History of the present disease (anamnesis morbi)
SCHEME OF THE CASE REPORT
Medical academy
named after S. I. Georgievsky
Department propaedeutics of internal medicine
Head of department
Teacher
CASE REPORT
(patient’s full name)
Clinical diagnosis:
Main diseases
Complications
Accompanying diseases
Student
year
group
I. PASSPORT DATA
Patient’s full name, age, sex, nationality, marital status, occupation, place of work, residence, time of admission.
II. INQUIRY (INTERROGATIO):
COMPLAINTS:
It’s essential to clear up the complaints while examining the patient at the moment of hospitalization, which describes the cause of his condition aggravation (main complaints), then to question the patient about his/her complaints of each organism system separately (secondary complaints).
The common complaints should also be revealed, such as: general malaise, fatigue, decrease of work capacity, loss of appetite, apathy, sleep impairment, body temperature elevation.
HISTORY OF THE PRESENT DISEASE (ANAMNESIS MORBI)
When, where and how the disease started. Whether the onset was acute or gradual. Initial symptoms of the disease and their development.
The description of chronic diseases must be given per exacerbation, but the description of acute diseases - per day.
Causes of the disease: psychological stresses, physical or mental overstrain, infections, cold.
Work ability during the course of the disease. Patient’s attention to the disease at different stages of its development.
Whether the disease influences family and work relationships. Relation to medical staff, procedures.
In chronological order to describe all the measures of diagnostics and treatment performed before.
Motives of hospitalization: exacerbation of disease, diagnosis verification.
LIFE HISTORY (ANAMNESIS VITAE)
It usually begins from collecting general biographical information: birth place, family parentage (workers, clerks, and peasants). Features of environmental conditions where the patient grew up. Conditions of life in childhood and adolescence and health during these periods of life (age of the patient when he began to walk; to speak; to study. Duration of studying, progress etc. if it is needed for diagnosis).
Professional anamnesis: describe when the patient started to work, condition of professional harms (industrial hazards, dusts, strong noise, vibration, high ambient temperature, draft), conflicts. Places of work and occupations during life.
Social anamnesis: state of apartment (separate, hostel. Country house), its features, climate indoors (dampness, illumination etc.). hygenic conditions. The family composition: large or small, their health, well-being, income.
Nutrition: whether it is regular or not, character of food (poor menu, lack of vegetables, fruits, meat, dairy products, etc.). Ask the patient about some dishes he prefers; whether his/her food too sweet, spicy etc.
Harmful habits: smoking (its duration, how many cigarettes a day are used), alcohol or narcotics usage (how often and dosage), abuse of coffee, tea, etc; prolonged using of some remedies.
Past illneses: traumas, operations, contusions. Ask the patient if he had tuberculosis, hepatitis, syphilis, typhus, malaria, rheumatism, etc.
Family anamnesis: diseases of the parents, sisters or brothers.
Special attention should be paid to tuberculosis, syphilis, malignant tumors, alcoholism, mental diseases, and diabetes mellitus.
Allergic anamnesis: abnormal response to some medication, foods, perfumes, chemical agents. Ask the patient about blood transfusion (or its derivates), his (her) reaction on this procedure.
Gynaecological anamnesis: menstruation (date of beginning, pain, duration of menstruations and interval between them, amount); deliveries (normal, pathological, amount); abortions (quantity); menopause (age, climax features); gynaecological diseases (inflammatory, tumors, operations).
Epidemiological anamnesis: contacts with infectious patients (influenza, tuberculosis, virus hepatitis).
II. PHYSICAL EXAMINATION
(Status praesens)
General condition: satisfactory, middle heaviness, grave.
Consciousness: clear, deranged (stupor, sopor, coma), irritative disorders (exitation: hallucinations, delirium; depression, apathy).
Patient’s appearance: corresponding to age (looking older or younger).
Patient’s posture: active, passive, forced.
Body structure: correct, irregular.
Constitution: normosthenic, asthenic, hypersthenic.
Height: normal (males 165 – 180 cm, females 155 – 170 cm), dwarfishness, gigantism.
Weight: normal, insufficient (cachexia), increased (obesity).
Posture or attitude: erect, straight, infringed, «proud».
Gait: energetic (active), weakened, etc.
Skin:
- colour (body-colour, pale, icterous, red, cyanotic, grey, bronze-like, pigmentation (hyperpigmentation, depigmentation);
- elasticity: elastic, nonelastic;
- humidity: usual, moist, dry; desquamation (location, expressiveness: moderate, intensive);
- eruption/rash: location, features of elements, their characters (roseola, petechias, papulas, vesiculas, erythema);
- haemorrages: location, expressiveness, characters (petechias, bruise);
- lesions: posttraumatic, postoperative scars, striae gravidarum (size, location);
- trophic changes: ulcers, bed-sores;
- external tumors: atheromas, angyomas (location, size).
