1. Collect and evaluate the genealogical history, life history and illness of the child.

When collecting a life history, find out:

Social history:

Family completeness: whether there is a father and immediate relatives of the mother.

Family educational level: specialized secondary education (technical school, vocational school).

Psychological climate of the family: attitude towards the child is even, affectionate; The relationship between the parents is friendly, are there any bad habits?

Housing conditions: does the family have a separate apartment with an area of ​​at least 6 m2 per person.

Financial security of the family: the financial security of the family is 60% of the minimum consumer budget of a family of four people.

The level of sanitary and hygienic conditions for caring for the child and the apartment: is sanitary and hygienic care for the child and the apartment provided?

Biological history:

Features of the antenatal period: absence of gestosis of pregnancy, extragenital diseases of the mother, occupational hazards in parents, surgical interventions, viral diseases during pregnancy, threat of miscarriage, etc.

Features of the intrapartum period: duration of labor, surgical intervention ( C-section), asphyxia at birth, birth injury, HDN, acute infectious and non-infectious diseases and other diseases.

Impacts that worsen health in the postnatal period: repeated acute diseases of any etiology, early transfer to formula feeding, complications after vaccination, etc.

Genealogical history:

Family pedigree, taking into account at least 3 generations (generations are designated in Roman numerals from oldest to youngest (from top to bottom), all family members of one generation are assigned a serial number, and symbols are used);

Absence or presence of hereditary diseases;

General history: index hereditary history complications = the total number of diseases for all known relatives: the total number of relatives of the proband (the patient from whom the study begins); an index of more than 0.7 indicates a burdened medical history;

Direction of burden: burden index for some disease(disease group) = total number of diseases in all known relatives (for example, diabetes mellitus): per total number of relatives of the proband; an index of more than 0.4 indicates a burdened history of the disease (group of diseases).

When collecting anamnesis of the disease, find out:

Complaints at the onset of the disease and during the observation period (based on the story of the patient or his parents).

Time, circumstances of development and course of the disease from the first day of occurrence until the moment of examination.

The dynamics of general symptoms of the disease (temperature, sleep, appetite, mood, lethargy, thirst, etc.).

Manifestations of the disease in all systems and organs (respiratory, cardiovascular, digestive, urinary, musculoskeletal, endocrine, nervous systems and sensory organs).

Previous treatment, its results, reactions to medications.

Conduct clinical examination(examination, palpation, percussion, auscultation) of a sick child.

During a clinical examination, evaluate:

The patient's condition: satisfactory, moderate, severe, very severe.

Position of the child: active, passive, forced.

Consciousness: clear, darkened, absent.

Nervous system, behavioral parameters: leading lines of NPR, behavior, pathological signs.

Condition of the skin and visible mucous membranes: color, cleanliness, moisture, skin elasticity, hairline and nails.

Subcutaneous fat layer: uniformity of distribution, fold thickness, presence of compactions and edema, their localization and prevalence; tissue turgor.

Condition of the muscular system: muscle tone and strength.

Condition of the skeletal system: size and shape of the head, large fontanelle (size, condition of the bone edges and soft tissues, bulging, recession), condition of the sutures of the skull, presence of craniotabes, shape chest, the presence of rachitic rosaries, Harrison's groove, bracelets and strings of pearls, curvature of the spine (kyphosis, lordosis, scoliosis) and limbs, flat feet; shape, size, mobility of joints (shoulder, elbow, wrist, hip, knee, ankle, small joints of the hands and feet).

Lymphatic system: size, quantity, consistency, mobility, sensitivity of lymph nodes (submandibular, chin, cervical anterior and posterior, occipital, parotid supra- and subclavian, axillary, thoracic inguinal, popliteal).

Anthropometry: body weight and length, head and chest circumference, other indicators.

Respiratory organs: voice, cry, presence of cough, sputum; breathing through the nose or mouth; type of breathing, number of breaths per minute, ratio of pulse to respiration, depth of breathing, rhythm; presence and type of shortness of breath (inspiratory, expiratory, mixed); symmetry of the chest; percussion and auscultation of the lungs.

