROTOCOL
FOCUSING ON THE PRIMORDIAL MANAGEMENT OF PT IN THE APPROACH OF IMPROVING TRAUMA PT MANAGEMENT AND REDUCING MORTALITY OF TRAUMA PT AT OUR RESPECTIVE HEALTH FACILITIES AS DOCTORS AND CLINICIANS WORKING IN THE EMERGENCY DEPARTMENT.
GIVEN THE NECESSARY EQUIPMENT AND FAVOURABLE AMBIENT WORKING ENVIRONMENT WE SHOULD BE ABLE TO OFFER OUR HUMANITY RACE QUALITY SERVICES BEARING IN MIND THAT LIFE COME FIRST AND ALL THE OTHER ATTRIBUTES IN LIFE FOLLOWS
The document discusses a seminar presentation about history collection and physical assessment. It covers key terminology, the importance and components of collecting a patient history, and the definition, principles, preparation, techniques, and components involved in performing a physical assessment. The presentation provides an overview of best practices for nurses to obtain comprehensive information about a patient's health status through thorough history collection and physical examination.
Health assessment By - Jitendra Bokha.pptxJitendra Bokha
Health assessment is defined as systematic and dynamic process by which nurse through interaction with client, significant others and health care providers, collect data about the client.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
This document provides an overview of how to take a thorough medical history and conduct respiratory and cardiovascular examinations. It outlines the traditional framework for taking a medical history, including the presenting complaint, past medical history, allergies, medications, and review of systems. It emphasizes important details to obtain for patients with respiratory symptoms, including a frailty assessment. The document also provides guidance on examining the chest, heart, and lungs, with notes on auscultation findings and common respiratory and cardiac conditions.
This document provides guidelines for preoperative patient assessment and fasting. It outlines conducting a thorough history and physical exam to determine the patient's surgical risks and optimize perioperative care. Key parts of the assessment include the patient's medical history, medications, allergies, review of systems, and fitness classification. Recommended preoperative tests vary based on the patient and surgery. Fasting guidelines differentiate clear liquids, which require only a 2 hour fast, from solid foods and milk requiring at least a 6 hour fast prior to anesthesia.
The document discusses diagnosis of disease in patients. It states that the first step is understanding a patient's medical history and symptoms. The next step is a physical examination, which includes inspection, palpation, percussion, and auscultation to examine the body. Blood pressure is also measured using a sphygmomanometer. The document then discusses arterial lines that are inserted into arteries to continuously and accurately monitor blood pressure.
The document provides information on trauma for anesthesia students. It defines trauma as cellular disruption from excessive environmental energy. Trauma is a leading cause of death globally for those aged 1-44 years. Road traffic injuries will be a major public health concern increasing to the 5th leading cause of death by 2030. The ATLS (Advanced Trauma Life Support) protocol is outlined, beginning with the primary survey of ABCDE (Airway, Breathing, Circulation, Disability, Exposure) to address life-threatening injuries first before a full secondary survey. Proper trauma management requires a multidisciplinary team approach.
The nursing process is a critical thinking framework used to address patient needs through 5 steps: assessment, diagnosis, planning, implementation, and evaluation. Nursing assessment involves collecting both subjective and objective data to understand a patient's health status and potential problems. It includes a health history, physical exam, and reviewing records. The assessment data is then analyzed and summarized to identify patient risks, problems, and strengths to inform the nursing diagnosis.
The document discusses peri-operative care, outlining the three phases: pre-operative, intra-operative, and post-operative care. It describes pre-operative care as including patient assessment, history, examinations, investigations, and preparation. Key aspects of pre-operative care are evaluating patient risk factors, medical history, and physical status to determine fitness for surgery and identify risks. The document also discusses classifications of surgery cleanliness and urgency, as well as common post-operative complications.
The document discusses the importance of preoperative evaluation in ensuring patient safety and optimal outcomes. A thorough evaluation includes obtaining medical history, conducting a physical exam, and ordering appropriate tests. Key areas of focus include assessing cardiovascular, pulmonary, coagulation, and gastrointestinal status. Airway evaluation helps predict potential difficulties. The goals are to identify and address any issues that could impact anesthesia or surgery, provide informed consent, and reduce risk through optimization when possible.
