The presence of a recent injury or a history of injury. Closed craniocerebral injury. Treatment of traumatic brain injury

10.07.2020 Tools and accessories

Catad_tema Back pain - articles

Patient with acute pain in the lower back general practice

Low back pain (LBP) is an extremely common symptom that neurologists, internists and family doctors encounter almost daily.
Depending on the duration, LBP is divided into acute, subacute and chronic. LBP is considered acute if it lasts 6 weeks or less, subacute if it lasts 6–12 weeks. Chronic pain lasts more than 12 weeks. Depending on the duration of pain, a prognosis can be assumed: 60% of patients with acute LBP return to work within a month, 90% within 3 months.
The causes of LBP are varied. For convenience, they are usually grouped into 3 categories: potentially dangerous diseases, sciatica and nonspecific pain symptoms caused by mechanical causes.

Potentially dangerous diseases
This group includes tumors, infections, spinal injuries, and cauda equina syndrome. They can be suspected during history taking and physical examination (Table 1). These diseases require immediate further examination and treatment.

Sciatica
Pain during sciatica radiates to the leg and corresponds to the zone of innervation of the compressed root or nerve. Sometimes the pain is localized only in the leg. The roots most often affected are L5 and S1 (Fig. 1). Sciatica is often accompanied by extremely severe pain, but in most cases it resolves with conservative therapy. Sometimes surgical treatment is indicated.

Nonspecific back pain caused by mechanical causes
Some patients report pain localized only in the back, not associated with radicular symptoms or any serious diseases. This category includes “mechanical” BNJS. Improvement in the patient's condition is achieved with conservative treatment.
The basis of differential diagnosis is anamnesis and physical examination.

Anamnesis
Diagnosis of LBP requires a careful history taking. Mechanical causes of acute LBP cause dysfunction of the musculoskeletal structures and ligamentous apparatus. Pain can come from the tissues of the intervertebral disc, joints and muscles. The prognosis for pain of mechanical origin is usually favorable.
Secondary pain requires searching for and treating the underlying disease. Secondary pain is much less common than pain caused by mechanical causes. Secondary LBP can be suspected in persons under 20 and over 50 years of age. Clinical symptoms contributing to the diagnosis are listed in Table. 1. Rarer causes of secondary acute LBP, not included in the table, are metabolic bone lesions, referred pain in diseases of the abdominal organs, retroperitoneum and pelvis, Paget’s disease, fibromyalgia, psychogenic pain.
Alarming symptoms that should alert the doctor and require further examination are listed in Table 2.

Physical examination
Gait and posture
Assessment of gait and posture is necessary in all patients with complaints of low back pain. Scoliosis may be functional, but it may also indicate muscle spasm or neurogenic disorders.
If the L5 root is affected, difficulties arise when walking on your toes; if the S1 root is affected, it becomes difficult to walk on your toes.

Range of motion
The patient's forward bending, extension, lateral bending, and upper body rotation should be assessed. Pain when bending forward is more common and is usually associated with mechanical causes. If pain occurs with spinal extension, spinal canal stenosis should be considered (Figure 2). Unfortunately, assessment of range of motion has limited diagnostic value, although it is useful for assessing the effectiveness of treatment.

Palpation and percussion of the spine
Pain on palpation and percussion of the spinous processes of the spine may indicate the presence of a fracture or infection of the vertebra. Palpation of the paravertebral space allows you to outline painful areas and identify muscle spasms.

Heel-toe walking and squat test
The inability to walk from heel to toe or squat is common in cauda equina syndrome and other neurological disorders.

Palpation of the sciatic notch
Pain on palpation of the sciatic notch with radiation to the leg indicates irritation of the sciatic nerve.

Tests with raising a straight leg (provocative tests)
The patient lies on his back, the doctor raises his straightened leg on the affected side. The angle of leg elevation should be assessed. The appearance of pain in the range of 30–60o indicates a positive Lasègue symptom. Bending the leg at the knee joint should reduce pain, and squeezing the popliteal area should increase it. Pressing the knee joint with a straightened and elevated leg while dorsiflexing the foot will also increase the pain.
The straight leg raise test gives a positive result in 95% of patients with a disc herniation; however, it is also positive in 80–90% of patients in whom no signs of disc protrusion are found during surgery. Another test - with raising the straight leg opposite the side of the lesion (same as in the previous test, is considered positive when pain occurs) - is less sensitive, but much more specific for diagnosing a disc herniation.

Reflexes, muscle strength and sensitivity
The study of knee and ankle (Achilles) reflexes in patients with radicular symptoms often helps in the topical diagnosis.
The Achilles reflex weakens (falls out) when the L5–S1 disc is herniated. With a herniated disc at L4–L5, the tendon flexures in the legs do not fall out. A weakened knee reflex is possible with radiculopathy of the L4 root in elderly patients with spinal stenosis. Disc herniations at the L3–L4 level are very rare.
Weakness in hallux and toe extension indicates L5 root involvement (Figure 4). Damage to the S1 root is characterized by paresis of the gastrocnemius muscle (the patient cannot walk on his toes).
Assessing the sensitivity of the skin of the leg and foot (Fig. 4) also allows us to assess the level of damage. S1 radiculopathy causes hypoesthesia along the back of the leg and the outer edge of the foot. Compression of the L5 root leads to hypoesthesia of the dorsum of the foot, big toe and first interdigital space.

Rapid neurological examination
At the initial presentation of a patient with LBP and radicular symptoms, a neurological examination may be limited to only a few tests: assessing the strength of dorsiflexion/extension of the foot and big toe (as an option - walking on toes and heels), knee and Achilles reflexes, checking the sensitivity of the foot and lower leg, as well as Lasegue's breakdown. This abbreviated examination allows us to identify clinically significant radiculopathy associated with lumbar disc herniation. If there is no improvement after a month, further examination or referral to a specialist is necessary. If symptoms progress, examination should be carried out immediately.