Cardiovascular system: external examination; pulsation of the carotid arteries, swelling and pulsation of the neck veins, pulsation of the heart and epigastrium; apical impulse, its location, strength, prevalence; pulse, its characteristics (synchrony, frequency per minute, filling, tension, rhythm); borders of cardiac dullness; auscultation of the heart; determination of blood pressure.

Gastrointestinal tract: condition of the mucous membrane of the oral cavity, oropharynx, tongue (coloring, moisture, plaque, follicles, cracks, condition of the papillae); condition of teeth (deciduous, permanent, number, timing and sequence of eruption, presence of caries); the shape and size of the abdomen, the presence of dilation of the veins of the anterior abdominal wall, visible peristalsis, divergence of the rectus abdominis muscles, the condition of the navel; determination of ascites, liver size; palpation of the abdomen; condition of the anus (cracks, gaping), rectal prolapse; stool and its character (color, smell, consistency, pathological impurities).

Urinary system: examination of the lumbar region, palpation of the kidneys and Bladder; frequency of urination, pain, urinary incontinence; diuresis, ratio of daytime and nighttime diuresis; examination data of the external genitalia.

Endocrine system: disturbance of growth (gigantism, dwarfism) and body weight (obesity, wasting), distribution of the subcutaneous fat layer, condition of the thyroid gland (size of lobules, isthmus, presence of nodes), genitals.

Conduct anthropometry and assess the physical development of children early age using the centile method, calculate the Chulitskaya (fatness, axial), Erisman, and Tour indices.

Determine the child's age group.

Carry out measurement and weighing according to generally accepted methods.

All anthropometric measurements are carried out on naked children, after sleep, before meals or 2-3 hours later. meals, preferably in the morning or early afternoon.

Body length measured in a lying position using a horizontal stadiometer (you can use any horizontal surface with a centimeter tape attached to it). The child is placed in the stadiometer on his back so that the top of his head tightly touches the stationary transverse bar of the stadiometer. An assistant fixes the child's head in a position in which the lower edge of the orbit and the upper edge of the external auditory canal are in the same vertical plane. The child's legs are straightened by lightly pressing on the knees. The movable bar of the stadiometer is pressed tightly against the heels. The distance between the movable and fixed bars corresponds to the length of the child’s body.

Body weight measured on special horizontal scales with a maximum permissible load of up to 25 kg. If the child can sit, he can be placed on the wide part of the scale, placing his feet on the narrow part. The scales should be carefully adjusted before weighing.

Chest circumference measured by placing a measuring tape in front at the level of the nipples, in the back under the lower angles of the shoulder blades. In this case, the child’s arms should be lowered. Breathing is calm.

Head circumference determined by applying a centimeter tape, passing it from behind along the occipital point, and from the front along the superciliary arches.

Body length represents the distance between the upper sternal and pubic points.

Leg length – the distance between the trochanteric and heel points.

The shoulder circumference is determined by placing a measuring tape at the site of greatest thickening of the biceps muscle.

Thigh circumference measured by placing a measuring tape under the gluteal fold.

Shin circumference determined at the site of maximum volume of the gastrocnemius muscle.

Assess the child's physical development.

The basis for assessing physical development is the child’s body length. Next, body weight and chest circumference are assessed. Anthropometric indicators are assessed using standard centile tables.

Table 33

Centile assessment of indicators

4.Define based on the results of comparison of centile estimates of length, body weight and chest circumference harmony of physical development.

Physical development is considered:

harmonious, If the difference in corridor numbers between any two of the three indicators (length, body weight and chest circumference) does not exceed 1;

disharmonious, if this difference is 2;

sharply disharmonious, if the difference is 3 or more.

Table 34

Basic anthropometric indices in children of the first year of life

Scheme of educational case history of a psychiatric patient

1. Passport part.

· Full Name

· Age

· Profession, place of work

· Home address

Date of hospitalization

· Diagnosis of the referring institution

Diagnosis upon admission

· Clinical diagnosis

2. Life history

A psychiatric history is a background history of the disease and at the same time a life history, which includes all the biographical data of the patient. This type of anamnesis is aimed at establishing connections between individual life events and identifying the origins of the disease in specific life situations. For diagnosis and therapy, the question of the time of the first manifestations of the disease, what served as the impetus for its occurrence, development and intensification is important.

