Enquiry about a functional condition of all the organs and systems.

A system of case recording

AND CLINICAL EXAMINATION OF PATIENTS

ON PROPAEDEUTIC OF INTERNAL DISIASE

(Guidelines for students on drawing up of the case report)

DONETSK 2005

Guidelines for students

are prepared by department of propaedeutic therapy and clinical cardiology

The Donetsk state Gorky’s medical university

under Doctor of Medicine G.A. Ignatenko

GENERAL BIOGRAPHICAL INFORMATION

Surname, name, patronymic _______________________________

Age _________________________ sex _____________________

Place of work _______________ Occupation _______________

Home address _______________________________________

Date of admission to hospital _____________________________

GENERAL INFORMATION
1. Surname, name, patronymic	What is your surname (first) (Christian) name, please?
2. Age, date of birth	How old are you? When were you born?
3. Sex
4. Permanent address	Where do you live?
5. Place of work (job)	Where do you work? What's you job?
6. Occupation	What is your occupation (profession)?
7. Date of admission to hospital	When were you admitted to the hospital?
8. The way of admission to the hospital	How were you admitted?

COMPLAINTS (PRESENTS ILLNESS)

The data revealed at enquiry are necessary for systematizing in the certain sequence. First name the principal (main) complaints of the patient which are testifying about the most expressed changes in an organism (pain, dyspnoea, cough, expectoration of blood (haemoptisis), vomiting, diarrhea, high temperature, oedema, swelling, loss of weight etc.). Then detail each of them. Don’t pass to subsequent complaints, not having finished detailed elaboration previous.

Then describe group of the general, secondary complaints which are indicating functional, neurotic disorder ("feel unwell", "aches a bit", "undue fatiguability", "irritability" etc).

The GENERAL ANAMNESIS

(Anamnesis communis)

Enquiry about a functional condition of all the organs and systems.

To state according to a specially outlined scheme (on behalf of the patient - the third person singular), instead of a terse answers to the submitted list of symptoms. To avoid recurrence of the same words and expressions. To use the synonyms most suitable on sense in each concrete case (complains, marks, specifies, feels, notices, pays attention, observes etc.). Thus, if the patient characterizes the painful figurative (and it is very successful!) it is necessary to put down them so-called.

If pathological deviations during enquiry on the investigation system are not present, it is necessary to describe physiological condition under the same circuit (with the educational purpose).

Note how the doctor starts the interview: An interview between a doctor and his patient
- What's brought you along today?
- What troubles you?
- What do you complain of?
- What do you suffer from?
- What's happened to you?
- How do you feel?
- Does the pain trouble you?
- What hurts you?
- What's wrong with you?
- What's the matter with you?
- What's troubling you?
- Now please tell me about your trouble.
- How can I help?
- What seems to be a problem?
- What do you now find difficult, which you used to be able to do easily?
Doctor writes all complaints and determines chief and additional ones. Then doctor makes detailed description of every complaint.
Detailed description of a complaint.
1. Site, location	Where does it hurt? Where is it sore? Which part of your body is affected? Show me exactly where the problem is, where do you feel the pain.
2. Quality of symptoms complaint character	What's the pain like? What kind of pain is it? What does it feel like? Can you describe the pain?
3. Intensity, severity of the problem	What is the character of: intense, severe, mild, very severe, persistent?
4. Radiation	Do you feel pain in one place? Does it radiate? Does it pain go anywhere else? To what place does the pain radiate? Does it spread anywhere else?
5. Permanent or periodic	Is the pain permanent? Have you attacks of pain?
6. Cause of onset	How did it start? What caused it? What's the cause of the pain? Does it come on any particular time?
7. Duration	How long does the pain last? How long has it been bothering you? Are the attacks long or short?
8. How often do the attacks of pain come on?	Are the attacks frequent or rare? Is the pain more frequent in the daytime or at night?
9. Relieving/aggra­vating factors	Is there anything that makes it better/worse? Does anything make it better/worse? On what side does the pain become more acute? On what side is it more comfortable for you to lie? In what position is the pain worse? Does the pain appear on deep breathing (coughing, physical exertion, emotional stress)
10. Accompanying symptoms	Are there any other problems apart from your pain? Is your pain accompanied by (cough, excitement)?

The general condition.

Weakness: its expressiveness, for a how long, progressing.

Loss of weight: how many kg has loss of weight, for a how long.

Decrease of efficiency, fast fatigue.

High temperature (pyrexia): up to what figures, during what time of day, for a how long time rice of body temperature. Character of fever: constant, separate increases, waviness.

Rigors: duration; perspiration. Tolerance of a fever: rather well, hardly.

QUESTIONS ABOUT GENERAL CONDITION (GENERAL SYMPTOMS)
Weakness. fatigue, malaise	Do you have weakness? Do you have fatigue? Do you feel fatigue? Do you feel malaise?
Change of body weight	Is your weight constant? Have you lost any weight? Have you gained any weight"? Are you losing weight? Now many KGs have you lost or gained?
Temperature: duration, frequency, time	Did you take your temperature? When is your temperature (in the morning, in the evening, in the afternoon, at night)? Do you have fever? For how many days have you had fever? Is your fever constant? Do you have sudden fits of fever? Does your temperature rise in the evening? Is your temperature rising gradually or abruptly? Was there a feeling of shivering, profuse or moderate sweats before fever? Is your fever accompanied by pains (cough, dyspnoea, excitement, collapse)? When did the temperature become normal? Do you have an abrupt fall of temperature? Do you have rigors (chills)? Does the fever alternate with rigors (chills)? Do you have profuse sweats after a fit of fever?
Perspiration	Do you have perspiration? Does your perspiration appear in the morning (in the evening, in the afternoon, at night)?

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