istoricul bolii copy
TRANSCRIPT
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Cum sa facem istoricul bolii corect?
Diaconu Olguta, studenta MG5
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MEDIC PACIENT
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Simptomul major1. data aparitiei2. natura3. mod de aparitie, evolutie si durata4. localizare5. relatia cu alte simptome, functii si activitati
ale corpului6. exacerbari si remisiuni7. efectul tratamentului
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majoritatea simptomelor (exceptie cele
generale)
afectarea unor aparate si sisteme anume
unele simptome
afectarea mai multor aparate si sisteme
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1. DATA APARITIEI
data precisa a apritiei/modificarii simptomului
Z/S/L in raport cu o data precisa
sambata trecuta, de doua saptamani
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2. NATURA SIMPTOMULUI Ajutarea pacientului cu terminoligie
Descrierea durereii viscerale natura manifestarii – arsura,torsiune, constrictie,
intepatura, lancinanta, surda, fulgeranta Intensitate – usoara, moderata, agonizanta
!! Afectare psiho-nervoasa pacient – CONFIRMAREA existentei durerii – grimase, gesturi
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3. MOD DE APARITIE, EVOLUTIE SI DURATA
aparitia pentru prima data brusc VS progresiv factori precipitanti evolutia si durata fiecarui simptom continua VS intermitenta durata tranzitorie VS constanta VS crestere in
intensitate
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4. LOCALIZARE
indicarea cu mana/degetul de cater bolnav
un singur punct / iradiere locala sau la distanta
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5. RELATIA CU ALTE SIMPTOME, FUNCTII FIZICE SAU ACTIVITATI
unele simptome aparent FARA legatura directa cu organul afectat
asociere cu simptomul major
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6. EXACERBARI SI REMISIUNI
pot fi ciclice
notate + date exacte => idee generala mult mai clara a evolutiei
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7. EFECTUL TRATAMENTULUI
automedicatie (remedii brevetate remedii cu aplicatie
fizica) la recomandarea altui medic
ATENTIE! – consemnare alte internari si tratamente anterioare
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