The Medical History of a Surgical Patient
The Medical History of a Surgical Patient
АртикулNF0007754
ISBN978-5-9704-4465-8
ИздательГЭОТАР-Медиа
АвторыМерзликин Н.В. и др.
Год2018
К-во страниц120
Переплетмягкий

This tutorial aims to formalize a standardized approach to the design of the medical history of a surgical patient. It gives detailed recommendations for the proper anamnesis collection, description of objective status, diagnosis and its substantiation, and diff erential diagnosis. It describes the order of documents registration for preparing and performing surgical intervention and anesthesia. It pays particular attention to the correct interpretation of the follow-up examination results. The appendices contain reference ranges for laboratory tests, a short version of the International Classifi cation of Diseases, interpretation of indicators of blood and urine tests on automatic analyzers, the new nomenclature of standard and surgical diets, recommendations for the prevention of infectious and thromboembolic complications, and registered forms of medical records.

The tutorial is designed in accordance with the Federal State Educational Standard of higher professional education for students pursuing a degree in General Medicine, Pediatrics, Dentistry.

List of abbreviations
Introduction
Medical history maintenance requirements
Offi cial data presentation
Anamnesis of current disease (anamnesis morbi)
Onset and development of disease
Anamnesis of life (anamnesis vitae)
Physical examination data (status praesens objectivus)
Body system physical examination data
The respiratory system
The cardiovascular system
The digestive system
The genitourinary system
The urinary bladder and urination
Male examination data
Female examination data
The neuropsychic status
Pathological site description (status localis)
Diff erentiation of descriptions of the lesion depending on its etiology
The provisional diagnosis
Diagnostics
Laboratory data and instrumental methods of examination
The clinical diagnosis and its substantiation (evidence)
The diff erential diagnosis
Treatment
Preoperative concept
Protocol of operation
Progress notes
Discharge (stage) epicrisis
End of the medical history of a surgical patient
Tests
Questions
Keys


Appendix 1. Form 003/У. The medical record of an inpatient
Appendix 2. Consent to personal data processing
Appendix 3. Medical documentation standards
Appendix 4. Disorders of Consciousness
Appendix 5. Determination of the body mass index
Appendix 6. "Face Masks"
Appendix 7. Types of pathological respiration
Appendix 8. Data of topographic percussion of the lungs of a healthy person
Appendix 9. Borders of the heart of a healthy person
Appendix 10. Stange and Gench functional tests
Appendix 11. The method of rectal examination
Appendix 12. Consent to medical endoscopic intervention (diagnostic/therapeutic)
Appendix 13. Preparation for sigmoidoscopy
Appendix 14. Laboratory indicators of a healthy person
Appendix 15. A Short Version of the International Classifi cation of Surgical Diseases
Appendix 16. Instructions for the organization of nutritional care in healthcare institutions
Appendix 17. Standard diets descriptions
Appendix 18. Determination of the degree of operational risk
Appendix 19. Classifi cation of operational anaesthesia risk (Moscow Scientifi c Society of Anaesthesiologists and Reanimatologists-89)
Appendix 20. Informed voluntary consent to an Aesthesia for medical intervention
Appendix 21. Perioperative antibiotic prophylaxis: concepts and rational strategies
Appendix 22. Russian clinical guidelines for diagnosis, treatment and prevention of venous thromboembolic complications
Appendix 23. Informed voluntary consent to surgical intervention
Appendix 24. Form 008/У-07. Record book of surgical interventions in the hospital
Appendix 25. Assessment of patient illness severity using SAPS
Appendix 26. Informed voluntary consent for the transfusion of blood components
Appendix 27. The protocol of transfusion of donor blood and (or) its components
Appendix 28. The temperature sheet of a surgical patient
Appendix 29. Types of fever
Appendix 30. Form 066/У. Discharged Patient Statistical Record
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