Comprehensive Medical Anamnesis and Physical Examination, Cheat Sheet of General Surgery

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Федеральное государственное бюджетное

образовательное учреждение высшего образования

«Смоленский государственный медицинский

университет» Министерства здравоохранения

Российской Федерации

(ФГБОУ ВО СГМУ Минздрава России)

CASE HISTORY

Patient’s Surname, Name, Patronymic: Clinical diagnosis:

1. Basic diagnosis
2. Complications of the basic diagnosis
3. Concomitant diagnosis (-es) Student: (Surname, Name, Patronymic) (Group) (Year) (Faculty) Teacher: (position, scientific degree) (Surname, Name, Patronymic) Period of patient’s observation: from «_ » 20 to « » 20

PATIENT’S PASSPORT DATA

1. Surname, name, patronymic:
2. Gender:
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:
   1. The basic diagnosis:
   2. Complications of the basic diagnosis:
   3. Concomitant diagnosis (-es):

PRESENT HISTORY (ANAMNESIS MORBI)

I. Onset, character and features of the basic disease course.

II. Findings of the laboratory and instrumental tests carried out before cur-

rent hospitalization. III. Previous treatment and its efficiency.

PAST HISTORY (ANAMNESIS VITAE)

I. Patient’s Physical and Intellectual Development.

• Patient born the first (second, third and so on) child in the family:
• Patient born in time (if the patient knows about it):
• The patient was breastfed or artificially fed (if the patient knows about it):
• When did patient start to walk, speak (if the patient knows about it):
• What was patient general health condition and development in childhood and youth (if the patient remembers about it):
• Have patient ever lagged behind your peers physically or intellectually?
• When did patient start to study? Was it easy or difficult to study?
• What is patient education?
• Have patient ever gone in for sports? Do patient have any sport category (rank)? Additional questions for men:
• Did the patient serve in the army? (if not, what are the reasons of the deferment of military service): Additional questions for women:
• At what age did woman patient have her first menstrual period?
• What is the duration of each menstrual period?
• How many children have woman patient borne?

• if he/she take food quietly or quickly:
• if it is masticated thoroughly:
• if hot food or drinks are consumed moderately hot or very hot:
• is diet 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 (ap- proximately): III. Patient’s Labor Activities (note the patient’s labor activity in chronological order since its beginning).
• term of job or occupation: from to.
• occupational hazard
• working day duration
• work schedule (at his last job place):

1. operation time
2. breaks
3. day or night shifts
4. time or piece-work
5. 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.

V. Hereditary Anamnesis. GENERAL SURVEY (STATUS PRAESENS) 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 (in metres),
• body weight (in kilograms),
• bearing: correct, slouch. Gait: usual, slow, shuffling, waddling [goose]. Body temperature (by Celsius scale). Chills: yes/no. Skin.
• skin color: rose-pink, pale with a shade (ash grey, sallow, greenish, icteric, «white coffee» etc.), red (blush), cyanotic (cyanosis: diffuse, acrocyanosis), icteric (su- bicteric, moderate icteritiousness, ochreous yellow, dark yellow, greenish), bronze, greyish-brown, grey. Presence of pigmentation and depigmentation: yes / no. Liver palms (palmar erythema): yes / no.
• skin moisture: normal; dry skin; general and local sweating: degree of sweat- ing (moderated, severe), dependence on the time of day (night sweating).
• skin rash: character (roseola, erythema, urticaria, purpura, petechia, herpes labialis, herpes zoster), localization and distribution; presence of xanthelasmas, «vas- cular spiders» (spider nevi), scars, skin consolidations, ulcerations, bedsores, scratches, varicose veins etc.

• tenderness: yes / no (if presented: at rest, on palpation, while moving; site of tenderness ),
• hypo- and atrophies: yes / no (if presented: their localiza- tion ). Bones.
• symmetry of the skeleton (yes/no),
• pains: yes / no (if presented: at rest, arising while moving (or on palpation, or on tapping)); site of tenderness ),
• deformities: yes / no,
• finger clubbing: yes / no. Form of the head: typical, atypical. Form of the nose: usual, saddle. Spinal column.
• its curvatures: physiological, pathological (lordosis, kyphosis, scoliosis, kyp- hoscoliosis);
• flatness of physiological curvatures: yes / no;
• a posture of “suppliant” (soliciting posture): yes / no. Joints.
• form: correct / 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,
• presence of tophi, rheumatoid or rheumatic nodes: yes / no. Findings of joint palpation local rise of tem- perature articular crepitus and crack- ling while moving fluc- tuation floating patella symp- tom ten- der- ness test of lateral compres-sion (by 4-point score (0–1–2– points) active and passive move- ments in joints (measured in degrees) articular circum- ference (in centi- meters) radiocarpal elbow knee ankle

SYSTEM REVIEW

RESPIRATORY SYSTEM

I. THORAX SURVEY:

Thorax form.

