This tutorial aims to formalize a standardized approach to the design of the medical history of a surgical patient. It gives detailed recommendations for the proper anamnesis collection, description of objective status, diagnosis and its...

List of abbreviations
Introduction
Medical history maintenance requirements
Official data presentation
Anamnesis of current disease (anamnesis morbi)
Onset and development of disease
Anamnesis of life (anamnesis vitae)
Physical examination data (status praesens objectivus)
Body system physical examination data
The respiratory system
The cardiovascular system
The digestive system
The genitourinary system
The urinary bladder and urination
Male examination data
Female examination data
The neuropsychic status
Pathological site description (status localis)
Differentiation of descriptions of the lesion depending
on its etiology
The provisional diagnosis
Diagnostics
Laboratory data and instrumental methods of
examination
The clinical diagnosis and its substantiation (evidence)
The differential diagnosis
Treatment
Preoperative concept
Protocol of operation
Progress notes
Discharge (stage) epicrisis
End of the medical history of a surgical patient
Tests
Questions
Keys
References
Appendices
Appendix 1. Form 003/У. The medical record of an
inpatient
Appendix 2. Consent to personal data processing
Appendix 3. Medical documentation standards
Appendix 4. Disorders of Consciousness
Appendix 5. Determination of the body mass index
Appendix 6. "Face Masks"
Appendix 7. Types of pathological respiration
Appendix 8. Data of topographic percussion of the
lungs of a healthy
person
Appendix 9. Borders of the heart of a healthy person
Appendix 10. Stange and Gench functional tests
Appendix 11. The method of rectal examination
Appendix 12. Consent to medical endoscopic
intervention (diagnostic/
therapeutic)
Appendix 13. Preparation for sigmoidoscopy
Appendix 14. Laboratory indicators of a healthy person
Appendix 15. A Short Version of the International
Classification of
Surgical Diseases
Appendix 16. Instructions for the organization of
nutritional care in
healthcare institutions
Appendix 17. Standard diets descriptions
Appendix 18. Determination of the degree of
operational risk
Appendix 19. Classification of operational anaesthesia
risk (Moscow
Scientific Society of Anaesthesiologists and
Reanimatologists-89) Appendix 20. Informed voluntary
consent to an Aesthesia for medical
intervention
Appendix 21. Perioperative antibiotic prophylaxis:
concepts and
rational strategies
Appendix 22. Russian clinical guidelines for diagnosis,
treatment and
prevention of venous thromboembolic complications
Appendix 23. Informed voluntary consent to surgical
intervention Appendix 24. Form 008/У-07. Record book
of surgical interventions
in the hospital
Appendix 25. Assessment of patient illness severity
using SAPS
Appendix 26. Informed voluntary consent for the
transfusion of blood
components
Appendix 27. The protocol of transfusion of donor
blood and (or) its
components
Appendix 28. The temperature sheet of a surgical
patient
Appendix 29. Types of fever
Appendix 30. Form 066/У. Discharged Patient
Statistical Record