И науки украины министерство здравоохранения украины медицинский институт

МИНИСТЕРСТВО ОБРАЗОВАНИЯ И НАУКИ УКРАИНЫ МИНИСТЕРСТВО ЗДРАВООХРАНЕНИЯ УКРАИНЫ МЕДИЦИНСКИЙ ИНСТИТУТ СУМСКОГО ГОСУДАРСТВЕННОГО УНИВЕРСИТЕТА М Е Т О Д И Ч ЕС К И Е Р Е К О М Е Н Д А Ц И И н а т е м у “КРАТКИЙ АНГЛО-РУССКИЙ СПРАВОЧНИК МЕДИЦИНСКИХ ТЕРМИНОВ И ВЫРАЖЕНИЙ” для преподавателей клинических кафедр, Медицинского института СумГУ Сумы Издательство СумГУ 2007 Методические рекомендации для преподавателей клинических кафедр Медицинского института СумГУ специальности “Краткий англо-русский справочник медицинских терминов и выражений” / Составители: В.Э. Маркевич, А.Н.Лобода, Н.П.Загородний, И.Э.Зайцев, И.В.Тарасова. – Сумы: Изд-во СумГУ, 2007. – 57 с. Кафедра педиатрии с курсом медицинской генетики CONTENTS Preface 5 ^ Part I. Scheme of student's case history: 6-16 Tittle page 6 I. General information 7 II. Complaints 7 III. Anamnesis morbi 7 IV. Anamnesis vitae 8-10 V. Physical examination 10-15 VI. Provisional diagnosis 15 VII. Plan of laboratory and instrumental examinations 15 VIII. Laboratory findings 15 IX. Cursus morbi (diary) 16 X.. Differential diagnosis 16 XI. Final diagnosis 16 XII. Treatment and its ground 16 XIII. Literature data on the present disease 16 XIV. Prognosis 16 XV. Epicrisis 16 XVI. Bibliography 16 XVII. Student’s signature 16 ^ Part II. Recommendations for student's case history writing 17-18 Part III. Short vocabulary for using in the clinic 19-64 I. Anatomical terms: 19-20 ^ II. Useful questions for obtaining case histories 21-30 III. Common findings on examination 31-35 IV. Investigations 35-38 V. Some common investigation results 38-40 ^ VI. Drugs 40-42 VII. Medical conditions 42-48 VIII. Medical abbreviations 48-64 Literature 65 СОДЕРЖАНИЕ Предисловие 5 ^ Часть I. Схема учебной истории болезни 6-16 Титульный лист 6 I. Общие сведения о больном 7 II. Жалобы 7 III. Анамнез болезни 7 IV. Анамнез жизни 8-10 V. Физикальные данные 10-15 VI. Предварительный диагноз 15 VII. План лабораторного и инструментального обследования 15 VIII. Результаты лабораторного обследования 15 IX. Дневники курации 16 X. Дифференциальный диагноз 16 XI. Окончательный диагноз 16 XII. Лечение и его обоснование 16 XIII. Обзор литературы по данному заболеванию 16 XIV. Прогноз 16 XV. Эпикриз 16 XVI. Использованная литература 16 XVII. Подпись студента 16 ^ Часть II. Рекомендации по написанию учебной истории болезни 17-18 Часть III. Короткий словарь для использования в клинике 19-64 ^ I. Анатомические термины 19-20 II. Стандартные вопросы при заполнении истории болезни 21-30 III. Общие данные при обследовании 31-35 ^ IV. Исследования 35-38 V. Некоторые общие результаты исследования 38-40 ^ VI. Лекарства 40-42 VII. Патологические синдромы 42-48 VIII. Медицинские аббревиатуры 48-64 ^ Список литературы 65 PREFACE Recent changes in the field of medical education, orientation on ESTS (European Credit Transfer System) have profoundly influenced pediatrics. This edition first of all has the aim to help the medical students studying pediatrics in English to overcome the problems of intercourse with patients in a children’s clinic and write training students’ case history. Our hope is that text will serve as a useful tool for students and residents. Part I. Scheme of student’s case history. Form of Case history: Ministry of Health of Ukraine ^ SUMY STATE UNIVERSITY MEDICAL INSTITUTE DEPARTMENT OF PEDIATRICS WITH COURSE OF MEDICAL GENETICS STUDENT’S CASE HISTORY (SCH) Patient’s name and age_______________________ Diagnosis:_________________________________ Student (In Charge): _______________ Group____________________________ Course (year)____________________ Teacher__________________________ Date of giving the SCH for checking up _______________________________ Mark Teacher's Signature________________ Date «__»___________________200_ ^ SUMY-200_ I. GENERAL INFORMATION Name _______________________________________________ Age, date of birth_________________________________ Address_____________________________________________Telephone___________________________________________Date and time of admission__________________________ By what medical establishment was directed to hospital__________________________________________ ________________________________________________With what diagnosis________________________________ ________________________________________________ II. COMPLAINTS (at time of admission)_______________ ________________________________________________ Their duration. ^ III. ANAMNESIS MORBI Mode of onset and dates of onset of the symptoms. Health immediately before illness. Supposed and possible causes, e.g. injury. Progress of the disease and appearance of fresh symptoms in their order as to onset. State of activity, appetite, bowels, sleep, changes in temperament, before and during the illness. Inquiry as to specific physical signs and symptoms if information is not