3 history taking & physical examinationawadfadlalla1
This document provides information on nursing history taking and physical examination. It discusses the importance of obtaining an accurate patient history, which is critical for diagnosis. The key components of history taking are identified as demographic data, chief complaint, history of present illness, past medical history, family history, drug history, review of systems, and physical examination. The principles and techniques of physical examination are outlined, including inspection, palpation, percussion, and auscultation. A head-to-toe assessment approach is recommended to perform a thorough physical exam.
Upper respiratory disorders and nursing mangementANILKUMAR BR
This document discusses nursing management of various respiratory disorders. It provides an overview of nursing assessment including history and physical assessment. It then discusses the etiology, pathophysiology, clinical manifestations, diagnosis and treatment of many respiratory conditions including upper respiratory tract infections, bronchitis, asthma, emphysema, pneumonia and others. It also reviews anatomy and physiology of the respiratory system and describes common diagnostic tests used to evaluate respiratory disorders.
The document provides guidelines for writing patient write-ups, including their purpose, structure, and common mistakes to avoid. It recommends the write-up be 3-5 pages long and include sections for source of information, chief complaint, history of present illness, past medical history, family history, social history, review of systems, physical exam, labs, and assessment and plan. For the history of present illness section, it provides detailed instructions on how to construct the topic sentence, chronology, pertinent negatives, and concluding remarks. Common mistakes include omitting pertinent negatives, discussing related complaints separately, using long narrative descriptions, and incomplete assessment and plans.
This document provides an overview of chest, abdominal, and genitourinary injuries. It discusses the anatomy and physiology of the chest and abdominal cavities. Key points include recognition of blunt versus penetrating chest and abdominal trauma. Chest injuries can involve the lungs and heart. Signs may include difficulty breathing, coughing up blood, and unequal chest rise. Abdominal injuries can damage solid organs like the liver or hollow organs like the intestines. Signs may include pain, guarding, bruising, or distention. Proper assessment and treatment focus on the ABCs, with priorities being control of bleeding and treatment for shock.
This document provides information on assessing the respiratory system. It begins with objectives of being able to introduce, describe anatomy/physiology, and assess the respiratory system. It then covers topics like landmarks, gathering subjective/objective data, techniques for examination including inspection, palpation, percussion and auscultation. Normal and abnormal breath sounds are defined. The overall goal is to properly examine the respiratory system and differentiate normal vs abnormal findings.
Pulmonary function tests (PFTs), such as spirometry, measure how well the lungs function by analyzing air flow. Spirometry yields measurements like FEV1, FVC, and their ratio (FEV1/FVC), which can help distinguish between obstructive and restrictive lung diseases. Obstructive diseases like asthma result in low FEV1/FVC due to airway narrowing, while restrictive diseases lower all lung volumes from reduced compliance. PFTs aid in diagnosis, monitoring treatment, and assessing pre-operative risk.
This document discusses the management of polytrauma patients. It defines polytrauma as injuries involving two or more major body systems. The goals of management are to save the patient's life, salvage limbs, and restore function if possible. A team approach is needed involving surgeons, physicians, and other specialists. The initial focus is a thorough primary survey and resuscitation to address life-threatening injuries like airway obstruction, hemorrhage, and spinal cord injury.
The document discusses pulmonary function tests (PFTs), specifically spirometry. It provides details on lung anatomy and physiology, the purpose of PFTs in evaluating lung function and disease, how spirometry is performed and interpreted, and what values it measures such as FEV1, FVC, and their ratios. PFTs including spirometry are useful diagnostic tools to evaluate symptoms, monitor treatment effectiveness, and distinguish obstructive from restrictive lung diseases.
1. Effective pediatric emergency teams have clear roles and responsibilities defined for team leaders and members. Team members should seek assistance early if a patient's condition deteriorates.
2. Team leaders should encourage knowledge sharing and suggest alternative interventions if needed. Team members should suggest changes confidently and question potential mistakes.
3. Teams should continuously evaluate patients after each intervention or if their condition changes, clearly communicating any significant changes.
