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МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ РЕСПУБЛИКИ БЕЛАРУСЬ

БЕЛОРУССКИЙ ГОСУДАРСТВЕННЫЙ МЕДИЦИНСКИЙ УНИВЕРСИТЕТ


КАФЕДРА ПРОПЕДЕВТИКИ ВНУТРЕННИХ БОЛЕЗНЕЙ

И. Л. АРСЕНТЬЕВА

УЧЕБНАЯ ИСТОРИЯ БОЛЕЗНИ


EDUCATIONAL CASE HISTORY
Методические рекомендации

Минск БГМУ 2015


УДК 616.1/.4-07(091) (811.111)-054.6(075.8)
ББК 54.1 (81.2 Англ-923)
А85

Рекомендовано Научно-методическим советом университета в качестве


методических рекомендаций 28.05.2014 г., протокол № 9

Р е ц е н з е н т ы: канд. мед. наук, доц. 1-й каф. внутренних болезней С. С. Леме-


шевская; ст. преп. каф. иностранных языков О. М. Костюшкина

Арсентьева, И. Л.
А85 Учебная история болезни = Educational case history : метод. рекомендации /
И. Л. Арсентьева. – Минск : БГМУ, 2015. – 24 с.
ISBN 978-985-567-115-3.
В данном издании имеются следующие разделы: образец оформления титульного листа истории
болезни, образец заполнения листа паспортных данных пациента, типы и примеры жалоб больного,
методика сбора анамнеза болезни и анамнеза жизни, физикального исследования систем
(дыхательной, сердечно-сосудистой, пищеварительной, мочевыделительной и др.), составление
плана лабораторных и инструментальных исследований, методика обоснования диагноза, методика
написания дневников врачебного наблюдения, принцип формирования эпикриза (выписки из
истории болезни).
Предназначены для студентов 3-го курса медицинского факультета иностранных учащихся
с английским языком обучения.
УДК 616.1/.4-07(091) (811.111)-054.6(075.8)
ББК 54.1 (81.2 Англ-923)
_______________________________________
Учебное издание

Арсентьева Ирина Леонидовна

УЧЕБНАЯ ИСТОРИЯ БОЛЕЗНИ


EDUCATIONAL CASE HISTORY
Методические рекомендации

Ответственный за выпуск В. П. Царев


Переводчики: И. Л. Арсентьева, О. М. Костюшкина
Компьютерная верстка Н. М. Федорцовой

Подписано в печать 28.05.14. Формат 6084/16. Бумага писчая «Снегурочка».


Ризография. Гарнитура «Times».
Усл. печ. л. 1,39. Уч.-изд. л. 1,32. Тираж 50 экз. Заказ 25.

Издатель и полиграфическое исполнение: учреждение образования


«Белорусский государственный медицинский университет».
Свидетельство о государственной регистрации издателя, изготовителя,
распространителя печатных изданий № 1/187 от 18.02.2014.
Ул. Ленинградская, 6, 220006, Минск.

ISBN 978-985-567-115-3 © Арсентьева И. Л., 2015


© УО «Белорусский государственный

2
медицинский университет», 2015
DEFINITION OF THE CASE HISTORY

The medical history or a case history is a structured assessment conducted to


generate a comprehensive picture of a patient’s health problems. It includes
the assessment of:
– the patient’s complaints;
– the patient’s current and previous health problems;
– the patient’s current and previous medical treatment;
– factors which might affect the patient’s health and their response to
the prevention or treatment of health problems (e. g. risk factors, occupational
conditions, lifestyle issues);
– the patient’s family health;
– the patient’s health in general.
Taking together the history, information from the physical examination and
any investigations or tests should provide all the information necessary to make
a diagnosis (i.e. to identify the nature of a health problem).
This training instruction allows medical students to have a clear view of
the scheme of examining a patient and the rules of case history writing. Besides it
helps to acquire such skills as a correct interviewing the patient, gathering data
about patient’s complaints and both present and past history, carrying out patient’s
physical examination, planning and assessment of laboratory and instrumental
studies.
The students will learn to formulate the final clinical diagnosis as
a conclusion point of patient’s clinical examination, and also gets a notion about
medical diaries and epicrisis. All sections of the medical case history which are
presented in the text is a scheme which the student must follow while writing
his/her own educational case history.

3
MODEL OF THE TITLE PAGE OF EDUCATIONAL CASE HISTORY
(the student should fill in all the gaps on this page)

HEALTH MINISTRY OF BELARUS


BELARUSIAN STATE MEDICAL UNIVERSITY
DEPARTMENT OF PROPAEDEUTICS OF INTERNAL DISEASES
Head of the Department of Propaedeutics of Internal Diseases,
M.D., Professor of Medicine, V. P. Tsarev

CASE HISTORY
Patient’s Surname, Name, Patronymic: __________________________________

Clinical diagnosis: __________________________________________________

_________________________________________________________________

Student: _______________________
______________________________
(Surname, Name, Patronymic)
______________________________
(Group)
______________________________
(Year)
______________________________
(Faculty)

Teacher: _______________________
(position, scientific degree)
______________________________
______________________________
(Surname, Name, Patronymic)

Period of patient’s observation: from «___»_____ 20__ to «___»_____ 20__

4
MODEL OF THE SECOND PAGE OF EDUCATIONAL CASE HISTORY

PATIENT’S PASSPORT DATA


(the student should fill in all the gaps from 1 to 8)

1. 1. Surname, name, patronymic: __________________________________


2. Sex: __________________________________________________________
3. Age: _________________________________________________________
4. Marital status: _________________________________________________
5. Full home address: _____________________________________________
6. Occupation ________(specify if the patient is a pensioner or the disabled
worker):___________________________________________________________
7. Work place (name of establishment): _______________________________
8. Clinical diagnosis (see explanations below): _________________________