Mucous membrane should be examined: conjunctiva, nasal and oral mucosa. Colour (pink, pale, cyanotic, icterous). Aenanthemas, their features.
Subcutaneous fat tissue: expressive local visions (moderate, insufficient, excessive).
Oedemas: their location (shin, lower back, ascites, anasarca), expressiveness.
Nails: shape, colour, breakage, longitudinal and transversal lines.
Lymph nodes: head, neck, trunk, extremities.
EXAMINATION OF BODY PARTS
Head: position (usual, unusial); shape (oval, round, etc.); proportions - correspondence of facial and cerebral parts (propotional, hydrocephalus, microcefalus, acromegalic); specific movements (Musset’ sign, parkinsonism); hair-covering: male/female type; abnormal growth of hair: baldness, alopecia (localization, expressiveness), hirsutism, hair pigmentation disorder.
Face: symmetry, expression (usual, apathic, suffering, impressed, exhausted, specific), shape (regular, sunken, swelled, oedematic, moon-like, acromegalic), asymmetric movements of facial muscles.
Eyes: width of eye slit (moderate, wide, narrowed), eye shape (usual, exophtalmus, enophthalmus), squins, hypersecretion of tears, scleras (usual, icterous, hyperaemic, haemorrages), pupils: symmetry (anisocoria); shape; size (miosis, mydriasis); accommodation; convergence; response to light.
Nose: expression of nasolabial folds, size of a nose, shape (usual, saddle-like).
Ears: colour of skin (usual, cyanotic, red), nodes.
Mouth:
- shape: symmetry of the angles, permanently open;
- odour: ammonic, acetone, putrid, fetid;
- lips colour: pink, red, blue; eruption (cold sores, herpes labialis, fissures);
- teeth: healthy, affected by caries, dentures, colour;
- gums: colour, oedema, ulceration, haemorrages, thin coating;
- soft and hard palate: colour (usual, icteric, pale, hyperaemic), hemorrhage, thin coating;
- tongue: size (usual, enlargement); colour; moist or dry; condition of papillae (hypertrophy, atrophy, smoothness), deviation of the tongue from the normal state;
- tonsils: size, colour, loosening, presence of patch, lacunas, purulent cork.
Neck: shape (usual, short, long), carotids pulsations, jugular pulsation, dilated jugular veins, diffuse or local enlargement of the thyroid gland; lymph nodes enlargement.
LOCOMOTOR SYSTEM
Examination and palpation:
Muscular system: development (usual, local atrophy); determination of muscular strength.
Spine: pathological deformation (scoliosis, lordosis, kyphosis, kyphoscoliosis);
Extremities: bone deformities, thickness and roughness in periosteum palpation, osteomalacia, tenderness on palpation and percussion, hands and feet (normal, thickened, plate, fingers of «drumsticks» and nails of «clock-glasses» shapes), varicosity of the veins.
Joint: swelling, redness, morbidity, deformation, dislocation, definition of local temperature, mobility (active and passive movements), the crackle during movements, the presence of exudate in them.
RESPIRATORY SYSTEM
Inspection:
Respiration: nasal, oral, acting of nose wings in breathing.
Chest shape: physiological (normosthenic, asthenic, hypersthenic), pathological (emphysematous, paralytic, funnel-shaped, rachitic, foveated).
Chest symmetry, patency of supra- and subclavicular fossas, direction of ribs (usual, vertical, horizontal), intercostals space size, epigastric angle (acute, dull, 90°); scapulas position (symmetry, attachment to ribs: wing-shaped scapula).
Dynamic inspection: type of respiration (thoracic, abdominal, and mixed); rhythm (rhythmic, arrhythmic: Grocco, Cheyne-Stokes, Biot); rate; depth (deep (Kussmaul), superficial); movements of chest in respiration (symmetrical, assymetrical).
Palpation:
Tenderness along the ribs, intercostals spaces, trapezoid muscles, intercostal nerves points.
Resistance of chest: longitudinal and transversal direction (moderate, decreased, increased).
Vocal fremitus: anterior, lateral, posterior (identically, strengthened, weakened).
Pleural friction sounds.
Percussion:
Comparative: character of percussion sound in symmetric parts of the chest (clear lung, duller, dull, tympanic).
Traube space: present, absent.
Topographic percussion: height of lung apexes (anterior, posterior), lower borders along topographic lines.
Mobility of lower borders of the lungs along mediaclavicular, medial axillary and scapular lines.
Auscultation:
Character of main respiratory sounds over symmetric parts of the chest: vesicular respiration, bronchial, mixed.
Adventitious sounds: rales (dry: sibilant, sonorous; moist: fine bubbling, medium bubbling and coarse bubbling, crackling (consonating and nonconsonating); crepitation; pleural friction sound (slight, rough).
Bronchophony on symmetric parts of the chest (identical, increased, weakened).
SYSTEM OF THE BLOOD CIRCULATION
Inspection:
Visible pulsation of the neck vessels: carotids, jugular veins (positive or negative venous pulse). Jugular veins dilation.
