Файл: Учебное пособие 2 по английскому языку Для студентов лечебного и педиатрического факультета (2 семестр) 2020 год.doc

Reading
IX. Read and translate the text

Case history taking

Advances in technology, genetic testing, and genomic medicine are revolutionizing patient care. Yet the mainstay of diagnostic work is still the patient history. The patient’s case history, medical history, or anamnesis (Greek: ἀνά, aná, ″open″ and μνήσις, mnesis, ″memory″) is the information gained by a physician by asking specific questions either the patient or other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient (persons familiar with the patient) are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel and results in a form of history taking.

Medical history form may exist in paper compiled variant and electronic one. The medical history is a longitudinal record of events to have happened to the patient since birth. As a result, it may often give clues to current disease state. The method by which doctors gather information about a patient’s past and present medical condition in order to make informed clinical decisions is called the history and physical (H&P). The standardized format for the history starts with:

Identification: name, age, height, weight.

Chief complaint (CC): the major health problem, and its time course.

History of the present illness (HPI): details about presenting complaints, enumerated in the CC including investigations, treatment and referrals already arranged and provided.

Past medical history (PMH): major illnesses, any previous operations. It may have dates of operations, what the surgeon did, including complications and trauma.

Immunization (obligatory for children): vaccination schedule, when the patient was vaccinated and the type of vaccine got.

Review of systems (ROS): systematic questioning about different organ systems: cardiovascular system, respiratory system, gastrointestinal system, nervous system, and others.

Family history : the health status of immediate family members, siblings and parents, as well as their causes of death (if known).

Social history: a chronicle of human interactions - living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, recreational drugs), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets, his/her careers and trainings, and religious training.

Regular and acute medications: those prescribed by a doctor and others obtained over-the-counter or alternative medicine.

Allergies to medications, food, latex, and other environmental factors.

Obstetric/gynecological history (for females). The obstetric history lists prior pregnancies and their outcomes, complications.

Conclusion & closure:a primary diagnosis based on the information above.

Programmed questionnaires and direct questioning comprise the two most common methods used in gathering a case history. A questionnaire gives the doctor an opportunity to review the data prior to seeing the patient so that he may formulate some of the basic questions in his mind prior to contact. Yet the patient’s interview is still the main method of history taking. The value of a case history is directly proportional to its completeness and accuracy. Accurate, well-documented patient medical histories provide a foundation for patient diagnosis and treatment. The obtained information through the history taking, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan.
X. Try to answer the questions in ‘Case History Quiz’

1. 
   What is patient’s medical history?
   

• 
  a record of patient’s life, birth, marriage, graduation
  
• 
  a record of events since patient’s birth: diseases, major and minor illnesses
  
• 
  a record of the patient’s interesting events
  

---

2. 
   What is a symptom?
   

• 
  the medically relevant signs reported by the patient
  
• 
  the medically relevant events reported by the patient
  
• 
  the medically relevant complaints reported by the patient
  

3. 
   What is ‘identification?
   

• 
  chief symptom
  
• 
  name, age, height, weight
  
• 
  citizenship
  

4. 
   What is a chief complaint?
   

• 
  the major health problem or concern, and its time course
  
• 
  the major health history, and its time course
  
• 
  the major health symptom or sign, and its time course
  

5. 
   What is a history of the present illness?
   

• 
  presenting symptoms including investigations, treatment and referrals already arranged and provided
  
• 
  presenting complaints including investigations, treatment and referrals not arranged and provided yet
  
• 
  presenting complaints including investigations, treatment and referrals already arranged and provided
  

6. 
   What is a past medical history?
   

• 
  minor illnesses, any previous surgery/operations including complications, trauma
  
• 
  major illnesses, any previous surgery/operations including complications, trauma
  
• 
  major illnesses, any previous surgery/operations including allergies
  

7. 
   What is a review of systems?
   

• 
  systematic questioning about different organ systems
  
• 
  systematic questioning about different conditions
  
• 
  systematic questioning about different complaints
  

8. 
   What is a family history?
   

• 
  the health status of immediate family members, uncles, aunts, and parents, as well as their causes of death
  
• 
  the health status of immediate family members, cousins and parents, as well as their causes of death
  
• 
  the health status of immediate family members, siblings and parents, as well as their causes of death
  

9. 
   What is a social history?
   

• 
  a chronicle of human reactions
  
• 
  a chronicle of human interrelationship
  
• 
  a chronicle of human interactions
  

10. 
    What are two most common methods used in history taking?
    

• 
  two programmed questionnaires
  
• 
  programmed questionnaires and direct questioning comprise
  
• 
  a series of interview
  

XI. Make a word combination, match the words:

case complaint

clinical record

physical use

history diagnosis

medical symptom

chief taking

drug history

primary sign

presenting examination
XII. Match the term (1-7) with the correct meaning (a-g):

1. 
   symptom
   
2. 
   sign
   
3. 
   anamnesis
   
4. 
   history of presenting complaint
   
5. 
   past surgical history
   
6. 
   allergy
   
7. 
   medication
   

1. 
   a drug or other or other form of medicine that is used to treat or prevent disease
   
