The Volgograd State Medical University
Faculty of the general surgery with urology
The circuit of drawing up of the case record
(Methodical recommendations for students of III rate of medical faculty)
Managing faculty A.A. Полянцев the doctor honey. Sciences, the professor
Volgograd 2006
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The basic primary medical document of the patient is the case record. In it complaints of the patient,
the beginning and the further current the illnesses given about diseases transferred earlier,
operations, inoculations and harmful habits are consistently stated. Further the objective data
describing a functional both anatomic and physiological condition of all bodies and systems of an
organism on the basis physical of methods of research are reflected.
The descriptive part of the case record comes to an end preliminary, and in clear cases and the final
diagnosis. Then the plan of inspection of the patient (laboratory, functional, tool, etc.) is stated.
After an establishment of true character of disease the plan of treatment of the patient, and in
necessary cases and the plan of preoperative preparation is necessarily planned,
In diaries dynamics{changes} of development of disease and results of treatment is reflected,
changes are brought in earlier planned plan of treatment, if necessary. In 10-12 days as этапного
эпикриза sums up the lead treatment, the tendency is reflected during pathological process.
If necessary applications of surgical methods of treatment in the case record the written approval of
the patient to operation with his{its} personal signature is marked. In case of impossibility (on a
state of health) to make it to the patient, his{its} consent makes sure the signature of two doctors
(зав. отд.). At несовершеннолетии the patient the written approval to operation is given by parents
(relatives). And at last, at mental inferiority of the patient the consent, on the basis of the conclusion
of the special commission, relatives or trustees of the patient give.
Indications to the operation, the elected technique of its{her} performance, a kind of anesthesia and
other. Are reflected in the special preoperative conclusion (concept). In the subsequent and the case
record the report of operation, the description a preparation, current after the operational period in
dynamics{changes} and an outcome of treatment is reflected.
The case record выписным эпикризом in which results of treatment are reflected comes to an end,
medical and labour recommendations are given, and if necessary patients go on ВКК and ВТЭК.
The circuit of the case record
1)
The GENERAL{COMMON} DATA (the Passport part)
Surname, name, patronymic. Age. A floor. A nationality. Formation{education}. A residence. A
trade, a post. Whom and when the patient on hospitalization is directed. Dates, time of receipt and
an extract. Diagnoses of the directed medical establishment and at receipt Accompanying diseases.
2)
COMPLAINTS OF THE PATIENT
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Complaints are made on all bodies and systems at date of primary survey of the patient It is
necessary to allocate the basic (conducting{leading}) and minor complaints (this division is
conditional). It is necessary to specify time and a place of occurrence of this or that
painful{unhealthy} sensation. Each complaint is as much as possible detailed on character, force,
conditions of occurrence or disappearance, communication{connection} with other moments
strengthening or weakening them
3)
The HISTORY of the PRESENT DISEASE (Anamnesis morbi)
Conditions in which there was a disease, influence on him{it} of working conditions and a life. It is
necessary to specify, what was carried out{was spent} treatment in various medical establishments
and his{its} efficiency, to collect data on previous diagnoses, results of laboratory and tool
researches. During interrogation it is necessary to pay attention on: seasonal prevalence of disease,
influence of weather, a climate and physical factors (cooling, overheating) and loadings on his{its}
current, value of negative emotions, catarrhal diseases, food factors, alcohol, smoking, contact
occurrence and current of disease.
4) The HISTORY of the LIFE of the PATIENT (Anamnesi vitae)
Biographic data from a life of the patient, the birthplace, a social origin, development and a state
of health at early age, material security of family are briefly resulted. The beginning of study what
has ended educational institutions. The beginning of an independent labour life and the further
labour anamnesis in view of working conditions (industrial intoxications).
Conditions of a life consistently during the various periods come to light: material security,
conditions of a life, a feed{meal}, use of rest, habitual intoxications (smoking, alcohol), reception of
drugs. The transferred illnesses, including traumas, operations, wounds, contusions. Thus weight
and duration of current illness, complications, medical actions is underlined. Contact to patients
with a tuberculosis and infectious diseases.
Time of puberty. At women - the beginning menses and their character (a regularity, duration,
morbidity).. The Effective date in a marriage{spoilage}. Quantity{amount} pregnancys, number
abortion, abortions, normal sorts. obstetrics a pathology. Quantity{amount} and health of children,
the reasons of death if have died. Health of the wife and the husband the Climax at women and men.
Allergology the anamnesis provides finding-out of an allergy at the patient and in his{its}
family (at parents, sisters, brothers and children of the patient), reactions not. Introduction of wheys,
vaccines and medicines. Hemotransfution and complications after their carrying out.
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Heredity. A state of health or the reasons of death of close relatives of the patient. It is paid
special attention to venereal diseases, illnesses of an exchange and blood, malignant tumours,
endocrine and psychological diseases.
5) The PRESENT{TRUE} CONDITION (Status praesens)
Estimation of weight of a condition of the patient: satisfactory, average, heavy, very heavy
The given measurements of a body temperature.
