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Medical history chart

Inspection by the attending physician together with the head of the department

Date and time of inspection.

Complaints

1. The state of the ENT organs.

2. The state of other organs and systems.

Medical history

Subjective anamnesis (according to the patient): the time of the appearance of the first signs of ENT disease, the dynamics of its course, the nature of the previous treatment, its effectiveness (in detail); if surgical treatment has been previously carried out, if possible indicate its volume.

An anamnesis is objective: 1) data on ENT disease according to references, radiographs and other documents; 2) the same about other diseases.

Anamnesis of life

Data on heredity, brief information about existing diseases of other organs and systems (diabetes mellitus, mental illness, damage to the cardiovascular system, etc.), infectious diseases (tuberculosis, sexually transmitted diseases, viral hepatitis, AIDS or HIV infection) , about working and living conditions, about bad habits (drinking alcohol, drugs, substance abuse, smoking, etc.). The presence of allergic manifestations (intolerance to drugs, certain foods, bronchial asthma, Quincke's edema, eczema, allergic rhinitis) is noted both in the patient himself and his parents and children. Indicate whether the patient has previously received steroid treatment, whether there were surgical interventions and blood transfusions.

Current status (Status praesens)

General inspection. General condition (satisfactory, moderate, severe). Patient behavior (active, passive, forced position). Build (normosthenic, hypersthenic and asthenic). Nutrition (high, low, normal). The skin and visible mucous membranes: color (pale pink, cyanotic, icteric, pale, earthy); the presence of pigmentation, rashes, telangiectasias, scars, trophic changes.

Subcutaneous fat (development, places of the greatest deposition of fat), edema (localization, prevalence, severity). Peripheral lymph nodes: localization of palpable lymph nodes, their size, consistency, soreness, mobility, fusion between themselves and with surrounding tissues, skin condition over the nodes.

Nervous system ', consciousness (clear, confused); the presence of neurological disorders; meningeal and focal symptoms; cranial nerve function; visual acuity, the presence of diplopia, ptosis, range of motion of the eyeballs, the reaction of the pupils to light; symmetry of nasolabial folds with teeth grinning; tongue position when protruding.

The state of the psyche ', orientation in place, in time and in a situation, the correspondence of intelligence to age.

Musculoskeletal system (muscles, bones, joints).

Circulatory system: auscultatory heart sounds, rhythm, blood pressure, pulse.

Respiratory system: respiratory rate, if there is shortness of breath, indicate its nature (inspiratory, expiratory, mixed); percussion of the lungs (sound clear pulmonary, blunt, boxed, tympanic); auscultatory: pulmonary respiration weakened, enhanced, vesicular, hard.

Digestive organs: palpation and percussion of the abdominal organs (liver, spleen), physiological poisoning.

Genitourinary system: the presence of dysuric disorders, the definition of Pasternatsky's symptom.

Endocrine system: increase or decrease in body weight, thirst, hunger, sensation of heat, chills, muscle weakness, eye gloss; palpation of the thyroid gland (size, consistency, soreness).

Inspection of JIOP organs. During an external examination, attention is paid to the appearance of the ENT organs. There are changes in the shape of the external nose, the projection area on the face of the walls of the frontal and maxillary sinuses, auricle, neck (for example, “there is a retraction of the nasal back in the bone section”, “a shift of the nose pyramid to the right”, “a star scar on the front of the neck in the lower region edges of the thyroid cartilage ”, etc.).

Before endoscopy of the corresponding JIOP organ, palpation is performed (regional lymph nodes, front and lower walls of the frontal sinuses, exit sites of the I and II branches of the trigeminal nerve, anterior walls of the maxillary sinuses, cartilage of the larynx, etc.).

Consistently perform a study of all ENT organs.

Nose and paranasal sinuses. Nasal breathing is examined using a cotton swab test, which allows it to be assessed as free or difficult (inhalation or exhalation is difficult). If necessary, rhinopneumometry is performed.

If there are complaints of a sense of smell, odorimetry is performed using a set of odorous substances: 0.5% solution of acetic acid (No. 1), 70% ethyl alcohol (No. 2), tincture of valerian (No. 3), ammonia (No. 4). For a more accurate study of smell, olfactometers are used.

Anterior rhinoscopy is performed sequentially, first from the right, then from the left. Separately, on the one and the other side, the state of the vestibule of the nasal cavity is recorded, attention is paid to the type of mucous membrane (color, gloss, humidity), the location of the nasal septum (in the presence of deformation, indicate its nature, location, severity, predominant displacement in one direction or another), sizes of nasal concha, lumen width of nasal passages, presence of discharge in their lumen and its nature (mucous, purulent, hemorrhagic, crust). If necessary, determine the contractility of the nasal mucosa during anemia.