This section of the educational medical history should reflect information about the facts of the patient’s life that are significant from a medical point of view. This information may be an important aid in establishing a preliminary diagnosis.

You must specify information about the birth and development of the patient: the presence of brothers and sisters, which child was born in the family, the course of pregnancy in the mother, the presence of perinatal brain damage, data on the timeliness of physical and intellectual development, childhood diseases, the presence of enuresis, timidity, capriciousness, stuttering, somnambulism, convulsive attacks.

When collecting a family history, along with identifying mental illnesses in relatives, one must pay attention to the presence of neurological diseases, cases of suicide in close relatives, the presence of consanguineous marriages, and hereditary diseases in the family. The patient’s position in the family during childhood, position among brothers and sisters, parents’ relationships with each other. If possible, establish the causes of death of close relatives. If necessary, a pedigree is compiled. The presence of early childhood violence in the family, the fact of upbringing in an incomplete family, the presence of difficult experiences in childhood, and other traumatic situations are reflected.

Indicated information about the education received: beginning of school, academic performance, individual inclinations, relationships with students, participation in public life, relationships with family and teachers, further education of the patient, military service.

Professional history: time of start of work, further training, occupational hazards, production problems, time of becoming disabled (if there is a disability group). Social connections, interests and hobbies.

Noted Family status: presence of children, living conditions. Particular attention is paid to relationships in the patient’s family, the relationship of each relative to the patient and the presence of mental illness. Attention is paid to sexual development, choice of partners (for example, the presence of homosexual tendencies and other deviant tendencies).

Information about illnesses suffered by the patient and existing chronic diseases, especially note those diseases against which various mental disorders can develop (arterial hypertension, rheumatism, diabetes mellitus, traumatic brain injury; episodes of loss of consciousness).

If possible, reflect the characteristics of the patient’s temperament and character, his individual traits until the present illness. Activity, resourcefulness, curiosity or passivity, self-doubt, shyness, isolation, ability for social contacts and connections. Suspiciousness, anxious and suspicious character traits. Pedantry, excessive concern with details. Ability to quickly learn new job, obedience to discipline, attitude to one’s responsibilities, initiative. Patience, persistence in fulfilling one’s desires or haste and impetuosity in actions. The ability to restrain one’s feelings, desires or a tendency to affective outbursts. The need for a change of environment. Fear or thirst for new things. Mood instability, causeless fluctuations.

Determine the presence of dependence syndrome on the use of alcohol and other psychoactive substances. If there are suspicions about the presence of alcohol or drug addiction, then find out the time of onset of the use of a psychoactive substance, the pattern of intoxication, the regularity of use, tolerance (the dose of the drug that causes a state of narcotic or alcohol intoxication), the presence and nature of withdrawal syndrome, methods of treatment before actual hospitalization, duration of remission after them.

The medical history reflects the presence of traumatic situations, shocks, and disasters in the patient’s life. Behavior in times of danger, reaction to life's troubles. Their influence on the patient’s subsequent life.

3. History of the disease

This section of the educational medical history should reflect information about the occurrence and course of the disease in a given patient. The first signs of the disease are indicated, as well as the time of their appearance, the presence of an external cause for the development of the disease, and similar short-term episodes in the past. Painful manifestations immediately preceding the development of the disease: headaches, dizziness, insomnia, fatigue, impaired performance, impaired attention, narrowing of interests, irritability, mood instability, changes in inclination, suspicion. The nature of the onset of the disease is noted (acute, subacute, gradual), as well as its further course (progressive, regressive, relapsing). The duration and persistence of remissions, if any, as well as the factors that caused the exacerbation of the disease are determined. Previous hospitalizations for this disease are indicated (if there are a large number of them, the date of the last hospitalization). The effectiveness of various treatment methods used in this patient (especially “shock therapy” methods - insulin shock, electroconvulsive therapy). This section of the educational medical history reflects the reasons and circumstances of the current hospitalization.

When collecting a medical history, you should use outpatient card patient, extracts from medical records and other medical documents.

