Part II. Recommendations for student’s case history writing - Краткий англо-русский справочник медицинских терминов и выражений - Конспект лекций
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Краткий англо-русский справочник медицинских терминов и выражений

Part II. Recommendations for student’s case history writing

The Student’s Case History (SCH) is the part of the curriculum designated for out-of-class work. It means that after primary examination and supervision of a patient in dynamics the student has to write the SCH according to the scheme proposed by the Department.

This scheme includes the basic elements of doctor’s diagnostic and curative actions during his professional activities: history taking, examination, diagnosis, differential diagnosis, treatment, prevention of disease, analyses of effectiveness, prognosis, keeping medical documents, etc.

For a fourth year student the task is to produce these actions in a written form. Thus it would be possible to objectively evaluate the student’s level of clinical training and theoretical knowledge. The student has to answer all the questions of the Scheme. If there is no proper information for some questions the student would answer adequately naming all the points. For example "Operation - there were no operations"; "Accidents and injuries - there were no ones", "Gastrointestinal tract - there were no vomiting, diarrhea, constipation, etc."

Working with the SCH under the guidance of his teacher the student receives from him the recommendations about the list of the diseases to be considered during differential diagnosis and consulting the students in the process of taking history, examination, prescribing the treatment, making the SCH.

In section "Present Illness" it is necessary to describe the course of the patient's disease from its onset till the initial examination by the student.

For sec. "Provisional Diagnosis" the student has to name all the symptoms, which would be the ground for diagnosis, complaints and results of the physical examination.

For VII sec. "Plan..." the student has to name all the investigations, which are necessary for confirmation of the provisional diagnosis.

For IX sec. "Diary" it is necessary to give quite brief information about the patient's state on the day of the examination. Obligatory data: Complaints. General Condition (mild, moderate, severe, unconsciousness, comatose, critical, etc.). Temperature. Pulse. Respiration rate. Skin. Throat. Breathing. Heart (Sounds). Abdomen. Liver. Spleen. Stool. Urination.

If there are any disturbances in the organs and systems the details of them have to be described.

The description of the status depends on the age of the patient. In infants more attention has to be paid to peculiarities of feeding, weight, and stool.

The structure of the status changes according to the nature of the disease. In patients with neurological pathology, neurological status has to be dynamically described; for gastrointestinal disorders stool and defecation are substantial, and so on.

The instructions concerning these aspects are to be obtained from the teacher.

In X sec. "Differential diagnosis" the student first reveals the patient’s symptoms, which are common both the supposed disease and for others. Then for every considered disease the student proves why the latter is denied.

In XI sec. "Final Diagnosis" means the summary in diagnosing.

In XII sec. "Treatment…" it is necessary to write prescriptions.

 

 

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