Nasopharynx: The nasopharynx is examined with posterior rhinoscopy using a nasopharyngeal mirror and an endoscope. The condition of the mucous membrane, pharyngeal (adenoids of I, II and III degree, signs of adenoiditis) and tonsils, pharyngeal orifice of the auditory tube, view of the posterior edge of the vomer, choanal clearance, posterior ends of the nasal concha, the presence and nature of the discharge in the posterior nasal passages are noted. If necessary, perform a digital examination.

Oropharynx. When oroscopy pay attention to the condition of the mucous membrane of the oral cavity, teeth and gums (the presence and severity of dental caries, periodontal disease, periodontitis), excretory ducts of the salivary glands. The nature of the mucous membrane (color, gloss, moisture), the condition of the palatine arches (hyperemic, infiltrated, swollen, fused with tonsils), the size of the palatine tonsils (behind the arches, hypertrophy of I, II or III degree), their surface (smooth or bumpy), the state of lacunae (not expanded or expanded), the presence of a pathological secretion in them (caseous, purulent plugs, liquid, thick purulent discharge are released when pressed), the state of the mucous membrane and lymphoid formations of the posterior pharyngeal wall. Swallowing function: evaluate the symmetry and mobility of the soft palate.

Hypopharyngoscopy ', the symmetry of the walls of the pharynx (pear-shaped sinuses), the presence of salivary lakes in the piriform sinus or foreign bodies, the size and condition of the lingual tonsil. Valecules are normally free.

Larynx. Normally, the larynx is of the correct form, passively mobile, the symptom of cartilage crunch is pronounced. Palpation of regional lymph nodes is performed. Indirect laryngoscopy assesses the condition of the mucous membrane of the epiglottis, the scapular adhortan and vestibular folds, the area of ​​the arytenoid cartilage, the intercarpal space. Normally, it is pink, moist, shiny, with a smooth surface. The vocal cords are pearly gray, with phonation symmetrically mobile, completely close, when you inhale the glottis is wide (normally from 15 to 20 mm), the sub-vocal space is free. The voice is sonorous, breathing is free. Identified pathology specifically indicate and characterize.

The ears. An external examination sequentially determines the shape of the auricles, the presence of inflammatory infiltrates and wounds in the parotid region, changes in the shells and external auditory canals. Pain on palpation of the parotid region, tragus and external auditory meatus is assessed.

Otoscopy is performed first on the side of a healthy, then a diseased ear; if both ears bother the patient, then the study begins with the one from which there is no discharge. The nature and amount of discharge in the external auditory canal (the mucous, purulent, purulent, hemorrhagic, in the amount of 1-2 "quilted" or more, odorless or with a ichorous odor), the width and shape of the external auditory canal (the presence of inflammatory changes in the skin, sulfur masses) are assessed. , exostoses, overhanging of the posterior upper wall).

When describing the tympanic membrane (Mt), attention is paid to its color (normally it is gray with a prelamuture shade) and identification points (a short process and a handle of a malleus, light cone, front and back folds, stretched and unstretched parts of Mt)).
In pathology, the eardrum can be hyperemic, infiltrated, retracted or swollen, thickened, the light cone is shortened or absent. In the presence of perforation, its size, localization, shape, type (central, marginal), gaping or the presence of a pulsating reflex are determined. In a number of cases, through the extensive perforation, the formation of the tympanic cavity is visible (thickened mucous membrane, granulation, remains of the auditory ossicles, etc.).

In the event that the patient has no complaints about the state of hearing, conduct a study of the perception of whispering speech, the result of which is fixed for each ear in the form (SR AD and AS = 6 ml). When detecting hearing loss and ear pathology, an auditory passport must be compiled and a study of the barofunction of the auditory tubes should be carried out. If there are complaints of dizziness and imbalance, an investigation of the vestibular function is performed (see below for a recording of the results of the study).

The results of hearing research in a whisper and colloquial speech, as well as using tuning forks, are entered into the auditory passport. Below is a sample auditory passport of a patient with right-sided conductive hearing loss.

Hearing passport

Conclusion: there is a decrease in hearing on the right type of impaired sound conduction.

The auditory passport of a patient with left-side sensorineural hearing loss is as follows.

Hearing passport

The Weber Experience (W)

Conclusion: hearing loss on the left as a violation of sound perception.

If necessary, the results of the experiments of Jelle (G), Bing (Bi), Federichi, Schwabach (Sch) are included in the auditory passport.

In the event that deviations are detected during vestibular tests, caloric and rotational tests are additionally performed, and in the presence of equilibrium disorders, stabilometry. The results obtained are drawn up in the form of a passport for vestibulometric studies, the vestibulologist analyzes them and draws a conclusion.