A health assessment is a plan of care that identifies the specific needs of a person and how those needs will be addressed by the healthcare system or skilled nursing facility. Health assessment is the evaluation of the health status by performing a physical exam after taking a health history.
Osteomyelitis is an infection and inflammation of bone that can be caused by bacteria or mycobacteria. The most common treatments are surgery to remove infected or dead bone portions followed by antibiotics administered either intravenously in the hospital or orally at home. For chronic osteomyelitis, treatment often requires a combination of long-term antibiotics and additional surgeries such as removing infected tissue or bone, draining pus, or amputating the affected limb if the infection has spread. Hyperbaric oxygen therapy may help some acute or chronic cases that do not respond to usual treatments by delivering high oxygen levels to promote healing, but more evidence is still needed on its effectiveness.
The Social Insurance Fund of the Russian Federation is a state budget fund created in 1991 to provide compulsory social security to Russian citizens. It is governed by Russian laws on compulsory social insurance and provides benefits such as temporary disability pay, medical rehabilitation aids, maternity benefits, and child allowances. It also provides supplemental health insurance payments for primary care and medical exams for workers.
This document discusses ultrasound and its properties. It defines ultrasound as mechanical longitudinal waves with frequencies above human hearing (20 kHz). Key properties discussed include:
- Velocity depends on the density and stiffness of the medium and is fastest in solids.
- Frequency ranges from 2-20 MHz, with lower frequencies penetrating deeper but having lower resolution.
- Wavelength is the distance over one cycle and depends on velocity and frequency.
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1. ГОСУДАРСТВЕННОЕ ОБРАЗОВАТЕЛЬНОЕ УЧРЕЖДЕНИЕ
ВЫСШЕГО ПРОФЕССИОНАЛЬНОГО ОБРАЗОВАНИЯ
«КАЗАНСКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ
ФЕДЕРАЛЬНОГО АГЕНСТВА ПО ЗДРАВООХРАНЕНИЮ
И СОЦИАЛЬНОМУ РАЗВИТИЮ»
КАФЕДРА ПРОПЕДЕВТИКИ ВНУТРЕННИХ БОЛЕЗНЕЙ
Схема истории болезни
Учебно-методическое пособие
Scheme of medical case report
Manual
Казань, 2010
3. CONTENT
1. Structure of educational medical case report …………………………………4
2. Form of educational medical case report……………………………………...8
3. References…………………………………………………………………...18
4. 4
STRUCTURE OF EDUCATIONAL MEDICAL CASE REPORT
A medical case report, a medical record, health record, or medical chart in general
is a systematic documentation of a single patient's long-term individual medical history
and care.
A patient's individual medical record identifies the patient and contains
information regarding the patient's entire case history.
Medical case report generally includes the following parts.
I. The patient identification data (ID).
II. Medical history.
The medical history or anamnesis of a patient is information gained by a
physician by asking specific questions, either of the patient or of other people who
know the person and can give suitable information (in this case, it is sometimes called
heteroanamnesis), with the aim of obtaining information useful in formulating a
diagnosis and providing medical care to the patient. The medically relevant complaints
reported by the patient or others familiar with the patient are referred to as symptoms,
in contrast with clinical signs, which are ascertained by direct examination on the part
of medical personnel.
A practitioner typically asks questions to obtain the following information about
the patient:
Identification and demographics: name, age, height, weight.
The "chief complaint (CC)" - the major health problem or concern, and its time
course (e.g. chest pain for past 4 hours).
History of the present illness (HPI) - details about the complaints, enumerated in
the CC. (Also often called 'History of presenting complaint' or HPC.)
Past Medical History (PMH) (including major illnesses, any previous
surgery/operations, any current ongoing illness, e.g. diabetes).
Allergies - to medications, food, latex, and other environmental factors
Childhood diseases - this is very important in pediatrics.
Family history (diseases) - especially those relevant to the patient's chief
complaint.
Psychosocial history (medicine) (PSH) - including living arrangements,
occupation, marital status, number of children, drug use (including tobacco, alcohol,
other recreational drug use), recent foreign travel, and exposure to environmental
pathogens through recreational activities or pets.