Rice. 1.
Variants of compression of the spinal cord roots at the lumbar level of the spine

Table 1.
Causes of LBP

Diseases	Keys to diagnosis
Nonspecific LBP caused by mechanical causes: diseases and damage to the osteoarticular and musculo-ligamentous apparatus	The pain is localized in the lumbosacral region, there are no radicular symptoms
Sciatica (usually disc herniation L4-L5 and L5-S1)	Radicular symptoms from lower limbs, positive test with straight leg raising (Lasegue maneuver)
Spinal fracture (compression fracture)	Previous injury, osteoporosis
Spondylisthesis (slippage of the body of the overlying vertebra, often at the level of L5-S1	Physical activity and sports are common provoking factors; pain intensifies when straightening the back; X-ray in oblique projection reveals a defect in the interarticular part of the vertebral arches
Malignant diseases (myeloma), metastases	Unexplained weight loss, fever, changes in serum protein electrophoresis, history of malignancy
Diseases connective tissue	Fever, increased ESR, antinuclear antibodies, scleroderma, rheumatoid arthritis
Infections (discitis, spinal tuberculosis and osteomyelitis, epidural abscess)	Fever, parenteral drug administration, history of tuberculosis, or positive tuberculin test
Abdominal aortic aneurysm	The patient is tossing about, the pain does not decrease with rest, a pulsating mass in the abdomen
Cauda equina syndrome (tumor, median disc herniation, hemorrhage, abscess tumor	Urinary retention, urinary or fecal incontinence, saddle anesthesia, severe and progressive weakness of the lower extremities
Hyperparathyroidism	Gradual onset, hypercalcemia, kidney stones, constipation
Ankylosing spondylitis	In most cases, men in the 3rd decade of life, morning stiffness, positive HLA-B27 antigen, increased ESR
Nephrolithiasis	Colicky pain in the lateral regions radiating to the groin, hematuria, inability to find a comfortable body position

Rice. 2.
Spinal stenosis

Due to the growth of osteophytes, the canal acquired a characteristic trefoil shape. In this case, possible compression of both the individual root and the roots of the cauda equina leads to mono- or polyradiculopathy. Often, with spinal stenosis, pseudo-intermittent claudication occurs: pain in the lumbosacral region (possibly in the buttocks and legs) appears while walking and goes away when the patient sits down.

Table 2.
Alarming symptoms in acute LBP

Anamnesis
Malignant neoplasms
Unexplained weight loss
Immunodeficiency (HIV infection, diabetes and etc.)
Long-term use of steroids
Intravenous administration medicinal (narcotic) drugs
Urinary tract infections
Pain that gets worse or doesn't get better with rest
Fever
Trauma, depending on age (eg, falls from height or motor vehicle injury in younger patients, falls from height or heavy lifting in older individuals or patients with potential osteoporosis)
Urinary retention or incontinence
Urinary or fecal incontinence

Physical examination
Saddle anesthesia (Fig. 3)
Loss of anal sphincter tone
Severe/progressive movement disorders in the lower extremities
Local pain on palpation and percussion of the spinous processes of the spine
Significant limitation of range of motion in the spine
Neurological symptoms lasting more than one month

Table 3.
Indications for radiography in acute LBP

Rice. 3.
Saddle anesthesia

Saddle anesthesia is often a manifestation of cauda equina syndrome, which in addition to anesthesia may include: bilateral sciatica, sudden onset of urinary retention or incontinence, fecal incontinence, lower flaccid paraparesis.

Rice. 4.
Symptoms of damage to the L4-S1 roots

Table 4.
Waddel criteria

	Inappropriate reaction
Soreness	Superficial (with slight pressure) and inconsistent with anatomical structures
Simulation
Vertical load on the head of a standing patient causes LBJ
	Passive rotation of the shoulder girdle and pelvis in one plane causes LBJ
Symptom discrepancy	Discrepancy between symptoms when performing a test with straight leg raising in a sitting and lying position
Regional disorders
Muscle weakness	Like a “gear”
Sensitivity	Loss of sensation that does not correspond to the dermatome
Patient overreaction	Excessive grimacing, talkativeness, or tremors during examination

Laboratory tests
As a rule, laboratory tests are not needed in the initial stages of examining patients with acute LBP. If a tumor or infectious process is suspected, a general blood test and ESR are required. Other blood tests are recommended only if a primary disease is suspected, such as ankylosing spondylitis or myeloma (HLA-B27 test and serum protein electrophoresis, respectively). If pathology is suspected urinary tract a general urine test is indicated.
To detect metabolic bone diseases, calcium, phosphate levels and alkaline phosphatase activity are determined.

X-ray examination
Indications for radiographic examination in acute LBP are listed in Table. 3.
It does not make sense to perform spinal x-rays on all patients with LBP, since certain changes can be detected in almost all patients. An X-ray of a patient who does not complain of back pain may show pronounced changes (osteochondrosis, deforming osteoarthritis, sacralization or lumbarization of the vertebrae). In contrast, in a patient with LBP, changes may be minimal.
If cauda equina syndrome or progressive muscle weakness occurs, a computed tomography, magnetic resonance imaging, myelography. Carrying out these studies is also advisable in preparation for surgery.

