ai a General Histo Hello, my name is Or. ... What is your name? How old are you? Why did you come in today? Intro Do you have any pain? Where does it hurt? Can you show me whora? When did the pain start? Is the pain strong, moderate, or mild? \s the pain sharp or dull? Pm os Ds Is the pain constant or intermittent? Does the pain move? Is there something thal (alleviates! aggravates) the pain? Have you had this pain before? Do you suffer from any medical problems? High blood pressure? Diabetes? Heart disease? Stroke? Hepatitis? Cancer? Asthma? Emphysema? HIV? AIDS? mieaical History rast medical problems? Have you ever been hospitalized? Are you taking any medications? Prescription? OTC? Herbal? 2 S a 2 Are you allergic to any medications? g ‘Are you married or single? Do you have any children? Where do you jive? Do you live alone? Do you work? Do you (smoke/ drink)? How many (packs do you smoke/ drinks do you have) a day? drinking)? Do your (hands shakel see things) when you stop drinking? >oclal History Have you ever used any drugs? Cocaine! Heroin/Opium/ Marijuana? \\ Do you use needles? Do any of your family members have Have you ever tried to quit (smoking! Ni3 hao3, wo3 shi ... yi sheng? Ni3 jiao4 shen2 me5 ming2 zis? Ni3 ji3 suid? Jin1 tian’ ni3 weid shen2 me lai3 zhe4 13? Ni3 hui4 tong4 ma5? Na3 li5 tong4? Ni3 ke3 yi3 gao4 sud wo3 shid zai4 nad li3 mas? Ni3 shi4 shen2 med shi2 houd kait shi3 tong4 de5? Shid hen3 tong4, you3 dian3 tong4, hai2 shid you3 yil dian3 dian3 tong4? ‘Shi4 cig tong4 hai2 shi4 yin3 yin3 zuo4 tong4? Shid bu2 duand de5 tong4 hai2 shid jian4 xie1 ded tong4? Ni3 de5 tong4 huid mand yan2 ma5? Zen3 yang4 cai2 hui ling’ nid (mei2 you3 nad me5/ geng4) tong4? Ni3 yi3 gian2 buid zhe4 yant Ni3 you3 shen2 meS bing4? mas? Gaot xie3 yat? Tang2 niao4 bing4? Xin1 zang4 bing4? Zhong4 feng1? Gan1 yan2? Ai2 zheng4? Xiao1 chuan3? Fei4 gid zhong3? Ai4 zi1 bing4? Ni3 deS jia! ren2 yous jian4 kang! wen4 ti2 ma5? Ni3 yi3 gian2 qu4 guo4 yit yuan4 ma5? Ni3 xian4 zai4 you3 mei2 you3 chit yao4? Yao4 fang1? Chu3 fang1 yao4? Zhong1 yao4? Ni3 huid duid yao4 wu4 quod min3 ma5? Ni3 jie2 hunt le5 ma5? Ni3 youd xiao3 hai2 mas? Nid zhud zai4 nar3? Nia xian zai4 zid ji3 yi2. ge4 ren2 zhud ma5? Ni3 you3 gong’ zu04 mas? Ni3 (chou yan1/ het jiu3) ma5? Ni3 yid tian (chout ji3 baot/ het jid bei jiu3)? Ni3 yous chang2 shi4 (jie4 yan1/ jie4 jiu3)? Ni3 ting3 zhi3 het jiu3 zhit hou4, ni3 (de5 shou3 you3 mei2 you3 chut xian4 dou3 chan4/ you3 mei2 you3 kan4 dao4 qi2 guai4 des dong! xis)? Ni3 youd yong4 du2pingma5? Ke3 ka3 yini? Haid luo4 yin1? Yat pian4? Dad