Examination of the patient – a complex creative process, the purpose of which is to establish the main diagnosis, as well as to clarify the features of the state of all organs and systems of the patient. Survey of surgical patients, along with general principles, has its own peculiarities. They are caused by the nature of a significant part of surgical diseases – their fleetingness and the possibility of developing formidable complications, which requires rapid diagnosis and treatment. In addition, it is necessary to take into account the peculiarities of the surgical method of treatment (the presence of a wound and other local pathological changes).
- Main part
For the schematic, examination of a surgical patient can be divided into several parts (stages). This division is very prudent and pursues more methodological goals, as it allows to systematize the data obtained by examining patients, to facilitate the diagnosis and avoid viewing and diagnostic errors.
- Stage I – primary examination of the patient.
- Stage II – additional examination of the patient.
- Stage III – dynamic monitoring of the patient.
- Stage IV – setting the final diagnosis. The primary examination of the patient is that the doctor finds out subjective (from the words of the patient) and objective (determined by himself) features of the patient’s condition. Based on these data, a preliminary diagnosis is established. The result of the examination is the writing of the so-called admission status – the basis of the patient’s medical history.
The main sections and rules for writing the medical history will be discussed below.
The plan of additional examination is determined on the basis of the preliminary diagnosis, taking into account the features revealed during the initial examination.
Dynamic observation of the patient allows us to clarify the main diagnosis, confirm or reject preliminary judgments about the condition of the patient’s organs and systems.
The formulation of the final diagnosis is carried out on the basis of a preliminary diagnosis, taking into account additional data obtained during the examination of the patient and dynamic observation.
Case history of a surgical patient
Writing a medical history is one of the most important activities in the examination of a patient. The correct implementation of this method allows you to accurately put the main diagnosis, identify co-morbid conditions, and help ensure that no little things escape the attention of the attending physician. Sometimes these “little things” influence the result of treatment, and their underestimation can cause serious complications, create iatrogenic situations. The history of the disease is the basis of the diagnosis. What is it?
The case history is a systematic presentation of subjective and objective facts related to the patient’s health condition both in the past and present, and in the future.
For the systemic presentation, the following main sections of the medical history are distinguished:
passport section;
- Complaints;
History of the disease;
- life story;
- objective examination of the patient;
- a preliminary diagnosis.
Passport part
The passport part of the medical history is usually filled in by the nurse in the receiving ward of the medical institution. In this case, the data is received directly from the patient, his relatives and from the relevant documents (passport, identity card).
In the passport part of the medical history the following items should be reflected:
- Surname, first name, patronymic of the patient;
- age;
- profession;
- location;
- date and time of receipt;
- who the patient is directed to;
- the diagnosis of the referring institution.
Particularly of great clinical importance are the last sections of the passport section. The date of admission and the diagnosis of the sending institution allow at least tentatively to determine the severity of the patient’s condition, the nature of the disease (surgical, urological, gynecological, etc.) and the urgency of providing therapeutic measures. It is absolutely clear that with the diagnosis of the direction: “profuse gastric bleeding, hemorrhagic shock of grade II”, the patient needs emergency surgical care. At the same time, the diagnosis of the direction of “adenoma of the prostate gland”, for example, means that the patient should be examined by a urologist, but there is no urgency, since his condition is currently not threatened. This estimate is certainly approximate, but with a large number of patients entering the hospital, it greatly simplifies the work of medical personnel and ensures the timeliness and quality of care provided.
It should be noted that on the standard forms of the clinical history of the patient, a diagnosis is made on the history front page when the patient is admitted, the clinical diagnosis and the final diagnosis, indicating the underlying disease, its complications and concomitant diseases, as well as the date and nature of the surgical operation performed, group of blood and Rhesus factor and about intolerance of medicinal preparations. Recently, the first page of the history of the disease is carried out and the insurance policy data (its number and name of the insurance company that issued the document).
All further sections of the medical history can be conditionally divided into two parts:
- subjective (complaints, history of the disease and life history);
- objective (objective research of the patient and data of additional research methods).
The subjective part of the medical history is filled on the basis of the patient’s answers to the questions asked, the objective part consists of the symptoms and parameters determined directly by the doctor.
