Схема академической истории болезни
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Start Date and Hour of Supervision Complaints (on the day of supervision). First set out complaints related to the underlying disease, then - with the concomitant. The following complaints should be identified: Headache (character, localization, frequency, intensity); Giddiness, weakness, malaise; Sleep (character, depth, duration, sleep disturbance - sleeplessness at night, sleepiness during the day); Mood, memory, irritability; Pruritus, intensity; Chills, their frequency, frequency, level of temperature rise in the morning and evening, fluctuations during the day; The sweats, their intensity and time of appearance; Pain in muscles, bones, joints, their character, strength and frequency, changes in the configuration of the joints, range of motion in them; Coloring of the skin and sclera; Rash (onset, nature, localization); Hemorrhagic manifestations (intestinal, uterine, nosebleeds, blood crusts in the nose, bleeding from the gums, hemorrhages on the skin, sclera, hematuria); Runny nose; Lacrimation, pain in the eyes; Sore throat, behind the sternum; Cough (persistent or periodic, dry or with sputum); Shortness of breath, asthma; Pain in the heart with a description of their nature and irradiation, palpitations; Edema (localization and time of their appearance); Disruption of appetite, aversion to meat food; Thirst, dry mouth; Free or difficult to swallow and pass food; Visual impairment (fog, mesh before eyes, double vision); Nausea, vomiting (frequency, nature of vomit, relationship with food intake, intensity); Abdominal pain (localization, nature, irradiation, communication with food intake, intensity); Stool (frequency, nature of feces - liquid, watery, offensive, presence of impurities of mucus, blood, pus, fecal mass - scanty or plentiful, color); False urges to the bottom, tenesmus; Back pain (character, irradiation, periodicity, at rest or associated with movements of the body); The amount of urine per day, dysuric phenomena, urine color. The history of this disease (before the day of supervision) When ill (date, hours, minutes). Onset of the disease: acute or gradual. Describe in detail the initial and subsequent symptoms of the disease, indicating the date of occurrence and the dynamics until the patient is cured to identify the type of fever, cyclical course, syndromes of the gastrointestinal tract, respiratory pathways, liver, etc. The date of the visit to the doctor, the treatment prescribed at home, the effect of it; results of examination (documented or according to the patient). Inpatient treatment, effectiveness, terms of the disappearance of symptoms of the disease. Previously transferred diseases, injuries, wounds, contusions and operations Specify the terms of past diseases, outcomes, injuries, surgical interventions. Pay attention to viral hepatitis and other infectious diseases. Diseases of the Immediate family When listing relatives' diseases, special attention should be paid to the presence of tuberculosis, malignant neoplasms, mental diseases and alcoholism. Life history Place of Birth. When I started studying, I graduated. Labor history. The nature of food, working conditions, occupational hazards. Physical education and sports. Family history, the presence of children. For men: whether they were in military service, indicate the type of military; if there was a commission, indicate the reason. For women: when menstruation began and their nature, spontaneous abortion, date of last menstruation. Harmful habits and intoxications: smoking, alcohol and drug use (at what age it consumes and in what quantity). Allergic history Tolerability of drugs (antibiotics, sulfamides and others). The presence of food allergies. Did blood flow in the past? Reaction to blood transfusion, plasma, administration of serum and vaccines Epidemiological history 1. Identification of the source of infection: a) contact with febrile patients for one month, icteric for 35 days, with persons who had gastrointestinal disorders for 7 days before the disease; b) the presence of similar diseases in the family, among neighbors, employees; c) contact with sick animals, dead animals, rodents, birds - 1.5 months before the disease; d) the presence of rodents in the life of the patient (house, cottage, place of work, recreation area, etc.), their pollution by secretions of the situation, food, water within 46 days before the onset of the disease 2. Identification of ways and factors of transmission: a) the sanitary and hygienic content of the sick person's home environment: how many people and on what area they live, a private house or apartment with all conveniences, partial, without conveniences; sanitary and hygienic condition of the toilet, the presence of insects (flies, cockroaches); the degree of pollution