2. 
   details about presenting complaints, enumerated in the chief complaints
   
3. 
   major illnesses, any previous surgery/operations
   
4. 
   the information gained by a physician with the aim of obtaining information useful in formulating a diagnosis and providing medical care
   
5. 
   a physical or mental feature which is regarded as indicating a condition or a disease, particularly such a feature which is obvious to the patient
   
6. 
   an indication of a disease detectable by a medical practitioner even if not obvious to the patient
   
7. 
   a damaging immune response by the body to a substance, especially a particular food, pollen, fur, or dust, to which it has become hypersensitive
   

XIII. Match the questions (A-J) and the part of the patient history (1-10):

1. 
   Identification and demographics
   
2. 
   Chief complaint 
   
3. 
   History of the present illness 
   
4. 
   Past medical history 
   
5. 
   Review of systems 
   
6. 
   Family history
   
7. 
   Social history
   
8. 
   Vaccination
   
9. 
   Regular and acute medications
   
10. 
    Allergies
    
11. 
    Obstetric/gynecological history
    

---

1. 
   Has your father ever had diabetes?
   
2. 
   How long have you had a high temperature?
   
3. 
   How old are you?
   
4. 
   How many pregnancies have you had?
   
5. 
   Do you have a high temperature in the mornings?
   
6. 
   Have you experienced any surgeries?
   
7. 
   What is your regular blood pressure?
   
8. 
   What medications are you currently taking?
   
9. 
   What’s your occupation?
   
10. 
    Are you sensitive to the pollen?
    
11. 
    Have you been vaccinated for tetanus/?
    

XIV. Read the Case Report and define the information for each section of Case History:
Case Report

Lucy has a set of medical conditions that are summarized as HERNS (Hereditary Endotheliopathy, Retinopathy, Neuropathy and Stroke). 10 years ago, she experienced symptoms of proptosis, tachycardia, thirst and vomiting and was diagnosed with Grave's disease. She was treated with Neomercazole. The coexisting medical condition may be exerting an impact on Lucy's current anxious state. In addition, her apparent poor coping mechanisms, which she has described as part of her personality trait, might also be facilitating her anxious state.

In 1996, Lucy experienced a minor stroke, which caused temporary paralysis in her left arm. She was monitored in hospital for three weeks and recovered.

3 years ago, Lucy was diagnosed as lupus carrier. Since the diagnosis, Lucy has been taking Warfarin and she expects to maintain Warfarin therapy for life. Her condition has exacerbated a series of endotheliopathies, predisposing Lucy to retinal microvascular occlusion.

2 weeks prior to her current hospital admission, Lucy was also diagnosed with hypercholesterolemia, a suspected genetic disorder. She is currently taking Lipitol to manage this.

Section	Data
Identification and demographics
Chief complaints
History of the present illness
Past medical history
Review of systems
Family history
Social history
Medications
Allergies

Speaking
XV. Try to predict the right answers for the questions:

1. 
   Who examines the patient?
   

• 
  nurse
  
• 
  doctor
  
• 
  doctor assistant
  

2. 
   What is the purpose of asking the patient name and birthdate?
   

• 
  to identify the patient’s diagnosis
  
• 
  to identify the patient’s background
  
• 
  to identify the patient’s personality
  

3. 
   How does the nurse teach the patient?
   

• 
  gives the information about follow-up appointment, explains the causes of disease
  
• 
  gives the information about drug taking and equipment usage, explains the impact of medications, suppliers with supporting information
  
• 
  explains what vital signs are, prescribes medicines
  

4. 
   How long should a patient take the antibiotics?
   

• 
  7-10 days
  
• 
  20-30 days
  
• 
  1-3 days
  

---

XVI. Watch the video ‘Taking a Patient's History (Nurse/Patient)’ and check your predictions and fill in the chart https://www.youtube.com/watch?v=NW-ZRo6GJnA

	Data
Name, birthdate
Chief complaint
Overall patient’s state
Presenting symptoms, complaints
Medications
Smoking
Vital signs (rates)
Follow-up visit
Administrations

LESSON 23
Grammar Revision: Forms of Infinitive, Modal verbs + Simple & Perfect Infinitive
Examination of the patient

I. Answer the questions:

• 
  Do you know what ’Physical Examination’ is?
  
• 
  Who examines the patient?
  
• 
  What kinds of examination do you know?
  