Treatment
Most patients with acute LBP require only symptomatic treatment. At the same time, about 60% of patients note improvement during the first 7 days of treatment and the vast majority - within 4 weeks. Patients should be instructed that if motor or sensory functions deteriorate, pain increases, or pelvic organ dysfunction occurs, they should immediately consult a doctor again for further examination.
As pain decreases, patients should be gradually returned to normal activities. Maintaining activity within the limits allowed by pain has been shown to promote faster recovery than bed rest or lumbar immobilization.
Patients with this pathology are also helped by moderate physical exercise with minimal stress on your back.
Medicines used for acute LBP include nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol. It is also possible to use muscle relaxants. Patients taking opioid analgesics have been shown to return to normal activities no faster than those taking NSAIDs or paracetamol. Muscle relaxants have a greater analgesic effect than placebo, but do not have advantages over NSAIDs. Oral glucocorticoids and antidepressants have no effect in such patients and their use is not recommended.
Currently, new drugs have appeared that act directly at the level of the spinal cord, which makes it possible to avoid many of the undesirable effects characteristic of the above groups of drugs. The first representative of a new class of substances, selective neuronal potassium channel openers (SNEPCO = selective neuronal potassium channel opener) is flupirtine i. It has a combination of analgesic and muscle relaxant properties, which is especially important in the treatment of musculoskeletal pain and muscle spasms.
Greatest effect Flupirtine should be expected for pain syndromes, the pathogenesis of which is a mirror image of the properties of the drug. Considering that it has both an analgesic and muscle relaxant effect, these are those acute and chronic diseases in which pain is caused by muscle spasm, especially pain in the musculoskeletal system (neck and back), muscle spasms in diseases of the joints.
Unlike traditionally used painkillers (NSAIDs, opioid analgesics, muscle relaxants), it does not inhibit cyclooxygenase, does not have opioid and general relaxant effects and is therefore free from the inherent effects of these substances side effects.
Several randomized studies have demonstrated the effectiveness of manual therapy. Some patients may find it helpful to wear special insoles or arch supports in their shoes. But exercises to “stretch” the spine, transcutaneous electrical stimulation, injections into trigger points or intervertebral joints and acupuncture usually have no effect. For some patients in whom conservative therapy does not respond and activity-limiting symptoms persist after a month of treatment, surgical treatment may be indicated.
Patients who, already at the first visit to the doctor, have identified the symptoms listed in table. 2, need prompt further examination and qualified treatment.

Difficulties of diagnosis in acute LBP
Sometimes complaints of acute LBP are due to nonorganic reasons. Psychosocial reasons can be economic (for example, increased financial compensation for time of incapacity) or social (job dissatisfaction) of a nature. If psychosocial factors are suspected, the doctor may ask the patient to mark the distribution of pain on a figure representing the human body. If the distribution of pain does not correspond to anatomical landmarks, psychogeny is highly likely. There is also a set of Waddel criteria (Table 4), which can easily be performed during a routine physical examination. G. Waddel noted that most patients with LBP of organic origin do not have these criteria or only one criterion is identified. If the patient has three or more Waddel criteria, we can speak with a high degree of confidence about psychogenic LBP or malingering.

Literature:
Bratton R.L. Assessment and management of acute low back pain. American Family Physician, 1999; 60(8):2299–2306.
Material prepared by R.I. Elagin, Ph.D. honey. sciences,
Department of Clinical Pharmacology MMA named after. THEM. Sechenov

Katadolon® - Drug dossier

Diagnostic tactics. Anamnesis.. In the anamnesis, not only current complaints are important, but also those that have already disappeared.. All previous diseases should be identified, including operations, injuries and mental disorders.. Details such as family history may also be significant anamnesis, vaccination and medication data, professional anamnesis, clarification of the travel route, information about the sexual partner, the presence of animals in the environment. Physical examination...

Anamnesis. Burdened family anamnesis regarding anemia, any manifestations of liver and biliary tract diseases. Contact with patients with infectious hepatitis, stay in hepatitis-endemic regions during the last 2 months, parenteral interventions, drug administration, casual sexual intercourse during the last 6 months. Working with hepatotoxic substances. Alcohol abuse. Treatment with hepatotoxic drugs. Biliary colic...

Pathomorphology. The spleen is enlarged and full of blood. The vessels of the portal system and spleen are enlarged, tortuous, they may contain aneurysms, hemorrhages, and parietal thrombi. Changes in the liver depend on the cause of PG. Varicose veins of the esophagus, stomach, rectum. Anamnesis. Presence of cirrhosis or chronic hepatitis. Indication of a history of gastrointestinal bleeding. Indications of alcohol abuse, blood transfusions, viral hepatitis B, C...

The true conjugate is less than 6.5 cm. Vaginal delivery is impossible even with the use of fetal destruction surgery. Diagnostics. Anamnesis: infantilism, past illnesses and injuries, obstetric anamnesis. Objective examination: general examination, height 150 cm and below, assessment of Michaelis rhombus, spinal curvature, joint mobility; a saggy belly in multiparous women and a pointed belly in primiparous women.

Huntington's chorea (choric dementia) is a hereditary disease. Choreic hyperkinesis appears at the age of 30-40 years, and later progressive dementia occurs, reaching the complete collapse of the personality. When differentiating from senile chorea, family history is of decisive importance. anamnesis; at the onset of the disease, diagnosis is facilitated by the administration of L-DOPA, which leads to a sharp increase in hyperkinesis.

Etiology. The vast majority of cases (more than 95%) are of rheumatic etiology. Overt rheumatic anamnesis can be collected from 50-60% of patients. Almost always debuting before the age of 20 years, after 10-30 years the defect becomes clinically pronounced. Non-rheumatic cases of the defect include severe calcification of the cusps and annulus of the mitral valve, congenital anomalies (for example, Lutembasche syndrome - 0.4% of all congenital heart diseases), neoplasms and blood clots in the mitral valve area and...

Risk factors. Gluten enteropathy. Family anamnesis dermatitis herpetiformis. Oncological diseases. Insolation. Clinical picture. Skin changes.. True polymorphic rashes: urticarial, erythematous elements, tense blisters on an edematous erythematous background (can also occur on unaltered skin) with a pronounced tendency to grouping and herpetiform arrangement.. The cover of the blisters is dense, the contents are first serous, then becomes cloudy...

Anamnesis. Contact with a patient with SI (hospital patients or care staff with inflammatory changes on the skin, mucous membranes or other organs, definitely or presumably of staphylococcal etiology) 1-10 days before the present illness. Consumption of food products infected with staphylococcus. The development of a purulent-inflammatory disease in a hospital setting, most often after 3 days from the moment of hospitalization. Surgical intervention with...

Clinical picture. Anamnesis. Chronic diseases of the stomach, duodenum, liver, blood. Complaints of weakness, dizziness, drowsiness, fainting, thirst, vomiting fresh blood or coffee grounds, tarry stools. Objective data. Pale skin and visible mucous membranes, dry tongue, rapid and soft pulse, blood pressure with minor blood loss is initially increased, then normal.

to subepicardial, which can lead to the development of secondary MI. The mechanism of rupture of the heart wall during blunt trauma is a sharp increase in pressure in the chambers of the heart during its anterior-posterior compression or a sharp influx of blood from the inferior vena cava during a seat belt injury. Clinical picture and diagnosis. . Complaints and anamnesis.. The main complaints in case of heart contusion are chest pain, shortness of breath and interruptions in the functioning of the heart.. Often numerous complaints...