The clinical diagnosis (or the final clinical diagnosis) should be made and
written down on the second page of a real case history only by the physician
treating the patient during current hospitalization. The clinical diagnosis should
have the following structure in both real and educational (training) case history:
1. The basic diagnosis. 2. Complications of the basic diagnosis. 3. Concomitant
diagnosis(es).
Note! Usually on the day of admission the following data should be detected
and written on the second page of the real case history by the doctor or by
the nurse in the reception ward: case history number; date and time of current
hospitalization; clinical department at which the patient will be treated; emergency
hospitalization (yes/no); the way which the patient was admitted (the patient has
presented by himself/brought by a first aid team (team number should be
specified)/directed by an out-patient department (out-patient department number
should be specified) or other clinic (clinic number should be specified)); the
diagnosis made at the referring medical institution; the diagnosis made by
the reception ward doctor; the final clinical diagnosis; phone number of patient’s
relatives and/or their address; the patient’s blood group and Rhesus blood factor
(if the patient knows these data; it is especially important for the surgical patient
and the patient with severe anemia); patient’s allergy to medicines or individual
adverse reactions (which the patient had suffered before the hospitalization;
if some allergies or adverse reactions occurred while being treated in this hospital
it should be written down on this case history page immediately). Besides, on
the day of leaving hospital, the following data should be written down on this
page: date and time of the discharge from the hospital, the quantity of the bed-days
spent, outcome of current hospitalization (the patient leaves clinic completely
cured/with improvement/with impairment/has been referred to other hospital (it is
necessary to write down the name of this hospital and the name of the person
responsible for the admission)/the patient has died (date and exact time of death).

5
PATIENT’S COMPLAINTS

For a correct diagnostic process it is necessary to identify the signs of


a disease. There are two basic methods of a complete health assessment:
subjective and objective.
Questioning a patient is a subjective method. It includes detecting patient’s
complaints and gathering information about Present History (the so called
«Anamnesis morbi», in Latin, it is data about the present illness) and about Past
History (the so called «Anamnesis vitae», in Latin, it is the history of the patient’s
lifestyle).
An objective method includes an estimation of general state of the patient
(General Survey); physical examination of systems as an assessment of the body
and its functions using visual examination, palpation (feeling with the hands),
percussion (tapping with the fingers), and auscultation (listening); carrying out
laboratory tests and instrumental investigations.
The first question which the physician usually asks the patient is a question:
«What are your complaints?» or «What is wrong with you?». At the beginning of
the talk the physician asks the patient about all present complaints. The doctor
should find out all patient’s health problems.
It is necessary to distinguish main and additional complaints and describe
them in the case history correctly. The main complaints are the complaints which
compose clinical features of the disease. The physician should analyze each of
the main complaints according to the scheme which means detailed questioning
about all the peculiarities of the complaint. It is necessary to specify the character,
intensity, localization and irradiation (for pain), time and reasons of complaint
occurrence, reasons of increasing or decreasing complaint intensity.
The detailed elaboration of the main complaints allows connecting their
existence with the impairment of some organs or systems of the patient. For
example, the pain in the chest (thorax) can be present in case of the coronary
artery impairment or pleurisy or intercostal neuralgia. But it is very important to
question the patient about the chest pain in detail. First of all it is necessary to
exclude the presence of the pain due to coronary artery impairment because it can
become the reason of fatal complications dangerous for the patient’s life.
So, coronary pain (as a basic symptom of angina pectoris) is a short attack of
pressing or burning pain localized behind the patient’s breastbone, and it usually
radiates to the left arm. Besides, this pain usually occurs on emotional or physical
strain, more frequently in the morning, disappears or decreases after taking
nitroglycerine. Thus, the physician finds out all these signs of angina pectoris only
thanks to the correct collecting of patient’s main complaints. Such complaints
compose main complaints as they are clinical characteristics of this disease.
Additional complaints reflect only the severity of the patient’s condition.
Additional complaints are characteristic of different systems and organs

6
pathology. For example: malaise, general weakness, working capacity loss,
irritability, sleep pattern impairment.
TYPES OF COMPLAINTS
Examples of typical main complaints seen in patients with pathology of
various organs are listed in this section. The physician should question the patient
as thoroughly as possible. For example, if the doctor suspects a heart disease,
he should ask the patient about possible existence of all other complaints from
the pattern given below:
1. Cardiovascular system — pain in the heart area, breathlessness (mixed or
inspiratory dyspnea), asphyxia attacks (at cardiac asthma), palpitation and (or)
cardiac arrhythmia, cough, blood spitting, syncope, pains and (or) feeling of
pressure in right subcostal space (hypochondrium), edema, complaints due to
changes in arterial pressure (headache, dizziness, vision impairment).
2. Respiratory system — pain in the chest (thorax), breathlessness (mixed or
expiratory types of dyspnea, asphyxia attacks (asthmatic fits), cough, blood
spitting and (or) pulmonary bleeding.
3. Digestive system — pain in the abdomen, nausea, vomiting, heartburn,
eructation, salivation, dysphagia, dry mouth, bitterness in the mouth, appetite
impairment, flatulence, inflation, bowel dysfunction (including constipation and
diarrhea).
4. Urinary system — pain in the lumbar area, dysuria, change of urine color
(first of all due to hematuria), pain in the lower abdomen, edema, complaints due
to arterial hypertension (headache, dizziness, visual impairment) and renal
insufficiency (nausea, vomiting, diarrhea, dry skin, itching skin, urea odor).
5. Musculoskeletal system — pain in joints, morning stiffness, joint
deformity, joint function impairment, sound phenomena in joints (crackling,
popping, crepitation), muscular pains, pains in ligaments and tendons.
6. Hemopoietic system — complaints due to anemic syndrome: headaches,
dizziness, ear noise, defective memory, raised irritability, syncope, palpitation,
breathlessness, pains in the heart area; in hemorrhagic syndrome: bleedings (nasal,
uterine, pulmonary, intestinal, etc.), hemorrhagic exanthema on the skin,
formation of hematomas (these often being painful) or hemarthrosis; in necrotic
syndrome (in leukosis): a sore throat, dysphagia, salivation, pains in the abdomen,
semi-liquid or watery feces, flatulence; in intoxication syndrome: absence of
appetite (anorexia), weight loss, itching skin; in lymphadenopathy syndrome:
multiple enlargement of lymph nodes, cough and (or) heavy breathing, hoarseness,
dysphagia, swelling of the neck or shoulder area, pressure and (or) pains in
the hypochondrium; in osteoarthropathy syndrome: pains in bones and joints
(arthralgia), joint swelling and movement impairment.
7. Endocrine system — weight gain or loss, thirst, feeling of hunger,
considerable urinary excretion, constant sensation of heat, sweating, chills,
convulsions, muscular weakness.

