5. Patient's life

(Anamnesis vitae)

The main data about patients life should be presented in a short form: the place of birth, family, living conditions and nutrition in childhood, education and work, military service, the nature and working conditions, occupational hazard, sanitation and hygiene in the workplace.

Present social conditions, the nature of work.

Postponed disease:.

Allergic history:

Family history:.

Heredity:.

II. Direct patient examination

(Status praesens objectivus)

1. Inspection

(Inspectio)

Overall condition: satisfactory, moderate, heavy, very heavy, moribund.

General appearence of the patient: age, respectively.

Consciousness: clear, vague (torpor (stupor), stupor (semisopor), syncope (coma), delirium (hallucinations)), the possibility of contact with the patient.

Body position in bed: active, passive, stimulated (what?).

Facial expression: normal, calm, excited, indifferent, agonizing, immovable characteristic of fear, anger. The symmetry of factures, flatness of nasolabial folds, cheeks, the presence of "a butterfly's wings", signs of acromegaly, myxedema, Korvisar's face.

Gait: slow, spastic, paretic, ataxic, fast, etc.

Posture: direct, stooping, arrogant.

Body type: type (normostenic, hiperstenic, asthenic), height, weight, waist circumference.

Skin: color - flesh, pale, pale pink, red, yellow (sharp, weak), earthy-gray, bronze, cyanotic (specify where there is the most pronounced cyanosis), hyperpigmentation, depigmentation, humidity (normal, dry, wet), humidity of palms, sweating general or local anesthesia (indicate the degree (mild, strong) and time of appearance), rash (exanthema)-rose rash, petechiae, papules, vesicles, pustules, urticaria, hemorrhage, erythema, hemorrhage; scratches, teleangioektazii, vascular "stars", angioma (point location with a detailed description of them)," blood drops ", post-traumatic and postoperative scarring, bed sores, ulcers (their localization and expression); skin turgor (saved, increase, decrease).

Visible mucous: color - pale pink, cyanotic, pale, jaundiced, congested; rash on the mucous membranes (enanthema).

Skin appendages: the type of body hair, hair loss and graying hair, hypertrichosis, hirsutism, shape of nails ( "hour glass slides", celonychia), brittleness, color, striped.

The hypodermic cellulose: the degree of development (moderate, weak, overweight), evenness of division, skinfold thickness in the area of the abdominal wall and the rib area of the arc, general obesity, emaciation, cachexia.

Edema: general, local, their localization (in the lumbar area, legs, face, general edema); consistency, puffiness; mucous (myxedema).

Head: shape, size, presence of asymmetry.

Eyes: a form of eye slits, exo-or endophthalmitis, strabismus, color of sclera hemorrhage; the size of the pupils, their symmetry, deformation, narrow, expanded, reaction to light, the state age, presence of edema, Xanthi, xanthelasma.

Nose: size, shape (saddle-shaped, duck, enlarged); color, presence of cyanosis, the blood vessels. The nature of breathing (nose, mouth) is complicated, free, participation of the wings of the nose in breathing.

Neck: size, shape, symmetry, presence of goiter, a swelling of the neck veins, the nature of the pulse of arterial and venous vessels of the neck, swelling, edema, asymmetry in the area of the larynx and trachea.

Lymph nodes: submandibular, cervical, occipital, axillary, elbow, inguinal, other location; their size (in centimeters), shape, texture, tenderness, mobility, unity with the surrounding tissues, among themselves, as well as with the skin.

The muscular system: the general degree of development (satisfactory, moderate, weak), tone (retained, reduced, increased - rigidity), local degeneration, atrophy, compaction, pain (self-dependent, during the movements, while probing).

Bone system: proportionality of parts of the skeleton, examination of bones of the skull, spine, chest, pelvis and extremities (distortion, thickening of the distal phalanxes in the shape of drumsticks, deformation, softening of bones), pain (involuntary or by probing and percussion of the sternum, ribs, tubular bones, the spine).

Joints: configuration change (swelling, thickening), condition of skin above the joints, pain, its character and strength, a change in local temperature, swelling, volume of active and passive movements (presence of pain, cracking, fluctuations, contractures and ankylosis), change of the diameter of afflicted joints (in centimeters) and evaluation of range of motion (in degrees).

SURVEY ON ORGANS AND SYSTEMS

(Status functionalis)