I.Basic Parts of Case History

Fill in the Case History of Mr./Mrs./Ms./Miss N according to the plan given below (use the special boxes (A, B, C) for details) (some gaps can be left without any information):

1) Hospital

Department _____

Doctor _____

Admitted to the hospital on _____

Hospitalization days number _____

Discharged from the hospital on _____

Transferred to _____

Died on _____

2^nd February Specialized Sanatorium, Sherwood John Smith, MD Department of Cardiology 2 weeks

Tropical Dermato-Venereology Department Professor Nick Swan 2 weeks 23^rd August 25NS

Doctor Anna Cornex Trauma TD6-01/02/2011 Car injury on 1^st February The injured unconscious person has been brought from Perlax Street

2) Identification of a patient

Name _____

Surname _____

Sex _____

Age _____

Citizenship _____

Place of employment _____

Profession _____

Diagnosis on admission _____

Chief complaints _____

History of present illness _____

Past History _____

Family History ______

Female Tram driver Lobar pneumonia Irish No cases of pneumonia Persistent dry cough, pains in the chest, fever Jane State Tram Company Half a year ago – series of colds 3 weeks of non-stopping cough Stompson

Peru Frequent cases of gum and nose bleeding among family members P.Lumumba University student Acute form of gangrenous stomatitis Ulceration of the mucous membrane of the cheek, profuse salivation Male Tumbu-Hadgeru The disease developed gradually after some hot days of bad hygiene and started from a burning sensation in the mouth

Male Closed skull injury is suspected Not known There is considerable displacement of bone fragments No information The patient has some open fractures Urgent case, no history Approximately 35 years old The patient is severely wounded The patient has multiple soft tissue bruises

3) System Review and Physical Examination

Laboratory tests/instrumental invesstigations _____

Clinical diagnosis _____

Complications _____

Surgery notes _____

Surgeon _____

Anaesthetist and anaesthetic used _____

Postoperative treatment _____

Doctor’s recommendations _____

Blood test – high level of leucocytes No liquid found in the pleural cavity No sequalae Clinically confirmed lobar pneumonia Adequate airway should be maintained

To rinse the mouth with a warm solution of sodium bicarbonate Clinically confirmed gangrenous stomatitis There is a facial asymmetry on account of swollen soft tissue Reddened and edematous mucosa Treat the oral cavity with antiseptics

Operation under general anesthesia Artificial respiration is being performed The patient is unconscious Pupils are dilated, no reaction to light The patient has depressed respiration Overdosage should be avoided

II.Taking Medical History

Choose the most suitable phrases for the situations below using the specialized Questionnaire and List of Commands (add your own variants if it is necessary):

1) You are questioning a patient on the state of his health. Find out:

A) the passport data, age, occupation, place of residence, marital status;

B) his complaints;

C) the onset of the disease.

2) You are taking the past history of your patient. You must know:

A) the diseases the patient had in his childhood;

B) if the patient was ill with TB (VD, AIDS);

C) if the patient has been operated on before;

D) if the patient consulted a doctor on his disease;

E) if a similar disease runs in the family.

3) You are questioning a patient on the signs and symptoms of the present illness. Try to find out:

A) the character of the onset of the pains (symptoms);

B) localization and character of the pain (symptom);

C) duration of the disease;

D) progress of the disease;

E) the factors aggravating the condition.

4) You are examining a patient with heart trouble. What do you say if:

A) you are listening to his heart;

B) you are listening to his lungs;

C) you are going to palpate (auscultate) him;

D) you are going to take his temperature;

E) you are going to measure his blood pressure.

5) You are examining a patient with an ulcer disease. Question him:

A) on the location of the pain;

B) on the character of the pain;

C) on the last fit of pains;

D) give your instructions to the patient how to prepare for the X-ray examination (roentgenoscopy) of the stomach.

Questionnaire

- What do you do?

- What’s your problem?

- Where do you feel the pain?

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

- How long have you been ill?

- Have you ever been seriously ill?

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

- How old are you?

- What’s your job?

- Do you have any pains on an empty stomach?

- What diseases have you had in the past?

- When do the pains come on? Do they appear after meals?

- What’s your address, please?

- Have you been exposed to any industrial hazards at your place of work? Which ones?

- How long after meals do the pains begin?

- At what age did you begin working?

- Are you allergic to any drugs?

- Are there any night pains?

- What relieves the pains?

- Is your appetite good?

- Is there any burning sensation in the stomach? When do you feel it?

- Does nausea trouble you? How often? When?

- When did you vomit?

- When did the first symptoms appear?

- What’s your occupation?

- How many times a day do you have stools?

- Do you take laxatives? Are you given an enema?

- Do you have constipation or diarrhea?

- Has anybody in your family had tuberculosis (cancer, heart diseases, bronchial asthma, epilepsy, alcoholism)?

- What has brought you here?

- Do you have any pain in the heart region?

- Do you have a heart trouble?

- Have you ever been in hospital, if yes, for what reasons?

- Do you have a pain in the joints?

- Have you ever suffered from some heart trouble like this before?

- When and in what hospital were you treated?