Anamnesis. Indication on the consumption of thermally unprocessed foods, products home canning and preserved under anaerobic conditions, mainly vegetables and mushrooms, as well as sausage, ham, smoked and salted fish, contaminated with bacteria. With wound botulism - lacerated or crushed wounds with significant tissue necrosis. Periods of illness. Incubation, lasting from 2 hours to 7 days (rarely up to 14 days).

. The acute form of Hirschsprung's disease manifests itself in newborns in the form of low congenital intestinal obstruction. Anamnesis. For Hirschsprung's disease, in contrast to other forms of megacolon (tumor, megacolon against the background of atonic constipation in the elderly, toxic megacolon with nonspecific ulcerative colitis), constipation is typical from birth or early childhood. Parents often note the presence of endocrine, mental and neurological abnormalities.

HSV-1 infection in people over 4 years of age in the population is more than 80% ( European countries and USA). Anamnesis. Indication of contact with a patient with a clinically manifest form of herpes infection during the last 2 weeks. If perinatal infection is suspected, information about the presence of herpetic infection in the pregnant woman in various clinical forms (including latent). Classification. Localized form. Disseminated form. Latent form. Clinical picture.

Clinical picture. Anamnesis. Contact with a patient with chickenpox or herpes zoster 11-21 days before illness; Direct contact is not required. . Periods of the disease.. Duration of the incubation period - 11-21 days.. Prodromal period (optional) - up to 1 day.. Period of rashes (main clinical manifestations) - 4-7 days.. Convalescence period - 1-2 weeks. . Clinical symptoms.. Intoxication syndrome: usually 3-5 days of fever with...

Diagnostics. Anamnesis. Visual field examination. Visual acuity study. Ophthalmoscopy. Treatment is etiotropic. Course and prognosis. With a stagnant disc, normal visual functions are maintained for a long time, even with severe swelling. Subsequently, the field of view narrows.

Classification. Latent (subclinical) form. Congenital form.. Acute form.. Chronic form. Acquired form. Anamnesis. Note on possible infection(fact of maternal infection according to laboratory data, miscarriage, stillbirth, blood transfusions and parenteral interventions in the past, sexual and/or close household contact with an infected or sick person, organ and tissue transplantation). Presence of possible primary manifestations...

Differential diagnosis. Great importance has a carefully assembled anamnesis, establishing the possibility of professional or household intoxication, taking into account the epidemiological situation in identifying the nature and cause of the disease. In unclear cases, you should first think about viral hepatitis. The detection of the so-called Australian antigen is characteristic of serum hepatitis B (it is also detected in virus carriers, rarely in other diseases).

Diagnostics. Anamnesis life (obstetric and postnatal) - the course of pregnancy, toxicosis, maternal diseases; course of labor, duration of the anhydrous interval, use of obstetric aids; monthly weight gain of the child, previous diseases in the early neonatal period. Social anamnesis(housing and living conditions, socio-economic condition of the family). Hereditary anamnesis- metabolic, endocrine diseases, enzymopathies in family members...

The clinical picture of the primary septic or primary pulmonary form is not fundamentally different from the secondary forms, but the primary forms often have a shorter incubation period - up to several hours. Diagnosis. The most important role in diagnosis in modern conditions is played by epidemiology. anamnesis. Arrival from zones endemic for plague (Vietnam, Burma, Bolivia, Ecuador, Turkmenistan, Karakalpak Autonomous Soviet Socialist Republic, etc.), or from anti-plague stations of a patient with the above...

Anamnesis: contact with a patient with polio 3 weeks before the onset of the first symptoms of the disease, stay in a region unfavorable for the incidence of polio. The fact of vaccination with live polio vaccine one month before the onset of the first symptoms of the disease or contact with a vaccinated person within the last two months (situations associated with a vaccine-associated form of the disease).

) - a set of information obtained during a medical examination by questioning the person being examined and/or people who know him. The study of anamnesis, like questioning in general, is not just a list of questions and answers to them. The style of conversation between the doctor and the patient determines the psychological compatibility, which largely determines the ultimate goal - alleviating the patient’s condition.

Anamnesis data (information about the development illnesses, living conditions, previous diseases, operations , injuries , pregnancies, chronic pathology, allergic reactions, heredity etc.) the medical worker finds out for the purpose of using them for diagnostics, method selection treatment and/or prevention. Taking anamnesis is one of the main methods of medical research. In some cases, in combination with a general examination, it allows an accurate diagnosis to be made without further diagnostic procedures. Taking an anamnesis is a universal method diagnostics, used in all areas of medicine.

Types of medical history (the list is not complete)

History of illness ( novolat. Anamnesis morbi)

Onset of the disease, dynamics symptoms from the onset of the disease to the moment of treatment, with what factors the patient associates this disease, what studies and what treatment were carried out and what the results were, etc.

Anamnesis of life ( novolat. Anamnesis vitae)

Previous diseases, existing chronic pathology from various organs and organ systems, operations, injuries, etc. And also where he lives and in what conditions.

Obstetric anamnesis

Have you had any pregnancies before, how did they proceed, what was their outcome.

Gynecological anamnesis

Previous gynecological diseases and surgeries on the female genital organs, menstrual cycle, its features, frequency, soreness and so on.

Family history

The presence of similar symptoms in blood relatives , hereditary diseases and so on.

Allergy history

Allergic reactions, including to medications, vaccines, foods, plants, etc. The nature of manifestations during the development of allergies.

History of the patient's diet

Collecting information about the nature of the food eaten food, frequency of its use and power mode over a certain period of time (usually 2-5 days). Such information allows the doctor to formulate simple nutrition-related recommendations.

Insurance (Expert) history

Availability/absence of a compulsory medical insurance (VHI) policy, period of incapacity for work for any reason over the last 12 months (“how long was on sick leave”).