of the yard: the location in it of toilets, dustbins, platforms for collecting food waste, their sanitary condition, chlorination; b) compliance with the rules of personal hygiene: washing hands with soap before eating and after using the toilet, the frequency of changing of underwear and bed linen, the presence of pediculosis in the family; c) the workplace of the sick person; general hanger, towel, dishes and other household items; toilet, its type, sanitary condition; d) dates for visiting cultural and public places; e) nutritional conditions: where the patient was fed within 35 days before the disease. Who prepared the food and where the food was taken, their storage. Sanitary condition of the canteen. When a patient has liquid stool, vomiting, abdominal pain, indicate that he had eaten a week before the disease with an emphasis on the last two days (list all products, their organoleptic properties, focus on eating curd, sour cream, milk from not thermally processed, as well as unwashed vegetables and fruits). Who else ate these foods, their well-being; f) water use conditions: sources of water supply and use of boiled water; g) departure outside this area, departure and return dates, type of transport, living conditions, water use, hygiene rules (see clauses a, b, e) h) arrival of unauthorized persons to the patient, terms, degree of contact; i) terms of stay in endemic regions for hemorrhagic fever with renal syndrome, tick-borne encephalitis, tularemia, malaria, etc .; mosquito bites, gadflies, sucking ticks; j) terms of bathing in open reservoirs and drinking water; k) transfusion of blood, plasma, blood substitutes; surgeries, instrumental examinations, injections, blood donation, treatment and removal of teeth, manicures and other manipulations for the last 6 months before the disease. 3. How has vaccination been subjected to over the past year? Epidemiological analysis: a conclusion about the source of infection, factors, ways and mechanism of transmission of infection. Objective examination data General condition (satisfactory, moderate, severe, very severe). Position (active, passive, forced). Body type. Weight. Color sclera, vascular injection. Face: skin color, puffiness. Skin turgor, moisture, scars, scratching marks, erythema palmar, spider veins, varicose veins. Rash: localization, nature, number of elements. Mucous membrane of the oral cavity: condition of tonsils, pharynx, pharynx, teeth. Subcutaneous tissue: development, edema. Peripheral lymph nodes. Osteo-articular and muscular systems. Nervous system Consciousness. Mind. Cranial nerves. Meningeal symptoms. Corneal, pharyngeal, skin, tendon reflexes. Pathological reflexes. Dermographism. Respiratory system Vote. The shape of the chest. The width of the intercostal spaces. Type of breathing. The number of breaths per minute. Data percussion and auscultation of the lungs. Bronchophony and voice tremor. Cardiovascular organs Apical thrust. Data percussion and auscultation of the heart. Pulse rate and its characteristic. Arterial pressure. Digestive apparatus The state of the language. Abdomen configuration. These superficial and deep palpation of the stomach, pancreas and intestines. The shape, thickness, mobility, pain of the colon. Free fluid in the abdominal cavity. Stool. Hepatolienal system Liver percussion: the upper and lower borders along the anterior midline, mid-clavicular and anterior axillary lines. Palpation: how many centimeters is the liver below the costal arch, its edge, surface, consistency, and pain. Symptom Grekov-Ortner. Soreness in cystic point, Courvosier's symptom, phrenicus-symptom. Percussion of the spleen: diameter - mid-axillary line, dlinnik - along the X edge; palpation; how many centimeters below the costal arch, consistency, pain. Urinary organs Swelling of the kidney area. Palpation of the kidneys. Soreness and projections of ureters. Palpation and percussion of the bladder. Symptom of Pasternack. Urine color (based on personal examination). Daily diuresis. Endocrine system Thyroid gland, its size, consistency. Secondary sexual characteristics. Provisional diagnosis Provisional diagnosis (indicating the nosological and clinical forms, the severity and period of the disease). Complications. Concomitant diseases. Provisional diagnosis diagnosis without justification. Curator's signature Survey plan General analysis of blood, urine, feces on helminth eggs, blood group and Rh factor, blood to Wasserman reaction, fluorography, ECG (if indicated). Additional and special research methods (biochemical, bacteriological, virological, serological, allergological, instrumental, etc.) to confirm the diagnosis and conduct a differential diagnosis. Consultations of various specialists (oculist, otolaryngologist, etc.) Curator's signature Treatment plan 1. Mode, its justification 2. Table number (features of the designated food regime, list the products that can be consumed to the patient). 3. Medical purposes, which must be rational and adequate to the disease of the supervised patient and conform in form and content to the requirements of the Pharmacopoeia. The drugs are written out in Latin, indicating the single and daily doses, the method of administration, the duration of the course of treatment. To substantiate the pathogenetic effect of all prescribed drugs. Curator's signature A diary