Sexual history, obstetric/gynecological history, and so on, as appropriate.
Medications and habits (MH) regular and acute medications (including those
prescribed by doctors, and others obtained over-the-counter or alternative medicine)
Review of systems (ROS) Systematic questioning about different organ systems
History-taking may be comprehensive history taking (a fixed and extensive set of
questions are asked, as practiced only by health care students such as medical students,
physician assistant students, or nurse practitioner students) or iterative hypothesis
testing (questions are limited and adapted to rule in or out likely diagnoses based on
information already obtained, as practiced by busy clinicians).
5
III. Physical examination
Physical examination or clinical examination is the process by which a doctor
investigates the body of a patient for signs of disease. It generally follows the taking of
the medical history — an account of the symptoms as experienced by the patient.
Together with the medical history, the physical examination aids in determining the
correct diagnosis and devising the treatment plan. This data then becomes part of the
medical record.
General examination. A systematic examination generally starts at the head and
finishes at the extremities. General examination includes
• estimation of general patient's status,
• patient's consciousness, position, constitution,
• taking temperature,
• defining of face expression peculiarities characteristic of certain diseases,
• as well as estimation of status of skin, nails, hair, observed mucous
membranes, subcutaneous fat, lymph nodes, muscles, bones and joints.
Data obtained by the clinician during general examination have a great diagnostic
importance giving a possibility on one hand, to disclose characteristic (although often
non-specific) signs of disease, on the other hand, to give a preliminary estimation of
pathologic process extent and functional disturbances degree.
Respiratory system.
Examination includes 4 parts: observation, auscultation, palpation, percussion
Observation involves observing the respiratory rate which should be in a ratio of
1:2 inspiration:expiration. It is best to count the respiratory rate under pretext of some
other exam, so that patient does not sub consciously increase his baseline respiratory
rate. Also observe for retractions seen in asthmatics. Retractions can be supra-sternal,
where the accessory muscles of respirations of the neck are contracting to aid
inspiration. Retractions can also be intercostal, there is visible contraction of the inter
costal muscles (between the ribs) to aid in respiration. This is a sign of repiratory
distress. Observe for barrel-chest (increased AP diameter) seen in COPD. Observe for
shifted trachea or one sided chest expansion, which can hint pneumothorax.
For palpation, place both palms or medial aspects of hands on the anterior and
posterior lung fields. Ask the patient to count 1-10. The point of this part is to feel for
vibrations (tactile fremitus) and compare between the right/left lung field. If the pt has
a consolidation (maybe caused by pneumonia), the vibration will be louder at that part
of the lung. This is because sound travels faster through denser material than air.
On comparative percussion, you are testing mainly for pleural effusion or
pneumothorax. The sound will be more tympanic if there is a pneumothorax because
air will stretch the pleural membranes like a drum. If there is fluid between the pleural
membranes, the percussion will be dampened and sound muffled.
If there is pneumonia, palpation may reveal increased vibration and dullness on
percussion. If there is pleural effusion, palpation should reveal decreased vibration and
there will be 'stony dullness' on percussion.
Lung auscultation is listening to the lungs bilaterally at the anterior chest and
posterior chest. First of all, identify the main breath sound. Then specify an
5. 6
adventitious breath sounds. Wheezing is described as a musical sound on expiration or
inspiration. It is the result of narrowed airways. Coarse crackles are bubbly sounds
similar to blowing bubbles through a straw into a sundae. They are heard on expiration
and inspiration. It is the result of viscous fluid in the airways. Fine crackles or
crepitation are only heard during inspiration. It is the result of alveoli popping open
from increased air pressure.
Cardiovascular system.
The precordial exam, also cardiac exam, is performed as part of a physical
examination. The exam includes several parts: inspection, palpation, percussion and
auscultation.
General Inspection: - inspect the patient status whether he or she is comfortable at
rest or obviously short of breath.
- inspect the neck for increased jugular venous pressure (JVP)or abnormal waves
Then inspect the precordium for: visible pulsations, apical impulse (apex beat),
masses, scars, lesions, signs of trauma and previous surgery (e.g. median sternotomy),
permanent Pace Maker, praecordial bulge.