7
PRESENT HISTORY
(ANAMNESIS MORBI)

The basic requirement to the correct Present History is to discover


the pathological process dynamics from the beginning of the disease to the current
hospitalization. It contains 3 basic sections which must be presented in a student’s
case history.
I. Onset, character and features of the basic disease course. The history of
the present disease should reflect causes and onset time, as well as the dynamics of
the disease development from its beginning till now. It is necessary to describe
first signs of the disease in detail. Describing the data should be short and clear
and represent the consecutive, logically and chronologically interconnected chain
of events. So, it is necessary to ask the patient:
– how long he feels ill / thinks to be ill;
– presence or absence of physician’s consultations concerning the current
disease;
– if the patient consulted – when and at what medical institution(s);
– all the results of examination and treatment in that (these) medical
institution(s), if the patient knows and remembers these data;
– whether the patient has been treated in hospital for this disease; when this
treatment took place; and what treatment was administered;
– whether the patient has hospital treatment results (epicrisis);
– whether the patient takes medicines for the present disease (during all
period of illness and now);
– if he does, what medicines the patient takes, in what dose, what their effect
is, etc.
Also it is necessary to reflect the reasons of the disease relapse or
exacerbation in chronological order. Specify remission periods and their duration.
Finally, establish the causes of hospitalization (disease exacerbation, more precise
diagnosis definition, etc.) and by whom the patient was referred to hospital.
II. Findings of the laboratory and instrumental tests carried out before
current hospitalization. In this section it is necessary to list briefly the results of all
laboratory and instrumental tests carried out before hospitalization (for example,
blood sugar measuring by emergency team) or during the exacerbation period (for
example, series of electrocardiograms taken at the out-patient department).
III. Previous treatment and its efficiency. In this section it is necessary to note
briefly the results of the treatment carried out before current hospitalization (to list
medicines taken by the patient, dose, route of administration and their effect). For
example, «to control an intensive heart pain (in case of acute myocardial
infarction) the emergency team administered Promedol 20 mg intravenously, with
positive effect» or «during the exacerbation of chronic bronchitis the patient self-
medicated with expectorant Ambroxol 30 mg three times a day, with no effect).

8
PAST HISTORY
(ANAMNESIS VITAE)

I. Patient’s Physical and Intellectual Development. This part represents


the patient’s medical biography based on the main periods of his life (infancy,
childhood, mature age). It is important to find answers to the following questions
(if it is possible):
– Were you born the first (second, third and so on) child in the family?
– Were you born in time (if the patient knows about it)?
– Did you get breast or artificial feeding (if the patient knows about it)?
– When did you start to walk, speak (if the patient knows about it)?
– What was your general health condition and development in childhood and
youth (if the patient remembers about it)?
– Have you ever lagged behind your peers physically or intellectually?
– When did you start to study? Was it easy or difficult to study? What is
your education?
– Have you ever gone in for sports? Do you have any sport category (rank)?
Additional questions for men:
– Were you in the army? If not, what are the reasons of the deferment of
military service?
Additional questions for women:
– At what age did you have your first menstrual period?
– What is the duration of each menstrual period?
– How many children have you borne?
– Have you had any abortion?
– Was your pregnancy(-ies) normal?
It is necessary to ask the patient about bad habits. If the patient confirms
that he smokes, and/or abuses alcohol, and/or uses narcotics, you may use
the following questions:
– Smoking. At what age did you begin smoking? How many cigarettes do
you smoke a day?
– Alcohol. At what age did you start to take alcohol? How often do you take
alcohol?
– Do you have a narcotic habit? What narcotic do you use? At what age did
you start to take narcotics? How often do you take narcotics and in what dose? etc.
Past diseases: the diseases suffered by the patient are considered in
a chronological order. If possible, specify at what age the patient had each disease,
trauma or operation. Ask the patient if he/she has ever had any kind of viral
hepatitis, any venereal diseases, tuberculosis (or a contact with tuberculosis patient).
II. Social History. This section means the detailed description of those social
features of the patient’s private life which may impact significantly the patient’s
health. For example, residing in a wet cold room can become a reason of chronic

9
bronchitis or the small budget can be a reason of alimentary anemia. So, the doctor
should ask about:
– living conditions: a flat, a private house or a hostel accommodation;
conveniences (yes/no);
– marital status: single, married; if the patient lives separately or with their
family;
– budget: wages and the general income of the family (it is unethical to
specify the size of a salary, the correct question is: “Is your income sufficient for
your needs?”);
– nutrition habits: how often, when and what meal the patient usually has;
if he/she intakes food quietly or quickly; if it is masticated thoroughly. It is
necessary to know if hot food or drinks are consumed moderately hot or very hot.
Ask if the patient’s diet is rich in fresh vegetables and fruits;
– daily regime: when the patient wakes up and goes to bed; his/her keeping
of personal hygiene; what the patient does before going to work and after
returning home (briefly); specify the distance from home to the place of work and
means of conveyance (approximately).
III. Patient’s Labor Activities. Labor anamnesis: note the patient’s labor
activity in chronological order since its beginning. If the patient changed his place
of job or occupation — specify the age, enterprise and term for each period in
which the patient was doing their job. Give a short characteristic of work
indicating occupational hazard and the working day duration. Work schedule
(at his last job place): operation time, breaks, day or night shifts, time or piece-
work, responsibility for the performed work (briefly).
Expert medical anamnesis: whether patient has the sick-list concerning
current disease (yes/no); total duration of the patient’s being on a sick-leave
during the current year; permanent disability (disability group, when it was
appointed).
IV. Allergological Anamnesis. Ask question whether there were allergic
reactions of immediate type (urticaria, angioneurotic (Quincke’s) edema, rhinitis,
asthma, anaphylactic shock, etc.) after using medicines, vaccines, serum,
foodstuff, pollen, insect stings, etc.; reactions to blood transfusion. If the patient
mentions allergic reactions, it is necessary try to find out carefully to what
concrete allergens the reactions were, how soon the reaction arises after the use
(or application) of allergen. In case of medicinal allergy one must to find out
pharmaceutical presentation and route of administration of the medicine.
V. Hereditary Anamnesis. Ask about the diseases with similar clinical
manifestations among relatives: mother, father, brother(s), sister(s), grandfather,
grandmother. Hereditary diseases running in the family. Noting in the case history,
for example: «Patient’s mother was suffering from arterial hypertension».