a2? Ni yong4 zhent quan3 mas? ——— esReview of Systems ee (Fevers/ Chills/ Night sweats)? : ngo Fal shaoil Han? chand/ Wane shang a : liu2 hang 1? § Weight loss? Ni3 zuid jin4 you3 mei2 you3 sto 8 5 Skin (rashes! itching color PiZ fut you3 (fa1 zhen3/ yang3! biat © changes)? yan2 se4) ma5? (Headaches/ dizziness)? (Tou2 tong4/ tou2 yun)? Loss of Consciousness? Shit qué zhit iue2? Vision changes? Shid lit you3 gad biané mad? De you bear as well as before? Ni3 ting1 dong! xi5 shi4 fou3 g (Vertigo! “innitus)? Gian2 yi2 yang4 hao3? (tou2 yu wu ming2?) © Nose bleeds? Liu2 bi2 xie3? Sore throat? Hou2 ? Bleeding gums? Pegi 8 Ya2 chuang? liu? xie3? (Indigestion! Heartburn? Diarrheal (Xiao1 huad bud liang2/ weld suant quod S Constipation)? duot/ fud xied/ biana mi4)? What color is your stool? Dad bian4 shen? me5 yan2 se4? (Heal cold) intolerance? (Pad re4/pa4 tenga)? Polydipsia? Folyuria? Ted bie2 kou3 ke3 ma5? Xiao3 biand G you3 bi2 ping2 shi2 cuo1 ma5? (Hair! nail) changes? (Tou2 fa/ zhit jia5) you3 gai3 bian4 ma5? Cough? Sputum? What color is it? Ke2 sou4? Tan2? Shen2 med yan2 se4? Shortness of breath? Hut xit kun4 nan5? __ Exposure to TB? Jie1 chud guod fei jia2 he2 bing4? 8 Chest pain? Palpitations? Xiong! tong4? Xin1 ji4? & How Many pillows do you use to Ni3 yong4 ji3 ge4 zhen3 touS shuid jiao4? sleep? How many blocks can you walk Ni3 2ou3 duo1 shao3 tiao2 jie1 cai2 hui4 before you get tired? jan3 daod iei4? « Anemia? Pin2 xie3? r 5 Do you bruise easily? Ni3 shi4 fou3 hen3 rong2 yid peng4 yu1? zz Fatigue? Hen3 lei4? Dysuria? Xiao3 bian4 bud tongt Urgency? Jin3 ji2? @ Daily frequency? Ni3 yit tiant xiao3 bians ji3 cig? Nocturia? Ye4 niao4 duo1? Hematuria? Xie3 niao4? Joint pain? Guan jie2 teng2 tong4? & Weakness? Xu ruo4? s Osteoporosis? Gu2 zhi2 shut song’ zheng4. Rheumatoid arthritis? Feng1 shit bin Problems with concentration? na z 4i2 zhong! jing’ shenS youd kun4 nand? = Mood changes? Qing2 xu4 bian4 dorig4? = Suicidal thoughts? You3 zid shat xiang’ fa52 0 ling2 11 shi2 yit Jan. yit yued | duty Gi yuea 1 we 12 shi2 er4 Feb. er4 yued Aug, bat yued 2 er4 13 shi2 sant Mar. sani yue4 Sep. iiu3 yueq 3 san1 14 shi2 si4 Apr. sid yued a shia yued 4 si4 15 shi2wu3 May. wu3 yued lov. shia vit yuea 5 wu 20 er4shi2 Jun. liud yue4 Dec. Shi2 ord yued li 30 sant shi2 ae | 5 i 40 sid shi2 Sun, xing’ qit tiant Wed, xingt b 1 50 wu3 shi2 Mon, xing1 qit yit Thurs yigaae ‘ ia 100 yi bald Tues. —_xing1 qit er4 10 shi2Physical Exam Sit down on the exam table £ Lie down. Sit up. Stand up. = Remove your clothes (except your underwear). | am going to take