The Medical History of a Surgical Patient

Николай Васильевич Мерзликин

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 substantiation, and differential diagnosis. It describes the order of documents registration for preparing and performing surgical intervention and anesthesia. It pays particular attention to the correct interpretation of the follow-up examination results. The appendices contain reference ranges for laboratory tests, a short version of the International Classification of Diseases, interpretation of indicators of blood and urine tests on automatic analyzers, the new nomenclature of standard and surgical diets, recommendations for the prevention of infectious and thromboembolic complications, and registered forms of medical records.