• normal: normosthenic (conical), hypersthenic, asthenic,
• pathological: emphysematous (barrel-like), rickets (pigeon [chicken]) breast, scaphoid breast, funnel breast, paralytic chest, kyphoscoliotic chest),
• thorax deformities ,
• spinal column curvatures: pathological lordosis, kyphosis; scoliosis, kypho- scoliosis,
• thorax symmetry or asymmetry: volume increase or reduction, falling back or bulging of supra- and subclavicular areas of the right and left thorax,
• position of clavicles: symmetry (yes / no), deformities (yes / no),
• position of 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/exhaletion (expiratory), mixed. Presence of distant rales: yes / no. Breathing rhythm: correct, pathological (Cheyne–Stokes respiration, Biot’s respi- ration, Kussmaul’s respiration, Grocco’s respiration).

II.Thorax palpation.

Determine the epigastric angle in degrees. Determine the thorax resistance: elastic, rigid. Thorax tenderness (local, diffuse): yes / no. Sites of tenderness indicating ex- actly its localization and borders Skin edema: absence / presence; its localization . Hypodermal fat crepitation: yes / no; its localization . Pleural friction rub (palpable): yes / no; its localization .

IV. Lung auscultation.

1. Comparative auscultation (character of auscultation findings on symmetric and compared chest sites with exact delimitation of the revealed pathological sound change in vertical and horizontal direction (along intercostal spaces, topographical lines)):

• Character of the main respiratory sounds:
• vesicular: normal, pathology (diminished, forced, rough, intermittent (saccadic),
• bronchial (normal, pathology (stenotic, metallic, amphoric):
• mixed (or bronchio-vesicular):
• absence of breath sounds: Additional respiratory sounds — present / 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):
• 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 (if positive, specify precisely its 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 visi- ble)). Palpation: define the degree of pulsation expressiveness (forced or not), vessel surface (smooth or nodular), elasticity

II. Pulse parameters on radial arteries:

• identical (or unequal) pulse strength on the right and left radial arteries (de- fine 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 / weak;
• tension: tense / soft;
• pulse size: large / small or thready;
• pulse form: fast / slow; dicrotic; paradoxical. Quinke’s (precapillar) pulse: present / absent. Auscultation of carotids, abdominal aorta, femoral and renal arteries:
• (Traube’s double tone (Traube’s sign): present / absent,
• Vinogradov–Duroziez’s double murmur (Duroziez’s sign): present / absent.

III. Arterial blood pressure measurement on brachial arteries using Korotkoff

method: Left hand

• systolic blood pressure level: mm Hg
• diastolic blood pressure level: mm Hg
• pulse pressure: mm Hg. Right hand
• systolic blood pressure level: mm Hg
• diastolic blood pressure level: mm Hg
• pulse pressure: mm Hg. IV. Examination of veins. Venous pulse on jugular veins: negative / positive. Palpation of peripheral veins

2. Borders of absolute cardiac dullness:

• the right border: in the intercostal space along line;
• the left border: in the intercostal space along line;
• the upper border: in the intercostal space along line; Auscultation of the heart. Cardiac rhythm: regular, arrhythmia, embryocardia. The rate of heartbeats: (per minute). Specific triple rhythms: the “quail” rhythm; the “gallop” rhythm (protodiastolic, mesodiastolic, presystolic). Characteristic of heart sounds in each of the 5 auscultation points. 1 point:
• the first heart sound: normal sonority, weakened, strengthened, clapping, split, doubled.
• the second heart sound: normal, accentuated, weakened, split, doubled.
• heart murmur: absent/present (systolic, diastolic; association of a murmur with heart sounds , murmur timbre , the point of the maxi- mum murmur loudness , a place of the murmur transmitting , change of murmur depending on the patient’s position / physical activity phases. 2 point: / respiration
• the first heart sound: normal sonority, weakened, strengthened, clapping, split, doubled.
• the second heart sound: normal, accentuated, weakened, split, doubled.
• heart murmur: absent/present (systolic, diastolic; association of a murmur with heart sounds , murmur timbre , the point of the maxi- mum murmur loudness , a place of the murmur transmitting , change of murmur depending on the patient’s position / physical activity phases. 3 point: / respiration
• the first heart sound: normal sonority, weakened, strengthened, clapping, split, doubled.
• the second heart sound: normal, accentuated, weakened, split, doubled.
• heart murmur: absent/present (systolic, diastolic; association of a murmur with heart sounds , murmur timbre , the point of the maximum murmur loudness , a place of the murmur transmitting , change of murmur depending on the patient’s position / physical activity / respi- ration phases. 4 point:
• the first heart sound: normal sonority, weakened, strengthened, clapping, split, doubled.
• the second heart sound: normal, accentuated, weakened, split, doubled.