Palpation: the valve areas are palpated for abnormal pulsations (known as thrills)
and precordial movements (known as heaves). Heaves are best felt with the heel of the
hand at the sternal border.The apex beat is typically palpable in the left fifth intercostal
space and 1 cm medial to the mid-clavicular line. It is not palpable in some patients
due to obesity or emphysema. To accurately determine the location of an apex beat
which can be felt across a large area, feel for the most lateral and inferior position of
pulsation. An apex beat in the axilla would indicated cardiomegaly or mediastinal shift.
Percussion of the heart allows to define relative and superficial cardiac dyullness
borders and to make idea about the heart configuration and its diameter.
Auscultation of the heart: one should comment on S1 and S2 - if the splitting is
abnormal or louder than usual. Should sound like [lub-dub lub-dub] and the presence
of S3 - like [lub de dub] sound, S4 - like [T lub-dub]. If S4 S1 S2 S3 were all present it
would sound like [T-lub-de-dub], also known as a quadruple gallop rhythm; diastolic
murmurs (e.g. aortic insufficiency, mitral stenosis), systolic murmurs (e.g. aortic
stenosis, mitral regurgitation), pericardial rub (suggestive of pericarditis).
Vessels examination includes blood pressure, pulse rate and rhythm, jugular
venous pressure (JVP) and pulse defining, palpation of peripheral arteries.
Gastrointestinal tract.
The exam includes several parts: inspection, auscultation, percussion and
palpation.
On inspection the patient should be examined for masses, scars, sinuses, lesions,
signs of trauma, bulging flanks - best done from the foot of the bed, jaundice/scleral
icterus, abdominal distension, caput medusae - dilated blood vessels radiating from the
umbilicus (may be present in liver failure). Especially pay attention on stigmata of
liver disease: fetor hepaticus, asterixis (flapping tremor); on hands: clubbing,
Dupuytren's contracture, palmar erythema; and estrogen related: spider nevi, testicular
atrophy, gynecomastia; associated with portal hypertension: hematochezia (blood in
7
stool), hematemesis - gastric bleed, esophageal varices, caput medusae (rare) - venous
distension, ascites.
Auscultation is sometimes done before percussion and palpation, unlike in other
examinations. It may be performed first because vigorously touching the abdomen may
disturb the intestines, perhaps artificially altering their activity and thus the bowel
sounds. To conclude that bowel sounds are absent one has to listen for 5 minutes.
Growling sounds may be heard with obstruction. Absence of sounds may be caused by
peritonitis.
Palpation in all 9 regions - light (superficial) then deep.
In light palpation, note any palpable mass, hernial orifices if positive cough
impulses, assessing muscle tone- there are 3 reactions that indicate pathology: guarding
(muscles contract as pressure is applied), rigidity (rigid abdominal wall indicates
peritoneal inflammation) and rebound (release of pressure causes pain) – positive
Shchetkin-Blumberg's sign. The lght palpation also includes examination for ascites:
bulging flanks, fluid wave test (fluctuation sign), shifting dullness test.
In deep palpation, detail examination of the mass, found in light palpation, bowel,
liver and gallbladder and spleen. Special maneuvers include complementary (Cair's,
Murphy's, Ortner's, Lepene's, Mussis') signs of cholecystitis.
Urinary system examination includes inspection of the kidneys area, kidneys deep
palpation, percussion of the lumbar region (Pasternatsky's sign), palpation of the
ureteral algesic points, and palpation and percussion of the urinary bladder.
IV. INVESTIGATIONS DATA
After the main organ systems have been investigated by inspection, palpation,
percussion and auscultation, specific tests may follow.
The results of testing, such as blood tests (e.g., complete blood count), radiology
examinations (e.g., X-rays), pathology (e.g., biopsy results), or specialized testing
(e.g., pulmonary function testing, ECG) are included. Often, as in the case of X-rays, a
written report of the findings is included in lieu of the actual film.
V. СLINICAL DIAGNOSIS
The assessment is a written summation of what are the most likely causes of the
patient's current set of symptoms. The diagnosis documents the expected course of
disease, its severity, complications and accompanied diseases according to
comprehensive classification of illnesses.
