THE SCHEME OF A SURGICAL CASE HISTORY
I. Common items of information (biographical data)
1. Surname, name
3. Place of work and address
5. Home address
6. Date of arrival in hospital
1. Complaints. Complaints (on the moment of the first contact). The main and minor complaints with their detailed elaboration. It is necessary to relate to the main complaints those which are the important symptoms of the given disease and which specify in this or that measure the localization of the process. The subjective sensations are those which indicate only the presence of a disease but they are not specific to define the illness (common weakness, feeling of fever etc.), or those complaints, which are connected to accompanying disease.
The complaints depending on a primary lesion of various organs and systems can be the following:
1. At diseases accompanied with lesion of skin and mucosas: itch, pain, rash, ulceration, bleeding etc.
2. At diseases accompanied with lesion of lymphatic nodes: increase of their sizes, localization of lesion, pain, festering etc.
3. At diseases accompanying with lesion of muscles: pains (their localization and link with movements), violation of movement, change of size etc.
4. At lesion of bones (vertebral column, ribs, sternum, tubular bones): pains (their localization, nature and time of appearance).
5. At lesion of joints: pains (in rest or at movement, day or night), violation of the function, localization of lesion, feeling of «heat» in joints etc.
6. At diseases of organs of respiration: nasal respiration (free, labored), character and amount of excreta from nose (slime, pus, blood). Pains in area of sinuses. Pains at talk and swallowing. Changes of voice. Pains in thorax: localization, character, link with respiration and coughing. Dyspnea, its character and conditions of occurrence. Asphyxia, time of its appearance, duration, accompanying phenomena. Cough (dry, wet, painful), time of its appearance and duration. Sputum, its excretion, amount, internal (impurity, lamination). Pneumorrhagia, condition of its appearance.
7. At diseases of the cardiovascular system: pains behind sternum and in the heart region (exact localization, character, duration, irradiation, what they are accompanied with, reason and condition of occurrence abirritating influences), dyspnea (degree of expressiveness, character), palpitation, arrhythmias, headaches, giddiness, «flying midges» before eyes, edemas, change of a diuresis.
8. At diseases of organs of digestion: appetite, taste, smell from a mouth, salivation, thirst, mastication, swallowing, heartburn, eructation, nausea, vomiting (character of emetic masses), time of their occurrence, dependence both on the amount and the quality of food, pain (localization, character, force, duration, dependence on time of eating, from movement and physical exertion, irradiation, ways of easing the pain), abdominal distention, heaviness, rumbling, the sense of the flow, intestine activity (stool), number of defecations,false impulses, itch in the anus area, hemorrhoids, prolapse of the rectum, defecation characteristics(amount, consistence, mucus, blood), loss of weight.
9. At diseases of hemopoietic and endocrine systems: bone and throat pains, rise of temperature, common weakness, bleeding, lymphoadenopathy, thirst, dryness in a mouth, increase of appetite (bulimia), increasing frequency of urination, itch in vagina, palpitation, loss of weight or obesity, sleepiness or sleeplessness, weakness in extremities, sweating or xeroderma.
2. History of the present disease (Anamnesis morbi)
When the patient got sick, what the disease began with (first symptoms). What the patient links his disease to, possible reasons of its occurrence (in patient’s opinion). How the disease developed up to the moment of patient’s examination. Sequence, intensification, decreasing or disappearance of earlier symptoms or appearance of new symptoms of the disease. Where the patient addressed for help, where he was examined and treated, what the diagnoses were, influence on current of illness.
The description of the present aggravation of condition (under what circumstances the patient was taken to the hospital).
3. History of patient’s life
- Infancy, childhood, youth
Place of birth, whether he was born in time, weight of the child at birth. Parents’ age at birth of the patient. Development in early childhood. School period: in what age the patient went to school, how he studied. Features of development in youthful age.
- Home anamnesis
Conditions of life beginning with patient’s childhood. Dwelling: warm, damp, cold, light, its square and number of people living there, municipal services, floor. Clothes and footwear. Nutrition during the whole life: character and full value of nutrition, regularity of reception of food, use of a plenty of liquid, cooking salt, strong tea etc. Rest, duration and sufficiency. Physical training and going in for sports.
- Labour anamnesis
Since what age the patient began to work, occupation and working conditions during all life. Whether there were harmful working conditions and during what time.
-Surgical anamnesis. Information about antecede operations and traumas.