Links

// Encyclopedic Dictionary of Brockhaus and Efron: In 86 volumes (82 volumes and 4 extras). - St. Petersburg. , 1890-1907.

Wikimedia Foundation.

2010.:

Synonyms
Gonfaloniere

La Rioja

See what “Anamnesis” is in other dictionaries: ANAMNESIS - (from the Greek anamnesis memory), represents honey. biography of the patient, presented by periods of life. According to A., it is possible to establish how the victim’s body reacted to all those external conditions of life and harmfulness that were in its past. History... ...

See what “Anamnesis” is in other dictionaries: Great Medical Encyclopedia - the result of a survey of the patient with information about his previous life, the course of the disease, well-being, etc., recorded as a memory. A complete dictionary of foreign words that have come into use in the Russian language. Popov M., 1907. ANAMNESIS information about the previous condition ...

See what “Anamnesis” is in other dictionaries: Dictionary of foreign words of the Russian language

Anamnesis Modern encyclopedia - (from the Greek anamnesis memory), information about the patient (life history) and his illness (illness history), collected during a survey of the patient and (or) people who know him, in order to establish a diagnosis, prognosis of the disease, select the optimal methods for it ... ...

anamnesis Illustrated Encyclopedic Dictionary - a, m. anamnèse f. gr.anamnesis memory. Information about living conditions, previous diseases, history of the disease, obtained from the patient or his relatives. BAS 2. Lex. Yuzhakov: anamnesis; SIS 1937: anamne/z; BAS 1 1948: ana/mnez… Historical Dictionary

anamnesis Gallicisms of the Russian language - (incorrect medical history). Pronounced [anamnesis]...

Anamnesis Dictionary of difficulties of pronunciation and stress in modern Russian language - an integral part of a medical examination is information, a list of information about the course of the disease, previous diseases, injuries, surgical interventions, residual effects. The most valuable information is about diseases associated with nervous, cardiovascular...

See what “Anamnesis” is in other dictionaries: Dictionary of business terms - [ne], ah, husband. (specialist.). A set of medical information obtained by interviewing the subject and people who know him. Allergic a. Psychiatric a. | adj. anamnestic, oh, oh. Dictionary Ozhegova. S.I. Ozhegov, N.Yu. Shvedova. 1949 1992 …

anamnesis- noun, number of synonyms: 1 message (87) ASIS Dictionary of Synonyms. V.N. Trishin. 2013… Synonym dictionary

Anamnesis- information about a person’s life, diseases suffered by him, their onset and course, data on professional, mental and physical performance employee, his behavior in the team and family...

Send your good work in the knowledge base is simple. Use the form below

Students, graduate students, young scientists who use the knowledge base in their studies and work will be very grateful to you.

Posted on http://www.allbest.ru/

MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

BELARUSIAN STATE MEDICAL UNIVERSITY

DEPARTMENT OF NERVOUS AND NEUROSURGICAL DISEASES

Head of the department, Doctor of Medical Sciences, Professor A. S. Fedulov

DISEASE HISTORY

Closed traumatic brain injury of moderate severity, concussion. Multiple bruises of both frontal and left temporal regions. Fracture of the frontal, parietal, occipital bones

Passport part

Full name: M P M

Age: 42 years (06/22/1972)

Gender: male

Marital status: Married

Profession: individual entrepreneur

Date of admission: 02/10/2015

Directed by: 9th City Clinical Hospital

Diagnosis on admission: moderate traumatic brain injury

Clinical diagnosis: moderate traumatic brain injury, concussion. Multiple bruises of both frontal and left temporal regions. Fracture of the frontal, parietal, occipital bones.

Patient's complaints

For headache of fronto-parieto-occipital localization, dizziness, nausea, general weakness.

Medical history

According to the patient: in the evening, around 21:00 02/09/15, he fell while getting off the bus and hit the back of his head on the asphalt. Denies loss of consciousness. When trying to get up, I felt dizzy, pain in the frontal-parietal-occipital region, and nausea. There was no vomiting. He came home himself. The next morning, the pain and nausea intensified, the temperature rose to 37.8, an ambulance was called medical care. The patient was taken to the 9th City Clinical Hospital, then sent to the emergency hospital, where he was hospitalized in the neurosurgical department with a diagnosis of moderate traumatic brain injury.

Anamnesis of life

I. Physical and intellectual development of the patient.

He was born as the first child in the family, at full term, and was breastfed by his mother. He started talking and walking at 10 months. Born full term, mentally and physical development did not lag behind peers. He grew and developed according to his age. I went to school at the age of 7. Material and living conditions in childhood were satisfactory. Studying was easy, I completed 11 classes. Served in the army.

Bad habits: smoking - denies; alcohol - denies; drugs - denies.

Past diseases: acute respiratory viral infections, acute respiratory infections. Denies Botkin's disease, sexually transmitted diseases, tuberculosis (denies contact with tuberculosis patients).

II. Material and living conditions.

Living conditions: lives in a two-room apartment with his wife. Marital status: married, lives with a family. Budget: wage and the overall family budget is satisfactory. Meals: regular, sufficient, varied, three times a day.

Eats fresh vegetables and fruits.

Non-working hours: gets up at 7 am, goes to bed at 10 pm. Maintains personal hygiene.

III. Expert labor history.

Work history: no occupational adverse factors were identified. The working day is 8 hours, with a lunch break. The work is daytime, the pace is moderate.

Expert anamnesis: for Last year the patient was not on sick leave; does not have a group.

IV. Allergy history.

Denies immediate allergic reactions (urticaria, angioedema, anaphylactic shock) to medications, vaccines, serums, foods, pollen, insect bites; Denies food allergies or reactions to blood transfusions.

V. Family history.

Not burdened.

Objective research data

Somatic status

General condition of the patient: moderate.

Consciousness: clear.

Patient position: active.

Facial expression: normal.

Correspondence appearance your passport age: corresponds.

Body type: constitutional type - normosthenic, height - 185 cm, body weight - 78 kg.

Body temperature 37.5.

Skin color: the skin is pale pink in color and easily folds. Pigmentation, rash, scratching, hemorrhages, scars were not detected. Visible mucous membranes are pink, moist, smooth, shiny; the tongue is covered with a white coating, dry.

