History Taking (Anamnesis) - Russian Medical University Format

TITLE PAGE

• University & Department name
• Chief of Department / Assistant Professor names
• Patient's full name (Surname, First name, Patronymic)
• Principal diagnosis
• Complications
• Concomitant (concurrent) diseases
• Curator (student's year, faculty, group, and full name)
• Date of admission / discharge

I. INQUIRY (INTERROGATION / РАССПРОС)

1. Patient's Identifying Data (Паспортная часть)

2. Chief Complaints (Жалобы / Главные жалобы)

• Record the patient's own words exactly as stated (e.g., "My stomach hurts and I feel awful.")
• If no complaints: note the reason for admission (e.g., "admitted for routine check-up")
• After chief complaints, screen all other body systems to uncover secondary complaints
• Secondary complaints arise from a systems review and may be unrelated to the main illness

1. Location - where exactly
2. Quality - character (sharp, dull, burning, pressing)
3. Quantity/Severity - how intense (scale 1-10)
4. Timing - onset, duration, frequency, course
5. Setting - when/where does it occur (at rest, on exertion, at night)
6. Aggravating/Relieving factors - what makes it worse or better
7. Associated manifestations - accompanying symptoms

3. History of Present Illness (Анамнез настоящего заболевания / История настоящего заболевания)

• Onset - when and how the illness began (sudden vs. gradual)
• Initial symptoms - first signs noticed
• Setting of development - circumstances at the time of onset
• Progression - how symptoms evolved over time
• Previous investigations and results - any labs, imaging, or tests done before
• Previous treatments and response - medications taken, procedures done, effect
• Hospitalizations - prior admissions for this condition
• Reason for current admission - what prompted this visit

Document the patient's response to symptoms and the effect the illness has had on their daily life and function.

4. Past Medical History (Анамнез жизни / История жизни)

a) Biographical History

• Place and date of birth
• Development in childhood (physical and mental)
• Schooling and education

b) Past Illnesses & Surgical Procedures

• Diabetes mellitus
• Hepatitis (A, B, C)
• Tuberculosis
• Hypertension
• Myocardial infarction
• Stroke
• Asthma
• Blood transfusions (when, why, reactions)
• Any operations or injuries

c) Epidemiological History (Эпидемиологический анамнез)

• Contact with infectious patients
• Recent travel
• Animal contact
• Insect bites
• Food sources (water, raw meat)
• Vaccinations history

d) Allergological History (Аллергологический анамнез)

• Drug allergies (specify the drug and nature of reaction)
• Food allergies
• Environmental allergies
• Intolerance to any substances

e) Medications Currently Taken

• Drug name, dose, frequency, duration

f) Gynecological History (for female patients)

• Age of menarche
• Menstrual cycle regularity
• Number of pregnancies, deliveries, abortions
• Menopause (if applicable)

g) Occupational History (Профессиональный анамнез)

• All occupations held (chronologically)
• Occupational hazards - chemicals, dust, radiation, noise
• Duration of exposure

h) Social History (Социальный анамнез)

• Living conditions (housing quality, number of occupants)
• Nutrition and diet
• Physical activity
• Marital status and family situation

i) Bad Habits (Вредные привычки)

• Smoking: number of pack-years (packs per day × years smoked)
• Alcohol: frequency, amount, type
• Drug use: type, frequency, route

j) Family History (Семейный анамнез)

• Health of parents and siblings (if deceased - cause and age of death)
• Hereditary diseases in the family:
  • Cardiovascular disease
  • Diabetes mellitus
  • Malignancies (cancer)
  • Tuberculosis
  • Mental illness
  • Allergic diseases

Logical Structure Summary

CASE HISTORY
│
├── I. INQUIRY (РАССПРОС)
│   ├── 1. Identifying Data (Паспортная часть)
│   ├── 2. Chief Complaints (Жалобы)
│   ├── 3. History of Present Illness (Анамнез morbi)
│   └── 4. Past Medical / Life History (Анамнез vitae)
│       ├── Biographical history
│       ├── Past illnesses & surgeries
│       ├── Epidemiological history
│       ├── Allergological history
│       ├── Medications
│       ├── Gynecological history (F)
│       ├── Occupational history
│       ├── Social history
│       ├── Bad habits
│       └── Family history
│
└── II. PHYSICAL EXAMINATION (Объективный статус)
    ├── General condition, temperature, posture, consciousness
    ├── Constitutional type, height, weight, BMI
    ├── Skin, mucous membranes, lymph nodes
    ├── Musculoskeletal system
    ├── Respiratory system
    ├── Cardiovascular system
    ├── Digestive system
    ├── Urinary system
    ├── Nervous system
    └── Endocrine system

