THE GENERAL PLAN OF PATIENT’S EXAMINATION



THE GENERAL PLAN OF PATIENT’S EXAMINATION

I. Inquiry (interview)

II. Status praesens (objective examination)

1. General Inspection

2. Examination of the respiratory system

3. Examination of the cardiovascular system

4. Examination of the digestive system:

5. Examination of the urinary system:

6. Examination of the endocrine system

III. Preliminary diagnosis and its argumentation.

IV. The plan of laboratory and instrumental explorations and what can we find using

that paraclinical methods

V. Treatment sheet

VI. Diaries.

VII. Final diagnosis

I. Inquiry (interview)

1. General data.

a.) First name, family name

b.) Age

c.) Profession, occupation

d.) Gender

e.) Address

f.) Data and time of hospitalization

2. Present complaints.

a.) main complaints (specific for the main disease; ex.: cough, chest pain, palpitations, dyspnea)

b.) other complaints or changes in the general state (fever, weakness, headache, loss of weight)

3. History of the present disease.

a.) the time of the disease's onset (hours, days, years; it is a chronic or an acute disease???)

b.) the character of the first symptoms (describe them)

c.) the probable course of the disease

d.) evolution of the symptoms (how they’ve changed in time)

e.) previous instrumental or laboratory examinations and their results

f.) treatment, if any (name the drugs), and its efficiency

4. The past patient's history (Anamnesis vitae )

a.) general biographical information

- birth place, number of the children in the family

- patient's health at birth, his physical and mental development

- conditions of life, well-being, income

- patient's diet

- physical activity (sports, exercises)

- unfavorable labor conditions, industrial hazards (harmful dusts, radiation, cold, noise, vibration)

b.) past il1nesses : ask about acute infections (tbc, HIV, hepatitis) operations, trauma.

c.) family history (health of parents, grand -, sisters, brothers; tbc, syphilis, hereditary diseases)

d.) allergological anamnesis: the form of allergy, if any (rhinitis, nett1-rash, Quincke's edema, anaphylactic shock); the possible allergens (foods, medicines, perfumes, pollen)

e.) sexual anamnesis (women's number of pregnancies, parturitions; the duration and amount of menstrual eliminations)

f.) harmful habits - alcoholism; smoking, narcotics.

II. Status praesens (objective examination)

1. General Inspection

1. General state (good, medium, grave, very grave)

2. Consciousness

- clear -normal

- stupor - patient can't orient himself to the surroundings, gives delayed answers,

- sopor - unusually sleep from which the patient recovers for short periods of time;

- coma - is a state of full loss of consciousness with almost complete absence of reflexes and deranged functions (alcoholic, diabetic, hepatic, uraemic, epileptic)

3. Posture of the patient:

- active (patient can change it’s posture himself)

- passive (in unconscious patients, laying down)

- forced (the one that can relieve pain, dyspnea, cough)

4. Constitution

- hypersthenic

- normosthenic

- asthenic

5. Size and shape of the head

6. Specific facial expression (hippocratic, Parkinson's)

7. Eyes - eyelids, shape of pupils.

8. Size of nose

9. Mouth (color and moistening of tongue, gums, lips, oral mucous, form of teeth)

10.Neck (pulsation, local enlargement)

11. Skin .

- Color (pallid, earth-like, yellowish, cianosis)

- elasticity

- humidity, moistening (perspiration, dry)

- eruptions ( roseola, erythema, weals, nettle rush, urticaria

- herpetic lesion

- scars

- desquamation

- abnormal growth of hair

- the size, form and pathological changes of the nails .

12. Subcutaneous fat (the thickness of skin hold in inguinal region (female) or Traube region (male). Should be normally 1-2 cm.

13. Presence of peripheral edema. Edema is subcutaneous liquid accumulation due to heart or renal failure. It could be appreciated by pressing the fingers over the region where the bones are placed close to the skin.

14. Palpation of the lymph nodes. Should be appreciated: form, elasticity, painful or not, dimensions, stick with surrounding tissues.

The order of lymph nodes palpation: occipital, postauricular, preauricular, submandibular, mentonier, anterior-cervical,posterior-cervical, supraclavicular, subclavicular, axillary, cubital, femoral, patellar ones.