Skin elasticity (turgor): normal. The skin is not changed.

Hair: male hair type, no hair loss, slight greying.

Nails: nails are oval, transparent. Nail beds are pale in color.

Subcutaneous fat: moderately developed, evenly distributed.

Lymph nodes are palpated in the inguinal, axillary, submandibular areas with a diameter of up to 0.5 cm, soft, elastic, painless, not fused with the surrounding tissues.

The development of muscle tissue corresponds to age, strength and tone are sufficient, contractions are coordinated; compactions, hypertrophy, and atrophy are absent.

When examining the osteoarticular system, no deformation or pain on palpation was detected. No swelling or nodules were detected. Movements are full and free. No dislocations, subluxations, hemorrhages, or fistulas were detected. Spinal mobility in the cervical and lumbar regions fine.

The joints are painless on palpation; crunching and fluctuation were not detected. There are no chest deformities, no polydactyly feet, no flat feet. There is no visible vein pulsation.

Respiratory system

Breathing through the nose is free, there is no feeling of dryness in the nasal cavity.

Inspection

The shape of the chest is normal, the epigastric angle is 90°, there is no chest asymmetry, retraction or protrusion. Mixed breathing type. The breathing rhythm is correct, respiratory rate is 20 per minute. Chest movements are preserved.

Palpation

Percussion

With comparative percussion, the sound is pulmonary over the entire surface of the lungs. The apices of both lungs stand above the collarbones in front by 3 cm, in the back at the level of the spinous process of the VII cervical vertebra. The width of the Krenig margins on both sides is 5 cm.

Location of the lower borders of the lungs:

Topographic line
l. parasternalis	5th intercostal space
l. medioclavicularis
l. axillaris anterior
l. axillaris media
l. axillaris posterior

l. paravertebralis		spinous process of 11th thoracic vertebra

Auscultation

Vesicular breathing, equal intensity in symmetrical areas; no wheezing, crepitus, or pleural friction noise were detected.

The cardiovascular system

The cardiac hump and apical impulse are not visually determined.

On palpation, the apical impulse is localized in the 5th intercostal space on the left, 1.5 cm inward from the left midclavicular line. He is positive, moderately tall, of normal strength. The cardiac hump is absent.

Limits of relative dullness:

1. Right - 4th intercostal space 1.5 cm outward from the right edge of the sternum.

2. Left - 5th intercostal space 1.5 cm medially from the left midclavicular line.

3. Upper - 3rd rib along the left parasternal line.

The transverse size of the heart is 14.5 cm.

The limits of absolute stupidity:

1. Right - 4th intercostal space along the left edge of the sternum.

2. Left - 5th intercostal space 1 cm medially from the midclavicular line.

3. Upper - 4th rib along the left parasternal line.

The vascular bundle is 5.5 cm wide, up to the 2nd intercostal space.

Cardiac auscultation data. On auscultation, heart sounds are clear and the rhythm is correct. The first sound is heard at the apex of the heart, the second sound at the base. There are no splits, bifurcations, or additional tones.

There is no noise.

The arterial pulse in the upper and lower extremities is the same. The frequency is 95 per minute, the rhythm is correct, there is no pulse deficit. The pulse is of good filling, normal tension, the size of the pulse waves is the same, the shape is normal. There is no capillary pulse.

Blood pressure 150/100 mm. rt. Art.

Peripheral vessels are soft, elastic, not tortuous. No expansion of the venous network was detected in the area of the anterior abdominal wall or in the lower extremities. The pulse in the peripheral arteries of the upper and lower extremities is clearly determined throughout.

Digestive system

Visible mucous membranes are pink, moist, smooth, shiny; the tongue is covered with a white coating, dry. The palatine tonsils do not protrude beyond the edges of the palatine arches and are clean. Swallowing is free and painless.

Teeth sanitized.

Inspection

When examining the abdomen, no bloating, retractions, retractions, or asymmetries were noted; no hernial protrusions of the anterior abdominal wall were detected. The stomach is involved in the act of breathing. There is no dilation of the saphenous veins or peristalsis visible to the eye.

The abdomen participates to a limited extent in the act of breathing in the right iliac region.

Percussion

The presence of free fluid was not detected.

Palpation

The abdomen is not tense, painless.

According to superficial palpation of the abdomen, the tone of the abdominal muscles is normal; The abdominal wall is soft and pliable. Symptoms of Shchetkin-Blumberg, Rovring, Sitkovsky, Voskresensky are negative.

The condition of the navel, muscles, white line of the abdomen without pathological changes.

Abdominal pain, dyspeptic disorders, nausea, and vomiting are absent.

With deep topographic sliding palpation according to Obraztsov-Strazhesko:

The sigmoid colon is palpated in the left iliac region in the form of a smooth, dense, painless, non-rumbling cylinder 3 cm thick; mobile - 3 cm;

The descending colon is palpated in the final part of the transverse colon, which passes into the sigmoid colon in the form of a smooth, dense, painless cylinder on palpation;

The cecum is palpated in the right iliac region;

The ascending colon is palpated in the initial part of the colon in the form of a smooth, painless cylinder upon palpation;

The transverse colon is palpated 3 cm downward from the lower border of the stomach in the form of an arcuate and transverse cylinder of moderate density, 2.5 cm thick, easily moving up and down; painless, not rumbling.

On auscultation, peristalsis is observed.

Percussion of the liver.

Liver dimensions according to Kurlov:

Along the midclavicular line 9 cm;

On the anterior median - 8 cm;

Along the left costal arch - 7 cm.

On palpation, the lower edge of the liver is located at the edge of the costal arch along the right midclavicular line. The edge is soft, sharp, slightly rounded, smooth, painless.

The gallbladder is not palpable.

The spleen is not palpable.

Percussion dimensions of the length - 6 cm. Diameter - 4 cm.

The stool is regular, 1 time per day, formed, of normal color.

Genitourinary system

Urination is free and painless. Frequency up to 5 times. The color is straw yellow. Urine is clear. There is no pain along the ureters, in the area of the kidneys. The kidneys are not palpable. Pasternatsky's symptom is negative on both sides.

