Writing a medical history is one of the stages in the training of students of medical universities and colleges. Thus, they learn to describe a specific nosology with all the symptoms, an anamnesis. They will learn how to diagnose what treatment methods are used in a particular case.
Many stages of writing a medical history are purely academic and are not used in medical practice. But this cannot be said about the section entitled "Local Status". This stage is very important for making the correct diagnosis. He will be discussed in this article.
Medical history chart
Before proceeding to the features of the description of the local status for various pathologies, we will analyze the general scheme for writing the patient’s history. It consists of such main parts:
- Passport part - the patient’s full name, gender, date of birth, place of residence and work are indicated.
- Complaints - describes in detail what the patient complains about, the intensity of the symptoms.
- Anamnesis of the disease - includes a description of the development of symptoms in dynamics from the onset of the disease to hospitalization.
- Anamnesis of life - they learn what diseases, injuries and operations the patient suffered, how he grew and developed. Find out the family and allergic history.
- Objective examination data - the condition 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 in which the place of occurrence of the pathological process is described in detail.
- Preliminary diagnosis.
- The survey plan and the results.
- Differential diagnosis - the alleged diagnosis is compared with two to three other diseases that have similar symptoms.
- Clinical diagnosis - indicate the main concomitant disease and complications, if any.
- Treatment - indicate drugs, form of release, route of administration and frequency of administration per day.
- Observation diary - the patient’s condition is noted every day he is in the hospital.
- Epicrisis is a brief retelling of medical history.
- Date, signature.
Description of local status
The section of the medical history in which the place of occurrence of the pathological process is described should be one of the most detailed. Some specific features of the local status in the medical history of different conditions will be described in the relevant sections.
What is the general outline for writing this section? For any pathology, it should contain the following items:
- position of the patient;
- condition of the skin: color, humidity, elasticity, local temperature, the presence of rashes or damage;
- position of the limb or trunk, when it comes to trauma or surgical pathology;
- palpation of the place 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. In order for the inspection to be the most informative, you need to adhere to some rules.
Depending on the severity of the patient's condition, he is examined in a prone position, sitting or standing. At the same time, they pay attention not only to the place of the pathology, but also compare it with symmetrical intact areas. Since what is pathological for one person is the absolute norm for another.
The examination of the patient was carried out completely only with its full exposure.
Describing the position of the patient, indicate his specific form:
- 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 posture 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.
An examination of the skin is also important. There are disease-specific symptoms. Therefore, the description of the skin condition also needs to be given attention.
If there is redness or hemorrhage, their number, size, shape, color and localization are indicated. If rashes are detected, their type is specified: petechiae, ecchymoses, papules, vesicles, etc.
If edema is detected, describe their consistency, speed of spread, vastness, color and temperature of the skin above them.
Technique of palpation, percussion, auscultation
When palpating the pathological process, pay attention to such features:
- change in skin temperature;
- the presence of seals or, conversely, softenings;
- pain on palpation, as well as where it gives pain;
- the presence of muscle tension;
- the presence of seals in the depths of the body.
If the doctor has found a seal, he should detail it. It is necessary to indicate the localization, size, soreness, quantity, consistency, uniformity, and the nature of its surface (uneven or smooth).
Percussion is carried out with two hands. The finger of one hand is placed on the affected area, and the middle finger of the other is gently tapped. The sound during percussion can be shortened, dull, dull or sonorous.
Auscultation can determine the nature of breathing, heart sounds, the presence of noise in the lungs, heart and intestines, crepitus in bone tissue during fractures.
Fracture description
The description of the local status during a fracture should contain the following elements:
- strain characteristic of a damaged limb;
- the presence or absence of damage to the skin;
- the presence of pathological limb mobility and crepitus;
- the presence of asymmetry of the limbs;
- characteristic volume of active and passive movements;
- the possibility of movement in 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 detected during palpation, sounds of crepitation of bone fragments are heard during auscultation. The patient cannot take away arm because of pain. There is a rotation of the right arm inward. There is virtually no movement in the shoulder joint. "
Burn description
When writing a local burn status, you need to pay attention to such characteristics:
- localization and extensiveness of the lesion;
- whether the epidermis (the outer layer of the skin) has peeled off;
- whether there is a scab, what character it has (wet or dry);
- color of the skin;
- the edges of the wound;
- whether the bubbles are determined, what is their content;
- presumptive age of the burn.
As an example, we give a description of a thermal burn on the lower extremity: “On the skin in the region of the right ankle joint you can see a burn that takes 2/3 of the foot. About 4% of the burn surface is under a dry scab. The wound has uneven edges, is covered with granulations. It stands out from the wound. serous-purulent fluid. "
Wound description
When writing the local status for damage to the skin, their following characteristics are described:
- damage localization;
- the shape and size of the wound;
- is there any bleeding;
- the condition of the edges of the wound;
- features of the skin around the damage: their color, swelling, soreness.
So, the description of the local status of the cut wound can look like this: “On the back surface of the upper third of the right shoulder there is a wound. It has an irregular shape, resembling a spindle. Its length is 6 cm, width is 0.9 cm. From the right end of the wound two incisions arranged in parallel. Their dimensions are 1 and 1.2 cm, respectively. The depth of the wound is 0.5 cm. "
Description of the abscess
Two types of purulent processes of soft tissues are distinguished: abscess and phlegmon. The latter is an extensive, diffuse purulent inflammation. It has no specific boundaries and is prone to even greater spread. An abscess, in turn, is a limited inflammation. It is fenced off from surrounding tissues with a capsule.
When describing the local status of the abscess, the examination features (skin color, edema) and palpation data (soreness, softening of tissues, skin heat) are indicated. Also, the size and location of the abscess must be indicated.
An example of an abscess description: "When the soft tissues of the buttocks are suppurated after injection, redness and swelling of the skin above the injection site is noted. Painful infiltration with softening in the center is palpated. The skin temperature above it is elevated. The skin is swollen."
Description of Quincke's edema
Quincke's edema is an acute allergic reaction that occurs when the body is hypersensitive to certain substances. This condition occurs suddenly and can become fatal if you do not provide assistance to the victim in time.
Local status in Quincke's edema is characterized by swelling of the skin, subcutaneous fat and mucous membrane. Most often it occurs in the following parts of the body:
- lips
- forehead;
- cheeks;
- eyelids
- scrotum;
- brushes;
- the back of the feet.
If there is swelling of the larynx, the patient is worried about the hoarseness of the voice, cough. There is a violation of swallowing and difficulty in inhaling. With swelling of the gastrointestinal tract, the patient complains of nausea, vomiting, colic in the intestine.
Usually in student case histories, laryngeal edema is described. It occurs most often and requires urgent measures.
Conclusion
Each student of a medical college or institute must be able to correctly write the local status. If in describing the objective status of organs that are not affected by the process, something can be missed, then in this case everything needs to be described in as much detail as possible. Further diagnosis and treatment depends on how well the doctor describes the place of development of the pathological process. It is also important for monitoring the disease over time.