Taking History 2 1

8/19/2019 Taking History 2 1

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Taking a history 1:section 1asking basic questions.

• Language focus 1

How the doctor starts the interview:

What has brought you along to today?

Other ways of starting an interview are:

what can I do for you? what seems to be the problem?


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How the doctors asks howlong the problem has lasted

• -How long have they been botheringyou?

• -How long have you had them?


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Language focus 2

• How the doctor asks where the problem is

-which part of your head isaected?

-where dose it hurt?

-where is it sore?


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How the doctor asks about thetype of pain

-can you describe the pain?

-what is the pain li!e? -what !ind of pain is it?


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Language focus 3

How the doctor asks if any thing relieves the

pain of headaches

• -is there any thing that ma!es them better?• -dose anything ma!e them worse?

octors often ask if anything elsea!ects the

problem: e"g

-what eect dose food have?

-dose lying down help the pain?


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• #ection 2 taking notes


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T$%&'( ')T*#


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• O"#$ on e%amination

• &'($ blood pressure

•

($ pulse• #)*$ ear+nose+throat

• ,I$ gastero-intestinal system

• .)$ central nervous system• /"0$ three days

• "23$ eight wee!s

• 2"13$ 4ve months


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#ection3+5eading s!ills: scanning a case history

• 6 case history is to be read'

• Information to be found andunderlined

about the patient through answering7uestions'


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Taking a history 2:$sking aboutsystems


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Language focus ,

• How the doctor as!s about the systems:

-Have you any trouble with yourstomach or bowels?

-What is your appetite li!e? -6ny problems with your waterwor!s?

-What about coughs or whee8ing or

shortness of breath? -Have you noticed any wea!ness or

tingling in your limbs?


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9atch each of the suspected problems in the 4rstcolumn with a suitable 7uestion from the secondcolumn.

• uspected problem 7uestion

depression have you had any pain in yourchest?

cardiac failure do you ever get whee8y?

asthma what sort of mood have you beenin recently?

prostate any problem with yourwaterwor!s?

coronary thrombosis have you coughed up blood? cancer of lung have you had any shortness of

breath?


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ection 3 as!ing aboutsymptoms

• Language focus 2How to as! aboutassociating problems or symptoms-;e'g fever


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-hich problems in the checklist do the


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-hich problems in the checklist do thefollowing questions refer to.

• =o you suer from double vision?

• 6ny shortness of breath?

•

=oes light bother you?• 6re your stool blac!?

• =o you have a cold?

#tudy this e/tract from a case history


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#tudy this e/tract from a case history0then put the questions that you might askthe patient to obtain the underlined

information"

• $ +year+old patient0 a teacher of *nglish0complained of sever chest pain which occurred

on e/ertion and was sometimes accompanied bysweating"He smoked , cigarettes a day" Thepain had 4rst appeared three months a go andwas becoming increasingly frequent" He hadnoticed some weight gain recently and also

complained that his hair had become very dull"He felt the cold much more than he used to" Hehad no palpitations or ankle oedema"


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Terms which a patient would easily understand as opposed to the


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Terms which a patient would easily understand as opposed to theoriginal medical terms

medical term non+medical term

1+parasthesia a+sweeling0 pu5ness

2+productive cough b+indigestion

3+anaesthesia c+coughing up phlegm or spit" ,+retrosternal chest pain d+trouble holding your water

+orthopnoea e+cramp in the leg muscles whichcomes and goes"

6+stress incontinence f+numbness

7+dysmenorrhoea g+sleeplessness 8+dyspepsia h+out of breath0out of

pu!0breathlessness

+oedema i+painful periods

1+intermittent claudication 9+pain behind the breast bone"

11+insomnia k+pins and needles

12+dyspnoea l+shortness of breath when liedown"

The doctor may use these terms in taking history from the patientbecause it is easier for the patient to understand 0 but in writingmedical report 0the medical terms should be used"

1 k02 c0 3 f0 ,90 l0 6d0 7i0 8b0 a0 1e0 11g0 12h"


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Letter of referral from a doctor to aconsultant concerning a patient"

edical terms are used in the report orreferral letter"

;omplete history regarding of the patientillness"

Findings on examination.