4. Objective examination.

This section of the medical history should describe the physical examination of the patient performed by the students. The severity of the patient’s condition is assessed (satisfactory, moderate, severe, extremely severe). The position in bed is noted (active, passive, forced). The skin and visible mucous membranes are described (color, presence of rash, its nature, presence of abrasions, bruises, hematomas, especially in the skull area). Body temperature, physique, and the severity of subcutaneous fat are reflected. Described the cardiovascular system(heart rate and pulse, presence of pulse in the carotid arteries, heart sounds, arterial pressure). The status is reflected respiratory system(rhythmicity, frequency and depth of breathing, the presence of expiratory or inspiratory shortness of breath, the presence of pathological breathing of Cheyne-Stokes, Biott, Kussmaul, central hyperventilation, data from percussion and auscultation of the lungs). The digestive system is described (data from palpation and percussion of the abdomen, the presence of diarrhea, constipation, periodic and true fecal incontinence). When describing the genitourinary system, it is necessary to reflect the presence or absence of enuresis, urinary retention, imperative urge to urinate, true and periodic urinary incontinence, priapism, impotence.

5. Mental status

Emotional-volitional sphere

The patient's contact and desire to communicate are assessed. Behavior during the examination - demeanor, appearance and posture of the patient, facial expressions and gestures, their features. Character and intonation of speech. Motor skills, signs of its impairment. The patient’s complaints at the time of supervision are also outlined here: the sequence and manner of their presentation. Emotional intensity of the conversation. The prevailing mood, its stability, the adequacy of emotional reactions. The patient’s desire, volitional orientation, strength and constancy of volitional acts.

The patient is outwardly sloppy (neat), shaved, his hair is dirty (clean), (not) combed. Dressed sloppily (according to social norms, according to fashion).

In psychiatry, compared to other clinical disciplines, the system for studying patients has its own specifics. If clarifying complaints, collecting anamnesis (history of life and illness) serve general method for all medical specialties, the very process of talking with a patient, observing his behavior, manner of holding himself, expressing his thoughts is of particular, extremely important importance for deciphering the mental status, mental state of the patient. In order to establish an accurate diagnosis, it is also necessary to carefully examine the somatic, neurological condition of the patient, have laboratory (clinical and biochemical), electroencephalographic, psychological research; it is required to study patients using computed tomography (kt), magnetic resonance imaging (mri), positron emission tomography (pet), functional computed tomography (fct), etc. In some cases, it is necessary to have an x-ray of the skull, results of a study of cerebrospinal fluid, level blood levels of hormones, adrenaline, serotonin. IN Lately Diagnostic scales are increasingly being used for the quantified assessment of depression, mania, cognitive functions, severity of instincts, memory pathology, etc.

Acquaintance and conversation with the patient should take place in a calm atmosphere, conducive to communication and frankness. It is advisable to talk with the patient alone, since the presence of strangers can distract him and interfere with the establishment of contact and trust, which are extremely necessary in psychiatric practice. You need to ask questions calmly, slowly, listen to the patient’s answers to the end, without interrupting him. This creates confidence in the patient that the doctor is not only interested in him, strives to find out all the features of the condition, but is sincerely interested in helping him.

The first conversation is very important, it takes a lot of time (sometimes more than one hour), but this time subsequently pays off completely, since the doctor receives fundamental data, which he later relies on in the process of monitoring the patient and his treatment. The first conversation is carried out extremely carefully, this allows you to get the correct idea about the essence of mental status. As a rule, the conversation begins about the patient’s well-being, and it is immediately clarified what exactly is bothering him. It is important to take into account that many patients do not complain about anything at all, although they show obvious signs of behavioral disorders, its inadequacy due to a lack of criticality, for example, with. Subsequently, it is very important to purposefully clarify the most important details of the mental status that allow you to obtain general impression about the mental state of the patient and highlight the main pathological disorder - whether it relates to the sphere of perception, thinking, affect, consciousness, memory, etc. The doctor conducts a conversation, discussing with the patient a wide range of problems, even beyond the scope of well-being and sensations. You can talk about the patient’s attitude to life, his habits, hobbies, daily activities, and move the conversation to other common topics. The development of questions into an interview further encourages the patient to trust, even if he is secretive, withdrawn, and dissimulates his condition. A conversation in private, without relatives, often helps to reveal underlying symptoms, what the patient hides from his loved ones.

