EXAMINATION OF SURGICAL

PATIENTS
SCHEME OF CASE REPORT
Praefatio
Praefatio
Anamnesis morbi (history
of present illness)
n  Patients complaints;
n  First symptoms of disease,
beginning of the disease and it's
course.
 Anamnesis vitae (life history,
past history)
n  Living condition (housing condition, main water, flat,
sewerage, heating, cloth);
n  Patients labor activities (change of professional working
hours, industrial hazards, professional record of service,
regime of work);
n  Patients habits (harmful habits, is he addicted to alcohol,
tobacco, narcotics, excesses in venereal);
n  Childhood diseases;
n  Alergologycal anamnesis;
n  Gynecological history;
n  Family history (hereditary history) - lues, tuberculosis,
mental diseases - among forefathers, brothers, sisters
and children.
Recommendation

n  Recommend one or more of the

strategies
n  Summarize the results if things go
as proposed
n  What to do next
n  Identify action items
 Status praesens (Present
state of the patient)
examen subjectivum - patient complaints
(pain, sickness, disability, weakness, cough,
shortness of breath, heart pain, appetite,
heartburn, hiccup, belching, vomiting,
constipation, nausea, diarrhea).
Examen objectivum (patients objective inves
tigation)
 General examination of
a patient
1. INSPECTIO: Body build, constitution
physique (asthenic, normos-thenic (athletic),
hypersthenic (digestive, picnic), dysplastic,
regular, cerebral, respiratory, cushingoid,
neurotic, schizoid);
2. Weight (weight loss, degree of nourishment,
emaciation), heigh;
3. Patients position, patients attitude
(active, passive, forced);
4. Mental state;
5. Skin integument;
6. Visible mucous membranes;
7. Lymph nodes (enlargement,
tenderness, hardness, consistency,
size, color);
8. Thyroid gland;
9. Osteal-articular system;
10. Muscular system.
 Respiratory system
Thorax, Thoracic cage (chest) - narrow,
barrel (emphysema-tous),
funnel (shoemaker's),
hypersthenic (broad and short),
chicken (keeled),
kypo (scolio) tic, lordotic, rachitic;
thoracic excursion.
Respiratory movements, respiratory
rate, depth of breathing.
Respiratory system
 Respiratory system

Instrumental methods: spirometry,

spirography (bronchospiro-graphy),
determination of vital capacity of the lungs.
bronchoscopy;
pneumotachometry;
CT (computed tomography);
scintillated electrokymography;
X-ray;
thoracoscopy.
 Cardiovascular
system
Inspection of heart area, palpation of the
area of the heart, it's apex.
Percussion of the heart, percussion of
aortic area;
Auscultation of the heart (hearts sounds,
cardiac sounds - quiet, weak, flapping,
accenting, weakening, splitting, doubling,
strengthening, murmurs, "gallop" rhythm,
friction rub).
 Urogenital sistem
Kidneys, palpation - tender (painful) kidney, floating
(wandering, mobile), nephroptosis, distopic, accessory,
lobular (embryonic), cystic (polycystic), normally -
positioned, enlarged, double, Pasternatsky's symptom.

Urether and urinary bladder: palpation, urination,

(mictura-tion), painful, difficult urination, involuntary
(leakage), fre-quent (polla-kisuria), infrequent
(oligakisuria), false urge to void urine (tenesmus),
imperative urge to void urine, retention of urine (isuria),
discharge of bloody urine (hematuria), incontinence of
urine, anuria (arenal, prerenal, intoxication, calculous,
obturative, postrenal, transito-ry, traumatic), hematuria
(macro-, micro-, initial, secondary, terminal, total);
 Urogenital sistem

Instrumental methods:
1. Cystoscopy
2. chromocys-tography and biopsy;
3. X-ray
4. CT,
5. MRI,
6. ultrasono-grphy of urinary tract;
 Nervous system
1. Consciousness,
2. sleep,
3. speech,
4. delirium,
5. muscles,
6. motor func-tion,
7. coordination,
8. sensitivity,
9. dermographizm,
10. reflexes (papillary, cuta-neous, tendon,
pathological - Babinski's, Bechterew's,
Oppenheim's).
Local signs of disease (locus
morbi, status locus)

Description of the injured area, organ or

region of organisme .
 Blood examination
1. Hemoglobin (Hb),
2. hematocrit (Hct),
3. number of erythrocytes,
4. leucocytes,
5. thrombocytes,
6. blood clotting (coagulation) time,
7. blood sugar,
8. differential blood count (basophils, lymphocytes,
monocytes, neutrophils, stab neutrophils, segmented
neutrophils, juvenile neutrophils, eosinophils),
9. blood serum protein,
10. blood enzymes,
11. lood electrolytes,
12. serum bilirubin.
 Diagnosis
1. admission diagnosis;
2. initial (provisional, tentative, suggeste
d, working, hypothetical);
3. differential diagnosis;
4. pastoperative diagnosis;
5. final diagnosis;
6. diagnosis on discharge;
7. pathologic (postmortem).
 Plan of supplemental
examination

Instrumental investigations;
Laboratory investigations;
 Prognosis

Prognosis quo ad valitudinem,

prognosis quo ad laborem.
1. p. quo ad vitam;
2. short- and long-term;
3. poor and favorable.
 Course of disease
(cursus morbi)
1. daily notes about patient's condition and
results of investigations;
2. base (ground) of operation
(indication for surgical operation);
3. protocol of surgical operation;
4. protocol of anesthesia;
5. daily notes about patient's condition and
treatment;
6. epicrisis of discharging.