Details of the treatment given.


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Here is a version of consultation0 complete the


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Here is a version of consultation0 complete thedoctor


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• */plaining$what the doctor isgoing to do to the patient'

• &nstructing$what the doctor wantsthe patient to do'

• =eassuring$to decrease the worryor fear of the patient about the

procedure to be done'


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#ection+1 */plaining0 &nstructing0 and=eassuring"

Language focus 8:'ote how the doctorstarts the e/amination >*ye*/amination?@+

I would you >ust li!e to e%amine your eye'

-could you >ust loo! at the chartfor me?

How the doctor indicates the e/aminationis 4nished:

-5ight +than! you very much indeed'

*/amining a patient+language


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*/amining a patient+languagefocus 6

#ection 1 (iving instructions

How the doctor instructs the patient what to do:> e"g" e/amination of the back?

-now I want to see you standing' -could you bend down as far as you can?

-!eep your !nees and feet steady'

&nstructions to change positions or remove clothing:

-would you slip o your top things+ please'?

-now I would li!e you to lean bac!wards'

Areparing the patient for the ne/t part of thee/amination

-I am >ust going to 4nd out where the sore spot is'


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octorBs e/planations ande/pressions of reassurance+add

one word in each gap.• 1 )ow I am @@'to put this thing on your chest'• 3 It is@@@@@a stethoscope'

• / It@@@@@@'be a bit cold'

• A OB?Cirst@@@'all+ I listen@@your front and @@''your

bac!'• 2 well@@''you did not move at all'

• D )ow I would@'to see your tummy+@'will you lie on thebed for a minute?

• 0 )ow while@@'lying there+@@feel your nec! and under

your arms'• 6re you@@@@@@@'?

• E@@@@'the top of your legs'

• 1F *hat is @@@@@@@@'very 7uic!+@@@@@@@'


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Language focus 7

How the doctor marks the endof each stage of e/amination"

-he pauses' -he uses e%pressions such as

OB+ CI)#+ *H6* I I*'


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atch the part to be e/amined from the 4rstcolumn with the appropriate instruction from

the second column"

#%amination instruction

• *he throat remove your soc! andshoe'

• *he ears remove your topclothing'

•

*he chest turn your head this way'• *he bac! open your mouth

• *he foot tilt your head bac!'

• *he nasal passage stand up'

-hat do you think the doctor is e/amining


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-hat do you think the doctor is e/aminingby giving each of these instructions?

• I want you to push as hard as you can against my hand'

• &reath in as far as tou can' )ow out as far as you can'

• ay EE')ow whisper it'

• .ould you 4% your eyes on the tip of my pen and !eepyour eyes on it?

• I want you to !eep this under your tongue until Iremove it'

• Would you roll over on your left side and bend your!nees up?

• I want to see you ta!e your right heel and run it downthe front of your left leg'

• (ut out your tongue' ay 6ah'

How to play the role of a


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How to play the role of adoctor

• > *"g :*ye e/amination?

• ,reet the patient'• Indicate that you have had a letter of referral'

• 6s! about the duration of the problem'

• 6s! about the patient occupation'

• 6s! about the eect on his occupation'

• Indicate that you would li!e to e%amine him'

• 6s! him to read the chart'

• 6s! about the right eye'• Gou change the lens-dose it ma!e any dierence?