The bladder is not accessible to palpation and percussion.

Endocrine system

Inspection of the area thyroid gland . The lobes of the thyroid gland are not palpable, the isthmus is determined during the act of swallowing, painless.

Nodular formations, no cysts, mobile when swallowing.

Auscultation of the thyroid gland: absence of systolic murmur.

There are no signs of dysfunction of the thyroid and parathyroid glands, adrenal glands, pituitary gland (Cushing's syndrome, diabetes insipidus, diabetes mellitus, pituitary dwarfism, acromegaly).

Sexual function

The external genitalia are developed according to the male type. There are no complaints or sexual disorders. The function is not affected.

Neurological status

Higher nervous activity

Consciousness is clear.

Position active.

Speech contact is not difficult. The attention is steady. During a conversation

intelligence corresponds to age, education, life experience, social status. The emotional sphere, mood, adequate behavior, delusions and hallucinations were not noted. Sleep, the speed of falling asleep, the depth of sleep are disturbed, the state of health after sleep is poor.

Speech: no motor, sensory or anamnestic aphasia was detected.

Idiatory, constructive and dynamic apraxia were not identified.

Olfactory, visual, gustatory, auditory, somatosensory gnosis is preserved.

CRANIAL NERVES

I pair- olfactory nerve (n. olfactorius)

Conclusion: the patient had no olfactory disorders.

II pair- optic nerve (n. opticus)

Conclusion: the outer field of view is located at an angle of 600, the upper limit is at an angle of 500, the lower limit is 600, color perception is good. Fundus: optic discs without features.

III, IV, VIcouples- oculomotor, trochlear, abducens nerves

Conclusion: the width of the palpebral fissures is the same. A direct and friendly reaction of the pupils to light is revealed. Denies doubling of objects before his eyes. Convergence of the pupils is not impaired.

Conclusion: There is no double vision when looking down. There are no restrictions in the movements of the eyeball.

Conclusion: double vision of objects before the eyes is denied, strabismus and limitation of movement of the eyeballs are not determined.

V pair- trigeminal nerve (n. trigeminus)

Conclusion: when you tap the chin with a hammer with your mouth slightly open, the jaws close as a result of contraction of the masticatory muscles. The chewing muscles are symmetrical.

The exit points of the trigeminal nerve are painless.

VII pair- facial nerve (n. facialis)

Conclusion: the nasolabial folds are smoothed on the left, the frontal folds are uniform. When the forehead is wrinkled, the eyebrows are frowned, or the eyes are closed, asymmetry is not observed. Tear production is normal. Salivation is normal. The taste sensitivity of the tongue is normal.

VIII pair- vestibular-cochlear nerve (n. vestibulocochlearis)

Conclusion: tinnitus, auditory hallucinations, hearing loss denies. Nystagmus - no.

IX, X pair - glossopharyngeal nerve(n. glossopharyngeus), vagus nerve (n. Vagus)

Dysphagia, dysphonia, nasolalia, dysarthria are not observed. Reflexes from the soft palate and posterior pharyngeal wall are normal. The soft palate is mobile on both sides. The soft palate is mobile on both sides. The sensation of salty, sour, sweet (posterior 1/3 of the tongue) is normal. The soft palate reflex and pharyngeal reflex are preserved.

XI pair- accessory nerve (n. accessorius)

Head movement in both directions is sufficient. Coordination is not impaired. No nystagmus is observed. A study for adiadochokinesis revealed lag in the right hand. There is no tremor at rest or in the limbs.

XII pair- hypoglossal nerve (n. hypoglossus)

Conclusion: when protruding the tongue, no deviation is noted; there are no fibrillary twitches or tremors.

Propulsion system

Volume of active movements, volume passive movements normal in all joints. Muscle tone and trophism of the flexors and extensors, adductors and abductors, pronators and supinators is normal on the left and right. Pathological reflexes are negative. Active movements in full. Muscle strength D=S. The range of passive movements is full, the tone is uniform in symmetrical areas, and is not changed. Atrophy, hypertrophy, fibrillary and fascicular twitching were not detected. Chvostek's and Trousseau's symptoms are negative. Performs finger-toe and knee-heel tests confidently. The test for adiodochokinesis is negative. Stable in the Romberg position.

Reflex Research

Superciliary reflex (periosteal): positive.

Pupillary reflex: positive.

Corneal and conjunctival reflexes: positive.

Pharyngeal reflex (reflex from the soft palate): positive.

Chin reflex (periosteal): positive.

Reflex from the biceps brachii muscle (tendon): positive.

Reflex from the triceps muscle (tendon): positive.

Carpal radial reflex (periosteal): positive.

Abdominal reflexes (skin): positive.

Knee reflex (tendon): positive.

Achilles reflex (tendon): positive.

Plantar reflex (skin): positive.

Pathological reflexes

Reflexes of Babinsky, Oppenheim, Gordon, Schaeffer, Rossolimo, Zhukovsky, ankylosing spondylitis-Mendel reflex, ankylosing spondylitis-Mendel reflex are negative.

Functions of the cerebellum

Finger-nose test: no misses or intentional tremors were detected when approaching the target.

Test for adiadochokinesis: no hand lag is observed.

Heel-knee test: no deviations were detected.

Extrapyramidal system

Muscle tone during passive flexion and extension in the elbow, knee and hip joints is the same in the arms and legs. Hyperkinesis was not detected. Facial expression is normal, speech is quiet. No resting tremor of the arms, legs, lower jaw, or head was detected.

Sensitive system

There is no pain or paresthesia along the nerve trunks. Superficial sensitivity (pain, temperature, tactile), deep (articular-muscular sense, vibration sensitivity, sense of pressure and weight) and complex types of sensitivity (sense of localization, stereognostic sense, two-dimensional and discriminatory sensitivity) are preserved.

Meningeal symptom complexes

The Kernig sign is positive on the left leg. Rigidity of the neck muscles, upper, middle, lower Brudzinski's symptoms, ankylosing spondylitis symptoms are absent. Meningeal posture is not observed. Kehrer's points are painless.