15. Muscular system. Should be appreciated:

- muscles development

- local atrophy

- strength

16. Bones

- defects

- deformities

17. Joints

- shapes

- articulation

- tenderness

- active and passive movement

- signs of inflammation

18. Extremities – presence of any abnormalities.

2. Examination of the respiratory system

Inspection

1. General configuration of the thorax (position of the clavicles, supra- and subclavicular fossae, blades)

1. Form of the chest (Normosthenic, hypersthenic, asthenic, emphysematous, rathitic, paralytic, funnel, foveated)

1. Deformation of spine (Scoliosis, Kyphosis, Lordosis)

1. Type of breathing (thoracic, abdominal, mixed)

1. Rhythm of breathing (normal, pathological)

1. Frequency of breathing

1. Involvement of the accessory respiratory muscles in the breathing

(sternocleidomastoideus,.trapezius, pectoralis major et minor)

Palpation

1. Identification of thoracic elasticity.

2. Identification of tender, pain areas.

3. Assessment of the observed abnormalities.

4. Assessment of tactile fremitus.

Percussion

1. Comparative percussion - to appreciate percussion note over the lungs (resonance, dullness, slight dullness, tympanic, hyperresonance)

1. Topographic percussion

a.) Determination of the upper borders of the lungs:

- superior anterior ( over the clavicles 3-4 cm )

- superior posterior ( at the level of the VIIth cervical vertebra)

- Kroenig's area (perpendicular to m. trapezius)

b) Determination of the lower borders of the lungs

Right Left

Parastermal line + -

Midclavicular line + -

Anterior axillary line + +

Midaxillary line + +

Posterior axillary line + +

Scapular line + +

Paravertebral line + +

c) Determination of the respiratory mobility of the lower pulmonary border

Auscultation – main respiratory sound: Vesicular breathing, bronchial breathing.

Adventitious respiratory sounds: Presence of adventitious sounds: rales (wheezes, crackles), crepitation, pleural friction.

2. Examination of the cardiovascular system

PALPATION

1.) Apex beat. It’s characteristics:

- Localization (in the fifth costal interspace 1,5 – 2,0 cm toward

the sternum from the left midclavicular line.

- Area = 1,5-2cm

- Height (high or moderate)

- Resistance (resistant or not)

- Force (forced or not)

So, in the hypertrophy of the left ventricle we'll have a diffuse, high, forced and resistant apex beat.

2.) Pulsation to the left of the sternal line over a vast area, extending to the

epigastric region - so-called cardiac beat, due to contractions

of the enlarged right ventricle.

3.) Pulsation in the second right interspace, due to enlargement of ascending

part of aorta.

4.) "cat's purr" symptom (due to narrowed lumen of the vessels).

PERCUSSION

Is used to determine : the size, position and the shape of the heart; the length of vascular bundle.

Determinate the heart’s borders:

1. Relative dullness of the heart, that corresponds to its true borders : right, left, upper borders.

2. Absolute dullness of the heart – corresponds to the anterior surface of the heart that is not covered by the lungs: right, left, upper borders.

3. Configuration of the heart

a.) Aortal configuration - in the dilation of left ventricle;

b.) Mitral configuration - in the dilation of the left atrium.

AUSCULTATION

Heart sounds, their intensity in each of 4 points of auscultation. Heart murmurs.

Areas of the valves auscultation are the following:

1. point - the area of the apex beat for the mitral valve

1. point - in the second interspace, to the right of the sternum - the aortal valve

1. point - in the second interspace, to the left of the sternum - the valve of the pulmonary trunk

1. point - the lower part of the sternum near its junction with the xiphoid process - for tricuspid valve;

1. point - the additional point - point of Erb - at the left of the sternum between 3rd and 4th costal interspaces.

6. Examination of the digestive system:

- Inspection of the abdomen;

- Auscultation of the abdomen

- Percussion of the abdomen;

- Superficial and deep palpation of the abdomen

- Percussion and palpation of the liver

- Percussion and palpation of the spleen

- Blumberg symptom

6. Examination of the urinary system:

- Inspection of the lumbar region

- Giordano symptom

- Palpation of the kidneys

6. Examination of the endocrine system

- Thyroid gland palpation

III. The Preliminary diagnosis

IV. The plan of laboratory and instrumental explorations and what can we find using that paraclinical methods

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