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  • B. Chief Complaints

  • Pain characteristics Location of pain

  • Quality

  • Circumstances which aggravate pain

  • Associated sensations or mixtures of sensations

  • Relation to physiologic function

  • Effects of disease

  • E. Personal History

  • F. Family History and familal tendency

  • Texts and dialogues

  • Учебное пособие НАР.ШАМ. 2008. Учебное пособие НАР.ШАМ. Kursk state medical university V. I. Narolina, I. F. Shamara


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    Enquiring into the Case History


    (Speech Models)

    A. Passport Data/Identification Data:

    — What is your full name?

    — What is your surname?

    — What is your first (Christian) name?

    — How old are you?

    — What is your nationality?

    — Are you single?

    — Are you married?

    — Are you widowed?

    — Are you separated?

    — Are you divorced?

    — What is your profession?

    — What do you do for a living?

    — Where do you work?

    — What is your business address?

    — What post do you hold?

    — Are you a housewife?

    — Are you on pension/retired?

    — Where do you live?

    — What is your home address?

    — When were you born?

    • Where were you born?

    B. Chief Complaints:

    — What kind of trouble do you have?

    — What is the matter with you?

    — What is wrong with you?

    — What are your complaints?

    — Any other problems?

    • No complaints?

    C. Present illness:

    Onset and Duration

    — Isthe trouble acute or chronic?

    — How long have you been ill?

    — When were you last well?

    — When did your symptoms first begin?

    — Was the onset of the disease sudden or slow?

    • Are there any known precipitating factors associated with the onset of illness?


    Pain characteristics

    Location of pain

    — Where do you have pain?

    — Would you show with your finger the place where it hurts you?

    — Does the pain remain localized, or does it travel or radiate to some other region?

    — Where is the pain? Outline the area with your finger.

    — Does it spread from this area?

    Temporal factors

    — How often does the pain occur?

    — Is it continuous or intermittent?

    — How long does it last?

    — What time of day does it start?

    • Does it come and go over short intervals?

    Character of pain

    — Is the pain sharp or dull?

    — Is it really pain or is it discomfort?

    — Does the pain appear suddenly and disappear quickly?

    • Does the pain gradually increase in intensity and slowly subside?

    Quality

    — What does it feel like?

    — Is it a burning pain, an aching pain?

    • Is it steady or throbbing?

    Intensity

    — How intense is the pain?

    — Is it mild, moderate, or severe?

    • Can you work with it or must you go to bed?

    Circumstances which aggravate pain

    • What increases the intensity of the pain (coughing, sneezing, straining, stooping, jolting or shaking the head, lying down, sitting up)?

    Factors which reduce pain

    — What reduces the intensity of the pain (ice bag, hot water bottle, massage, finger pressure over temporal or other arteries, lying down, sitting up, sleeping, coffee, aspirin, or other medication)?

    Associated sensations or mixtures of sensations

    • What other symptoms are associated with the pain (anorexia, nausea, vomiting, distention, diarrhea, frequent urination, swelling of any part of the body)?

    Progress

    — Has the trouble developed rapidly or slowly?

    — Have the symptoms become worse or better?

    • Are they better at times and worse at others?

    Relation to physiologic function

    — Are the symptoms worse when you are standing, sitting or lying down?

    — What effect does exercise produce?

    — Does eating relieve the symptoms or aggravate them?

    • Does sleep bring relief?

    Effects of disease

    — Have you been treated for your ailment and what was the treatment?

    — What was the opinion of other physicians?

    — Have you become weak and lost weight?

    • Did you ever have any fever, chills or sweats lately?

    D. Past Illnesses:

    — What diseases have you had in the past?

    — What diseases did you have as a child?

    — What childhood diseases did youhave?

    — Have you ever had scarlet fever/measles/chickenpox/rubella/whooping cough/mumps?

    — Have you ever had a venereal disease/malaria/diabetes mellitus?

    — Have you ever had an infectious disease/tuberculosis/syphilis/heart attacks/fits?

    — Have you been seriously ill before?

    — Did you ever have a serious operation/injury/trauma?

    — Have you been operated on?

    — Have you ever been in hospital, if yes, for what reason?

    — Are you allergic to any drugs?