Position: active, passive, compelled (sedentary, lying, etc.)/
The consciousness clear, confused, indifferent, coma.
Behaviour of the patient usual, excited (impellent, fussiness, trembling, etc.)
Look: induced, indifferent, маскообразное, amimic, person Gippokrata, suffering.
Constitution, normal, asthenic, hipersthenic, athletic.
Growth, weight, proportionality, condition of a feed{meal}. Skin and mucous membranes: color
of a leather{skin} and seen mucous (pallor, cyanosis, hyperemia, yellowness. Pigmentation,
depigmentation), elasticity of a leather{skin}, dryness. sweating(diffuse, limited). A rash,
combed, hypodermic haemorrhages.
Hair type pilosis, virilism, loss, caniti.
Nails, the form, « hour glasses », spoonlike, fragility, « drum-type sticks ».
Hypodermic fat a degree of development: normal, weak (emaciation, cachexia), excessive
(fatness, adiposity). Speed emaciation . Hypostases and their distribution: finitenesses, the person,
eyelid, a stomach, bloated, пастозность, myxedematic, the general{common} hypostases. Property
of hypostases: dense, soft.
Lymphatic system
palpation . Lymph nodes:mentals , submaxillary, cervical,
Occipital, supraclaviculars, subclavials, axillary, ulnars, inguinals, femoral, popliteal. Size, the form
(oval, round, wrong). A consistence (firm, soft). Morbidity at palpation, cohesion among themselves
and its{her} surrounding fabrics, a leather{skin}.
Muscular system
Degree of development (normal, weak, an atrophy). A tone (normal, raised{increased}, lowered).
Force of muscles of a hip, flexors and extensors a shoulder. Morbidity of the mouse at palpations and
movements. Measurement of a circle of a shoulder, a forearm, a shin and a hip. Bone system.
Survey: proportionality of a parity{ratio} of parts of a skeleton (deformation, periostitis, curvatures),
measurement of absolute and relative length of finitenesses. Articulate system.
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Humeral joint, survey, movements, configuration, palpation (definition of bone identification
points: acromial a shoot, beakeda shoot ) scapula.
Humeral joint: survey (a configuration, color of integuments above a joint, position of an axis of
a forearm in relation to an axis of a shoulder), movements (bending, extension, the pronation,
supination), palpation (definition of a parity{ratio} of identification points ulnar a joint), (a top
ulnaris a joint,epicondylic ulnar bones), a line and triangle Понтера.
radiocarpal a joint: survey, movements., palpation.
Coxofemorala joint: survey (position of finiteness, comparative volume of both hips and
buttocks, definition of a level of standing of both anterosuperior arista
повздошной bones).
Movements (symptom Трендилинбурга). Palpation(definition of bone identification points: the
head of a hip, the big spit), morbidity at cross-section prelum a basin. Research of line РозерНелятона, triangle Бриана, line Охумакера and Потерса
Knee joint: survey, the form, a relief, надколенника, external and internacondylesl
hips,
articulate edge{territory} tibial bones, the head fibular bones. Definition of a crunch, balloting
надколенника.
Ankle joint: survey, movements,palpation .
Bodies of breath.
Nose: external examination and palpation, a smell from a nose, a bleeding, flow of pus,
additional cavities (гайморова, frontal).
Throat and a drink: a voice, survey and palpation throats.tonsil : a hypertrophy, an atrophy,
hyperemia, an inflammation, fuses, pus in lacunas.
The form of a thorax (,normosthenic hypersthenic, asthenic),
Position scapula, expressiveness above and subclavial fossa. Breath through a nose. Type of breath
(chest, belly, mixed), depth, a rhythm, symmetry of respiratory movements. Participation of
auxiliary muscles in the certificate{act} of breath. Frequency of breath in one minute. A short wind
and its{her} character (inspiratory, expiratory, mixed). Definition of the maximal respiratory
excursion of a thorax (measurement of a circle of a thorax at a level papillas and the bottom
cornersscapulas at height of a breath and an exhalation).
Palpation: resistency of a thorax, definition of painful{unhealthy} points, puffinesses, a condition of
intercostal intervals, presence hypodermic emphysema, definition of voice trembling, sensation
friction of a pleura.
Percussion: local character percussed a sound (clear, stupid{blunt}, pulmonary, tympanic. Box).
Comparative and topographical percussion with definition of the bottom borders easy on all lines.
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Definition of height of standing of tops of fields Кренига. Mobility of the bottom edge{territory}
easy on среднеподмышечным andscapular to lines
Auscultation: character of breath vesicular(, rigid, weakened, bronchial), respiratory collateral noise
(rattles dry and damp,crepitation , noise of friction of a pleura). bronchophony. Under the
attitude{relation} to all pathological data it is necessary to specify their exact localization, using the
accepted topographical designations.
Cardiovascular system.
Survey and palpation intimate area. A top push: localization, force {normal, poured), an intimate
push. A symptom of " the cat's purring ». A condition of cervical vessels « dancing каротид »,
swelling of veins.