Key Differences from Western History Taking

Tips for Russian University Examinations

1. The history is written in third person, past tense (e.g., "The patient complained of...")
2. Chief complaints must be listed in order of importance
3. Anamnez morbi and Anamnez vitae are always written as separate sections - never combine them
4. Every complaint in the chief section must be elaborated in the History of Present Illness
5. The document must be signed with the curator's details and dated
6. At Russian universities, students are expected to write the full case history (История болезни) which is typically 20-30 pages

Percussion (Перкуссия) - Physical Examination

Definition

• Size, shape, and borders of organs
• Consistency of underlying tissue (air, fluid, solid)
• Presence of pathological changes (fluid, consolidation, cavities)
• Position and displacement of organs

Classification of Percussion

A. By Technique (Method of Performance)

1. Direct Percussion (Непосредственная / Прямая перкуссия)

• Definition: Tapping directly on the patient's skin with one or two fingers, without a pleximeter
• How: Use the tip of the middle or index finger to tap directly on the body surface
• Used for: Assessing sinuses (frontal, maxillary), children's examination, areas where indirect percussion is difficult
• Advantage: Simple, quick
• Disadvantage: Produces a less distinct sound; not suitable for deep structures

2. Indirect (Mediate) Percussion (Опосредованная / Медиатная перкуссия)

• Definition: Tapping is performed through a pleximeter (an intermediary)
• Two subtypes:
  • Finger-to-finger percussion (most common): The middle finger of the left hand acts as the pleximeter, placed firmly on the skin; the middle finger of the right hand (the plexor) strikes it
  • Hammer-and-pleximeter percussion: A percussion hammer strikes a pleximeter (rubber/ivory plate) - used historically, less common now
• How (finger-to-finger):
  1. Place the left middle finger (pleximeter) flat and firmly on the skin
  2. Only the middle phalanx should contact the skin
  3. Strike with the tip of the right middle finger (plexor) using a quick, wrist-flicking motion
  4. Two strikes per location, then move
  5. Strike perpendicular to the pleximeter finger
• Used for: Lungs, heart, liver, spleen, abdomen - most clinical percussion
• Advantage: Most precise, widely used, reproducible

3. Blunt (Fist) Percussion (Перкуссия кулаком / Поколачивание)

• Definition: Using the ulnar edge of a fist (or the fist itself) to strike the body - this is actually a percussion-palpation technique
• Used for:
  • Kidney tenderness (Pasternatsky's sign / симптом Пастернацкого) - fist strikes over the costovertebral angle
  • Liver pain assessment
  • Spine tenderness
• Note: In Russian schools, this is classified as a separate form; in Western schools it may be called "blunt percussion" or "indirect fist percussion"

B. By Purpose (Goal of Percussion)

1. Comparative Percussion (Сравнительная перкуссия)

• Goal: Compare sounds over symmetrical areas of the body (left vs. right)
• Used for: Lungs - comparing right and left, upper vs. lower zones
• Technique: Strike with equal force over mirror-image locations
• Detects: Unilateral dullness (fluid, consolidation), unilateral hyperresonance (pneumothorax, emphysema)

2. Topographic Percussion (Топографическая перкуссия)

• Goal: Determine the boundaries, size, and position of organs
• Technique: Percuss from resonant area toward dull area; the border is where the sound changes
• Rule: Always move from clear (resonant) → dull; mark the border on the dull side
• Used for:
  • Upper and lower borders of the lungs
  • Cardiac borders (right, left, upper border of cardiac dullness)
  • Liver size and borders
  • Spleen borders
  • Bladder (when distended)

C. By Force of Strike

1. Loud (Deep) Percussion (Громкая / Глубокая перкуссия)

• Strong blows; sound penetrates 7-8 cm deep
• Used for: Localizing deep structures, fluid in the pleural cavity, deep masses

2. Quiet (Threshold) Percussion (Тихая / Пороговая перкуссия)

• Light blows; sound penetrates 4-5 cm deep
• Used for: Determining organ borders more precisely (e.g., heart borders, liver)

3. Quietest Percussion (Тишайшая перкуссия)

• Very gentle taps; penetrates only 1-2 cm
• Used for: Superficial structures, determining absolute cardiac dullness (area directly in contact with chest wall without lung overlap)

Percussion Sounds (Перкуторные звуки)

Pneumonic for Sounds (Loud → Quiet):

Topographic Percussion of the Lungs (Clinical Example)

Lower Borders of the Right Lung:

Lung Mobility (Respiratory Excursion):

• Normally 6-8 cm along the midaxillary line

Rules of Percussion Technique (Russian University Exam Standards)

