Writing a medical history is one of the stages in the education of students of medical universities and colleges. Thus, they learn to describe a specific nosology with all the symptoms, anamnesis. They will learn how to make a diagnosis, what methods of treatment are used in a particular case.
Many of the steps in writing a medical history are purely academic and not used in medical practice. But the same cannot be said for the section called "Local Status". This stage is very important for making the correct diagnosis. It will be discussed in this article.
Case chart
Before turning to the features of describing the local status in various pathologies, let's analyze the general scheme for writing a patient's history. It consists of the following main parts:
- Passport part - the full name of the patient, gender, date of birth, place of residence and work are indicated.
- Complaints - describes in detail what the patient complains about, the intensity of symptoms.
- Amnesis of the disease - includes a description of the development of symptoms in dynamics from the onset of the disease to hospitalization.
- Anamnesis of life -learn what diseases, injuries and operations the patient suffered, how he grew and developed. Find out family and allergic history.
- Data of an objective examination - the state of all organs and systems of the patient is gradually indicated. Systems not affected by the pathological process are described more briefly.
- Local status - a section that describes in detail the place of origin of the pathological process.
- Preliminary diagnosis.
- Survey plan and results.
- Differential Diagnosis - The suspected diagnosis is compared with two or three other diseases that have similar symptoms.
- Clinical diagnosis - indicate the underlying disease, concomitant disease and complications, if any.
- Treatment - indicate drugs, form of release, method of administration and frequency of administration per day.
- Diary of observations - the patient's condition is noted every day of his stay in the hospital.
- Epicrisis - a brief retelling of the medical history.
- Date, signature.
Description of local status
The section of the case history, which describes the location of the pathological process, should be one of the most detailed. Separate specific features of the local status in the case history of different conditions will be described in the relevant sections.
What is the general pattern for writing this section? For any pathology, it should contain the following items:
- patient position;
- stateskin: color, moisture, elasticity, local temperature, presence of rashes or damage;
- position of a limb or torso when it comes to trauma or surgical pathology;
- palpation of the site of development of the pathological process;
- percussion (tapping) of this department;
- auscultation (listening) if there is damage to the lungs, heart or gastrointestinal tract.
Inspection technique
When describing the local status, the doctor first of all examines the place of the pathology. To make the inspection the most informative, you need to follow some rules.
Depending on the severity of the patient's condition, he is examined in the supine position, sitting or standing. At the same time, attention is paid not only to the place of pathology, but also compared with symmetrical intact areas. Since what is pathological for one person is the absolute norm for another.
Examination of the patient was carried out completely only with his full exposure.
Describing the position of the patient, indicate its specific type:
- active - indicates that the damage is not severe and does not affect the patient's behavior;
- passive - determined in severe conditions;
- forced - the patient takes a specific position to alleviate his condition.
If the position is described as forced, be sure to indicate exactly how the patient is located. Since this may lead to a specific diagnosis.
Inspection is also importantskin covers. There are disease-specific symptoms. Therefore, the description of the skin condition also needs to be paid attention.
If there is redness or hemorrhages, their number, size, shape, color and localization are indicated. If rashes are detected, specify their type: petechiae, ecchymosis, papules, vesicles, etc.
If edema is detected, describe their consistency, speed of spread, extent, color and temperature of the skin above them.
Technique of palpation, percussion, auscultation
When palpating the site of the pathological process, pay attention to the following features:
- change in skin temperature;
- presence of seals or, conversely, softening;
- pain on palpation, and where the pain radiates;
- presence of muscle tension;
- presence of seals deep in the body.
If the doctor felt a seal, he should detail it. It is necessary to indicate the localization, size, soreness, quantity, consistency, uniformity, the nature of its surface (bumpy or smooth).
Percussion is done with both hands. The finger of one hand is placed on the affected area, and a gentle tapping is carried out with the middle finger of the other. The sound on percussion can be short, dull, dull, or ringing.