VI. SUBSTANTIATION OF BASIC DIAGNOSIS
List the typical (pathognomonic or specific) symptoms and signs, changes in the
laboratory and instrumental diagnostic methods data which prove your diagnosis.
VII. PATHOGENESIS OF SYMPTOMS AND SIGNS
Describe pathogenesis of symptoms and signs found in the course of patient’s
examination. Try to find ―cause-consequence‖ relationships within found signs,
grouping them in the syndromes typical of established disease.
6. 8
FORM of MEDICAL CASE REPORT
THEME_______________________________________________________________
Student name_______________________________________________________
Group №__________________ Date____________________________
I. PATIENT'S ID.
1. Name_______________________________________________________________
2. Age (date of birth)_____________________________________________________
3. Occupation__________________________________________________________
4. Home address_______________________________________________________
5. Date of admission___________________________________________________
II. MEDICAL HISTORY
1. CC________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Symptoms analysis (location, quality, quantity, chronology, setting, aggravating-
alleviating.factors, associated manifestations)_________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Secondary complaints___________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
__________________________________________________________________
2. HPI______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
9
History of recent admission______________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
3. PMH
A. Other medical problems________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
B.
Allergies______________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
C. Major childhood illnesses_______________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
D. Injuries, hospitalizations, and operations___________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
E. Immunizations (hemotransfusion)________________________________________
______________________________________________________________________
______________________________________________________________________
4. FH
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
7. 10
5 PSH
A. Infancy, childhood, adolescence. Date of birth________________, in time (before
term), from_______________pregnancy. Age of parents in the time of child birth:
father's_______y., mother's___________y. Breast-feeded or not (underline the
necessary). Began walking at ____ y., speaking at______ y., gone to school at_____y.,
had______________marks. In intellectual and physical growth and development didn't
(did) delay from coevals (underline the necessary).
B. Lifestyle.
Typical day for the patient________________________________________________
______________________________________________________________________
Recreation the patient engages in__________________________________________
______________________________________________________________________
______________________________________________________________________
____________________________________________________________________
Sports________________________________________________________________
______________________________________________________________________
Religious beliefs patient holds_____________________________________________
______________________________________________________________________
Patient’s school experience________________________________________________
After graduating school___________________________________________________
______________________________________________________________________
______________________________________________________________________
Patient’s military experience_______________________________________________
______________________________________________________________________
Clothes and footwear: (non) hygienic, (not) correspond to the season (underline the
necessary).
Feeding: (not) full, (not) regular (underline the necessary), prefers_________________
______________________________________________________________________
Apartment: ___rooms, separate (communal), (un)comfortable, with all (partial)
facilities (underline the necessary).
C. Homelife. Emotional atmosphere at home__________________________________
Marriage status________________________ Family___________________________
______________________________________________________________________
D. Occupational life. Nature of the occupation________________________________
______________________________________________________________________
______________________________________________________________________
Toxic exposures________________________________________________________
______________________________________________________________________
______________________________________________________________________
E. Sexual history. Pubertal period had gone without (with) complications at ______y.
Had sexual contacts from______y, has (not) _____childs (underline the necessary).
Menstrual function. Menarche from_____y, cycle length______d, (ir)regular, duration
of bleeding___d, amount of bleeding_______. Menopause from_________y.
Amount of pregnancies: deliveries_____, abortions_____, misbirths________.
11
6. MH
Medications (name, dosage, and regimen of each drug the patient is using)__________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Habits. Tobacco smoking_________________________________________________
______________________________________________________________________
______________________________________________________________________
Alcohol consumption____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Illicit drugs using_______________________________________________________
_____________________________________________________________________4
III. PHYSICAL EXAMINATION FINDINGS
General condition_________________________, t______°С.
Patient's position_______________, level of consciousness _____________________
Face expression_________________________________________________________
______________________________________________________________________
______________________________________________________________________
Constitutional type_____________________. Height________cm, weight_______kg,
BMI______kg/m2. WC……cm. HC……..cm. WC/HC………cm.