Laboratory and instrumental data Inclusion in the history of the disease the results of laboratory, radiological and other special studies with the date, as well as these consultations of specialists. Conclusion on the analysis - note the identified changes. Differential diagnosis The basis is a leading syndrome or symptom of a disease in a given patient (fever, intoxication, jaundice, gastroenterocolitis syndrome, meningeal syndrome, renal, hemorrhagic, etc.). The differential diagnosis is carried out by comparing the symptoms that exist in the supervised patient with the clinical picture of a disease. The cyclicity in the development of the disease, age, sex, season of the year are taken into account. Objective data and laboratory results are compared. The epidemiological history is taken into account. Differential diagnosis is carried out in 3 - 5 diseases. The clinical diagnosis is established. Rationale for clinical diagnosis It is carried out on the basis of symptoms or syndromes characteristic of a given disease and their cyclicity, pathological changes in the body, detected during an objective examination, data from laboratory and instrumental methods of investigation, and epidemiological history. The form of the disease, the severity of the disease (according to the clinical classification) are separately substantiated. Complications (justify). Concomitant diseases (transfer). Curator's signature Epicrisis Patient name, age, entered the clinic of infectious diseases (date) on ____ day of illness with complaints ______________________________________ Directional diagnosis_________________________________________________ Provisional diagnosis_________________________________________________ Reasons for his statement (complaints, history of the disease, epidemiological history, objective data and laboratory, if they were carried out before hospitalization). What diseases were used for differential diagnostics ________________ Clinical diagnosis __________________________________________________________ Grounds for his statement (complaints, history of the disease, epidemiological history, objective, laboratory, instrumental, radiological and other used examination methods). If the clinical diagnosis coincides with the preliminary, then in the justification we exclude complaints, history of the disease, epidemiological history, objective data. The dynamics of the disease, especially the course, complications. Concomitant diseases_____________________________________________________ Treatment: etiotropic (indicating the course dose of antibiotics, sulfonamides, immunoglobulins, etc.), pathogenetic (if CGS is used, then indicate the course dose), symptomatic, local. The condition of the patient at the time of termination of the supervision or discharge. Forecast (nearest and remote) in relation to life, disability. VVE (for curators of the Navy). Rules of discharge according to the orders of the Ministry of Health of Russia. Medical recommendations at the time of discharge. Clinical examination. Curator's signature Current disinfection in the outbreak Prevention Annex 1 Accounting form 58 Emergency Notification of Infectious Disease 1. Diagnosis ____________________________________________________________ 2. Surname, name, patronymic _______________________________________________ 3. Husband, female (emphasize). 4. Age of _________ 5. Address: populated area _______________ district ___________ ___________ street No. _____ sq. _______ 6. Name and address of the place of work, study (for children - children's institution), position _______________________________________________ 7. Date of illness ________________________________________________________ 8. Date of initial treatment (for this disease) __________________ 9. Place and date of hospitalization ______________________________________________ 10. If poisoning - indicate where it happened and what _____________________________ 11. Conducted primary anti-epidemic measures and additional information _____________________________________________________________________________________________________________________________________________ 12. Date and time of primary signaling of the disease in sanitary-epidemiological service Last name of the person who reported _______________ Who received the message ________________________ Appendix 2 |