volunteered, e.g. wasting or loss of weight, with reference to weight-card if available, vomiting, pain, cough, convulsions, enuresis. ^ IV. ANAMNESIS VITAE A. Previous Health Antenatal. Health of the mother during the pregnancy (medical supervision, diet, etc.). Rubella or other infections, medication, and stage of pregnancy at which it occurred. Vomiting. Toxemia. Antepartum hemorrhage. (Supplement from antenatal records in indicated cases, e.g. Wassermann reaction, Rhesus constitution). Employment during pregnancy. Postnatal. Gestational age. Birth weight. Duration of labor and method of delivery. Whether infant was born at home or in hospital (in the latter case, supplement from hospital record if indicated, including resuscitation, oxygen administration). Neonatal. Apgar score. Whether skin color, cry and respiration were normal; jaundice; feeding difficulties, rashes; twitching, flaccidity. Any other abnormalities noted. Transfusion or other treatment (confirm from hospital record). ^ Later life. Exact details of feeding in early months; whether breast-fed, and if so, for how long; type of formula feeding used; whether vitamin additives were given, and if so, the preparation's amount and duration. Weaning transition to solid feeding: age and ease with which carried out. Appetite in infancy and subsequently. History of convulsions, skin rashes, diarrhea, infectious or other illnesses. Inquire specifically measles, rubella, pertussis, mumps, and chicken pox. Immunization and tests. Operations. Recent contact with infectious diseases, especially tuberculosis. B. Development Ages of head balance, sitting and unsupported walking, talking (words and sentences), reading. Ages at which gained control of bowel and bladder (a) during day, (b) at night. Any special difficulties in toilet training. Whether child can eat and dress himself, and if so, how early he began to do so. School progress, e.g. average age of class and place in class; school report if indicated. Special aptitudes. Social adjustment with other children at home, at school. C. Family history Parents’ age and whether any consanguinity exists. (In familial conditions, including genealogical tree, showing affected members, any consanguinity marriages, etc.)- Health of close relatives (especially hereditary and congenital disorders, nervous and mental diseases). The children in their order, with details of age and health, and including death, stillbirth, and abortions. ^ PEDIGREE CHART Standard symbols for pedigree charts: - Unaffected male - Affected male - Abortion - Unaffected female - Affected female - Sex unknown - Stillbirth - Death in infancy - Unknown whether individual affected - Marriage coupling bar - Consanguineous marriage bar - Brother and sister relationship Sibs hip of which details are unknown or only the number is known: - Identical twins - Non-identical twins D. Social history Whether the mother is employed part-time or full-time, and if so, what care provided for children. Size of house, situation, sanitation, ventilation, lighting, access to playground or open air. Details of family income if relevant. E. Habits Eating: appetite, food dislikes, feeding habits of child’s parents. Sleeping: hours, disturbances, snoring, restlessness, dreaming, and nightmares. Exercise and play. Urinary, bowel. K. Disturbances Excessive bed wetting, masturbation, thumb sucking, nail biting, breath-holding, temper tantrums, tics, nervousness, undue thirst, other. Similar disturbances among members of the family. School problems (learning, perception). ^ V. PHYSICAL EXAMINATION Temperature, pulse rate, respiratory rate, blood pressure, weight, height, head circumference (The results of investigations must be compared with age standards). GENERAL APPEARANCE Does the child appear well or ill. Degree of prostration: degree of cooperation; state of comfort, nutrition, and consciousness; abnormalities; gait, posture, and coordination; estimate of intelligence: reaction to parents, physician, and examination: nature of cry and its degree; facial expression. SKIN Color (cyanosis, jaundice, pallor, and erythema), texture, eruptions, hydration, edema, hemorrhagic manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, nevi, Mongolian (blue-black, coffee-like) spots, pigmentation, turgor, elasticity, and subcutaneous nodules. Striae and wrinkling. Sensitivity, hair distribution, character, and desquamation. ^ LYMPH NODES Location, size, sensitivity, mobility, consistency. (One should routinely attempt to palpate the suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal lymph nodes). HEAD Size, shape, circumference, asymmetry, cephalohematoma, fossae, craniotabes, fontanel (size, tension, number, abnormally late or early closed, suture, dilated veins, scalp, hair-texture, distribution, parasites, etc.). FACE Symmetry, paralysis, the distance between a nose and mouth, depth of the nasolabial