10
GENERAL SURVEY
(STATUS PRAESENS)

Preparation for physical examination. The patient should feel as


comfortable as possible. The patient should be adequately undressed. A warm
room, comfortable patient’s posture and the doctor’s composure will create
the necessary patient’s relaxation. Confidence is also a necessary condition.
If the patient is tense, usually very little information can be gained. The doctor
should explain to the patient what he/she is going to do and to ask permission
to start.
Investigation pattern. The student should assess the patient’s condition
consistently, as it is specified in the text below, and to choose from the offered
variants what is a fact and record them in the case history.
Patient’s general condition: satisfactory, moderately bad, bad, very bad.
Consciousness: clear, confused (stupor), indifferent (sopor), deep
unconscious (coma), excited (including delirium or hallucinations).
Position of the patient: active, passive, forced.
Look: usual (without any painful expression), suffering, depressed, excited,
indifferent, specific («mitral facies»), etc.
Correspondence of the appearance to the passport age: corresponds, looks
younger/older.
Constitution: constitutional type (asthenic, normosthenic, hypersthenic),
height, body weight, bearing (correct, slouch). Gait (usual, slow, shuffling,
waddling [goose]).
Body temperature. Chills (yes/no).
Skin color: rose-pink, pale with a shade (ash grey, sallow, greenish, icteric,
«white coffee» etc.), red (blush), cyanotic (cyanosis: diffuse, acrocyanosis), icteric
(subicteric, moderate icteritiousness, ochreous yellow, dark yellow, greenish),
bronze, greyish-brown, grey. Mottled skin, presence of pigmentation and
depigmentation. Liver palms (palmar erythema): yes/no.
Skin moisture: normal; dry skin; general and local sweating: degree of
sweating (moderated, severe), dependence on the time of day (night sweating).
Rash: character (roseola, erythema, urticaria, purpura, petechia, herpes
labialis, herpes zoster), localization and distribution; presence of xanthelasmas,
«vascular spiders» (spider nevi), scars, skin consolidations, ulcerations, bedsores,
scratches, varicose veins etc.
Skin elasticity (turgor): normal, decreased, increased. The skin is not
changed/flaccid/wrinkled.
Visible mucosa and conjunctiva coloring: normal, pale, icteric, cyanotic.
Presence of ulcerations, pigmentations, hemorrhages.
Hair: type of hair distribution, loss, canities, fragility, etc.
Nails: normal form, in the form of watch glasses, spoon-figured
(koilonychia); nail surface: smooth, striated; color, fragility.

11
Hypodermal fatty tissue: poorly (moderately, excessively) developed;
evenly/unevenly developed; places of the greatest fat accumulation; measurement
of a skin folds thickness: subscapular skin fold, skin fold at the navel, triceps skin
fold, etc. Presence of edemas, edema features according to their localization and
distribution (general, local), consistency (soft, dense); conditions of their
occurrence and disappearance; nodules, nodes (their tenderness, density, size).
Peripheral lymph nodes: it is necessary to carry out the consequent palpation
of occipital, parotid, submandibular, submental, cervical (anterior and posterior),
jugular, supra- and subclavicular, sternal, axillary, cubital, inguinal, popliteal
nodes. If the results of palpation are positive it is necessary to determine their size,
number, consistency, tenderness, mobility, fusion among themselves or with other
organs or with the skin (tumor invasion); presence (or absence) of fistulas.
Muscles: the degree of general muscular system development (good,
moderate, weak), tone (normal, increased, decreased), strength (decreased,
sufficient), tenderness (at rest, on palpation, while moving); indicate the site of
tenderness. Presence (or absence) of hypo- and atrophies and their localization.
Bones: symmetry of the skeleton (yes/no). Pains: absence/presence (at rest,
arising while moving (or on palpation, or on tapping)); indicate the site of
tenderness. Deformities (yes/no). Finger clubbing (yes/no). Form of the head
(typical, atypical). Form of the nose (usual, saddle). Form of the spinal column
and its curvature: physiological, pathological (lordosis, kyphosis, scoliosis,
kyphoscoliosis); flatness of physiological curvatures (yes/no), a posture of
“suppliant” (soliciting posture): yes/no.
Joints: correct form, change of joint form (swelling, defiguration,
deformities). Deformities: ulnar deviation, “a swan neck”, “a buttonhole”,
an “opera glass” hand, Heberden’s, Bouchard’s nodes: yes/no. Skin hyperemia
over the joints: yes/no. Findings of palpation — local rise of temperature, articular
crepitus and crackling while moving, fluctuation, floating patella symptom,
tenderness: yes/no. Test of lateral compression (a 4-point score (0–1–2–3 points):
3 points correspond to the maximum pain manifestation, 0 points — the pain is
absent). Presence of tophi, rheumatoid or rheumatic nodes: yes/no. Articular
circumference of large joints: radiocarpal, elbow, knee and ankle joints (in
centimeters). Active and passive movements in joints (measured in degrees).