The success of the conversation depends on the erudition of the psychiatrist, and on his sincere spiritual interest, and on his ability to ask, which is determined by the doctor’s experience and knowledge. The success of the questioning and the effectiveness of the conversation ultimately depend on the skill of a simple but interested conversation with the patient. P.B. Gannushkin believed that the success of psychiatric research is achieved only on the condition that “a young psychiatrist will treat the mentally ill with sufficient thoughtfulness and attention, if he is truthful and as simple as possible in communication; A mentally ill person will not forget or forgive hypocrisy, sweetness, especially direct lies.” It must be borne in mind that, while trying to discover the personality of the patient, the psychiatrist himself reveals himself to him as a person.

Studying the patient's condition is inseparable from the need to study his medical history. Obtaining a subjective history is a mandatory part of the questioning. When a particular mental disorder is detected, the doctor simultaneously finds out when, how, and with what manifestations (symptoms) it began. This is extremely important, since the opportunity to obtain data on the main type of pathology is because the primary manifestations of currently existing disorders are rooted in the distant past, so in-depth questioning makes it possible to obtain data on the dynamics of the leading pathology.

While listening to the patient and collecting anamnesis, the doctor pays attention to how the patient interprets the changes occurring to him at the present time, being under the influence of pathological experiences (delusional interpretation of the past, forgetting events, etc.).

When collecting anamnesis, information about heredity, illnesses of parents, relatives, how the patient’s mother felt during pregnancy, how her birth went, what were the characteristics of the patient’s mental and physical development in infancy and adolescence are very important. It is necessary to find out data on diseases suffered during life, the presence of physical and mental injuries. Questions are asked about whether the patient had irritability, night terrors, enuresis, seizures, etc. in childhood. Thus, the patient’s attitude towards family and friends, the formation of basic character traits, and attitude to school are studied. Important data are about the course of the pubertal crisis, the formation of sexuality, the direction of desire, the age at which wet dreams appear in a man or the menstrual cycle in a woman. The onset of the disease is carefully studied, all the circumstances preceding it, the manifestation of progression or attenuation of painful episodes are clarified. Such a thorough study allows you to obtain data on a preliminary, and in some cases, an accurate diagnosis, after the first conversation.

The doctor obtains an objective history from close relatives, colleagues, acquaintances, and from medical documentation, if available (it can be requested). Collecting objective data, the doctor once again clarifies information about heredity (the presence of mentally ill people in the family, cases of suicide, special characterological traits in relatives with the manifestation of oddities in behavior, eccentricity, imbalance, isolation, suspicion, pathological greed, etc.). It is also clarified in detail what the patient’s living conditions are in the family, the attitude of relatives and relatives towards the patient. It is especially important to obtain information about how relatives discovered the first signs of the disease, how the patient himself relates to his illness, how much and how he has changed during the illness. The doctor should guide the story of relatives and friends so that instead of describing the disease, the patients’ guesses about the causes and essence of the disease are not taken into account.

While questioning the patient, the doctor simultaneously observes him, notes features of facial expressions, gestures, facial expressions, changes in voice in terms of expressiveness or dullness, monotony. The behavior of the patient in the department where he is placed is observed and described by the staff. By analyzing behavioral characteristics, one can obtain objective data on the presence of fear, delirium, depressed or euphoric mood, thinking disorders, various paroxysms, signs of autism and other symptoms of the disease.

The patient’s main complaints, which forced him to see a doctor, form the central part of the anamnesis, and therefore careful clarification and clarification of them is extremely important.

Complaints are divided into:

1. certain (pain, cough, vomiting, fever) associated with delineated anatomical changes in organs;
2. vague, erased (unwell, “not at ease”), characteristic of long-term chronic diseases;
3. neurotic, with their characteristic hyperbolization of sensations, excessive brightness and detail.

When clarifying complaints, you should never ask the patient what hurts him. It is necessary to give the patient the opportunity to speak freely, and only then clarify his complaints with the help of additional questions. The nature of the process of identifying complaints should quickly acquire the framework of a frank, natural conversation between the patient and the doctor. First of all, it is necessary to determine the most accurate location of pain possible. It is necessary to determine the nature of the pain itself, as well as its distribution (irradiation): for example, for pain in the heart - it spreads to the left shoulder and arm with angina pectoris, for pain in the right hypochondrium - to the right shoulder and arm, under the right shoulder blade, etc. .Listed features pain syndrome are called the pain spectrum. In addition, the duration of the pain and the means to relieve it (nitroglycerin - for angina, soda - for pain in the pit of the stomach, etc.) are of a certain importance.

