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Subjective and objective methods for examining patients.
1. Subjective examination (patient's sensations) - information comes from the patient himself when questioned.
Subjective examination includes several sections :
1. General information about the patient (passport): last name, first name, patronymic; age, gender, education, profession, position, place of work, home address, date of admission, who sent the patient;
2. Complaints of the patient : identification of the main (main) - “What bothers you the most?”, And then the other minor (related) complaints - “What else bothers you?” , Their details;
: 3. And the history of the present disease (anamnesis morbi) - you need to get accurate answers to the following questions :
1) when the disease began;
2) how did it start;
3) how did it proceed;
4) when and how did the last deterioration that led the patient to the medical institution;
5) what conditions exacerbate pain symptoms or relieve them;
6) what effect the previous treatment had.
4. And the life history of the patient (anamnesis vitae) - the main goal is to establish those environmental factors (including household, social, economic, hereditary, etc.) that could somehow contribute to the onset and further development of the disease. In this regard, the following sections should be reflected in chronological sequence in the patient’s life history:
- Childhood and youth . Where and in what family was born, the profession of parents? Was born on time, what is the number of the child? Was mother fed milk or artificially? When did you start walking, talking? Material and living conditions in childhood, the general state of health and development (didn’t lag behind peers in physical and mental development?). When did you start to study and how did you study at school? Further study. Wasn’t he exempted from physical education while studying?
- Working and living conditions . Start and further work in chronological order. It is important to establish not only working conditions, but also whether there were occupational hazards during labor activity. Work schedule (day or night work, its duration).
- Housing conditions : sanitary characteristics of the dwelling, its area, on which floor is the apartment, how many family members live in the apartment.
- Nutrition characteristics : regularity and frequency of food intake, its usefulness, dry food, hasty food, addiction to any food.
- Leisure : How to spend free time, the organization of leisure. How do you spend your vacation? Physical activities, sports and physical education.
- Family and sexual history . The questioning in this section should be conducted in confidence, without the presence of other patients. It turns out the marital status (at what age married or married), the composition of the family and the health of its members. Women find out the state of the menstrual cycle (the time the first menstruation appeared, when they were established, their duration, intensity, pain, menopause), pregnancy and childbirth, their course, abortions and their complications, miscarriages. In men, the time of onset of puberty (the appearance of a mustache, beard, the beginning of pollutions ), the characteristics of sexual life, are found out.
- Heredity . The male and female genealogies of the patient are specified. The health status of relatives. If they died, you should find out at what age and from what disease this happened. Did the parents and immediate family suffer from a similar disease like that of a patient.
- Past diseases . Shown in a chronological sequence transferred acute diseases, as well as the presence of concomitant chronic diseases. It is important first of all to identify those transferred diseases that may be pathogenetically associated with this disease.
- Bad habits . This section of the anamnesis is also desirable to collect without witnesses in view of the sensitivity of the questions asked. Information is collected about smoking (how long and what smokes, the number of cigarettes or cigarettes smoked per day). Drinking alcohol (at what age, what, how often and in what quantity?), Drugs ( promedol , morphine, opium , cocaine , codeine , etc.), sleeping pills and sedatives, strong tea and coffee.
- Allergic and medicinal history . First of all, it is specified whether the patient took medications in the past and present. If so, how did you tolerate them, were there any adverse reactions or allergies (fever, rashes, itching, shock). What medication specifically indicated severe allergic reactions? The name of the allergen medicine is displayed on the front page of the medical history, as well as on an outpatient card. Further, possible cases of food allergies, allergic reactions to household chemical goods, cosmetics, the influence of cold, etc. are specified.
1) Examination of patients:
- General - examination of the patient "from head to toe."
- Local (regional, local) - inspection by systems. For example, examination of the chest, heart, abdomen, kidneys, etc.
The main requirements during the inspection : good lighting conditions, comfortable conditions, compliance with the "technique" of inspection, strict sequence, regular inspection.
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