12
SYSTEM REVIEW

RESPIRATORY SYSTEM
I. Thorax survey:
Thorax form (1. Normal: normosthenic (conical), hyper- or asthenic.
2. Pathological: emphysematous (barrel-like), rickets (pigeon [chicken]) breast,
scaphoid breast, funnel breast, paralytic chest, kyphoscoliotic chest).
Other thorax deformities and spinal column curvatures (pathological lordosis,
kyphosis; scoliosis, kyphoscoliosis).
Symmetry or asymmetry of the thorax (volume increase or reduction, falling
back or bulging of supra- and subclavicular areas of the right and left thorax).
Position of clavicles, scapulas: symmetry (yes/no), compactness of scapulas
adjoining (yes/no). Synchronism of the thorax movement (both frontal and
posterior halves): yes/no; if no, indicate exactly sites where the thorax lagging is
revealed while breathing.
Participation of additional respiratory muscles in breathing: yes/no.
Breathing type: mainly abdominal, mainly thoracic, mixed. Respiratory rate
per minute.
Breathlessness (dyspnea): with forced breathing in (inspiratory), with forced
breathing out/exhalation (expiratory), mixed. Presence of distant rales: yes/no.
Breathing rhythm: correct, pathological (Cheyne–Stokes respiration, Biot’s
respiration, Kussmaul’s respiration, Grocco’s respiration).
II. Thorax palpation.
Use palpation to specify chest peculiarities revealed on survey.
Determine the epigastric angle (measured in degrees).
Determine the thorax resistance (elastic, rigid).
Thorax tenderness (local, diffuse): yes/no. Note the sites of tenderness
indicating exactly its localization and borders.
Skin edema: absence/presence (specify its localization). Hypodermal fat
crepitation (may be present in case of subcutaneous emphysema): yes/no (if yes,
specify its localization). Pleural friction rub (may be palpable in severe dry
pleurisy): yes/no (if yes, specify its localization).
Vocal fremitus (tactile fremitus): it is not changed on symmetric sites; it is
decreased (increased): indicate its exact localization.
III. Lung percussion.
1. Comparative percussion:
Character of percussion sound on symmetric or compared sites (clear
pulmonary sound, dull, bandbox, tympanic).
Exact delimitation of the revealed pathological sound change in vertical and
horizontal direction (along intercostal spaces, topographical lines).

13
2. Topographical percussion:
On the right On the left
2.1. The level of lung apex above the clavicle
(anterior chest), in cm:
2.2. The level of lung apex with respect to the 7th
cervical vertebra prominence (posterior chest):
at the level, above, below (in cm):
2.3. Kronig’s area width (in cm):
2.4. Lower border of the lung along the topographic
lines:
a) parasternal
b) medial clavicular (midclavicular)
c) anterior axillary
d) medial axillary (midaxillary)
e) posterior axillary
f) scapular
g) paravertebral
Note: the measurement on the parasternal and medial clavicular lines on the left is not
carried out.
2.5. Lower lung border excursion along
the topographical lines: in inspiration,
in expiration, total (in cm):
a) medial clavicular / midclavicular
b) medial axillary / midaxillary
c) scapular
Note: the measurement on the medial clavicular lines on the left is not carried out.

IV. Lung auscultation.


1. Comparative auscultation (character of auscultation findings on symmetric
and compared sites):
Character of the main respiratory sounds (describe exactly the borders of
the possible pathology revealed):
– vesicular: normal, pathology (diminished, forced, rough, intermittent
(saccadic));
– bronchial (stenotic, metallic, amphoric);
– mixed (or bronchio-vesicular);
– absence of breath sounds.
Additional respiratory sounds — present or absent (if present, specify
precisely the sites of pathological respiratory sounds):
– dry rales (rhonchi): low-pitched (humming, buzzing), high-pitched
(squeaky, whistling), wheezes (sibilant rhonchi, «musical» rhonchi);
– moist rales: coarse, medium or fine bubbling rales (sonorous, not
sonorous);
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– crepitation: true, false;
– pleural friction rub (soft, grating).
Note the influence of deep breathing and/or coughing on the intensification of
additional respiratory sounds (or their displacing / their disappearance).
2. Bronchophony: negative, positive (specify the localization).

CARDIOVASCULAR SYSTEM
I. Examination of arteries. While carrying out the survey and palpation one
should pay attention to peripheral arteries: temporal, subclavicular, carotid,
cubital, radial, femoral, popliteal and dorsal arteries of feet (visible or not,
convoluted or not (if visible)). Palpation: define the degree of pulsation
expressiveness (forced or not), vessel surface (smooth or nodular), elasticity.
Pulse parameters on radial arteries:
– identical (or unequal) pulse strength on the right and left radial arteries
(define symmetry and synchronism);
– pulse rhythm (regular, irregular; if it is irregular, specify the deficiency of
pulse);
– pulse rate — the number of beat per minute (normal rhythm, tachycardia,
bradycardia);
– pulse volume (full or weak);
– tension (tense or soft);
– pulse size (large, small or thready);
– pulse form (fast, slow; dicrotic; paradoxical).
Pay attention to Quinke’s (precapillar) pulse (it is revealed or not).
Carry out the auscultation of carotids, abdominal aorta, femoral and renal
arteries (for example, in aortic insufficiency on femoral arteries Traube’s double
tone (Traube’s sign) and Vinogradov–Duroziez’s double murmur (Duroziez’s
sign) is listened).
Measure arterial blood pressure using Korotkoff method (determining both
systolic and diastolic blood pressure levels in mm Hg) on brachial and femoral
(if it is possible) arteries. Determine pulse pressure.
II. Examination of veins. Examination and palpation of peripheral veins.
Determine venous pulse on jugular veins (negative or positive).
If vein dilatation is revealed on examination, specify the localization (thorax,
anterior abdominal wall, extremities, etc.), degree of vein dilatation, presence (or
absence) vein consolidations and tenderness.
Carry out the auscultation of veins (in patients suffering from anemia «nun’s
murmur» is listened over the jugular vein bulbs).
III. Heart examination.
Survey of the heart region and large blood vessels. Apex beat: visible
(specify the localization) or invisible. Cardiac beat and other pathological
pulsations in the heart region and in large blood vessels area: if visible, specify

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localization. Constant deformity of ribs over the heart area (cardiac «humpback»
sign): yes/no.
Examine the epigastric area. If the pulsation is observed in epigastric area,
determine its causes (enlarged right ventricle, or abdominal part of the aorta, or
enlarged liver).
Palpation of the heart. Palpate the heart area to:
– reveal more accurately the apex beat and determine of its properties
(localization, width (area), height (amplitude), strength, resistance);
– confirm the presence or absence of cardiac beat;
– determine systolic and diastolic thrill (the “cat’s purr” symptom) at
the heart apex or base.
Percussion of the heart.
Determine the borders of the relative cardiac dullness. It is necessary to
determine the heart configuration by percussion; is means to determine
the borders of relative cardiac dullness and borders (width) of the vascular bundle,
on intercostal spaces with respect to the anterior midline, in centimeters.
A healthy person will have a normal heart configuration. Its borders are
the following:
Intercostal spaces On the right On the left
2 2.5–3 cm 2.5–3 cm
3 3–4 cm 4–5 cm
4 3–4 cm It is allowed not to determine
5 It is not determined 8–9 cm

