Тема 14. Прийом у лікарню. Заповнення історії хвороби >I. Active vocabulary




НазваТема 14. Прийом у лікарню. Заповнення історії хвороби >I. Active vocabulary
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In a hospital

Taking a patient’s history, clinical examination

Тема 14. Прийом у лікарню. Заповнення історії хвороби

I . Active vocabulary

establish - встановлювати

initial - початковий; попереджати

affect - уражати

fits - конвульсії

faint - знепритомшти; непритомшсть, зомлшня

disturbance - порушення

vertigo - запаморочення

clue - ключ (до розгадки)

elicit - установлювати, виявляти

relevant - доречнии; що стосуеться справи

obtain - отримувати

intolerance – нетерпимість

indigestion - розлад травления

heartburn - печія

account - звіт

previous - попередній, що передував

history - історія хво­роби

investigation - дослідження

to carry out - проводити

to recommend - рекоменду­вати, радити

waiting - список осіб, які очікують

appropriate - відповідний; доречний, придатний; при­таманний

vacant - (про місце) незайняте, вільне

to report to the hospital - з'явитися до лікарні

to enclose - вкладати; прикладати

to outline - накреслити в загальних рисах

routine - заведений поря­док; узвичаєна практика

detail - подробиця; деталь

visiting hours - години відвідування

as a result of sth - унаслі­док чогось

immediate - негайний, невідкладний

care - турбота, піклування, догляд

attention – увага

unlike - не схожий на; не такий, як

unconscious - непритом­ний, що знепритомнів

they arе accompanied by - вони супроводжуються ...

Emergency treatment - не­відкладне лікування

admission card - картка пацієнта/хворого

civil state - цивільний стан

date of birth - дата народ­ження

^ II. Leading work with the vocabulary.

1. Read the following sentences. Find sentences in the Present and Past Perfect Tenses and translate them into Ukrainian.

▪ The students have already got a lot of information about histon taking.

The nurse didn't return to the operating room on time.

▪ They had discussed the symptoms of the patient and were ready to make clinical examination.

▪ They have already collected a very interesting data.

▪ More and more patients use medical plants for treatment.
^ III. Work with the text read and translate the text

Taking a History

Taking a patient's history is the initial part of clinical examination and its main aim is to find out the patient's present problem and how it affects the quality of their life.

The history is a review of the patient's current state of health and past medical condition. When taken carefully, it may give valuable information about the nature of the patient's problem and provide the necessary clues to help the doctor establish a preliminary or differen­tial diagnosis.

The history-taking process is a well established and commonly used sequence.

^ 1. History of presenting complaint (HPC). The main symptoms should be clearly defined as soon as possible, to find out the cause of admission or seeking medical advice. The onset, severity, progression, associated features or symptoms are all important. A special focus is also made on pains associated or not with specific organs.

^ 2. History of present illness (HPI). The patient is requested to give an account of recent events in their own words which in this way may be recorded in the history sheet.

3. Systemic enquiry (SE) also known as the review of systems (RoS). The history is taken of the main symptoms of the major bodi­ly systems:

General: mood, fatigue, anorexia, fever, night sweats, rashes, heat/cold intolerance.

Cardiovascular system (CVS): chest pain, palpitations. Respiratory system (RS): shortness of breath, cough, sputum, wheeze, haemoptysis.

Gastrointestinal system (GS): nausea, vomiting, indigestion, ab­dominal pain, heartburn, change in bowel habit. Genitourinary system (GUS): nocturia, frequency, incontinence, change in color/smell of urine, menstrual difficulties. Central nervous system (CNS): headaches, weakness, dizziness, fits, faints, vertigo.

^ 4. Past medical history (PMH). Patients are asked about their previous medical/surgical diseases.

5. Drug history (DH) and allergies (ALL). Information is ob­tained on any medication prescribed, self-administered drugs.

6. Family history (FH) provides information about any predis­position to disease, and relevant information on relatives.

7. Social history (SH). Information is collected about the pa­tient's occupational, social, personal factors, such as habits, employment, housing, interests, sports, hobbies, physical exercise, the use of alcohol, tobacco, recreational drugs.

To accomplish the purpose, a set of the following practical tips has been developed.

• Show the patient your attention.

• Start by eliciting the presenting complaint.

• Let the patient tell story in their own words.