Gait and bearing abnormalities_____________________________________________
______________________________________________________________________
Skin:
Color: physiologic, pale, cyanosis, hyperemia, icterus, other
changes_________________ (underline the necessary)
Moisture_________________elasticity__________ state of the hair_______________
presence of exanthema, hemorrhages, vascular changes,
scars_______________________________________________________________
______________________________________________________________________
Nails_________________________________________________________________
_____________________________________________________________________
Subcutaneous fat: degree of its development __________________________________
Distribution (places of biggest fat deposition)_________________________________
______________________________________________________________________
Thickness of cutaneous fold below the scapula______cm, presence of
edema____________________________________________(point the level of edema)
Thyroid gland__________________________________________________________
Lymph nodes (size, shape, consistency, motility tenderness, adhesions with each other
and surrounding tissues __________________________________________________
______________________________________________________________________
8. 12
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Muscles: general development_____________________________________________
Tenderness on palpation__________________________________________________
Muscular tone__________________________________________________________
Muscle strength_________________________________________________________
Bones. On examination of skull, chest, spine, extremities tenderness and deformations
are (not) revealed (underline the necessary)___________________________________
______________________________________________________________________
____________________________________________________________________
Joints_________________________________________________________________
___________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Respiratory system
Nasal breathing is (not) laboured. Nasal form____________________________
Chest shape___________________________constitutional type__________________
Deformities__________________, symmetry_________________, respiratory
pattern_______________Respiration is (ir)regular, respiration rate__________per
min.
Chest respiratory motions of both sides of the chest: (un)even, (a)symmetric, there is
(no) a lag in motion on___________side of the thorax.
Additional respiratory muscles_______________________________(don't) participate
in respiration.
Tenderness on palpation______________________________, elasticity____________
Tactile fremitus_________________________________________________________
______________________________________________________________________
___________________________________________________________________
On comparative percussion________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Topographic percussion data:
Height of apices pulmones standing: from the front: on the right – ________cm above
clavicle, on the left – ________cm above clavicles;
from the rear: on the level of _______vertebra.
Krenig's areas width: on the right – _______cm, on the left – _______cm.
13
Lower lung borders:
Topographic lines Right Left
Parasternal
Midclavicular
Anterior axyllary
Midaxyllary
Posterior axyllary
Scapular
Paravertebral
Defining of diaphragmatic excursion
Topographic lines Right (cm) Left (cm)
inhal. exhat. total inhal. exhat. total
Midclavicular
Midaxyllary
Scapular
Lung auscultation_______________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Bronchophony__________________________________________________________
______________________________________________________________________
____________________________________________________________________
Cardiovascular system
Inspection of precordium________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Apical impulse (location, area, height, strength, resistance_______________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Cardiac impulse_______________________Epigastric pulsation_________________
Other pulsations________________________________________________________
______________________________________________________________________
______________________________________________________________________
9. 14
Thrills________________________________________________________________
______________________________________________________________________
___________________________________________________________________
Heart percussion
Cardiac relative dullness borders: righ_______________________________________
______________________________________________________________________
left___________________________________________________________________
______________________________________________________________________
upper_________________________________________________________________
______________________________________________________________________
The heart diameter:___+____ = ____cm
Heart configuration__________________________________
Cardiac superficial dullness borders: right____________________________________
______________________________________________________________________
left___________________________________________________________________
_____________________________________________________________________
upper_________________________________________________________________
______________________________________________________________________
Superficial dullness diameter: ________cm.
Vascular bundle width________cm
Heart auscultation
Heart sounds___________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Murmurs______________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Heart rate – ______per 1 min,. (ir)regular____________________________________
______________________________________________________________________
______________________________________________________________________
Vessels examination
Arterial pulse_____per 1 min, (ir)regular, filling_______________,
strain_________________, contour______________, (un)equal on both arms.
Arteries palpation and auscultation__________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
BP on the left arm____________mm Hg, on the right arm_____________mm Hg..
Venous pulse: negative, positive. Central venous pressure_____________cm.
15
Gastrointestinal tract.