Word building

Suffix	Meaning	Example
-algia (-algesia, -algy)	suffering, pain, or sensitivity to pain	neuralgia
-scope	a means for viewing	microscope
-uria	a condition of the urine	albuminuria

Noun Suffix – ness

Nouns suffix – ness derives fromOld English -nes, -nis and means quality of, state of, measure of: darkness, awareness, oneness.
II. Read and translate the following words

redness, weakness, shortness, stiffness, dizziness, sleeplessness, breathlessness, tenderness

III. Read and translate the words of Latin-Greek origin

Europe [‘juqrqp], reason [‘rJzqn], manifestation [,mxnIfes`teISn], subjective [sAb’Gektiv], objective [‘Ob’Gektiv], edema [I`dJmq], cephalalgia [sI`fxldZq], syndrome [`sIndrqum], polyuria [,pOlI`jVqrIq], dysuria [dIs`jVqrIq], haematuria

[,hemq’tjuqriq], tremor [`tremq], appetite [‘qepitQit], observation [,Obzq`veISn], palpation [pxl`peISn], percussion [pe`kASn], auscultation [,Lskl`teISn], subcutaneous [,sAbkjH`teInIqs], stethoscope [`steTqskqup]
Active vocabulary

manifestation [,mxnIfes`teISn] - проявление болезни

to affect [q`fekt] - влиять, воздействовать, поражать

itch [IC] – зуд

rale [rRl] - хрип

fever [`fJvq] - жар (высокая температура), лихорадка

swelling [`swelIN] - опухоль, припухлость, вздутие

weight loss [`weIt] - потеря веса

weight gain [geIn] – увеличение веса

malaise [mq`leIz] – недомогание

sputum [`spjHtqm] - мокрота

shortness of breath [`breT] – одышка

---

wheeze [wJz] - хрип, сопение, стерторозное дыхание

on exertion [Ig`zWSn] – при напряжении, при нагрузке

palpitation [,pxlpI`teISn] –учащённое сердцебиение, трепетание

nausea [`nLsIq] - тошнота

vomiting [`vOmItIN] - рвота

constipation [,kOntstI`peISn] – запор

dizziness [`dIzInqs] – головокружение

faint [feInt] – обморок, потеря сознания

stiffness – тугоподвижность

ulcer [`Alsq] - язва

rash [`rxS] - сыпь, высыпание

sore throat [`sL,Trqut] – больное горло

vital signs [saIns] - признаки жизненно-важных функций

gait [geIt] - походка, поступь

tenderness [`tendqnqs] – болезненность, чувствительность

to confirm [kqn`fWm] - подтверждать, подкреплять
Usefulvocabulary

concern [kqn`sWn] - беспокойство, озабоченность, проблема

encounter [In`kauntq] - встреча, первый опыт (общения)

review of systems [rI`vjH] - данные обследования, обзор систем органов

general symptom [`dZenqrql] – общий симптом

to appreciate [q’prJSieit] - оценивать, понимать

check-up [`CekAp] – полный медицинский осмотр, обследование, диспансеризация

to give somebody a check-up – осмотреть кого-либо

general examination [Ig,zxmI`neISn] – общий медицинский осмотр

assessment [q`sesment] (evaluation [I,vxlju`eISn]) – оценка, анализ

abnormality [,xbnL`mxlItI] - отклонение от нормы, патология, нарушение, расстройство

differential diagnosis [,dIfq`renSql] - дифференциальный диагноз

provisional diagnosis [prq`vIZqnql] - предварительный диагноз

versus [vWsqs] - в сравнении, против

IV. Read and translate the following word combinations paying attention to the word formation:

to present - presenting symptom - presentation, to affect - the affect - affected , to swell –swelling - swelled, to find – to find out –findings, to weigh – the weight - overweight, short – to shorten - shortness, to exert– exerted – exertion - on exertion, to digest – digestive –digestion - indigestion, to examine - examiner - examination, to provide– provided - provider, to evaluate - evaluating - evaluation, abnormal - abnormality, to assess - assessment
V. Read and translate the following word combinations

the major health problem or concern, problem or condition, to obtain further information about the patient's symptoms, the affected person, to be supported by physical signs observable to the examiner, questions about each major body system, the taking of the medical history, to investigate the body of a patient for signs of disease, to develop a baseline assessment, to identify normal versus abnormal findings, to include evaluation of general patient appearance and specific organ systems, to reflect abnormalities in the body systems, the process of evaluating objective anatomic findings, to review the appearance for signs of any potential conditions, to feel for abnormalities during a health assessment, a list of potential causes of the symptoms, further investigations to clarify the diagnosis

Grammar

VI. Read and translate the sentences paying attention tothe form of Infinitive:

1. A sign or a symptom is never an isolated phenomenon but has multiple interrelationships, some physiological and some psychological, which can be of a major or minor importance. 2. For the patient, the time spent at the hospital can be substantially longer due to various waiting times. 3. When obtaining the chief complaint, medical students are advised to use open-ended questions. 4. A physical examination may include checking vital signs, including temperature examination, blood pressure, pulse, and respiratory rate. 5. To give another example, a neurological related complaint might be evaluated with a specific test, such as the Romberg maneuver. 6. If necessary, the patient may be sent to a medical specialist for further, more detailed examinations. 7. The word ‘symptom’ is used to label any manifestation of disease. 8. The doctor's role should be as much preventive as it is therapeutic. 9. When information about the patient has been tabulated, it must be reviewed in light of the doctor's basic science knowledge and clinical experience.

---