folds, the bridge of the nose, a size of the mandible, swellings, hypertelorism, Chvostek’s sign, tenderness over the sinuses. EYES Photophobia, visual acuity, muscular control nystagmus, Mongolian slant, Brushfield spots, epicanthic folds, lacrimation, discharge, the lids, exophthalmos or enophthalmos, the conjunctivas; papillary size, shape, and reaction to light and accommodation; medial (corneal opacities cataracts), fundus, visual fields (in older children). NOSE Exterior, shape, mucosa, patency, discharge, bleeding, pressure over the sinuses, flaring of the nostrils, the septum. THROAT The tonsils (size, inflammation, exudates, crypts, inflammation of the anterior pillars), mucosa, hypertrophic lymphoid tissue, postnasal drip, epiglottis, voice (hoarseness, stridor, drunting, type of cry, speech). EAR The pinnas (position, size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoid tenderness and swelling, hearing. NECK Position (torticollis, opisthotonos, inability to support the head, mobility), swelling, the thyroid (size, contour, bruit, isthmus, nodules, tenderness), lymph nodes, veins, position of the trachea, sternocleidomastoid muscle (swelling, shortening), webbing, edema, auscultation, movement, tonic neck reflex. THORAX Shape and symmetry, the veins, retractions and pulsations, heading, Harrison’s groove, flaring of the ribs, pigeon breast, funnel shape, size and position of the nipples, breasts, length of the sternum. Intercostal and substernal retraction, asymmetry, the scapulas, clavicles. EXTREMITIES A. General: deformity, hemiatrophy, bowlegs (common in infancy), knock-knees (common after two years); paralysis, edema, coldness, posture, gait, stance, asymmetry. B. Joints: swelling, redness, pain, limitation of motion, tenderness, rheumatic nodules, carrying angle of the elbows, tibiatorsion. C. Hands and feet: extra digits, clubbing, simian lines, curvature of the little finger, deformity of the nails, splinter hemorrhages, flat during the first two years, abnormalities of the feet, dermatoglyphics, the width of the thumbs and big toes, syndactily, length of various segments, dimpling of the dorsa, temperature. D. Peripheral vessels: presence, absence or diminution of arterial pulses. ^ SPINE AND BACK Posture, curvatures, rigidity, a webbed neck, spina bifida, pilonidal dimple or cyst, tufts of hair, mobility, Mongolian spots, and tenderness over the spine, pelvis, and kidneys. LUNGS Type of breathing, dyspnea, duration of expiration, cough; expansions, local fremitus; flatness or dullness to percussion, resonance, breath and voice sound, rales, crepitation, wheezing. Percussion: inferior border of the lungs Border Right lung Left lung ^ CARDIOVASCULAR SYSTEM Inspection and palpation of the heart area (apex beat, cardiac humpback, murmurs, etc.). Percussion: border of the heart dullness (relative) Border In child Normally Right Upper Left Auscultation: quality of heart sounds, compared with pulse as to rate and rhythm. Murmurs (location, position in cycle, intensity, pitch, effects of change of position, transmission, and effect of physical exercises). Blood pressure. ABDOMEN Size and contour, visible peristalsis, respiratory movement, the veins (distention, direction of flow), umbilicus, hernia, musculature, tenderness and rigidity, tympana, shifting, dullness, rebound tenderness, pulsation, palpable organs or masses (size, shape, position, mobility), fluid wave, reflexes, bowel sounds. LIVER Size (palpation, percussion). Tenderness. Surface. Inferior margin. SPLEEN Palpable or not. Size, surface, tenderness. ^ UROGENITAL SYSTEM Urination. Frequency, painfulness, retention of urine. Pasternatsky’s sign. Genitalia. Abnormal development. RECTUM AND ANUS Irritation, fissures, prolapse, anal atresia (in newborns). STOOL NERVOUS SYSTEM General behavior, level of consciousness, intelligence, emotional status, memory orientation; illusion; ability to understand and to communicate, speech, ability to write, performance of skilled motor acts. Vegetative reactions. Dermography. Reflexes: Babinski's, Brudzinski's; meningeal. Organs of sense. Sense of smell, sight, taste, touch, hearing. ^ VI. PROVISIONAL DIAGNOSIS (Diagnosis based on the facts of the Case History and Physical Examination). PLAN OF LABORATORY AND INSTRUMENTAL EXAMINATIONS LABORATORY FINDINGS ^ CURSUS MORBI (DIARY) Date Results of examinations of patient Prescription 1. 2. ^ X. DIFFERENTIAL DIAGNOSIS XI. FINAL DIAGNOSIS (TO GROUND) XII. TREATMENT AND ITS GROUND (FOR THE DISEASE IN GENERAL AND FOR THE PRESENT ONE IN PARTICULAR) XIII. LITERATURE DATA ON THE PRESENT DISEASE (etiology, pathogenesis, clinical manifestations, classification, treatment, and prevention in general and concerning the present patient). ^ XIV. PROGNOSIS XV. EPICRISIS XVI. BIBLIOGRAPHY (list of used literature) XVII. STUDENT’S SIGNATURE

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