Medical history

Anamnesis is a set of information reported by the patient to the doctor examining him, which is used to make a diagnosis and determine the prognosis of the disease.

The process of obtaining anamnestic information by a doctor is called collecting, or taking an anamnesis.

Anamnesis is a kind of confession of the patient to the doctor. Therefore, it is extremely important that the patient has goodwill and complete trust in the examiner. Taking an anamnesis is in many ways an art, which is constantly being improved as the doctor improves his qualifications and gains experience. Only in the process of collecting anamnesis does the doctor have the opportunity to assess the intelligence, characterological characteristics of the patient, and the characteristics of his mental sphere. All this leaves a significant imprint on the patient’s presentation of his feelings, the analysis of which is so necessary for the examining doctor.

Anamnesis should be collected according to a specific plan.

Procedure for collecting anamnesis

• History of the present illness - detailed description the development of the disease from the very beginning, and not just its last exacerbation (not limited to listing the dates of contact with the doctor and indicating the diagnoses).
• Patient's life history:

1. biographical information;
2. list of diseases: similar to this one, diseases in childhood, in mature age, wartime diseases (nutritional dystrophy, scurvy, wounds, contusions), venereal, gynecological diseases, mental trauma, epidemiological anamnesis;
3. chronic intoxication (smoking, alcohol, drugs);
4. allergy history;
5. survey about relatives (information about heredity and predisposition to diseases similar to this);
6. family history: menstruation (regularity, duration, abundance), sexual life, marriage, pregnancy, childbirth, abortion;
7. social and everyday history: recent working conditions (hygienic conditions, nature of work), being on vacation; living conditions (number of rooms, floor, heating); regularity, quality of nutrition;
8. insurance history: frequency of use of the certificate of incapacity for work, presence of a disability group, since when the patient currently has a certificate of incapacity for work.

It is important to remember that taking an anamnesis is an active research method, in the implementation of which the doctor plays a decisive, leading role. The anamnesis must be complete, exhaustive and strictly systematized. To obtain maximum information and not to miss any important details, when collecting an anamnesis of the disease, it is necessary to adhere to a certain, always the same sequence of questioning. According to many clinicians, the first 15-20 minutes of contact between the doctor and the patient are most important for a high-quality history taking.

G. A. Zakharyin believed that “taking an anamnesis requires a lot of endurance, tact, knowledge and skills,” and “the skill must be constantly improved.” According to him, the questioning is complete “if there is nothing to add.” The anamnesis only at first sounds like a monologue of the patient, and then gradually, with the hidden initiative of the doctor, imperceptible to the patient, it should transform into an interested, friendly dialogue.

History of present illness

The history of the present disease is a very important section of the anamnesis, creating the basis, the foundation for the diagnostic hypothesis.

Schematically, it can be distinguished:

• the nakedness of the disease (the first signs and their causes according to the patient);
• course - continuously progressive or intermittent (with “light” intervals), recurrent;
• treatment, according to the patient’s words and according to the medical documents he has (extracts from medical records, medical certificates), objectively characterizing the course and treatment of the disease;
• reasons for the latest deterioration (important circumstances, life situations).

It is possible to distinguish between two types of history taking. The first is used for acute diseases, which most often begin suddenly, against the background of complete well-being. In this case, the patient is asked questions: how did the disease begin, was it preceded by any other disease - a cold, sore throat or acute respiratory viral infection, fatigue, exercise stress; if the latter was accompanied by an increase in temperature, then what was it and what was the nature of its increase. It is necessary to highlight the main signs of the disease: for example, fever, cough, headache, general state, and then day by day - until admission to the hospital - try to find out the dynamics of the main symptoms that may persist or regress.