• Gou try another one'

• Indicate that the e%amination is over'

&'C*#T&($T&)'#


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&'C*#T&($T&)'#

*DAL$&'&'( $' E##&'( &'C*#T&($T&)'#

*DAL$&' -H$T TH* );T)= ()&'( T) ) $'-HF"*"( Gnow & am going to take some uid o!

your back to 4nd out what is giving you theseheadaches"

&'#T=E;T TH* A$T&*'T T) T$%* EA TH* ;)==*;TA)#&T&)'" *"g+now & want you to move right to

the

edge of the bed"

=*$##E=* TH* A$T&*'T $I)ET TH*&'C*#T&($T&)'

*"g+it will not take very long"

+now & am going to give you a localanaesthetic so it willnot be sore"

)rder of e/planation to a patient to do sternal


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)rder of e/planation to a patient to do sternalmarrow

investigation

1-Cirst of all+I am going to wash the area with a bitof antiseptic'

3-)ow the ne%t thing I am going to do is to put atowel+over the area'

/-)ow I am going to give you an in>ection of localanaesthetic'Cirst into the s!in and then into thebone'

A-)ow we are ready to do the actual test'

2-)ow I am going to remove the actual cells fromyour bone'

D-ust going to remove the needle from your bone'

0-*hen we will put a dressing over the area'

• #equence of instructions by


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#equence of instructions byphysiotherapist

• -4rst of all +you lie down@

• -now place your hands on your bac!

• How the physiotherapist advice thepatient

• -you should do these e%ercises three times aday+ preferably on empty stomach'

• -you should try to do them as slowely and

smoothly as possible'• How the physiotherapist warns the

patient

• -you should try to avoid >er!ing your body'

*/pressions used between doctors in discussing a choice of


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*/pressions used between doctors in discussing a choice ofinvestigations.

*ssentialJ should0 must beKrequired essential important indicated

#'g:-the patient shuold be given an%-ray

-it is important to give an %-ray -an %-ray is indicated'

Aossibly usefulJcould'ot required +++need not be0 not necessary

not required not important*ssential not to doJshould not must not beKcontraindicated"

ki di i


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aking a diagnosis• #%pressions used between doctors in

discussing a diagnosis: .ertain Cairly

certainncertain

Ges Is

9ust

e'g HC

eems

(robably

Li!ely

9ight

.ould

9ay

)o ;annot 0 */clude

e4nitely not

=ule out

e'g HC.

nli!ely (ossibly

6possibility

• Little information to base adiagnosiswe can


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gsay@the pt"might have cervical spondylosis"

• )r cervical spondylosis is a possibility"

•

#ome diagnoses become more likely whileothers become less likely@e"g he seems tohave temporal arteritis"

• There is no neck sti!ness"&t is unlikely that

he has got cervical spondylosis"• #tronger evidence for 4nal diagnosis

• *"graised *#= makes temporal arteritisvery likely"

• +normal =& e/cludes space occupyinglesion"

• Minally0following the biopsy0we can say@

•

+he must have temporal arteritis"

L f E


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Language focus E

How the doctor reassures the patientby e/plaining

what she is going to do and indicatingthat verything

is all right:

;an & have a look at you to 4nd outwhere your bad

cough is coming from.""that is 4ne"

L f 1


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Language focus 1 How doctor uses a rephrasing technique to

encourage the patient and give him time toanswer"

#'g have you been here long?

In this house+have you been here long?

how long have you been living in High

treet?

*he rephrased 7uestion is often preceded by

an e%pression li!e =O GO 5#9#9 @#',

-=o you remember where this is?where is thisplace?

*/amples of The rephrasing with the


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p p gcorresponding

test question"6-7uestion do you remember when you were born?

what ''was the year of your birth? can you remember that?

&-7@@@@ do you remember what time of themonth?

what ''was that day?Jc@@'how old will you be now?

Jd @@''what year is this year? =o you@know that ?@

Je @'''4ne and what month are we in? well+tell me is summer or winter ?

Jf Kdo you remember what day of the wee! it is?

or do the days not mean a great deal to you

now that you are…not working………?

ental impairment


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ental impairmentmeasurement

6s! the patient the following 7uestions'

ore 1 for correct answer+F for an error'• 1-What is the name of this place?• 3-what day of the wee! is it today?• /-what month is it?• A-what year is it?• 2-What age are you?• D-in what year were you born?• 0-in what month is your birth day"• -what time is it?•

E-how long have you been here?