Complaints
The subjective part of the medical history begins with the clarification of complaints – the one that worries the patient at the time of the examination by the doctor. In
the time for collecting complaints from a doctor requires attention and sensitivity to the patient. In addition, to clarify all the necessary features of the disease you need to have a certain skill: to know what questions to ask, what to give increased attention to, and what to miss, etc. It is always necessary to direct the conversation in the right direction, not allowing the patient to move away from the topic of conversation, while remaining extremely attentive and tactful to the patient, which will make it possible to maximize his frankness. All this concerns not only the collection of complaints, but the entire subjective part of the medical history. All complaints can be conditionally divided into two groups:
- the main complaints;
- Survey on systems and organs.
Basic complaints
After the question to the patient about his complaints, he sets out his feelings immediately at the time of examination or sensation, characteristic in principle for his present state.
The main complaints are those that are associated with the development of the underlying disease.
Among the main complaints are three groups:
- complaints of pain;
- General complaints;
- complaints related to the violation of the functions of the authorities.
Complaints of pain
When complaining about pain, the following questions are clarified:
- localization of pain;
- radiation (a place of pain reflection);
- time of appearance (day, night);
- duration (permanent, recurrent, paroxysmal);
- intensity (strong, weak, interfering or not interfering with sleep, work);
- character (aching, stitching, cutting, dull, sharp, throbbing, etc.);
- the cause causing pain (a certain position of the body, movement, breathing, eating, nervous state, etc.);
- concomitant pain phenomena (palpitation, nausea, vomiting, sensation of lack of air, etc.);
- Change in general pain (weakness, loss of sleep, changes in appetite, irritability, etc.).
All these parameters are extremely important, since they allow differentiating the pain syndrome for different diseases.
So, dull aching pains in the area of the epigastrium without irradiation, arising at night or on an empty stomach, are characteristic for an uncomplicated duodenal ulcer. Irradiation of such back pains usually indicates the development of a complication: penetration of the ulcer into the head of the pancreas. At the same time, the occurrence of pain in the area of the epigastrium after eating indicates the localization of ulcers in the stomach.
Another example. The pain in the right side of the abdomen can be caused by various diseases of many organs located here (liver, pancreas, gastric outlet, part of the duodenum, small intestine loops, appendix, blind, ascending gut and part of the transverse colon, right kidney). However, a thorough elucidation of the peculiarities of the pain syndrome allows one to suspect an attack of cholelithiasis (attacks of pain in the right hypochondrium with irradiation into the shoulder or collarbone that occur after taking fatty and fried foods) or renal colic (severe pain in the right half of the abdomen with irradiation in the back and perineum, not giving the patient to be at rest: he is rushing from pain, can not find a position in which it would become easier).
General complaints
- weakness;
- malaise;
- increased fatigue;
- poor appetite;
- poor sleep;
- weight loss;
- headache;
- decreased efficiency.
Elucidation of general complaints not only makes it possible to clarify the nature of the disease, but also helps to assess the general condition of the patient.
Complaints related to organ impairment
Complaints related to the impairment of the functions of the primary affected system of the patient have peculiarities due to the nature of the most affected organ or system (for cardiovascular
the system is characterized by weakness, palpitation, pain in the left half of the chest, etc., for the respiratory system – dyspnea, cough, for the digestive system – belching, nausea, vomiting, etc.).
Interview on systems of organs
This section is of particular importance in therapy, when it is especially important to take into account the condition of all organs and systems of the patient during treatment. When examining a surgical patient, this section does not distinguish, and the nature of concomitant diseases is reflected only in the “life history” section.
With the help of additional questions it is necessary to conduct a survey on all the systems of the body. In this case, only pathological abnormalities are recorded. Below are the possible main complaints.
- Nervous system: decreased efficiency, irritability, the nature of sleep (it is easy to fall asleep and wake up, the depth of sleep, whether using sleeping pills or drugs).
- Cardiovascular system: shortness of breath, palpitation, swelling, pain in the left side of the chest.
- Respiratory system: shortness of breath, cough, chest pain, sputum character.
- Digestive system: a violation of appetite, dyspeptic phenomena, the nature of the stool, abdominal pain (their localization, irradiation, duration).
- Urinary system: dysuric phenomena, pain in the lumbar region, changes in the nature of urine.
The history of the disease (anamnesis morbi)
This section describes all the details of the manifestation of the underlying disease, that is, the disease that causes the severity of the patient’s condition and his main complaints, in connection with which he entered the hospital.
In surgical patients, the underlying disease is considered to be a surgical intervention. If the patient has competing diseases, two history of the disease is written.