Percussion: borders of absolute and relative dullness of heart. A diameter of intimate
dullness,percussion a vascular bunch{beam} in the second intercostal.
Auscultation: tones of heart, noise, their attitude{relation} to phases of intimate activity, a timbre,
duration, localization and irradiation. Noise of friction of a pericardium and a place of his{its}
auscultation. Survey and palpation peripheral arteries. A pulsation, elasticity, tortuosity, auscultation
of large arteries.
Pulse (sleepy, subclavials, axillary, humeral, beam, femoral, popliteal, заднеберцовых, back
arteries. Stops), frequency in minute, a rhythm, a pressure{voltage}, filling, size, speed,
synchronism. Deficiency of pulse at presence arrhythmia. Capillary pulse.
Research of veins: expansion of veins of a thorax, a forward belly wall, the bottom finitenesses,
presence venous collaterals. Condensation and morbidity of separate veins Definition of a blood
pressure on both hands.
To check up symptoms: Панченко. Самузльса, Гольдфдяма: tests of the Burgher - Оппеля,
Wander - Троянова-Тренделенбурга, Дельбе-Пертеса.
Bodies of digestion
Mouth: a smell from a mouth (putrefactive, ammoniac), a teeth (the dental formula,
quantity{amount} absent; a teeth, carious a teeth, artificial limbs,crown ), a condition of a mucous
membrane Gingivas, lips, cheeks, the soft and firm sky, (color, loosened, bled, aphthas, ulceris),
language (painting, humidity, presence of strikes, cracks, язвочек, atrophies papillas).
Stomach, survey (a configuration, size, participation in the certificate{act} of breath, the
hypodermic venous network seen peristalsis, its{her} localization, presencecicatrixs , area, the form)
Superficial palpation: a condition of belly muscles (a tone, morbidity, muscular protection, a
divergence of direct muscles of a stomach). Measurement of a circle of a stomach at a level navel.
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.percussion Deep palpation (methodical, deep, sliding, topographical on a method It is exemplary
and Стражеско).
Stomach: morbidity, definition of painful points,percussion and auscultation, definition of the big
curvature of a stomach, пилорического a department.
Intestines: palpation departments of a thick gut, auscultation a stomach, a chair (color, a consistence,
frequency). Research of a direct gut.
Liver: survey (its{her} seen increase, delimitation of relative dullness: top - by corresponding
bottom border easy, bottom - on right среднеключичной lines and on an average line of a stomach;
the sizes of a liver on Курловув see: a diameter - on среднеключичной. переднеподмышечной
and an average line.
Palpation a liver: character palpated anteroinferior edges{territories} of a liver (sharp, rounded, soft,
dense, rough, painful{unhealthy}) and its{her} surfaces (soft, dense, rough,tuberous ).
Spleen: palpation spleens in horizontal and lateral position of the patient on the right to a side (a
consistence palpated edges{territories}, bumpy, morbidity, mobility). The sizes of a spleen on
Курлову-Кассирскому.
urinary system: frequency emiction, dysuric the phenomena, survey of area of kidneys and a
bladder. Palpation kidneys. Symptom Пастернацкого from both parties{sides}.
Percussion and palpation a bladder.
Nervous system
Pupils: size, the form, reaction to light (a straight line and содружественная)Dermographism (pink,
white, proof). Stability in pose Ромберга.
Endocrines glands .
Thyroid gland: size, a consistence, a surface. Eye symptoms (goggle-eyeds, symptoms Gref,
Moebius, etc.). Giantism, adiposity, an exhaustion, pigmentation.
6)LOCAL CONDITION
7)THE
(Миавпа/оса/и)
DATA LABORATORY, TOOL AND OTHERS
8)SPECIAL PATIENTS.
9)SUBSTANTIATION OF
THE DIAGNOSIS
On the basis of synthesis of all clinical data received at research of the patient, the substantiation of
the established clinical diagnosis is made. And the clinical diagnosis it is underlined: а) the basic
disease
б)
Complications of the basic disease
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в)
Accompanying diseases
9)
THE PLAN OF INSPECTION OF THE PATIENT
10)TREATMENT
WITH THE SUBSTANTIATION AND THE EXPLANATION OF THE
MECHANISM
11)ACTIONS
OF MEDICAL PRODUCTS AND OTHERS USED
12)METHODS
OF TREATMENT, SWITCHING AND OPERATIVE
13)DIARIES
In diaries the daily brief, exhaustive information on all changes reflecting dynamics{changes} of
current of illness and treatment is conducted:
а)
Changes past{last} for expired day in the subjective and objective status
The patient:
б)
Results lead{carried out} this day laboratory and tool
Research, and also the data of consultations of the patient with other experts;
в)
The new purposes{assignments} made to the patient and changes in former
purposes{assignments}.
12)THE
FORECAST
13)Epicrisis
To the case record the list of the used literature is applied. At the end of the case record the signature
of the student - curator is obligatory.
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