• Try not to interrupt.

• Use the language which the patient understands.

• Summarize the story for the patient to check, correct and add more relevant details.

• Obtain the patient's history also from other sources of information.

Having completed history taking, the doctor will perform the next stage of clinical examination, which is physical examination. The di­agnostic process will proceed, but the first clues have already been obtained to formulate a preliminary diagnosis, which will help the doctor to develop their own approach to the patient's problem during physical examination.
^ IV. Language Development

1) Match the following Ukrainian word combinations with the English ones.

1 біль в черевній порожнині

a to provide information




2 порушення мови

b present problem




3 генетичне захворювання

с abdominal pain




4 причина гостпіталізації

d speech disturbance




5 поставити діагноз

e genetic diseases




6 диференщальний діагноз

f present complaints




7 надавати іформацію

g previous diseases




8 теперішня скарга

h differential diagnosis




9 дана проблема

i cause of admission




10 попереднє захворювання

j to establish diagnosis






2) Match expressions and their definitions.

1. coronary thrombosis

2. asthma

3. canser of lung

4. ulcer

5. depression

6. diabetes

7. adenoma

a. What sort of mood have you been in recently?

b. Have you had any pain in your chest?

c. Have you had any shortnss of breath?

d. What is your level of sugar?

e. Do youever get wheezy?

f. Have you had a heartburn?

g. Have you ever coughed up blood?




1. present complaint

2. history of present illness

3. systemic enquiry

4. past medical history

5. family history

6. drug history

a. details of patient's medical records over a period of time

b. all the symptoms of the diseases are present

с. recent events in the case history

d. review of systems

e. records of earlier illnesses

d. information about parents, relatives


3) Complete the following sentence choosing suitable words from the box.

1. The patient gives a month's history of ... pain.

2. These results are consistent with ... disease.

3. On a recent visit he complained of nausea, vomiting and speech

4. A thorough inquiry elicited relevant symptoms: ..., faints and fits.

5. Having completed history taking the doctor made ... diagnosis.

6. Family history provided information about ... disease.

7. There was ... detailed information on patient's relatives.

8. Practical recommendations have been developed which help to ... diagnosis.
4) What body systems are these questions related to?

Cardiovascular system = CVS Respiratory system = RS Gastrointestinal system = GS Genitourinary system = GUS Central nervous system = CNS Endocrine system = ES Ear, nose and throat = ENT

1. Do you have any nausea, vomiting, diarrhea, dyspepsia?

2. Does your pain behind your breastbone irradiate to your back, neck, arm?

3. How long have you been having these headaches?

4. Do you keep awake at night?

5. Have you any trouble with your stomach or bowels?

6. What's you appetite like?

7. Do you have any problems with your waterworks?

8. Are you still having your periods regularly?

9. Do you have pain in the chest, palpitation, swelling of the ankles?

10. What about coughs or wheezing or shortness of breath?

11. Are you diabetic?

12. Have you ever had nose bleeding?
5) Match each of the suspected problems in the first column with a suitable question from the second column.

Common phrases used by patients and their meaning. Use them in your sentences

^ When a patient says ...

the doctor understands

I can't breathe

I can't eat or I've lost my appetite

My skin looks yellow

My hair is falling out

I can't remember a thing

I can't move

I have a cavity

I cough up blood

I'm having my period

My skin looks blue

My chest feels constricted

I can't sleep

I fell like I'm going to throw up

My ankle is swollen

dyspnoea

anorexia

jaundice

alopecia

amnesia

paralysis

caries

haemoptysis

menstruation

cyanosis

thoracic pain

insomnia

nausea

oedema





Answer the questions.

1. What are the main components of clinical examination?

2. Why does taking history come first?

3. How does an interview usually start?

4. Why are systems reviewed?

5. Why are patients asked about their previous medical diseases?

6. What may drug history reveal?

7. What recommendations should be followed to get accurate infor­mation?

8. What is crucial in history taking?

9. Is it necessary to obtain the patient's history from different sourc­es of information?

10. What information should be defined during taking history of pre­senting complaint?
6) Ask the type of question the sister used in the dialogue and fill in this form.

Surname

First Names ....

Address

Phone Number Date of Birth ..

Civil State

Religion

Occupation

Next of Kin ....
7) Read the following sentences. Find sentences in the Present and Past Perfect Tenses and translate them into Ukrainian.