- Sexual anamnesis
Period of a puberty. For women — time of appearance of menses, its regularity, painfulness, duration. How many pregnancies and birth deliveries she had, artificial abortions, miscarriages. Weight of children at birth. Menopause, time of its appearance and signs.
- Pernicious habits (habitual intoxications)
Smoking, use of alcohol and alcoholic drinks, narcotics (since what age, amount).
- Previous diseases
What diseases the patient had (since childhood), in what age and their consequences. Wounds, operations, contusions. Venereal diseases. Mental traumas. Poisonings. Contact to the infectious patients (epidemiological anamnesis). Whether there is a physical disability, from what time and what group, the frequency of being on sick list.
- Allergological anamnesis
Presence of allergic diseases (bronchial asthma, urticaria, eczema etc.) in the anamnesis for the patient and his relatives. Antibiotics taken earlier. Inoculations. Hypersensibility to medicines, intolerance of foodstuff.
- Family anamnesis and heredity
Information about relatives: their age, status of health, reason of death and age of parents, brothers, sisters, children, grandfathers and grandmothers death both on the part of the father, and on the part of the mother. Parents’ diseases, which the patient suffers from, and such diseases as tuberculosis, syphilis, alcoholism, malignant tumors etc.
III. Objective examination
1. Common examination
A. Common condition (good, satisfactory, moderate heaviness, serious, agonal), temperature of a body.
B. Position of the patient in bed (active, forced, passive).
C. Consciousness (clear; aberration: stupor, sopor, coma, delirium).
D. Patient’s expression (doesn’t reflect any painful processes, melancholy, exited, indifferent).
E. Body height, weight, body build, constitution.
F. Skin and mucosas: skin and visible mucosas color. Skin, moisture its turgor, elasticity, eruption, hemorrhages, scars, peeling, ulcer, «vascular stars». Hair and nails.
G. Hypodermic fat, degree of development of hypodermic fat (excessive, moderate, weak), thickness of dermal pleat (in cm) in a lower corner of a scapula. Edemas: localization, density. Hypodermic emphysema. Thyroid gland (degree and character of increasing).
H. Lymphatic nodes (submandibular, above- and subclavial, cervical, axillary, inguinal): size, form, consistence, mobility, painfulness, cohesion with each other and with adjacent tissues.
I. Muscle: development (good, satisfactory, atrophy, painfulness at palpation, tone, infiltration, contractions, asymmetry of separate muscular groups).
J. Bone (vertebral column, ribs, tubular bones): curvatures, thickening, painfulness at palpation and percussion.
K. Joints: configuration, tumescence (circle in cm), change of outside skin, morbidity at palpation and movement. The function of joints: is normal, is disturbance(active and passive movements, ankylosis), crunch at movement. Presence of exudate in joints.
2. Respiratory system
Examination: the form of nose, larynx, neck, form of thorax, its deformation, asymmetry; type, rhythm, frequency and depth of respiration, character of dyspnea (expiratory, inspiratory, mixed), uniformity and symmetry of respiratory movements of both sides of thorax. Involvement of additional respiratory musculation in the act of respiration.
Palpation of thorax: resistance, painfulness places, skin edema, voice jitter (the same from both sides, diminished, amplified with indicating of the place of change). Palpate determination of pleural rub.
Percussion — comparative percussion information: character of percussion sound (pulmonary, boom-box, tympanic, dull,
sounds of mixed character), various changes of percussion sound above lungs; topographical percussion information: height of apexes, width of apical fields (Crenig’s fields), low lungs bounds, active mobility of lower lung edge, semi-lunar space of Traube.
Auscultation. Respiratory murmurs: main (vesicular and bronchial respiration, its variety) and additional (dry bronchial and wet with the caliber indicating, crepitation, pleural rub). Bronchophony (not changed — identical from both sides).
3. Cardiovascular system
Examination of cardiac area: cardiac murmur, visible pulsing in the field of heart, in the basis of heart, in jugular fossa, in epigastric region.
Examination of arterias and veins: "«carotid shudder", tortuosity of arterias, filling and pulsing of cervical veins in rest and at test of Plesh.
Palpation: apical push, its localization, prevalence, force, height, direction, cardiac push, symptom of «cat’s purr» (fremissement cataire), its localization and ratio to cardiac cycle.
Percussion of heart: boundaries of relative dullness of heart (right, upper, left), configuration of dullness (normal, mitral, aortal), sizes of a diameter in cm, width of vascular fascicle in cm, boundary of absolute dullness of heart (right, upper, left).