    — Have you had (have you) any unusual reaction to any drug, serum?

    E. Personal History:


    Martial Status:

    — How many years have you been married?

    — Is your wife (your husband) in good health?

    — Are you happily married?

    — Do you have difficulties with your wife (your husband)?

    —Are sexual relations desired, enjoyed, satisfying for both marital partners?

    — How many children do you have?

    — How old are your children?

    Habits:

    — Do you smoke? How many cigarettes a day do you smoke?

    — Have you a narcotic habit/an excessive drinking habit/some drug habit?

    — How often do you take alcoholic drinks?

    — How much alcohol do you drink daily?

    — What amount of narcotics do you take daily?

    Occupation:

    — What was your first job?

    — What was its nature and duration?

    — What other kinds of job have you had?

    — Why did you leave/retire?

    — Are your present work and salary satisfactory?

    — Do you consider your work too hard or too easy for you?

    — What are the sanitary conditions at your work?

    — Do you work under unfavourable hygienic conditions?

    — Are you exposed to any occupational hazards?

    — What industrial hazards are there in your enterprise?

    — Do you work with lead (mercury, acids, alkalis, arsenic, ammonia, antimony, nickel, benzine, benzol, radioactive substances)?

    F. Family History and familal tendency:

    • Are your parents living or dead? What caused their death?

    • At what age?

    — Do you have brothers, sisters? Are they healthy?

    — Is anyone in your family seriously ill? (Has anyone in your family been seriously ill?)

    — Is there any history of tuberculosis (syphilis, cancer, diabetes mellitus, kidney disorders, hay fever, epilepsy, hypertension, alcoholism) in your family?

    — Does ... run in your family?

    — Is there anybody in your family who has similar complaints?

    G. System Review:

    HEAD


    — Do you have headache or pain anywhere in the head?

    — Does the pain spread to the jaw or the neck?

    — Is there tenderness on the scalp?

    — Where is it most tender?

    — Has your head ever been injured?

    — Have you ever been unconscious following a head injury?

    • How long were you unconscious?

    Respiratory

    — Do you have a sore throat / cough?

    — Do you have difficulty in swallowing?

    — Do you ever have hoarseness?

    — Do you have your tonsils out?

    — Do you have caryso?

    — Do you suffer from a constantly running nose?

    — Are you often troubled with bad spells of sneezing?

    — Is your nose continually stuffed up?

    — Is the sense of smell normal?

    — When did you have your adenoids removed?

    — Do you often catch severe colds?

    — Do you frequently suffer from heavy chest colds?

    — Do frequent colds keep you miserable all winter?

    — Do you have to clear your throat frequently?

    — Are you troubled by constant coughing?

    — Is the sputum profuse?

    — How much sputum do you raise dally?

    — Have you ever spit up blood?

    — Have you ever coughed up blood?

    — Have you ever had a chronic chest condition?

    — Have you ever had ТВ (tuberculosis)?

    — When did you have your chest X-rayed?

    — Do you get hay fever?

    • Do you suffer from asthma?

    Cardiovascular

    — Do you have pain in the heart region?

    — Do you have a heart trouble?

    — Do you have pain in the joints?

    — Did you have such heart troubles before?

    — When and in what hospital were you treated?

    — Was the disease relapsing?

    — Have you had your E. C. G. made?

    — Do you have edemata?

    — When did this swell appear?

    — Is your breathlessness constant or does it appear from time to time?

    — Have you ever been short-winded?

    — Do you often have difficulty in breathing?

    — Do you have shortness of breath on exertion?

    • Do you become breathless on any unusual effort?

    • Do you ever get breathless when walking upstairs?

    — Does shortness of breath occur while you are at rest?

    — Do you ever have pains in the heart or chest?

    — Have you ever had a pain in your chest on exercise?

    — How long does the pain last?

    — Where does the pain radiate?

    — Is the chest pain promptly relieved by rest?

    — Do you ever have a sense of substernal oppression or pain?

    — Do you ever have a sensation that the heart has "stopped"?

    — Are you ever troubled with palpitations of the heart?

    — Does the heart ever beat irregularly?

    — How often do you have heart attacks?