1. The students have already got a lot of information about history taking.

2. The nurse didn't return to the operating room on time.

3. They had discussed the symptoms of the patient and were ready to make clinical examination.

4. They have already collected a very interesting data.

5. More and more patients use medical plants for treatment.
^ V. Speaking.

A young man was delivered to the Emergency Department with an ab­dominal pain. Complete the interview with the doctor's questions.

Doctor: Good morning. I'm doctor Smith. ..., please?

Patient: John Wilson

D.: Ok John, ... tell me ... your problem?

P.: It's that severe pain in my belly.

D.: ...

P.: It came two days ago.

D.

P.

D.

P.: At fin

D.: ...

P.: Yes, r

D.: ...

P.: I feel

D.: ...

P.: Yes, ii

D.: ... P.: Oh! M D.: ...

P.: It's a 1

D.: John, appendicitis.

P.: Oh, if

P.: At first it was mild, but then it became worse.

D.

D.

Yes, now it's in that particular place all the time.

P.: I feel so sick that can't eat anything.

D.: ...

P.: Yes, it was 38.5 yesterday.

D.: ...

P.: Oh! When you take your hand away it's even worse.

D.: ...

P.: It's a bit better when I'm lying on my side. D.: John, it's necessary to do a blood test — it most probably is appendicitis.

P.: Oh, it's horrible!
^ 1. Read and dramatize the following dialogues:

Patient Excuse me, nurse. Is this Dixon ward? Sister Yes, this is Dixon.

Patient Well, I'm Peter McLeod. You sent me a let­ter telling me to report here at half past two.

Sister That's right, Mr McLeod. Would you come in and sit down, please? We have to fill in an admission card.

Patient Thank you.

Sister Now, your surname is McLeod — would you mind spelling it, please?

^ Patient M C capital L E O D.

Sister Thank you. And your Christian names?

Patient Peter John.

Sister Where do you live?

Patient 26 Greenend, Waterbeach.

Sister What's your telephone number?

Patient Waterbeach 234 750.

Sister And when were you born?

Patient 21st December 1964.

Sister Are you married?

Patient Yes, 1 am.

Sister And what's your occupation?

Patient I'm a carpenter.

Sister What's your religion?

Patient Church of England.

Sister It says here, 'Name and address of next of kin'. Who is your nearest relation?

Patient My wife, Mary.

Sister And you live at the same address?

Patient Yes, of course.

Sister Now, who is your family doctor?

Patient Dr Beale.

Sister And his address?

Patient The Oaks, High Street, Landbeach.

Sister Do you know which doctor is in charge of your case

Patient Er... I believe it's Dr Thorpe.

Sister All yes. Mr Thorpe — he's a surgeon, you see.
^ 2. Make up doctor's questions and try to guess the diagnosis.

Doctor: Come and sit down here. What's brought you along today

Patient: It's pain in the chest. IX: ...

P.: I suppose about two days ago.

D.: ...

P.: It was a bad pain and I couldn't breathe.

D.: ...

P.: Just here, across my chest.

D.: ...

P.: A half an hour.

D.: ...

P.: I took nitroglycerine.

D.: ...

P.: It comes back when I work hard or when I am nervous.

D.: ...

P.: Usually my pulse and blood pressure are normal, but recently I noticed some elevation of blood pressure.

D.: …
^ 3. Make up doctor's questions for the answers and act out the dialogue.

Doctor: And how long have you had this temperature?

Patient: Oh. I don't know exactly. About two months on and off.

D.: …

P.: Well, sometimes I'm all right during the day, but I wake up n( night feeling shivery. D.: ...

P.: I have been feeling a bit tired and weak. And I just don't seem to have any energy.

D.: ...

P.: Yes, yes. I have lost some weight.

D.: ...

P.: Weil, I've really been off my food this last while. I just haven't felt like eating.

D.: ...

P.: Oh, yes. I have. Nearly all the time 1 bring up a lot of phlegm.

D.: ...

P.: No, not always, but sometimes I notice blood in it.

D.: ...

P.: I feel pain only if I take a deep breath.

D.: …
^ 4. Can you do these tasks on your own?





Yes

No

Need more practice

Take a history of the present complaint

Take the present and past history

Take the family history

Take the drug history

Review the systems










General symptoms of patients, and care of them.

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