The second type of history taking, used for chronic diseases that last for years or decades, is much more complicated. In this case, one should determine the leading initial signs of the disease and, in the process of collecting anamnesis, try to identify the dynamics of these symptoms over a certain period of time (a year, several years, decades). At the same time, the question of the addition of new symptoms is clarified. At the same time, the doctor’s focus is on the course of the disease and the effectiveness of treatment. Such anamnesis collection is significantly supplemented by the medical documents available to the patient, which expand the understanding of the nature and course of the disease. The last deterioration is analyzed by the doctor in more detail; the history taking should be close to the first type.

By the quality of collecting anamnestic data on the history of the development of the disease, one can judge the doctor’s qualifications, his professional skills, ability to approach the patient, and the ability to distinguish between major and minor, insignificant information that characterizes the features of the pathology and its course in each specific case.

Patient's life story

It is in the life history that the influence of the social environment and the patient’s relationship with it, which affects his health, is clearly visible. In this aspect, anamnestic studies are carried out teenage years, the conditions of life, nutrition, study during the period of formation are identified, the start time labor activity, working and living conditions in adulthood, living conditions that are directly related to the course of many chronic diseases. Here, nutritional features and eating habits are also clarified. The moments connected with the Great Patriotic War, any extreme situations, injuries, contusions, the development of pathology associated with the siege of Leningrad (scurvy, nutritional dystrophy). When a patient is in besieged Leningrad, it is necessary to roughly find out which form of dystrophy took place - edematous or cachectic (the patient is “fluff” or “dry” from hunger).

First, they ask about diseases suffered in childhood (measles, scarlet fever, diphtheria, whooping cough, etc.). The fact that the patient was sick a lot in childhood can explain to the doctor the weakening of the body of the patient under study, indicate its reduced resistance, greater susceptibility to the subsequent formation of secondary manifestations of immune deficiency (infantilism, youthfulness), characteristic of patients with certain endocrine diseases (pathology of the gonads, pituitary gland ) or patients who have suffered from mitral heart disease since childhood (a beneficial effect on the tissues of chronic hypoxia is expected).

When questioning the life history, the profession that is in modern conditions has a relatively small effect on the occurrence of the disease and has a greater impact on its course. Some production factors remain important: chemical (vapors of acids and alkalis) and physical effects (dusty premises, physical inactivity). In conditions of widespread violation of most environmental standards, these factors increase their influence on the course of many chronic diseases.

Currently, when collecting a life history, special attention must be paid to tuberculosis, which is last years sharply intensified, including the reappearance of active forms - with bacilli excretion.

An important issue is about promiscuity, which is increasingly relevant these days due to the possibility of developing hidden (latent) urinary infections (chlamydia, mycoplasmosis, etc.).

When surveying chronic intoxications, in addition to smoking and drinking alcohol (very toxic surrogates are possible), it is necessary, but extremely difficult, to identify hidden drug addiction or substance abuse, which have become quite common among young people. This is far from easy and only doctors with extensive experience can do it.

Particular attention should be paid to anamnestic information about heredity, predisposition - a complex of functional and morphological characteristics of the body that favors the occurrence of the disease and increases or decreases resistance to a number of external conditions. This predisposition various diseases implemented differently. It exists in bronchial asthma, hypertension (HTN), diabetes mellitus, peptic ulcer disease. Hereditary predisposition is determined in approximate form by asking the patient about the health of his parents, sisters and brothers, grandparents, close relatives in the ascending line (uncles and aunts).

When collecting anamnesis from women, the gynecological aspect is important, which includes information about pregnancies, the number of abortions, characteristics of menstruation (duration, abundance, presence of spotting during the intermenstrual period). Increased fetal size indicates the possibility diabetes mellitus, and long-term polymenorrhea can cause the development of iron deficiency anemia.

Survey on systems and organs

The doctor questions the patient about individual physiological systems, i.e., finds out what sensations the patient experiences from the activity of individual systems internal organs, starting from the central nervous system and ending with musculoskeletal. It must be emphasized that the data collected by the doctor in this section cannot contain the phrase: “There are no complaints from this or that system.” Both positive and negative information are important here. An example would be a question about the state of the central nervous system: “Sleep is disturbed, sleeps for 4-5 hours, has insomnia, has difficulty falling asleep, over the past 5 years has regularly resorted to sleeping pills. Irritable, periodically notices headaches in the temporal region, more often in the afternoon (migraine type), dizziness, does not complain of noise in the head. There has been a decline in memory over the past 3-5 years. Vision is normal, hearing is somewhat weakened in both ears, and tinnitus occurs occasionally.”