    — Are the attacks of heart pain accompanied by pallor of the face, perspiration, coldness of the limbs, weakness, palpitation, disturbance of breathing, asthma, nausea, vomiting, faintness?

    — Are the attacks of severe substernal pain accompanied by agitation, worrying, fear of impending dissolution?

    • What drugs relieve a fit of pain?

    Gastrointestinal

    — Do you have a good appetite? Do you have lack of appetite?

    — When did you lose your appetite?

    — Do you ever have any excessive thirst?

    — Do you ever have any pain in your stomach or bowels?

    — Does the pain have any relation to your meals?

    • Is the pain relieved by the ingestion of food?

    • Do you ever have pains on an empty stomach?

    — Do you ever have hunger pains in the stomach?

    — Do you ever have pain in the pit of the stomach after meals?

    — Do you have belching? Is it of a sour or bitter taste?

    — Do you usually belch a lot after eating? Do you suffer from a hiccup?

    — Is there any burning sensation in the stomach? When? Does nausea trouble you?

    How often (when) does it trouble you?

    — Do you watch a diet?

    — Have you ever vomited? When do you vomit?

    — Have you ever thrown up blood? Do you suffer from indigestion?

    — Have you ever had severe bloody diarrhea?

    — Do you constantly suffer from bad constipation?

    — Do you have any trouble with your bowels?

    — How many times a day do you have stools?

    — Do you move your bowels every day?

    — What colour is the stool (light yellow, dark brown, dark green, red, black, whitish,

    clay-coloured, burgundy red, tarry, discolored)?

    — Have you ever noticed blood, mucus, pus in stools?

    — Do you suffer from constant stomach trouble?

    — Are there any night pains? What relieves the pains?

    — Has a doctor ever said you had stomach ulcers?

    — Have you ever had jaundice (yellow eyes and skin)?

    — Have you ever had serious liver or gallbladder trouble?

    — Do you ever have bellyache?

    — Do you ever have abdominal cramping (colics)?

    • Do the pains subside after applying a hot-water bottle?


    Texts and dialogues
    At the Doctor’s Consulting Room
    P:May I come in, Doctor?

    D: Sure. Come in, please. Sit down here.

    P: Thank you.

    D: Well. What is your name?

    P: My name is ____.

    D: ____, I must fill in your patient's card. Could you give it to me?

    P: Yes of course. Here you are.

    D: Well. You should answer some of my questions.

    P: O.K. I am ready.

    D: How old are you?

    P: I am __.

    D: When and where were you born?

    P: I was born in 1980 in ___.

    D: Are you married?

    P: No, I am single.

    D: I see. Now tell me, where do you work or study?

    P: I am a second year student of medical University.

    D: Pleased to hear that. OK, now let's talk about your condition. What do you complain of?

    P: You see, doctor, I feel rotten.

    D: What troubles you?

    P: Oh, doctor, it is my sore throat.

    D: Really? Does it hurt much?

    P: Oh, yes. And I cough and sneeze too.

    D: Is the cough dry?

    P: Yes it is.

    D: What about your temperature? Is it high?

    P: Yes. I have a fever. My temperature is 38 degrees.

    D: Oh, I see. Your condition is poor. And what about headache?

    P: Yes I have a splitting headache and my nose is running too.

    D: Do you have muscular pains?

    P: Yes, I do, and I am very weak.

    D: Yes, I see. Now I must examine you. Will you strip to the waist please?

    P: Yes, I am ready. Will you listen to my heart?

    D: Yes, and to your lungs too... Give me your arm. I'll take your blood pressure.

    P: Is my blood pressure normal?

    D: Yes, it is. Now I must feel your pulse. Give me your hand. OK.

    P: Usually I have no problems with the heart.

    D: Yes, it is in order. But...

    P: What is the matter with me, Doctor?

    D: I suppose it is the flue.

    P: Yes, maybe. But what should I do?

    D: You should stay in bed and follow my prescriptions.

    P: Shall I take any drugs?

    B: Sure. Here is a prescription for some drugs. Take them every 6 hours.

    P: All right.

    D: I'll give you a sick-leave for 6 days. You should come to me next time on Tuesday, at 10 a.m.

    P: OK, Doctor. Thank you. Good-bye.

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