Auscultation of heart (is to be carried out on all 6 points). Heart sounds: volume (normal volume, amplified, diminished), splitting and bifurcation, III heart sound. Presence (or absence)of accent of II tone of the basis of heart. Click of opening of mitral valve(rhythm of quail). Pendulum-like rhythm, gallop rhythm (presystolic, protodiastolic). Murmur: localization, ratio to phases of cardiac cycle, volume, character, timbre, duration, direction of conduction. Extracardial murmurs (pericardial rub, pleuropericardial murmur).
Examination of vessels
Pulse characteristics on radial arterias. Synchronism, sameness of expressiveness of pulse on both arms, frequency, rhythm, filling, tension, character, pulse speed and height. Pulse deficiency. Capillary pulse on both arms. Palpation of aorta (in jugular fossa, in abdominal aorta), of veins (venous pulse).
Auscultation of vessels: symptom of a «whipping top», murmur of Vinogradov — Duroziez, stenotic murmurs in other arterias, symptom of Cucoverov – Sirotinin.
Arterial pressure on both arms and legs (in mm of hg).
4. Organs of digestion
Examination: oral cavity (teeth, gingivas, tongue, pharynx and tonsils), stomach — its configuration, circle in cm, condition of umbilicus, presence of extended hypodermic veins, movement of abdominal wall at the act of respiration, presence of scars, of hernial derivations.
Percussion: character of percussion sound (tympanic, diminished -tympanic), definition of free fluid in abdomen cavity.
Palpation: surface palpation information — condition of muscles of abdomen (tone, muscles tension, divergence of recti muscle, hernia), painfulness at palpation and its localization, symptom of Schetkin - Blumberg, murmur of splash, fluctuation; stomach deep palpation information — of a deep methodical slipping palpation according to Obraztsov - Strazhesko (palpation of intestine, of large curvature of stomach, palpation of pillorus, its location, form, mobility, painfulness, rumbling etc.), palpation of pancreas, painful points.
Auscultation: auscultation of intestinal murmurs, definition of low bound of stomach by methods of percus-palpation, ausculto-affriction.
5. Liver and bile-ducts.
Examination: protrusion, deformation in the liver area.
Percussion: sizes of liver dullness on right mid clavicle line, on median body line, on left rib arc (liver sizes according to Kurlov).
Palpation: sizes of liver, its edge, surface, consistence, painfulness; gall-bladder: its palpation, painfulness, pain symptoms of cholecystitis.
Examination: protrusion, deformation in the lien area. Percussion: percussive boundaries of lien.
Palpation: sizes, consistence, character of edge and surface.
Auscultation (for revealing of episplenitis).
7. Urinary system
Examination of region of kidneys.
Palpation of kidneys, of urinary bladder. Painfulness at palpation in the kidneys region, symptom of Pasternatskij.
Percussion: definition of upper edge of urinary bladder.
8. Main surgical sins for this patient
Main signs, symptoms or syndromes according acute or chronic surgical diseases.
IV. Primary diagnosis
At diagnosis formulation the main disease, accompanying disease, complications of the disease are singled out.
V. Schedule of laboratory- instrumental examination of the patients
а) Must be carried out for all the patients, irrespective of the character of the disease:
1) Common analysis of blood,
2) Common analysis of urine,
3) Test of arterial pressure,
5) X-ray examination of a thorax,
6) Research of a faeces for eggs of helminths,
7) Wassermann reaction,
8) Definition of group of blood,
b) The laboratory and instrumental examination of the patient is strictly individual and it is defined by the schedule which is made regarding the features of the disease.
1) biochemical blood analysis (according diseas)
1) US-examination, dopplerography
2) X-ray examination of abdominal cavity (with or without the contrast mass)
6) phlebography and angigraphy
VI. Tactic of treatment.
Plan of treatment of the patient should reflect the strategy of patient’s curation and must be personalized as much as possible.
Protocol of operation
3 day diary
Description of used surgical methods
VII. Clinical diagnosis
Formulation of main disease, accompanying disease, complications of the diseases.
VIII. Differential diagnosis.
Compare with the 3 consimilar surgical diseases (explaining on 2 pages).
IX. SUMMARY OF A CASE HISTORY
In summary of a case history the substantiation of the clinical diagnosis is given, the features of the development of the disease are defined, the efficiency treatment is estimated, the guidelines on further tactics of patient’s curation are given, the necessity of the continuation of outpatient observation and treatment is defined.