Present state

1. General condition and neural system characteristic.

General state of the patient is (satisfactory, moderate severity, grave, extremely grave). Patient’s position is (active, forced patient’s attitude position, passive patient’s position). State of consciousness. Mental state , estimate of intelligence, memory, speech. Abnormalities of gait, posture, coordination.

2. Physical development and its assessment.

Weight, length, head and chest circumference of patient. The result of investigation must be compared with age standards

.

3. Nervous system characteristics.

State of sensitive organs: vision, hearing, skin sensitivity, olfactory, taste characteristic.

4. Skin and mucous membranes characteristic

Colour (cyanosis, jaundice, pallor, erythema), texture , hydratation, turgor and elasticity(good, satisfactory, decreased). Edema , hemorrhagic manifestations, scars, rash (character and location), dilated vessels. Character nails and hair distribution, colour of visible mucous membranes.

5. Subcutaneous tissue characteristic

Thickness of subcutaneous fat fold, turgor, edema and subcutaneous formation, it`s location and sizes.

6. Lymphatic system characteristic. Palpation of groups of lymphatic nodes (suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sub-linqual, axillary, epitrochlear and inguinal), there quantity, shape and size, conjunction of each with other, with near-by tissues.

7. Muscle system characteristic.

Tone, strength.

8. Bone system characteristic. Head size, shape, asymmetry. Configuration of joints , active and passive movements.

9. Respiratory system characteristic. State type of respiration (thoracic, abdominal, mixed). Appreciate respiration rhythm (rhythmic respiration, arrhythmic respiration, Chene-Stoke`s respiration, Biot`s respiration, Kussmaul`s respiration). Respiratory rate ,

Palpation of the chest. Elasticity of the chest (the chest is elastic, elasticity of chest is decreased, the chest is rigid). Pain in the chest wall (“surface” pain) (the chest is painless, pain of the chest wall is determined, to indicate location).

Percussion of lungs. Comparative percussion of the lungs (clear pulmonary sound, dulled pulmonary sound, tympanic sound, bandbox sound, cracket-pot sound, metalic sound, dull with tympanic tone and to indicate location).

Auscultation of the lungs. The main respiratory sounds (puerile, vesicular breathing, decreased vesicular breathing, to indicate location of weakening of vesicular breathing, increased vesicular breathing, harsh breathing, vesicular breathing with longer expiration, bronchial breathing, amphoric respiration. Adventitious respiration sounds

(dry rales-high-pitched-sibilant, low-pitched-sonorous, moist rales (fine bubbling, medium bubbling, coarse bubbling, consonating and non-consonating, crepitation – initial, resolve, pleural friction sound, to indicate location of adventitious respiratory sounds.

10. Cardiovascular system characteristic.

Observation and palpation. Presence of the chest deformation in the heart region (the chest deformation is absent, the chest deformation is present, indicate the cause: pericarditis with effusion, cardiac “humpback”). Presence of the apex beat (the apex heat is not determined, the apex beat is determined (indicate location by attitude to the left medioclavicular line).

Auscultation of the heart. Rhythm of the cardiac activity (regular, irregular – to determine the type of rhythm disorder, extrasystolia, fibrillation, etc). The number of beat sounds (two, three reduplication, splitting of the second sound over). The rate of cardiac contraction (RCC) per minute . Appreciate RCC according age norm, tachycardia, bradicardia.

Examination of the vessels. Aortic pulsation (invisible, visible, to indicate location). Periphery arteries (temporal, carotids, subclavian, brachial, intercostal, invisible, visible). The subcutaneous veins (jugular, veins of the upper and lower extremities, veins on the front surface of the chest and abdomen are invisible, visible (to describe), general swelling of the veins, local swelling of the veins (is present, is absent).

Palpation. Examination of pulse on radial artery. Comparison pulse size on both hands (pulse is same on the both hands , is different on different hands). Rhythm of the pulse waves (the rhythm is rhythmic, arrhythmic), pulse rate per minute , pulse deficit, pulse pressure (of satisfactory tension, the pulse is hard, soft), volume of pulse (of satisfactory volume, the pulse is full, the pulse is empty, pulse size (of middle size, the pulse is large, the pulse is small, the pulse is thread), pulse speed (the pulse of middle speed, the pulse is quick, the pulse is slow), pulse character (quick, and high, slow and small).

Examination of the arterial pressure.

1. Systolic (SAP)

2. Diastolic (DAP)

3. Pulse pressure (PP)

Assessment of AP: norm, pathology .

11. Digestive organs and abdominal cavity characteristic.

Observation. Condition of mucous membrane of oral cavity, throat, tonsils (colour – normal, pink, hyperaemia, dry or moist, coated tongue, follicules, fissures, geographical tongue). Teeth condition (deciduous, permanent, teeth quantity, teeth formula, caries presence). Shape and size of the abdomen (distended abdomen, scaphoid abdomen, board-like abdomen, frog abdomen), visible peristalsis, respiratory movement, veins, umbilicus, hernia . Examination of the perianal area (gaping anus, mucosal prolapse of the rectum, fissures of the anus).

Palpation superficial and deep. Muscular tenderness and rigidity, painful points, local infiltration

(soft abdomen, abdominal distension, tympany, meteorism, tense abdomen, “acute”/surgical abdomen, location of painful points).

Liver palpation (liver is not palpated, palpated for 2,0 and more cm below rib`s arches, its consistency – soft, firm; shape, type of margin – rounded, sharp, tenderness. Percussion of the liver

(the upper margin of liver is defined, along the mammillary line in the fifth intercostal space).

Percussion of the abdomen, to detect ascites (fluid wave, fluctuation).

Palpation of large and small intestines

. Auscultation of the abdomen (intestinal peristalsis, intestinal tones – is marked, is not marked).

Stool, its character, color, consistence, pathological admixture, frequency of stool

(orange-yellow, homogenous, sourish stool, shaped, pale grey, pale yellow, dryish, foul, starvation stool, dyspeptic stool – loose, watery, green, in form of discrete flakes, admixture of mucus and blood, bulky, greyish, dark-brown stool).

12. Urorenal system characteristic.

Observation of lumbal region, bimanual palpation of kidneys (kidneys are palpated, are not palpated), palpation and percussion of urinary bladder (a smooth, elongated fluctuating organ is palpated above the symphysis pubis, percussion produces a flat sound above it). Painful points (pain in the lower abdomen, pain in the urethra, bladder pain, low back pain), renal colic. Pasternacky`s symptom . Urination rate . Painful difficult urination . Involuntary urination . Diurnal urine excretion . Correlation of daily urine flow and nocturnal urination .

13. Endocrine system characteristic.

Disorder of growth (gigantism, nanism), and body mass (malnutrition, obesity), allocation of subcutaneous adipose tissue . Condition of thyroid gland (lobatar and isthmus size).

Observation of genital organs (development of genitals are corresponded with age, degree of development of secondary sexual characteristic).

Date: 2014-12-22; view: 1028