Vegetative functions

Trophic disorders in accessible tissues, intrasecretory and vasomotor disorders are not determined. Sweating, sebum secretion, salivation are not impaired. Dysfunction of the pelvic organs is not determined. There were no vegetative paroxysmal states (fainting, dizziness, acrocyanosis, angioedema, urticaria, vasomotor rhinitis, bronchial asthma, hypothalamic crises, attacks of insomnia and drowsiness) at the time of examination and in the medical history.

Checking the condition of local dermographism: the response to skin irritation with the blunt end of a hammer is fast and persistent.

The pilomotor reflex is normal.

Psychic sphere

Orients himself in space, time, his own personality, surrounding objects and persons.

He communicates well with others and critically assesses his own health.

Thinking, memory, attention, intelligence correspond to age, level of education and social status.

The patient's identity has been preserved. Behavior is appropriate. Sleep is not deep and not long. After waking up he feels bad.

Data from additional research methods

(laboratory and special research)

Biochemical blood test 02/10/2015

Total protein 73.68

Total bilirubin 15.49

Direct bilirubin 5.37

Urea 7.42

Creatinine 103.67

Cholesterol 5.43

Glucose 6.32

Total calcium 2.46

Sodium 139.23

Conclusion: increased levels of total bilirubin, urea and potassium.

General urine test 02/10/2015

Specific gravity 1.02

Reaction 6

Bilirubin negative

Protein neg.

Ketone bodies neg.

Nitrites neg.

Urobilinogen 0.2

Leukocytes negative

Red blood cells negative

Conclusion: no pathologies.

CT scan of the brain 01/10/2015

Conclusion:

Electrocardiogram 02/11/2015

Heart rate 50 beats per minute.

Conclusion: the rhythm is correct, the shape of the QRS complex in V4 is changed.

Serological analysis for antitreponemal antibodies 02/11/2015

Conclusion: ELISA negative.

Rationale for diagnosis

Based on the medical history: complaints of headache, dizziness, nausea.

Medical history: the injury was caused by a fall and a blow to the head.

Objective examination data: he performs coordination tests uncertainly, is not stable in the Romberg position, there are abrasions on the face and in the frontal region, a diagnosis can be made: mild traumatic brain injury, concussion. Bruised wound on the forehead on the left. Soft tissue bruises, facial abrasions on the left.

Differential diagnosis

It is necessary to differentiate this disease from subarachnoid hemorrhage, since the symptoms are largely similar: the presence of general cerebral symptoms, absence or minor focal symptoms, and extremely rarely loss of consciousness. But SAH has a different etiology: aneurysm rupture due to hypertension, and in our case, traumatic origin; the presence of severe meningeal symptoms.

sol analgini 50% - 2.0 v.m

PCP of wounds, aseptic dressing

Favorable for recovery, favorable for work.

Supervision diaries

The general condition is of moderate severity. Position active. Consciousness is clear.

The skin and visible mucous membranes are pale pink, without visible changes. Conscious, oriented, active position, good mood. Lymph nodes are not enlarged.

The pulse is symmetrical, rhythmic, of good filling and tension, 85 beats/min. Heart sounds are clear and pure. Blood pressure 145/90 mmHg. Breathing is vesicular, well carried out in all parts, there is no wheezing. RR 18/min. Morning body temperature - 37.0. Evening body temperature - 37.1.

The abdomen is soft, symmetrical, painless. There are no peritoneal symptoms. Peristalsis is active. There was no stool, no gases.

Urination is free and painless. Urinates on his own.

General condition is satisfactory. Position active. Consciousness is clear.

The skin and visible mucous membranes are pale pink, without visible changes. Conscious, oriented, active position, good mood. Lymph nodes are not enlarged.

The pulse is symmetrical, rhythmic, of good filling and tension, 85 beats/min. Heart sounds are clear and pure. Blood pressure 130/90 mmHg. Breathing is vesicular, well carried out in all parts, there is no wheezing. RR 18/min. Morning body temperature - 36.8. Evening body temperature - 37.0.

The abdomen is soft, symmetrical, painless. There are no peritoneal symptoms. Peristalsis is active. There was no stool, no gases.

Urination is free and painless. Urinates on his own.

medical history neurological reflex diagnosis

The patient, kmk, 55 years old (05/23/1959), was hospitalized at the 9th City Clinical Hospital, in the neurological department, from 02/12/15 to 02/26/15, with a diagnosis of intracerebral hemorrhage in the left hemisphere of the brain with moderate motor aphasia, paresis of the right arm and leg, acute period. Arterial hypertension stage III, risk 4. IHD: cardiosclerosis. Atherosclerosis of the aorta. CHF FC IV.

He was admitted on 02/12/15 with complaints of weakness and loss of sensation in the right arm and right leg, general weakness, and loss of appetite. Laboratory and instrumental studies were carried out: biochemical blood test 02/12/15 (increased total and direct bilirubin, increased cholesterol, triglycerides, LDL, VLDL, glucose, AST, ALT), general blood test 02/12/15 (relative lymphopenia, increased hemoglobin level) , general urine analysis (without pathologies), hemostasis study on Konelab30 05/12/15 (without pathologies), X-ray examination 02/11/15 (without pathologies), CT scan of the brain 01/11/15 (intracerebral hemorrhage in the left hemisphere of the brain), serological analysis antitreponemal antibodies 02/13/15 (ELISA negative).

Treatment carried out:

1. Sol. Aminocaproiciacidi5% - 100.0 i/v

2. Contrykali25 thousand units 2 times a day

3. Dicynoni 250 mg per day parenterally

4. Tab. Captoprili 50 mg (sublingual)

5. Sol. Emoxipini 3% - 100 i.v.

6. Vitamin therapy

Sol. Acidi nicotinici 1% - 1 ml.

The patient was discharged on February 26, 2015 with improvements.

Recommended: Avoid bad habits(smoking, drinking alcohol), a balanced diet, it is recommended to limit the consumption of table salt, fats and simple carbohydrates. You should do moderate physical activity every day. Blood pressure control is necessary (if it exceeds 140/90, then you need to take antihypertensive drugs).

Posted on Allbest.ru

...