When describing anamnesis morbi, it is necessary to consistently state the positions presented below.
- Onset of the disease: when and how the disease began (gradually, suddenly), its first manifestations, the alleged cause of development (fatigue, inaccuracies in the diet, the influence of professional, household, climatic factors).
- Course of the disease: the sequence of development of individual symptoms, periods of exacerbation and remission.
- Results of previous studies: laboratory, instrumental.
- Methods of treatment used previously: medical, surgical, physiotherapeutic, etc., assessing their effectiveness.
- Immediate cause of this hospitalization: deterioration of the condition, failure of the previous treatment, clarification of the diagnosis, routine therapy, emergency admission.
There is a simpler diagram of the history of the disease, expressed in just seven questions.
- When (date and time) did the disease begin?
- What factors contributed to the onset of the disease?
- How did the disease begin (the first manifestations)?
- How did the symptoms develop in the future?
- How was the patient examined and how he was treated earlier?
- How did disability change?
- What prompted the patient to see a doctor at this time?
It should be noted that when collecting an anamnesis (a subjective part of the medical history), you can not only listen to the patient’s answers, but also use medical certificates and documents (an outpatient card, excerpts from the medical history, expert opinions).
History of life (anamnesis vitae)
The patient finds out all the features of life, having at least some significance for the diagnosis and treatment of the patient. Schematically, the main sections of anamnesis vitae can be represented as follows.
General part (brief biographical information)
- Place of birth with a description of changes in climatic factors throughout life.
- Education with specifics of physical and mental development.
Professional anamnesis
- At what age does it work?
- The main profession and its changes.
- Working conditions.
- Characteristics of the working room (lighting, air features).
- Working hours.
- Presence of unfavorable occupational factors (physical, chemical, forced position during work, excessive mental or physical stress).
Household history
- Living conditions (housing, hygiene, recreation).
- Diet.
Bad habits
- Nature of abuse (tobacco, alcohol, drugs).
- From what age and how often it is used.
Postponed diseases and injuries
- Postponed surgical interventions with the date (year) of their implementation, the features of the course of the postoperative period.
- Serious injuries, including neuropsychic.
- Postponed severe diseases (myocardial infarction, cerebral circulation, pneumonia, etc.).
- Concomitant chronic diseases (coronary heart disease, hypertension, diabetes, etc.), features of their course, the nature of the therapy used.
Epidemiological anamnesis (epidemics)
- Presence or absence of the following infectious diseases: hepatitis, tuberculosis, malaria, venereal diseases, HIV infection.
- Blood transfusions, injections, invasive methods of treatment.
Diagnosis
After the initial examination of the patient, the doctor must make a preliminary diagnosis.
Preliminary diagnosis is formulated on the basis of a collection of complaints, an anamnesis of the disease and life, an objective study of the patient. It should logically follow from the data obtained by subjective and objective research. In the preliminary diagnosis, the main disease and its complications are identified, as well as the underlying co-morbidities. Established directly during the initial examination of the patient, it largely determines the effectiveness of the further diagnostic process and treatment. It is the preliminary diagnosis that determines the urgency and scope of the diagnostic and therapeutic measures taken.
In addition to the preliminary, there are still clinical and differential diagnoses.
Clinical diagnosis is formulated on the basis of data obtained during the collection of complaints, anamnesis, objective examination of the patient, as well as the results of the additional examination. In it, just as in the preliminary, but more fully and accurately identify the underlying disease, concomitant diseases, complications.
Differential diagnosis is the analysis of the revealed symptoms and syndromes, their comparison with similar manifestations in other diseases. As such, a differential diagnosis does not appear in the medical history. It is necessary for an accurate statement of the clinical diagnosis.
III. Conclusion
In the clinical history of the disease there is no lengthy reasoning, it is maximally adapted to work in the department. Every doctor or nurse, having looked through it, can quickly navigate in the environment and make appropriate decisions. The clinical history of the disease has a number of additional sections compared to the academic history of the disease, while some sections are reduced.
After the preliminary diagnosis and its justification are made, the “Patient examination and treatment plan”. The section is then filled in according to the findings of the additional research methods and a clinical diagnosis is formulated. Sections “Etiology and pathogenesis”, “Pathological changes in organs”, “Prevention” and “Literature” are omitted, instead of them are introduced sections: “Pre-operational epicrisis”, “Operation protocol”, “Diary of observation”, “Epicrisis”.