Concluding the examination of the patient, the attending physician should analyze the results of studies previously performed on an outpatient basis or in other medical institutions (laboratory tests, radiographs, ECG, audiograms, conclusions of consultants, extracts from the medical history, etc.). The most significant of these documents are taken into account when establishing a diagnosis along with the results of studies conducted in the hospital.

The clinical diagnosis is made by the attending physician and the head of the department after a joint examination of the patient and is formulated in accordance with the nomenclature or the generally accepted classification.

The plan of examination and treatment of the patient is made by the attending physician together with the head of the department at the first examination in the hospital. In medical institutions of Moscow, in accordance with the requirements of insurance medicine, when planning diagnostic and therapeutic procedures, it is necessary to take into account the recommendations of the management “Medical Standards of Inpatient Care” (M., 1997). In the appointment of additional studies that go beyond the "standards" in the medical history, justification of the appropriateness of their conduct is necessary.

The plan indicates the necessary and general clinical, biochemical, radiological, special functional (ECG, EEG, REG, dopplerography, angiography, etc.) and ENT studies (audiological, vestibulometric, etc.), necessary consultations of doctors of related specialties, planned surgical treatment indicating the method of anesthesia.

Inspection by the head of the department

Confirmation of the clinical diagnosis, agreement with the plan of examination and treatment of the patient, additions.

Preoperative Epicrisis

1. Name, age of the patient, clinical diagnosis, objective signs of a surgical disease (for example, there is a pronounced curvature of the nasal septum in the bone section with impaired breathing function).

2. The duration of the disease, the frequency of exacerbations; evidence of the ineffectiveness of conservative treatment; The main results of laboratory and functional studies carried out in preparation for the operation.

3. The purpose of the operation and its main stages, the proposed method of anesthesia, a note on the informed consent of the patient to the operation, a psycho-preventive conversation, as well as the fact that the patient is warned about possible complications of the operation. The patient’s own signature is mandatory, for children under the age of 15 years - the signature of the parents. Surgeon and assistants are indicated.

Signature of the curator.

Signature of the department head.

In the event that the operation is planned with the participation of an anesthesiologist, then there must be a record of the patient's condition and the necessary preparations for anesthesia.

Operation (name, number)

Date, time of the beginning and end of the operation. Local anesthesia ... (or narcosis). Sequentially mark the incision ..., separation ..., removal ..., opening ..., exposure ..., inspection under a microscope ..., features of the pathological process ..., tamponade ..., suturing .. ., bandage .... To note the volume of blood loss ..., complications (if any), the condition of the patient immediately after surgery and after withdrawal from anesthesia. Indicate what material is sent for histological examination. The postoperative diagnosis. Destination.

Surgeon.

Assistant.

All operations are controlled (appointment, result, outcome) by the head of the department personally, and, if necessary, by the head of the department or his deputies.

Keeping a diary. In the first 3 days after surgery, the attending physician makes detailed entries in the diary; in severe cases, daily diaries and notes of the doctor on duty are needed, reflecting the dynamics of the patient's condition during the period when the attending physician is absent. Entries in the diary should contain notes of the attending physician on the receipt of the results of laboratory and functional studies with an interpretation of these results. In the diary, the attending physician must also justify all new appointments.

Every 10 days, a staged epicrisis is necessarily issued, which briefly reflects the patient’s condition, the main results of the examination and treatment (including surgery), and indicates a plan for further management of the patient.

If the patient is incapacitated for 30 days (taking into account the days of incapacity for work before admission to the hospital), then he is presented to the clinical expert commission (CEC) to decide on the validity and need for further extension of the incapacity certificate.

In the event that the duration of the period of incapacity for work is 4 months, it is imperative that the patient be referred to the Medical and Social Expert Commission (MSEC) to decide on the advisability of transferring him to disability or the possibility of further extension of the certificate of incapacity for work (if there are prospects of cure).

The day before discharge, the patient is examined by the head of the department in order to assess the objective condition of the patient, the results of surgical treatment and confirm recommendations for further treatment at the place of residence.

Prescribed Epicrisis

Name, patronymic, was in the ENT department from ... to ... 2001

regarding ............. (final diagnosis), date of operation, performed under ............. anesthesia ........... ... (full name of the operation). The operation and the postoperative period, complications, especially the course of the operation, the main operational findings, the results of histological examination of the directional material, especially the postoperative period). Briefly objective picture of the state of the operated organ (reactive phenomena, functions, for example, hearing in the right ear before surgery: SR - at the sink, at discharge: SR - 3 m).

It is discharged in satisfactory condition under the supervision of an otorhinolaryngologist at a regional clinic, recommended ... (the nature of the treatment effects, the number of days at home).

Therapist:

Department Head

(Deputy Chief Physician of the Hospital for Surgery):

When the patient is discharged, the attending physician also fills out a card of the patient who has left the hospital.
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