Approximate record of percussion results: “The width of the vascular bundle


is 6 cm. The diameter of relative cardiac dullness is 11 cm. The configuration of
the heart is normal”.
Pathological configurations of the heart: aortal, mitral, triangular (or
trapeziform): yes/no.
Next one should determine the borders of absolute cardiac dullness: the right
border (for healthy person in the 4th intercostal space); the left border (for healthy
person in the 5th intercostal space); the upper border (for healthy person on
the upper edge of the 4th rib along the left parasternal line).
Auscultation of the heart. Cardiac rhythm: regular, arrhythmia, embryocardia.
Specific triple rhythms: the “quail” rhythm; the “gallop” rhythm (protodiastolic,
mesodiastolic, presystolic): yes/no. The rate of heartbeats (per minute).
It is necessary to give the characteristic of heart sounds in each of
the 5 auscultation points. The first heart sound: normal sonority, weakened,
strengthened, clapping, split, doubled. The second heart sound: normal,
accentuated, weakened, split, doubled. Specify the points where the listed changes
are found.
Heart murmurs: absent/present. If present, describe the characteristic of heart
murmurs according to auscultation points. The relation of murmurs to cardiac
cycle phases: systolic, diastolic. Murmur timbre, association of a murmur with
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heart sounds, the point of the maximum loudness, a place of the murmur
transmitting. Change of auscultative data depending on the patient’s position,
physical activity and respiration phases.
Pericardial friction rub (it is listened/not listened). Pleuropericardial friction
rub (it is listened/not listened).
Record of auscultation results, for example: “The cardiac rhythm is regular,
98 per minute, tachycardia. Both heart sounds are weakened in all auscultation
points. Heart murmurs are absent. Pericardial friction rub and pleuropericardial
friction rub are not audible”.

DIGESTIVE SYSTEM
Oral Cavity Examination. The examination of the mouth may reveal angular
stomatitis, thrush, signs of dehydration, ulcers, etc.
Gums: pink, pale, moist, pure, ulcerated, edematous, bleeding. Teeth: cured,
carious, loose, false teeth/dentures.
Tongue: moist, pure, dry, coated (moderately, severely), bald, raspberry
tongue, ulcerated, with fissures.
Oral mucosa: pink, pale, moist, pure, reddened, ulcerated.
Fauces: pink, red, moist, dry, mucosal swelling, pure, plaques.
Tonsils: normal size, increase (decrease) in size (right, left), pink, redness,
swelling, pure, plaques, presence of purulent plugs in lacunes.
Pharynx: the mucosa is pink/red, moist (or not), shining (or not), granulated
(or not).
Examination of the abdomen
Survey of the abdomen: one must note symmetry of the abdomen (yes/no),
any distension (yes/no), abdominal respiration (yes/no), bruising (yes/no), scars
(yes/no), stoma (yes/no), hernias (yes/no) or any visible peristalsis (yes/no), etc.
A hypodermic venous network: it is invisible/visible, Medusa head symptom
(yes/no).
Abdomen size and form: enlarged (or not), flattened (or not), symmetric (or
not). In case of enlargement: moderate or considerable enlargement, frog-like
abdomen (bulging flanks in patient lying supine), the abdomen protrusion is
uniform (or not). Hernias: umbilical, inguinal, midline (Linea alba) hernia.
Determine the abdominal circumference at the navel level (in cm).
Percussion of the abdomen. A generally resonant abdomen (yes/no) suggests
much flatus whilst tumor or liquid under the fingers will be dull. Dullness of
the flanks may be the first sign of ascites. Percussion for shifting dullness:
positive, negative.
Auscultation of the abdomen. Peristalsis: normal, decreased, increased,
absent. Listen for peritoneal friction (yes/no).
Palpation of the abdomen. The free fluid can be revealed by a fluctuation
method. Eliciting a fluid thrill by palpation: an impulse or “fluid thrill” is felt
or not.
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Superficial palpation of the abdomen: approximate and comparative.
It is painless, painful (tenderness is diffuse; tenderness is limited, specify
the localization). Search for local protrusions, hernial orifice(s), etc.
Deep, methodical, sliding palpation by Obraztsov–Strazhesko. Findings
of deep palpation of sigmoid, caecum, ascending, descending, transverse colon.
In case of positive palpation it is necessary to record the following parameters of
intestine parts palpated: diameter, presence or absence of tenderness, mobility,
consistency (dense, elastic), surface (smooth, uneven), rumbling.
Determining the lower stomach border (using the method of auscultative
palpation («rustle»)) should be carried out before the palpation of the transverse
colon. Finding of lower stomach border deep palpation: consistency (dense,
elastic), surface (smooth, uneven), tenderness (presence or absence).
Examination of the liver
Survey of the liver area (right hypochondrium): evident bulging (present,
is not present).
Percussion of the liver: the upper and lower borders of the liver. The upper
border is determined on 3 lines: the right parasternal, right midclavicular and right
anterior axillary. The lower border of the liver is determined on 5 lines: the right
anterior axillary, right midclavicular, right parasternal, anterior midline and on
the left rib arch.
Liver size by Kurlov:
– on the midclavicular line (in cm),
– anterior midline (in cm),
– the left costal margin (in cm).
Palpation of the liver: liver lower edge is palpable (or not); in positive
case — does not protrude from under the costal margin on right midclavicular
line/protrudes from under the costal margin on _____ cm; describe all
the following features of liver edge which will have been found during palpation:
сonsistency (soft, firm…); surface (smooth, tuberous); tenderness (presence or
absence).
Examination of the gallbladder: it is not palpable/palpable; tenderness in
the gallbladder area (yes/no). Courvoisier’s symptom: negative/positive.
Georgievskiy–Myussi’s symptom (phrenic nerve sign): negative/positive.
Murphy’s symptom: negative/positive.
Examination of the spleen
Survey of the spleen area (left hypochondrium): evident bulging (present/is
not present).
Percussion of the spleen: length on the 10th rib (in cm); diameter between
the 9th and 11th ribs on left midclavicular line (in cm).
Palpation of the spleen (both when the patient supine and on his right side):
does not protrude from under the left costal margin/protrudes from under the left
costal margin on _____ cm. The healthy spleen is not palpable, but if palpable one

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must describe next features of the spleen: consistency (soft/firm), surface (smooth
or not), tenderness (yes/no).