Fetor oris______________________________________________________________
Visible mucous of oral cavity______________________________________________
______________________________________________________________________
Tonsills_______________________________________________________________
______________________________________________________________________
Gums_________________________________________________________________
Carious tooth___________________________________________________________
Tongue_______________________________________________________________
______________________________________________________________________
______________________________________________________________________
Abdomen shape: flat, rounded. protruded [(un)even], scaphoid (underline the
necessary)
Respiratory motions of abdominal wall______________________________________
______________________________________________________________________
Auscultation data_______________________________________________________
______________________________________________________________________
______________________________________________________________________
Percussion data_________________________________________________________
Superficial palpation data_________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Shchetkin-Blumberg's sign _______________________________________________
______________________________________________________________________
Sigmoid colon__________________________________________________________
______________________________________________________________________
______________________________________________________________________
Cecum________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Transverse colon________________________________________________________
______________________________________________________________________
______________________________________________________________________
Ascending and descending colon___________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Using percussion, auscultopercussio, auscultoaffriction, splashing sound methods the
lower stomach border is defined at the level__________________________________
Gastric greater curvature__________________________________________________
Pylorus_______________________________________________________________
Pancreas______________________________________________________________
Inspection of the liver area________________________________________________
10. 16
______________________________________________________________________
Signs of ascites_________________________________________________________
______________________________________________________________________
Liver span after Kurlov___________________________________________________
______________________________________________________________________
Liver palpation_________________________________________________________
______________________________________________________________________
______________________________________________________________________
Gallbladder____________________________________________________________
______________________________________________________________________
Complementary signs____________________________________________________
______________________________________________________________________
_____________________________________________________________________
Inspection of the spleen area_______________________________________________
______________________________________________________________________
Spleen percussion _______________________________________________________
______________________________________________________________________
______________________________________________________________________
Spleen palpation________________________________________________________
______________________________________________________________________
______________________________________________________________________
Urinary system
Inspection of the kidneys area______________________________________________
______________________________________________________________________
______________________________________________________________________
Kidneys palpation_______________________________________________________
______________________________________________________________________
______________________________________________________________________
Pasternatsky's sign______________________________________________________
Ureteral algesic points____________________________________________________
Urinary bladder________________________________________________________
IV. INVESTIGATIONS DATA
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
17
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
V. СLINICAL DIAGNOSIS
Main_________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Accompanied__________________________________________________________
______________________________________________________________________
______________________________________________________________________
VI. SUBSTANTIATION OF BASIC DIAGNOSIS
Diagnosis is based on____________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
VII. PATHOGENESIS OF SYMPTOMS AND SIGNS
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
11. 18
REFERENCES
1. A Guide to physical examination. Third Edition./B. Bates, R. A. Hoekelman.-
J.B. Lippincott Company, Philadelphia, 1995, 539p.
2. Introduction to clinical medicine./J.L.Willms, J.Lewis. – Williams and
Wilkins, Baltimore, 1991, 260p.
3. Manual of Introductory Clinical Medicine./R.M.Maclis, M.E.Mendelson,
G.H.Mudge.- Little. Brown and Company, Medical division, Waltham, 1997,
251p.
4. Схема истории болезни./В.Н.Ослопов, А.Р.Садыкова, А.Р.Шамкина. –
М.; МЕДпресс, 2001, 32с.
5. Пропедевтика внутренних болезней Учебно-методическое пособие.
Часть I. Introduction to Internal Diseases. Manual Part I. /В.Н.ослопов,
А.Р.Садыкова, И.В.Карамышева. Казань, 2005, 65 с.
6. Пропедевтика внутренних болезней Учебно-методическое пособие.
Часть II. Introduction to Internal Diseases. Manual Part II. /В.Н.ослопов,
А.Р.Садыкова, И.В.Карамышева. Казань, 2005, 86 с.
7. Пропедевтика внутренних болезней Учебно-методическое пособие.
Часть III. Introduction to Internal Diseases. Manual Part III. /В.Н.ослопов,
А.Р.Садыкова, Л.А.Ануфриева. Казань, 2005, 77c.
8. Пропедевтика внутренних болезней Учебно-методическое пособие.
Часть IV. Introduction to Internal Diseases. Manual Part IV. /В.Н.ослопов,
А.Р.Садыкова, Л.А.Ануфриева. Казань, 2005, 103 c.