Similarly, data on all organs and systems is collected and recorded.

It should be recalled that with inept and careless behavior, a doctor can cause serious mental trauma to the patient. It's about about the possibility of developing iatrogenic diseases.

In psychiatric practice, interviewing the patient is the most important examination method. The main part of the symptoms of mental illness can be detected only from the patient’s words. Such disorders include phenomena of mental automatism, delusional ideas, intrusive thoughts and fears, deceptions of feelings, depersonalization and derealization. Other mental disorders can only be suspected based on observation of the patient’s behavior. These disorders include auditory hallucinations (the patient listens to something), delusions of persecution (the patient looks tense and frightened). In the case of sudden agitation, stupor, or impaired consciousness, the patient should be questioned only after these conditions have passed. It is better to talk with a patient in a psychotic state after first receiving information about him from family and friends. For non-psychotic disorders, it is first of all better to ask the patient himself, which increases his confidence in the doctor.

Interviewing a patient requires special skills from a psychiatrist. A unified survey scheme is simply impossible, since, on the one hand, the patient must be allowed to speak out, and on the other hand, the initiative must always be in the hands of the doctor. You need to start a conversation with the patient with what served as the basis for contacting a psychiatrist. The doctor is always required to have patience, restraint, goodwill, and also sympathy for the patient, even with his clearly hostile attitude towards the psychiatrist. At the same time, it is necessary to avoid familiarity and maintain distance. In no case should you hide the purpose of the questioning from the patient or introduce yourself as someone other than a psychiatrist. In case of refusal to answer the questions posed, the most important of them should still be asked to the patient. In this case, the doctor must note the patient’s reaction to these questions.

The purpose of the questioning is to find out how much the patient understands what is happening around him, how he is oriented in place and time, whether his memory is preserved for the most important events in his life, as well as for events that occurred before going to the doctor. The psychiatrist must ask the patient to provide an explanation for his actions or statements that those around him could suggest a mental disorder. If the patient himself does not speak out about his painful experiences, then the doctor should ask leading questions about hallucinations, delusions and other disorders. It is useful to ask the question about the presence of suicidal thoughts in the patient’s mind, not only in the present time, but also at any time in the past. In addition, it is necessary to find out the patient’s attitude towards all detected painful experiences and behavioral characteristics, such as a complete lack of criticism, partial, unstable or sufficiently critical attitude towards them.

Questioning of the patient is carried out only in the absence of his relatives and friends.

Psychiatric history is divided into subjective and objective.

Subjective history. In this case, information is collected from the patient himself during the interview process. Anamnesis of the disease consists of finding out the time of the first appearance and characteristics of the signs of the disease, what events preceded it, how the manifestations changed when they disappeared. The life history includes the patient’s memories of the family he grew up in, who his parents were, how he was educated, and what behavioral disorders he had in childhood and adolescence (for example, running away from home). It is necessary to find out whether there was abuse of alcohol, drugs or other intoxicating drugs, at what age it began, and how severe it was. Equally important are data on the patient’s assessment of his social status – labor and family. The psychiatrist must find out whether the patient is satisfied with his status, what he is burdened with and what he lacks. Information about those events is also important past life which the patient himself considers the most difficult, how he experienced them, whether there were suicidal thoughts and attempts at such moments. The somatic anamnesis takes into account previous diseases, information about traumatic brain injuries, even with a short loss of consciousness, brain infections, neurointoxications, and a tendency to allergic reactions.

Objective anamnesis reflects information received from relatives and friends of a mental patient. It is recommended to obtain this information from each person individually. The psychiatrist should guide the conversation by asking only the facts. At the same time, you need to stop any attempts to impose someone else’s opinion on yourself. In addition, an anamnesis of the disease itself is collected. In the process of collecting this anamnesis, they find out when and what manifestations of the disease arose, and what reason could have contributed to this. They also collect an anamnesis of the patient’s life, focusing on information about hereditary burden. From the patient's parents you can learn about the developmental features of childhood. After this, they are asked the same questions as the patient himself. It is important to find out those facts that the patient kept silent about.