- Did the disease recur from time to time?

- Have you consulted any doctor about this disease?

- Have you had your ECG made?

- Have you noticed any swelling?

- Have you ever been treated in a surgical department?

- When did this swelling appear?

- Do you always feel short of breath or does the breathlessness come from time to time, or at a certain time?

- What drugs relieve a fit of pain?

- Are you married or single?

- What diseases did you have in your childhood?

List of Commands

- Show where the pain is the most acute.

- Lie down flat on your back.

- Show me your tongue.

- Watch my finger.

- Let me look into your throat.

- Bend your body forward.

- Say ah.

- Undress, please.

- Strip to the waist.

- Turn your head and breathe.

- Breathe deeply.

- Breathe normally.

- Take a deep breath in and keep it.

- Dress up, please.

- Slip off your coat, please.

III.Medical Examination

Choose the proper set of questions (from part B) for the following points (from part A):

Part A:

1) Identification

2) CC (Chief Complaints)

3) HPI (History of Present Illness)

4) PH (Past History)

5) FH (Family History)

6) √ (Diagnosis)

Part B (I):

1) - What is the problem?

- I have difficulty in breathing, especially at night. You know, it constantly keeps me awake. I quite often have episodes of wheezing. The shortness of breath comes more and more frequently.

2) - Are you married?

- Yes.

- Have you got any children?

- No.

- Are your parents alive?

- Yes. They are healthy.

- And what about your grandparents?

- They died of heart failure when they were elderly.

- Your uncles and aunts?

- In good health.

- Have you ever heard your relatives talk about asthma in your family?

- No, never.

3) – Your diagnosis is bronchial asthma. It is a very serious disease. I advise you a change of climate, first of all.

4) – Who are you?

- Ann Brag.

- How old are you?

- 26 years old.

- What’s your address, please?

- 32, Forest Street, Eastpoint, Missouri.

5) – What diseases did you have in your childhood?

- Measles, mumps, chicken-pox.

- Any surgery?

- No, doctor.

- Will you tell me more details about your present illness?

- Yes, of course, I started having wheezing when I was 5. My parents told me that I had had shortness of breath after attacks of children diseases.

6) – When do you think the disease began? How long has it been troubling you?

- I was taken ill when I was 5 years old. Our family doctor advised my parents to take me to the sea for a change of air.

- How did you feel there?

- Fine. I had no trouble while staying at the sea. But when we returned home my breathing ailment recurred. I don’t feel well in cold and rainy weather.

- What treatment did your physician prescribe you?

- Inhalations. But my condition became worse, more severe. You know, tobacco smoke irritates me badly. My husband is a heavy smoker.

- Oh, my dear, you need only pure fresh air. He should know this.

Part B (II):

1) - Are you married?

- Yes.

- Do you have any children?

- Yes, two boys and a girl.

- Do you have any close relatives living?

- Yes, my parents and a brother are alive and healthy.

2) – What’s your name?

- __________ (fill in the gap)

- How old are you?

- __________ (fill in the gap)

- Where do you live?

- __________ (fill in the gap)

- What’s your occupation?

- __________ (fill in the gap)

3) – What diseases have you had?

- Whooping cough, mumps, measles.

- Have you ever had pneumonia or kidney trouble?

- I often caught colds in winter and had pneumonia, that’s all I remember.

- Any harmful habits?

- I neither smoke nor drink.

4) – What’s your trouble?

- I have persistent coughing and pains in the chest.

5) – I suspect you have pneumonia as a complication after influenza. But to confirm the diagnosis you have to have your tests of blood, urine and X-ray examination made.

6) – When did you notice the first signs of the disease?

- I had influenza a week ago, but I followed the doctor’s recommendations and recovered rather quickly.

- When did you feel chest pain for the first time?

- Two days later.

- Can you relieve it by any drug?

- No.

- Do you cough up any phlegm?

- Yes, a little.

Part B (III):

1) - Are you married?

- Yes, but we are childless.

- Do you have parents? Are they well?

- My mother died of diabetes, my father of heart trouble.

- Have you any sisters or brothers?

- No, I have no relatives.

2) – Have you ever been sick?

- In childhood I had some children diseases but I don’t remember which of them.

- Have you ever been operated on?

- Five years ago I had urethral resection made.

- Any bad after-effects of the surgery?

- No, not any.

- Did you seek medical attention to clear the cause of your trouble?

- Yes, my family doctor advised me some drugs and to have a good rest, but with no effect.

3) – What’s your opinion, are these epileptic attacks?

- No, I’m sure you have been suffering from heart trouble for a rather long time. Your seizures have been connected with cardiac standstill. It is difficult to manage. I think of installing a pacemaker, with your coming for check-ups yearly.

4) – What problem do you have?

- I have been having a feeling of heaviness in my chest for more than a year.

- Any pain?

- Not any, Doctor, but three or four times when I was gardening, I had recurrent episodes of convulsions, brief seizures.

- Do you have headaches?

- No, not often.

- Do you feel worried or nervous?

5) – What’s your name?

- I’m Mrs. Gross.

- How old are you?

- I’m 50, doctor.

- Your address?