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URINARY SYSTEM
Examination of the kidneys
Survey of kidney area: hyperemia and the swelling in the kidney area
(present/absent).
Palpation of the kidneys. Palpation of kidneys is carried out in horizontal and
vertical positions using two hands. Examine for enlarged/reduced kidneys, renal
form, consistency, tenderness, kidney falling degree. The findings may be
the following: kidneys palpable/are not palpable; if palpable one must describe
next features of kidney: tenderness (yes/no), kidneys consistency (dense, elastic),
kidneys surface (smooth, tuberous); one (or both) kidney is dropped (3 degrees of
nephroptosis) /is not dropped). The healthy kidneys are not palpable.
Method of tapping (Pasternatsky’s symptom): negative, slightly positive
(insignificant tenderness is present), positive (moderate tenderness), full-blown
positive (significant tenderness, the patient does not allow to continue
the procedure), on the right and/or on the left.
The auscultation of the renal artery projections area from the front and
behind is carried out to reveal a renal artery stenosis if the physician suspects
renovascular hypertension (negative result/positive result).
Examination of the urinary bladder
Percussion of the bladder: when the bladder is detected it is a positive result
of percussion (bladder is filled by urine). The level of the bladder upper border
over the pubis must be determined (in cm).
Then deep, methodical, sliding palpation by Obraztsov–Strazhesko is
performed. It is necessary to record the following parameters of the bladder
palpated: surface (smooth/not smooth), tenderness (presence/absence), consistency
(dense/elastic), mobility.

ENDOCRINE SYSTEM
Survey of the thyroid gland area: sitting or standing, and also throwing back
patient’s head (angle of 10 degrees). The skin is examined for the presence or
absence of scars after strumectomy, color changes and an assessment of vascular
change as a sign of substernal goiter or tumor invasion with local signs
manifestation. It is necessary to pay attention to the patient’s voice hoarseness,
swelling of neck veins, absence of pulse on the carotid artery from the side of
thyroid gland tumoral growth (presence/absence).
Palpating the thyroid gland. The thyroid gland is examined to establish its
diffuse enlargement and presence of local protrusions: nodular masses, cysts
(presence/absence), mobility assessment on swallowing (mobile/slightly mobile/
immobile).
The healthy thyroid is not palpable (or in case of atypical thyroid
localization). If it is enlarged, determine the degree and character of this
enlargement (diffuse, nodular, or diffuse-nodular [mixed]), tissue consistency
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(soft, dense), surface condition (smooth, tuberous), mobility (easily mobile, a little
mobile, fused to the skin and adjacent tissues), tenderness (clearly marked,
evident, is absent). Also by palpation it is necessary to determine the trachea
position (typical/atypical), and the presence or absence of regional
lymphadenopathy.
Auscultation of the thyroid gland area allows the physician to find out
systolic murmur in thyrotoxicosis (presence/absence).
Search for endocrinous ophthalmopathy (Dalrymple’s sign, Jellinek’s
symptom, Rosenbach’s symptom, Kocher’s sign, Graefe’s sign, Stellwag’s
symptom, Möbius’s symptom): positive/negative.
Assessment of fat distribution. Body fat distribution is an important
predictor of obesity-related morbidity and mortality. Abdominal obesity associates
with high risk of the coronary heart disease, high blood pressure, stroke, non-
insulin dependent diabetes mellitus, cancer and sleep apnoea. Body fat distribution
is defined via:
1) waist-hip ratio (WHR): waist volume (cm) divided by hip volume (cm).
Android type: index 0.9 or higher for male (0.85 or higher for female) is a risk
factor for obesity-related morbidity (see above) and mortality (these values are
based primarily on evidence of increased morbidity risk in European populations,
and may not be appropriate for all age and ethnic groups). Gynoid type: index less
than 0.9 for male (less than 0.85 for female) is a risk factor for venous
insufficiency;
2) measurement of a skin fold thickness (subscapular, triceps, etc.), it is
especially important for people with ascites;
3) body mass index (BMI) also should be calculated. BMI is defined as
the subject’s weight divided by the square of their height and is calculated as
follows:
BMI = m / h2,
where m and h are the subject’s weight in kilograms and height in meters
respectively.
Normal range: 19–25 kg/m2. Overweight: 25–29.9 kg/m2. Obesity: more than
30 kg/m2 (class I obesity: 30–34.9; class II obesity: 35–39.9; class III obesity:
more than 40). Ranges for Asian people may be others.

HEMOPOIETIC SYSTEM
Skin examination: hemorrhagic symptoms (petechial hemorrhage,
ecchymosas, hematomas), telangiectasias, leukemids (presence/absence).
Percussion: tenderness at tapping on the breastbone, tubular bones (presence
or absence).
Lymphadenopathy. Palpation of lymph nodes (occipital, parotid,
submandibular, submental, cervical (anterior and posterior), jugular, supra- and
subclavicular, sternal, axillary, cubital, inguinal, popliteal nodes): localization of
palpable nodes, their size (cm), tenderness/painlessness, consistency (soft, dense),
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mobility (mobile, fused to the skin). In the conforming cases the description of
lymph nodes must be supplemented with the spleen characteristic (its criteria are
given in section «Digestive System»).
“Pinch” test/bandage sign (Konchalovsky–Rumpel–Leede symptom):
positive/negative.

NERVOUS SYSTEM
One should estimate consciousness level, orientation, memory, mood
(preserved/impaired), speech functions (preserved, dysarthria, aphasia).
Receptor investigation: sense of smell, hearing, vision, temperature, tactile
sensation (are preserved/are impaired). Tenderness along the branches of
a trigeminal nerve (presence/absence).
Motor sphere investigation: palpebral fissure (are narrowed, dilated; ptosis),
eyeball movements (are preserved, impaired; nystagmus). Romberg’s test:
patient’s steadiness/unsteadiness.
Reflex investigation: pupils (identical/unequal), light reflex (quick/slow,
consensual or not), tendon reflex (identical/unequal; overactive/hyporeflexia).
Pathological changes of muscle tone (rigidity, spasticity, floppiness), involuntary
movements (are absent/are present (tremor, chorea, dystonia, myoclonus)).
Vegetative sphere: dermographism (red, white; stable/unstable, diffuse);
hyperhidrosis (yes/no).
Pathological reflexes: Babinski’s sign, Rossolimo’s sign, Oppenheim’s
reflex, Brudzinski’s reflex, Kernig’s sign, (negative/positive); occipital muscle
rigidity (yes/no).

