Most people, after hearing such a phrase as "a medical history, peptic ulcer" imagine a story about the disease, with interesting and entertaining factors of its treatment in the past, about when it was first diagnosed and the like, but this is far from the truth. In fact, in the history of the disease, the ulcer refers to a particular patient and all that is associated with him and his disease.
Let's look at the history of the disease with peptic ulcer:
- ;
- Patient Complaints;
- Survey data;
- Data obtained during the general inspection;
- Preliminary diagnosis;
- Analysis data;
- Clinical diagnosis with rationale;
- Description of the method of treatment;
- Prevention and counseling;
- Epicrisis.
Now consider all the components of the history of stomach ulcers in more detail.
In the section passport data indicate the patient's name, age, occupation, home address, date of admission and diagnosis( for example, peptic ulcer in the phase of exacerbation).
In the complaints section, indicate anything that worries the patient, provokes or vice versa, reduces pain.
As for the questionnaire, it is important to clarify from what time the patient feels sick( when the symptoms of the disease first appeared).When was the first complaint with the doctor, in which clinic / hospital? Where was it sent and how was it treated? Have the patient diagnosed gastritis before the onset of an ulcer, how often do relapses occur? In addition, it is necessary to find out how the patient developed as a child: is there a genetic predisposition? Be sure to clarify the household history( compliance with doctor's recommendations, bad habits), allergic anamnesis( products / drugs that cause allergies), transferred diseases, operations.
After collecting the information, you can proceed to the inspection. During the examination, the doctor fixes the general condition of the patient: height, weight, physique, position, skin and scalp, nails and visible areas of the mucosa. It is also important to note the heart rate, blood pressure and BH of the patient, note the presence / absence of deformation of the chest, abdomen and pelvis, test the reflexes.
After the examination, a preliminary diagnosis is made and it is planned which tests the patient will be sent to. Usually it is a question of scintigraphy of the spleen and liver, RW blood analysis, stool analysis, abdominal ultrasound, FGD, ECG, general urine analysis, biochemical composition of blood, clinical blood.
Based on the results of the analysis, a clinical diagnosis that can confirm or disprove the preliminary diagnosis is a peptic ulcer. When the history of the disease of therapy is given great importance. This part details what preparations and in what doses are prescribed, what table is needed during an exacerbation and what diet is recommended for the coming years / for life, as well as the ongoing physiotherapy procedures.
The recommendations indicate what it is worth to look after, how to plan the day and what to do so that the period of remission is as long as possible.
Well, they finish the epicrisis, in which the passports data, the date of admission, the complaints on admission and the patient's condition, which studies were performed, the diagnosis( gastric ulcer), which procedures were prescribed, are again indicated.