your (blood Pressure/ pulse). Do this. (to mimic physical actin) Follow my finger, Look at the light. Raise your eyebrows. ,. (Smile/ frown). & \ need to check your teeth, I'm going to examine your nose. Push against my hand with your face Raise your shoulders against my . Stick out your Swainw, {am going to examine your (heart/ a Wwnas). Breathe deeply. Breathe out. 1am going to examine your abdomen. @ Tell me whether this hurts, when | {press/ let go). | am going to do a recta! exam. Roll over onto your (left/ right) side. Tell me 2s soon as you see my finger wiggling. Do you hear this? {s it louder in your right ear or your left? Crest Walk on your (toes’ heels). Walk like this. Stand like this with your feet together. % Close your eyes. @ lam going to test your balance. © Touch my finger. Touch your nose. 3 Do it again. Faster. (Push/ pull) agains! my hand. Squeeze. Harder. ; Does this feel the same as this? Does it feel sharp or dull? Say “one” or “two” according to how many points you feel. I — going to check your reflexes. Qing3 zu04 zaid chuange shang, Tang4 xiad. Zuo4 qi3 {ai2. Zhand gd lai2 Chu? le5) nid de5 nei4 yil, gings tuo’ xia4 ni3 deS yit fus. Wo3 yao4 bang nid liang2 (xie3 yatl maid bo2). Gent zhe5 wo3 zu04. Kan4 zheS wo3 de5 shous zhi3. Kan4 wo3 de5 deng1. Tai2 qi3 ni3 de5 mei2 maod. (Xiao4 yi2 xia4/ Zhoud mei2). Wo3 yao4 jian3 cha2 ni3 de5 ya2 chi3, Wo3 yao4 jian3 cha2 ni3 de5 bi2 zi5. Yongé ni3 deS lian3 tui1 wo3 de5 shou3, Wo3 yong4 shou3 an4 zhe5 nit de5 shi2 hous, tai2 qi3 ni3 des jian1 bang3 Zhang’ kai1 ni3 de5 zui3 baS. shuot “anh.” Tun yi2 xia4. Wo3 ya04 jianid cha2 ni3 de5 (xin1 zang4/ fei2). Shen1 hut xit. Tu gid. Wo3 yao4 jian3 cha2 ni3 de5 fud bud. Dang4 wo3 (an4 xia4 qu4/ fang4 kai1) de5 shi2 houS, gao4 su4 wo3 tong4 bu2 tong4. Wo3 yao4 zuo4 da4 chang? jian3 cha2. Xiang4 (zv03/ you4) tang3. Kan4 dao4 wo3 de5 shoud zhi3 niu3 dong4 de5 shi2 hou5, ging3 gao4 su4 wo3. Nid ting1 jian4 ma5? Ni3 de5 youd er3 ting1 dao4 da4 sheng! yil dian3 hai2 shi4 zuo3 er3 ting1 dao4 da4 sheng1 yit dian3? Yong4 ni3 de6 (jiao3 zhi3 touS/ jiao3 gent) zou3 lu4. Xiang4 zhe4 yang4 de5 zou3. Shuang} tui3 yit qi3 zhe4 yang4 zhan4 qi3 lai2. Bi4 shang4 ni3 de5 yans jing5. Wo3 yao4 jian3 cha2 ni3 de5 ping2 heng2. Peng4 wo3 de5 shou3 zhi3. Peng4 ni3 deS bi2 zi5. Zai4 zuo4 yi2 ci4. Kuai4 yi1 dian3. (Tuit/ la1) wo3 de shou3. Yongé lid ji3. Gan3 jue2 gen1 zhe4 ge4 yi2 yang4 ma5? Shi4 cid tongd hai2 shi4 yin3 yin3 zuo4 tong4? Gent ju4 n'3 gan3 dao4 duo1 shao3 cid, shuo! “yit” huo zhe3 “er4”, Wo3 yan4 jian3 chad ni3 de5 tiao2 jiand fan3 she4.