1. The pleximeter finger must lie parallel to the expected border
2. Tap with the tip of the plexor finger, not the pad - use a wrist snap, not elbow motion
3. Two equal taps per site, then move
4. Always move from resonant → dull when determining borders
5. Mark the border on the dull side (the side from which you are approaching)
6. The patient must be in the correct position - standing or sitting for lung percussion
7. Room must be quiet
8. Apply equal force for comparative percussion

Summary Table

Topographic Percussion of the Lungs (Топографическая перкуссия лёгких)

1. Determination of the upper borders (apices)
2. Determination of the lower borders
3. Determination of the excursion (mobility) of the lower borders

General Rules of Topographic Percussion

• Always move from resonant (clear) sound → dull sound
• Mark the border on the dull side (the side toward which you are moving)
• Use quiet (threshold) percussion - lighter force for more precise borders
• The pleximeter finger lies parallel to the expected border
• Perform on both right and left sides
• Patient position: standing or sitting (upright)

I. Upper Borders of the Lungs (Apices / Верхушки лёгких)

Anterior (Front):

• Place pleximeter parallel to the clavicle
• Percuss from the middle of the clavicle upward and medially
• Move until dullness appears

Normal: Apex is 3-4 cm above the clavicle (both sides)

Posterior (Back):

• Place pleximeter parallel to the spine of the scapula
• Percuss from the middle of the scapular spine upward toward C7
• Move until dullness appears

Normal: Apex is at the level of the spinous process of C7 (7th cervical vertebra)

Width of Kronig's Fields (Поля Кренига):

• The band of resonance over the apex (on the trapezius muscle) measured in cm
• Percuss medially and laterally from the middle of the trapezius
• Normal: 4-8 cm on each side

II. Lower Borders of the Lungs (Нижние границы)

Technique:

• Start above the expected border (in the area of clear resonance)
• Percuss downward along each topographic line, one intercostal space at a time
• Mark the border where the sound changes from resonant → dull

Normal Lower Borders - Table (Normosthenic Person)

Note: The left lung borders are not determined along the parasternal and midclavicular lines because the heart occupies that area (cardiac dullness). Left lung borders are assessed from the anterior axillary line downward.

Memory Aid (Right Lung):

III. Excursion (Mobility) of the Lower Lung Border

Technique:

1. Find the lower border at quiet (normal) breathing - mark it (Point A)
2. Ask the patient to take a deep breath and hold - percuss down again, mark new border (Point B)
3. Ask the patient to exhale fully and hold - percuss up from below until dullness, mark border (Point C)
4. Total excursion = distance from Point B to Point C

Normal Values of Respiratory Excursion:

The midaxillary line has the greatest excursion (6-8 cm) and is the most clinically important.

IV. Changes in Borders - Clinical Significance

Bilateral Lowering of Lower Border:

• Asthenic body type (tall, thin)
• Acute pulmonary dilation - bronchial asthma attack
• Chronic pulmonary dilation - emphysema

Bilateral Elevation of Lower Border:

• Hypersthenic body type (stocky)
• Pleural effusion (bilateral)
• Ascites (pushes diaphragm up)
• Acute bloating/meteorism

Unilateral Lowering of Lower Border:

• Unilateral emphysema
• Compensatory emphysema (opposite lung after pneumonectomy)
• Unilateral pneumothorax

Unilateral Elevation of Lower Border:

• Pleural effusion (on affected side - dull sound, border rises)
• Pneumonia / consolidation (lobe involved)
• Atelectasis (lung collapse)
• Diaphragmatic paralysis

Decreased Excursion (Mobility):

• Inflammatory processes in the lung (pneumonia)
• Decreased elasticity - emphysema (most common cause)
• Pleural effusion or pleural adhesions
• Diaphragmatic fixation/obstruction

Increased Excursion:

• Compensatory (opposite lung after lobectomy)
• Athletic/deep breathing individuals

V. Changes in Upper Borders

Summary Diagram

TOPOGRAPHIC PERCUSSION OF LUNGS
│
├── UPPER BORDERS
│   ├── Anterior: 3-4 cm above clavicle
│   ├── Posterior: level of C7
│   └── Kronig's fields: 4-8 cm
│
├── LOWER BORDERS (Right)
│   Parasternal → 5th ICS
│   Midclavicular → 6th ICS
│   Ant. axillary → 7th ICS
│   Midaxillary → 8th ICS
│   Post. axillary → 9th ICS
│   Scapular → 10th ICS
│   Paravertebral → T11
│
└── EXCURSION
    Midaxillary: 6-8 cm (most important)
    Midclavicular / Scapular: 4-6 cm