LABORATORY AND INSTRUMENTAL INVESTIGATIONS

In this part of the educational case history student should present results of
those laboratory tests and instrumental investigations which will confirm a future
clinical diagnosis and had been made during the current hospitalization. Besides,
the student should be able to explain which test results proves a clinical diagnosis
precisely.
While writing the educational case history, the findings of laboratory tests
and instrumental investigations are recorded according to the following plan:
1) laboratory clinical tests (the common blood counts (results), biochemical tests
(results), urine counts (results), etc.), 2) instrumental tests (the electrocardiogram
(its description and conclusion), the chest X-ray (its description and conclusion),
etc.), 2) special methods of investigation. Special methods of investigation include
laboratory instrumental complexes enabling the doctor to reveal additional
systemic information. Thus, to reveal diseases of the cardiovascular system it is
necessary to investigate enzymes, carry out some rheumatologic tests, heart
ultrasound test, exercise electrocardiogram, etc.

22
The obtained data should confirm clinical diagnosis and exclude diseases
with similar clinical manifestations.
Medical tests also are used to evaluate the response to medical treatment.
Furthermore they are used to monitor the course (and/or prognosis) of a disease.
Examples of this may include daily analyzing of ECG in patient after heart attack.

CLINICAL DIAGNOSIS AND ITS SUBSTANTIATION

The diagnosis is made on the basis of the 1) patient’s complaints analysis,


2) present and past history data (for example, risk factors found from the patient’s
past history), 3) findings of objective medical examination (relevant data of
General Survey and Systemic examination), 4) relevant data of laboratory and
instrumental tests.
To substantiate a diagnosis it is necessary to assess and list the relevant
information that confirms the diagnosis suggested. Use the plan suggested:
1) the basic disease;
2) complications;
3) accompanying diseases.

DIARY OF MEDICAL SUPERVISION

The student should write not less than two medical diaries for showing
changes in a patient's condition during current hospitalization.
A medical diary is a daily short medical record in the medical documents
reflecting dynamic change of the patient’s complaints and condition occurring
during the day as well as the findings of examination and prescribed treatment
effect, tolerance (or intolerance) of prescribed drugs.
Usually the physician writes 1–2 diaries a day, but in severe cases (e. g. in
intensive care units) it may be plenty of diaries (as many as necessary).
Medical diary should also include the brief description of the objective data
(including vital functions (pulse and respirations rate), body temperature
measuring, special features of stool and diuresis), plan of diagnostic and treatment
manipulations, and preparation for them.
The student also includes a temperature chart in the educational case history.
It is a graphic curve of the data about body temperature, heart and pulse rate,
respiratory rate, weight, diuresis, systolic and diastolic arterial pressure (for each
date of supervision) represented on one sheet.

CONCEPT OF EPICRISIS

Epicrisis is an extract from the case history, including the patient’s passport
data, terms of the hospital treatment (date of admission and discharge), clinical
diagnosis, short anamnesis and objective data, short findings of laboratory tests

23
and instrumental investigations carried out during hospital treatment course, list of
medicines and the effect of treatment, recommendations as for the treatment and
life style (including job recommendations) in out-patient follow-up period.
REFERENCES

1. Comprehensive Russian-English medical Dictionary. M. : РУССО, 2000. 704 с.


2. Harrison’s Principles of Internal Medicine. 11 Ed. Singapore : McGRAW-HILL
BOOK COMPANY, 1992. 789 p.
3. Ivashkin, V. T. Internal diseases propedeutics / V. T. Ivashkin, A. V. Okhlobystin. M. :
GEOTAR-Media, 2006. 176 p.
4. Nemtsov, L. M. Special Propedeutics of Internal Diseases : Lecture course /
L. M. Nemtsov. Витебск : ВГМУ, 2011. 319 с.
5. Vasilenko, V. Internal Diseases. An Introductory Course / V. Vasilenko, A. Grebenev.
M. : Mir Publishers, 1989. 648 p.
6. Waist circumference and waist-hip ratio. Report of a WHO expert consultation,
Geneva, 8–11 December 2008 // Report of a WHO experts. 2011. 39 p.
7. Волмянская, О. A. Русско-английский словарь и разговорник для медицинских
работников / О. A. Волмянская. Минск : Новое знание, 2000. 368 с.
8. Новый англо-русский словарь / В. К. Мюллер [и др.]. 8-е изд. М. : Рус. яз., 2001.
880 с.
9. Петров, В. И. Русско-английский медицинский словарь-разговорник / В. И. Пет-
ров, В. С. Чупятова, С. И. Корн. М. : Рус. яз., 2000. 596 с.
10. Схема учебной истории болезни по пропедевтике внутренних болезней : метод.
рекомендации / В. П. Царев [и др.]. Минск : БГМУ, 2006. 19 с.

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CONTENTS

Definition of the Case History .......................................................................... 3


Model of the Title Page of Educational Case History (Passport Data) .............. 4
Model of the Second Page of Educational Case History ................................... 5
Patient’s Complaints ......................................................................................... 6
Present History ................................................................................................. 8
Past History ...................................................................................................... 9
General Survey ................................................................................................. 11
System Review ................................................................................................. 13
Respiratory system .................................................................................... 13
Cardiovascular system .............................................................................. 15
Digestive system ....................................................................................... 17
Urinary system .......................................................................................... 19
Endocrine system ...................................................................................... 19
Hematopoietic system ............................................................................... 20
Nervous system......................................................................................... 21
Laboratory and instrumental investigations ....................................................... 21
Clinical diagnosis and its substantiation ............................................................ 22
Diary of medical supervision ............................................................................ 22
Concept of Epicrisis .......................................................................................... 22
References ........................................................................................................ 23

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