The history of the disease describes the dynamics of its development from the beginning of the manifestation of the first symptoms and before entering the hospital patient. The reasons that led to acute pancreatitis are necessarily indicated. In some cases, for example, chronic pancreatitis, ulcerous, cholelithiasis and others, pathological processes practically do not change for a long time. Therefore, there is no need to describe seizures each time so that the history of the disease is not filled with recurring symptoms. It is sufficient to draw out a typical first sign of acute pancreatitis, and then it is enough to limit ourselves to ascertaining the duration and frequency of manifestations of diseases. Also in history, it is necessary to introduce a manifestation of complications of the clinical course.
Information on previous resort, inpatient and outpatient treatment is being provided. All documents submitted to the patient( instrumental studies, laboratory tests, extracts, certificates, etc.), which characterize the course of the disease of acute pancreatitis, are carefully studied. All relevant information is recorded in the history. If the student is in charge of a patient who has been in a hospital for a long time, the sections include information about treatment activities, their effectiveness, changes in the condition, the results of the examination and the expected diagnosis after the patient's admission.
Acute pancreatitis - medical history surgery
Surgical history of the disease Acute pancreatitis is a legal document and testifies to the correct actions of the doctor, the processes of managing the patient and committing possible errors. On the basis of this document, it is possible to judge the development and causes of the disease, its course, the need for therapeutic and preventive and diagnostic measures, including the examination of professional and disabled fitness.
As the main goal of the examination scheme is to provide a planned and consistent study of the objective and subjective manifestations of such a disease as acute pancreatitis. Due to careful and correct examination, you can avoid any diagnostic errors. The history of acute pancreatitis for surgery should be well-formed, because among other things it is a criterion for the high level of the doctor's work. Also, surgical history is the basis for imposing fines or payment for work, for which it is estimated by experts of insurance companies.
Case history Acute pancreatitis:
therapy Initially, active complaints are collected, which should be described in detail with full characteristics. The history of the disease in therapy, for example, acute pancreatitis must necessarily characterize each complaint in detail. After assessing active complaints, sometimes you can make the first assumptions about the disease and determine the affected body system. After this, the patient clarifies the complaints related to the diseases of the alleged systems. It is worth saying that he could not mention them. We are talking about so-called complaints of a passive nature.
In the history of acute pancreatitis therapy, the anamnesis is recorded most often from the date and the description of certain moments of manifestation of symptoms, all characteristics of the diagnosed disease. Clarify the reasons that it could cause. In chronological order indicate the appearance of symptoms, their development, as well as the manifestation of new ones.
Describes the treatment that was conducted earlier, its result, the medications prescribed by the doctor. In addition, it is necessary to describe the deterioration and causes of hospitalization: the upcoming examination, the peculiarities of the condition, and so on. The history describes the patient's ability to work for the entire duration of the illness, its dynamics, as well as the effectiveness of the measures taken and treatment from the period of hospitalization immediately prior to the start of supervision.
Nursing history of acute pancreatitis
The nursing history of acute pancreatitis includes various recommendations, medical prescriptions and medical diagnosis. The quality of the analysis can largely determine the success of further stages of diagnosis and treatment. Also, subjective data about the patient are collected, an important role is played by excitement and possible fear of operations. Objective data are obtained in the process of the conducted surveys: laboratory studies( special list of analyzes), body temperature, blood pressure and so on. All information obtained during the nursing survey is necessarily documented.
Acute pancreatitis - epicrisis
Epicrisis is a brief and capacious description of the disease. It necessarily introduces the results of the conducted studies, which, in fact, serve as the main indicators in the formulation of the correct diagnosis. The need for possible surgical intervention is briefly described. At the same time, the planned date of the operation, its nature, features should be indicated. Further features of conducting postoperative treatment of acute pancreatitis with a description of the characteristics of healing processes of wounds, as well as mandatory indication of the dates of removal of drains and superimposed sutures are described.
The patient, who is already discharged, is prescribed certain purposes of resort and sanitary treatment, the regime of life and work, diet, observation from other specialists, including in the place of residence. Various measures are prescribed to eliminate the progression of acute pancreatitis( taking alcohol, fatty foods, playing sports, smoking, and so on).The forecast for life, labor recommendations, and work capacity are indicated. At the end of the epicrisis there must be a signature and a full diagnosis is indicated.