Protrusion in the heart area (cardiac humpback). Visible pulsation of the heart area (jugular fossa, 2-nd intercostal space, apex beat, cardiac beat, epigastric pulsation).
Palpation:
Apex beat: location, width (diffuse, restricted), height (high, low), strength (moderate, weakened, and forced), shape (elevated, domed, negative).
«Cat’s murmur» phenomenon (shaking or vibration): diastolic or systolic.
Percussion:
Borders of relative and absolute cardiac dullness: right, upper, left.
Borders of vascular bundle: right, left.
Auscultation:
On auscultation of the heart points (apex, second intercostal space, base of xiphoid process and 5-th point (Botkin-Erb) mast be described: amount of tones, rhythm (regular, irregular, «gallop rhythm», «triple rhythm»), rate, sounds intensity, presence of accent, splitting or reduplication, murmurs (location, according to the cardiac phases of heart (systolic, diastolic), character (soft, blowing, rough), force (intensive, weak, moderate), duration (long, short, decreasing, crescent), irradiation).
Vessels investigation:
Condition of palpable arteries (consolidation of walls, curvatures): temporal, carotid, radial and foot arteries.
Arterial pulse: symmetry, rhythm, rate, filling, tension.
Capillary pulse: positive, negative.
Arterial pressure: systolic, diastolic, pulse in mm Hg.
Venous pressure: indirectly on raising of hand.
Auscultation: carotid, abdominal, femoral artery (presence of Traube double tone and Vinogradov-Durozier double murmur); jugular vein (presence of «top murmur»).
DIGESTIVE SYSTEM
Inspection:
Abdomen:
• symmetry;
• shape, size (flat, loose-hanging, protruding, depressing, «frog»);
• navel: protruded, depressed;
• mobility of the abdominal wall during breathing (hresent, absent);
• skin of the abdomen (pigmentation, depigmentation, scars, striae
gravidarum, scratches, extended hypodermic veins);
• visible peristalsis.
Palpation:
Superficial palpation:
• strain of the abdominal wall (distinctly expressed, decreased, local muscles resistance), tenderness, hernial separation of muscles and protrusion, presence of tumors;
• Mendel’s symptom (percussion tenderness);
• Shchetkin-Blumberg symptom (peritoneum irritation sign).
Deep palpation by Obraztsov and Strazhesko: location, of the intestinal parts; tenderness, diameter, consistency, condition of the surface, mobility, presence of rumbling sound in all parts of the large intestine.
Palpation of the stomach is preceded by determining its inferior border (auscultative-percussion method).
Auscultation of the abdomen: peristalsis sounds (louder, rate); vessels sounds.
Examination of the liver:
• visible enlargement of the liver;
• percussion of the liver by Curlov and Obraztsov;
• characteristic of the lower edge of the liver during palpation (soft, hard, sharp, rounded, smooth, tuberous, painful)
• auscultation of the liver region.
Examination of the gallbladder:
• palpation of gallbladder, Courvoisier symptom (in case of palpation)
• pressing symptoms of gallbladder: Kera, Murphy (positive, negative)
• tapping symptoms (Ortner, Lepene, Vasilenko,)
• tender points: gallbladder, choledocho-pancreatic, diaphragmatic (phrenicus symptom), acromin, subscapular, paravertebral to the right;
• sites of hyperesthesia in the zones of Zakharyin-Head.
Examination of the pancreas:
Palpation of the pancreas is carried out in its projection points (choledocho-pancreatic, Katsch, tail)
Tender points: projection points, diaphragmatic (phrenicus symptom), acromin, subscapular, paravertebral to the left; sites of hyperesthesia in the zones of Zakharyin-Head.
Examination and palpation of anus is necessary in the presence of complaints on painful defecation, tenesmus, mucus and blood in faeces, falling out rectum.
URINARY SYSTEM
Inspection:
Special attention is paid to:
• Oedema
• face (facies nephritica),
• hyperemia and swelling of the loin.
Palpation and percussion:
•Palpation of kidneys: enlargement, kidney displacement, mobility, size, consistence, character of the surface (smooth, tuberous).
• Pasternatsky symptom.
• Tender points of kidneys and ureter.
BLOOD SYSTEM
Palpation:
Flat bones or epiphyses of tubular bones (presence of tenderness during palpation and tapping).
Palpation of the lymph nodes: location, size, tenderness, fusing with skin and conglomerate formation.
Examination of the spleen:
• visible enlargement;
• borders of the spleen dullness;
• data of palpation (size, consistency, characteristics of the edge (sharp, dull), of the surface (smooth, tuberous), tenderness, mobility during breathing.
III. INITIAL DIAGNOSIS
Diagnostic conclusion is formulated on the base of the complaints, anamnesis morbi and vitae, the results of objective examination (inspection, palpation, percussion, auscultation) with indication of syndromes revealed.
Then a plan of additional laboratory and instrumental investigations is administered for specification of the diseases.