• heart murmur: absent/present (systolic, diastolic; association of a murmur with heart sounds , murmur timbre , the point of the maximum murmur loudness , a place of the murmur transmitting , change of murmur depending on the patient’s position / physical activity / respiration phases. 5 point:
• the first heart sound: normal sonority, weakened, strengthened, clapping, split, doubled.
• the second heart sound: normal, accentuated, weakened, split, doubled.
• heart murmur: absent/present (systolic, diastolic; association of a murmur with heart sounds , murmur timbre , the point of the maximum murmur loudness , a place of the murmur transmitting , change of murmur depending on the patient’s position / physical activity / respiration phases. Pericardial friction rub: it is listened / not listened. Pleuropericardial friction rub: it is listened / not listened. DIGESTIVE SYSTEM I. Oral Cavity Examination. 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).

II.Examination of the abdomen.

Survey of the abdomen.

• 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, if yes: umbilical, inguinal, midline (Linea alba) hernia.
• visible peristalsis: yes / no,
• a hypodermic venous network: invisible / visible,
• Medusa head symptom: yes / no.

Transverse colon: not palpable / palpable (diameter (cm), tenderness (pre-sent / absent), mobility (present / absent), consistency (dense / elastic), surface (smooth / uneven), rumbling (present / absent)).

III. Examination of the liver.

Survey of the liver area:

• evident bulging in right hypochondrium: present / absent. Percussion of the liver: The upper border of liver is determined on 3 lines:
• on the rib along right parasternal line,
• on the rib along right midclavicular line,
• on the rib along right anterior axillary line. The lower border of the liver is determined on 5 lines:
• on the rib along right anterior axillary line,
• along right midclavicular line,
• along right parasternal line,
• along anterior midline,
• by the left rib arch along left line. Liver size by Kurlov:
• on the midclavicular line: cm,
• on the anterior midline: cm,
• on the left rib arch (costal margin): cm. Palpation of the liver:
• liver lower edge is palpable / not palpable,
• if liver lower edge is palpable: does not protrude from under the costal mar- gin on right midclavicular line / protrudes from under the costal margin on cm,
• features of liver edge which will have been found during palpation: сon
• sistency (soft / firm); surface (smooth / tuberous); tenderness (present / absent). IV. Examination of the gallbladder.
• gallbladder is not palpable / palpable;
• tenderness in the gallbladder area: present / absent.
• Courvoisier’s symptom: negative / positive,
• Georgievskiy–Myussi’s symptom (phrenic nerve sign): negative / positive,
• Murphy’s symptom: negative / positive. V. Examination of the spleen. Survey of the spleen area:
• evident bulging in the left hypochondrium: present / absent. Percussion of the spleen:
• length (by the 10 th^ rib): cm;
• width (between the 9 th^ and 11 th^ ribs on left midaxillary line): cm. Palpation of the spleen:

1. When the patient supine:

• spleen does not protrude from under the left costal margin / protrudes from under the left costal margin on cm.

• if spleen palpable: consistency (soft / firm), surface (smooth / uneven), ten- derness (present / absent).

2. When the patient on his right side:

• spleen does not protrude from under the left costal margin / protrudes from under the left costal margin on cm.
• if spleen palpable: consistency (soft / firm), surface (smooth / uneven), ten- derness (present / absent). URINARY SYSTEM I. Examination of the kidneys. Survey of kidney area:
• symmetry in the kidney area: present / absent,
• hyperemia in the kidney area: present / absent,
• swelling in the kidney area: present / absent,
• scars in the kidney area: present / absent. Palpation of the kidneys. Palpation of right kidney carried out in horizontal position:
• palpable / is not palpable,
• if kidney palpable: enlarged/reduced kidney, renal form , con- sistency (dense / elastic), tenderness (present / absent), kidneys surface (smooth / tuber- ous), kidney is dropped by cm) / is not dropped). Palpation of right kidney carried out in vertical position:
• palpable / is not palpable,
• if kidney palpable: enlarged/reduced kidney, renal form , con- sistency (dense / elastic), tenderness (present / absent), kidneys surface (smooth / tu- berous), kidney is dropped by cm) / is not dropped). Palpation of left kidney carried out in horizontal position:
• palpable / is not palpable,
• if kidney palpable: enlarged/reduced kidney, renal form , con- sistency (dense / elastic), tenderness (present / absent), kidneys surface (smooth / tu- berous), kidney is dropped by cm) / is not dropped). Palpation of left kidney carried out in vertical position:
• palpable / is not palpable,
• if kidney palpable: enlarged/reduced kidney, renal form , con- sistency (dense / elastic), tenderness (present / absent), kidneys surface (smooth / tu- berous), kidney is dropped by cm) / is not dropped). Method of tapping (Pasternatsky’s symptom) on the right costovertebral angle: negative, slightly positive (insignificant tenderness is present), positive (moderate tenderness), full-blown positive (significant tenderness, the patient does not allow to continue the procedure). Method of tapping (Pasternatsky’s symptom) on the left costavertebral angle: negative, slightly positive (insignificant tenderness is present), positive (moderate