Auscultation can determine the nature of breathing, heart sounds, the presence of noise in the lungs, heart and intestines, crepitus in the bone tissue in fractures.
Description of the fracture
Description of the local status whenthe fracture must contain the following elements:
- characteristic of the deformity of the injured limb;
- presence or absence of damage to the skin;
- presence of pathological limb mobility and crepitus;
- presence of limb asymmetry;
- characteristic of the volume of active and passive movements;
- ability to move nearby joints.
For example, with a fracture of the right clavicle, the local status may look like this: "The right shoulder girdle is lowered, deformation is observed in the outer third of the clavicle. There is also a slight subcutaneous hemorrhage. Pathological movements are determined on palpation, sounds of crepitation of bone fragments are heard on auscultation "The patient cannot abduct his arm because of pain. There is rotation of the right arm inward. There is practically no movement in the shoulder joint."
Description of the burn
When writing a local status on a burn, you need to pay attention to the following characteristics:
- localization and extent of the lesion;
- whether the epidermis (outer layer of the skin) exfoliated;
- is there a scab, what character does it have (wet or dry);
- skin color;
- wound edges;
- are bubbles determined, what is their content;
- probable age of the burn.
As an example, we give a description of a thermal burn on the lower limb: "A burn is visible on the skin in the region of the right ankle joint, which occupies 2/3 of the foot.surface is under a dry scab. The wound has uneven edges, covered with granulations. A serous-purulent fluid is exuding from the wound."
Description of the wound
When writing a local status in case of damage to the skin, the following characteristics are described:
- damage localization;
- shape and size of the wound;
- is there bleeding;
- condition of wound edges;
- features of the skin around the injury: their color, swelling, soreness.
Thus, a description of the local status of an incised wound may look like this: "There is a wound on the back surface of the upper third of the right shoulder. It has an irregular shape, resembling a spindle. Its length is 6 cm, width - 0.9 cm. From On the right end of the wound, there are two more incisions arranged in parallel. Their dimensions are 1 and 1.2 cm, respectively. The depth of the wound is 0.5 cm".
Description of an abscess
There are two types of purulent processes of soft tissues: abscess and phlegmon. The latter is an extensive, diffuse purulent inflammation. It has no specific boundaries and tends to spread even more. An abscess, in turn, is a localized inflammation. It is fenced off from the surrounding tissues with the help of a capsule.
When describing the local status of an abscess, the characteristics of the examination (skin color, presence of edema) and palpation data (pain, softening of tissues, skin heat) are indicated. Also be sure to indicate the size and locationabscess.
Example of a description of an abscess: "In case of suppuration of the soft tissues of the buttocks, after the injection, redness and swelling of the skin over the injection site is noted. A painful infiltrate with softening in the center is determined by palpation. The temperature of the skin above it is increased. The skin is edematous."
Description of angioedema
Quincke's edema is an acute allergic reaction that occurs when the body is hypersensitive to certain substances. This condition occurs suddenly and can be fatal if not treated promptly.
Local status in Quincke's edema is characterized by swelling of the skin, subcutaneous fat and mucous membranes. It most often occurs in the following areas of the body:
- lips;
- forehead;
- cheeks;
- eyelids;
- scrotum;
- brushes;
- back of feet.
If there is swelling of the larynx, the patient is worried about hoarseness, cough. There is a violation of swallowing and difficulty in breathing. With swelling of the gastrointestinal tract, the patient complains of nausea, vomiting, colic in the intestines.
Usually, student case histories describe swelling of the larynx. It occurs most often and requires urgent action.
Conclusion
Every student of a medical college or institute should be able to write local status correctly. If, when describing the objective status of organs that are not affected by the process, something can be missed, then in this case everything should be described in as much detail as possible. From how goodthe doctor will characterize the place of development of the pathological process, further diagnosis and treatment depends. It is also important for monitoring the disease over time.
