- •A system of case recording and clinical examination of patients
- •Guidelines for students
- •Complaints (presents illness)
- •The general anamnesis
- •Enquiry about a functional condition of all the organs and systems.
- •Nervous system
- •Locomotor system
- •Respiratory system
- •Cardiovascular (blood-circulation) system
- •Alimentary Gastro-intestinal system
- •Urinary organs
- •Sexual function
- •Hematosis system
- •(Anamnesis morbi)
- •Patient anamnesis
- •Physical examination (Objective examination) (Status praesens)
- •General assessment
- •Respiratory system
- •Comparative percussion of lungs
- •Auscultation of lung
- •Cardiovascular system
- •Percussion of heart
- •Auscultation of hearts
- •Alimentary (Digestive) system
- •Inspection of the abdomen in vertical position.
- •Light (superficial, tentative) palpation.
- •The analysis of the data of enquiry and Objective examination of the patient (substantiation of the provisional diagnosis)
Nervous system
Headaches: site (localization), character (of organic origin are described in terms – intermittent, felt mostly over the frontal, occipital, temporal and usually relieved by sutable analgesics; psychogenic headaches – pressure, tightness, lightness; dull, constricting, throbbing), intensity, frequency, duration, time of occurrence (in the morning, by the end of day, at night).
Vertigo (dizziness, giddiness): frequency, conditions of occurrence (at walking, fast change of position), duration, stagger at walking (in what side); noise in a head.
Blackouts (loss of consciousness, faints, syncope): frequency, duration, aggravating factors (excitements, insolation, for no apparent reason), bruises, bit one's tongue, involuntary urination during an attack. Reduction of blood flow: syncope, simple faints (vasovagal attacks), postural syncope, etc.
Memory: good, it is weakened (forgets remote, not old events).
Sleep: good, pathologic (sensitive, disturbing, interrupted, nightmare), falling asleep duration, insomnia, reception soporific (frequently, regularly); drowsiness.
Mood: equal, quiet, excited, depressed, indifference, fast change of mood, irritability, irascibility; sociability, isolation, interest to work, reaction on environmental, experience of disputed situations, hopelessness, suicidal impulses, sadness etc.
NERVOUS SYSTEM |
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Ability to work
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What's your ability to work? Do you feel poorly? Do you get tired quickly? |
Mood |
What's your mood like? What's your mood generally? Is your mood cheerful? Is your mood depressed? Do you have a desire to laugh (cry)? Are you gripped by a sensation of fear, alarm? Have you felt sad or depressed? Have you felt anxious or worried? |
Memory |
What's your memory like? Is your memory good (bad)? |
Attention |
What's your attention? Have you ever been absent minded? |
Sleep |
How do you sleep? Is your sleep good? Do you sleep badly? Do you suffer from insomnia (sleeplessness)? How do you fall asleep? Do you fall asleep quickly (slowly)? Do you sleep much (little)? At what time do you go to bed? At what time do you wake up? How many hours a day do you sleep? |
Headache |
Do you have a headache? Do you suffer from headache? Do headache trouble you? In what part of the head do you get the pain? In what part of the skull or face does the headache localize? |
Location |
Docs it spread all over the head? Does it spread over the back of the head (forehead)? |
Character |
What is the character of your headache? |
Intensity |
Do you have a bad (acute) headache? |
Permanent, periodic |
Is this headache constant, fitlike? Is it worsening? |
Cause |
What's the cause of the pain? How did it start? When does the headache begin? Does your headache appear because of noise, light, some exertion? |
Duration |
For how long have you had it? |
Accompanying symptom |
Is there a sensation of pulsation, burning, pressing when you have a headache? |
Vertigo (dizziness, giddiness) |
Do you have giddiness? What caused it? How did it start? Do you fed giddy? |
Vision |
Do you have any problems with your eyes? Have you noticed any blurring of vision? Have you ever seen flashing lights? |
Hearings |
Do you have any problems with your hearing? |