8 or normal0 to7 moderateimpairment01 to , sever impairment0 ocomplete failure"

• =eading skills: =eading $rticles


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=eading skills: =eading $rticles

• Headings commonly used in articles"

•

Title• $uthors

• *ditor note

• #ummary• &ntroduction

• aterials and methods

• =esults

• ;omment

• =eferences


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=*$##E=$';* -&TH-$='&'(

• &T #H)EL ')T I* A$&'MEL0IET F)E -&LLI* $-$=* )M $ M**L&'( )M A=*##E=*"

• TH $F M**L $ L&TTL* I&TE';)M)=T$IL*0IET &T -&LL')T T$%*

L)'("

L f 17


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Language focus 17

escribing causes and e!ects" *"g: cause e!ect

bending the knee the tension is taken

o! the nervestraighten it the nerve goes taut"

-e can link a cause and an e!ect likethis:

if we bend the knee0 the tension is taken o!the nerve"

if we straighten it0 the nerve goes taut"

Link each cause and e!ect to make


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a simple statement used ine/planation to a patient"

• If the stomach produces too much acid+ itmay cause stomach pain

• If a woman gets ,erman measles during

pregnancy+ the baby may be born withdeformities'

• If you vomit several times in 7uic!

succession+ you may burst a blood vesselin the gullet'

• If your blood pressure remains high+ you

may have stro!e'

The patient would e/pect his


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The patient would e/pect hisdoctor to answer the followingquestions after the diagnosis.

• What is the cause of my problem?

• How serious is it?• What are you going to do aboutit?

• What are the chances of a fullrecovery?


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edical treatment

How the doctor advises the patient " -the duration of treatment:-you will need a few

treatment'

How the patient must conducthimself during the treatment:+ -you should rest for a day or two''

-it is readily not good to rest for longer than

that'-if you rest for a long time+ your muscles will get

wea!er and the pain will heal worse'

-dont wait until the pain is out of control

How to advise each of


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How to advise each ofthese patients

• 6 hypertensive 2F-year-olddirector of small company'

• 6 D2-year-old schoolteacherwith osteoarthritis of the hip'

#ome abbreviations used in


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#ome abbreviations used inmedicine

• 9itte Kgive

• ig' Kwrite "label

• *ab' Ktablet

• ('c Kafter food'

• D hrly-every si% hour'

octor instr ctions to his patient


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octor instructions to his patientregarding his treatment

• *ablets which you are going tota!e two of every si% hours

'*ry to ta!e them after food ifpossible in case they causeyou indigestion' Gou can ta!e

them during the night as wellif you are awa!e with thepain'

edical abbreviations


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• .6&,$coronary artery bypass

graft'• L6=6$ left anterior desending

artery

• 5.6 $ right coronary artery'

• O91$CI5* O&*# 965,I)6L'

• LM $left ventricle'• L6 $left atrium'

•

&'( $ blood pressure' • $ free te/t e#H>medical sub9ect heading? T*=

i h i l


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• =rug preparation pharmaceutical

• *reatment therapy+ therapeutics

•

&aldness alopecia• Limb e%tremities

• tro!e cerbrovascular accedent

• Heart attac! myocardial infarction

• &leeding nose epista%is

• 6thlete foot tinea pedis

• &oils furunculosis

•

&lood poisoning septicemia• .ancer neoplasms

• 9iscarriage abortion+spontaneous

=eading skills: using an online database


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Areparing a search0 the search strategyinvolves:

•

1+Aosing the search question" e"g howe!ective paracetol in controlling pain aftersurgery.

• 2+&dentifying the main topics" e"gthe main

topics will be@paracetamol00and pain followingsurgery"

• 3+eciding how to search for the main topics"Iy using edical #ub9ect headings0e#H"

*"(neural pathways0 analgesics0 digestivesystem disease"

• ,+formulating the search query""e"gparacetamol and pain0postoperative

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Taking History 2 1

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