Anamnesis ‘Nu vorbim roméné foarte bine dar incercém si avem o comunicare cét mai bund. ‘imi pare ru dar, vorbesc putin limba romana. / am sorry; | only speak a little Romanian. Pot si va pun o intrebare? Multumese. Can / ask you a question? Thank you. Va rugim si vorbiti mai rar! Please speak slowly! 1. Cum va numiti? /Cum va cheama?. What is your name? 2. Cati ani aveti? / Ce varstd aveti ? How old are you? MOTIVELE INTERNARII — CHIEF COMPLAIN 3. Ce va supar&? What is your problem? - Unde vi doare? Where is the pain? Indicati zona va rog. Indicate the region please, - Ce v-a facut s8 veniti la doctor What made you come to the doctor? 4, De cat timp aveti aceasta durere? Since when do you have this pain? 5. Ati venit cu programare sau e urgent? Did you had an appointment or was it an emergency? ‘ANAMINEZA a) Antecedente heredo-colaterale - Family history 6. P8rintii dumneavoastra traiesc? Are your parents alive? Ifnot: La ce varst& au decedat? At what age did they die? = Din ce cauzd au decedat? What was the cause of their death? De exemplu: Accident; probleme cardiace; cancer; boli infectioase; boli ereditare: care anume? e.g. Accident; heart problems; cancer; infectious diseases; hereditary diseases: which? 7. Aveti Copii? Cati? Do you have children? How many? Fat8/fic8 daughter/Fiu son - Copiii dumneavoastr sunt snatosi? Are your children healthy? 8. Avetifrati si surori? Do zou have brothers or sisters? Sunt sanatosi? Are they healthy? TrBiesc? Are they still alive? Dacé nu, la ce varsta au decedat? Din ce cauz8? /f not, at what age did they die? What was the reason? 9. Exist8 boli in familia dumneavoastra pe care le stiti? Is there any disease in the family? De exemplu: diabet zaharat ; hipertensiune; Astm; Boli cu transmitere sexual ; hepatit’; ‘Atac de Cord/; Epilepsie, si asa mai departe? (and so on?) 10. Cand /Cum a fost diagnosticat? When / who was it diagnosed? 11. Ce tratament ati primit? What treatment did you get? b) Antecedente personale, fiziologice si patologice ~ Personal history pentru femeie: 12. Cand ati avut prima/ultima menstruatie? When did you have your first/last menstruation? = Atiavut probleme cu ciclurile menstruale? Did you have problems with menstruation cycle? = Aveti dureriin timpul menstruatiei? Do you have pain during menstruation? - _Aveti singerdri neregulate? Do you have irregular bleedings? = Cand ati avut menopauza? When did you have menoapause? - Medicamente hormonale luati? Do you take hormonal medications? ~ Cat de multe sarcini ati avut? / De cate ori ati fost insarcinat8? How many pregnancies did you have? - Atiavut vreodati avort, avort spontan? Have you ever had an abortion /misscarriage?13. Ati avut bolile copilfriei? Did you had any childhood disease? De exemplu: rujeol8, varicels, febra reumatic’, poliomielita measles, chicken pox, rheumatic fever, polio 14. Ati avut boli cu transmitere cronic&? Do you have any chronic disease? De exemplu: tuberculozé, sifils, SIDA, hepatitis tuberculosis, syphilis, AIDS, hepatitis 15. Ati fost vaccinat(8)? Have you been vaccinated? = Ce fel de vaccin? Which type of vaccine? - Pentru ce anume ati fost vaccinat? For what did you get vaccinated? Ati avut/ Aveti boli cu transmitere sexuala? Did you have/Do you have a sexual transmitted disease? 17. Aveti alergii? Do you have allergies? - Impotriva cdror medicamente? Against any particular medications? -Polen, animale? 18. Ati suferit vreo interventie chirurgicals? Have you had any surgeries? = Cand? When? - Pentru ce ati suferit interventia? Which? De exemplu: apendice, amigdale, hernie, tumoare 19. Sangerati usor? Do you have any bleeding tendencies? 20. Ce grup sangvind aveti? What is your blodd group? 16. ©) Conditii de viata si munca ~ Social history 21. Unde locuiti? Where are you living? sat village, oras town, casi house, apartament locuiti singur? Do you live by yourself? 22. Care este ocupatia dumneavostra? Care este slujba dumneavoastra? What is your job? 23. Cand va-ti pensionat? When did you retire? 24. Aveti o relatie bund cu familia? Do you have a good relationship with your family? 25. Faceti sport? Do you do sports? 26. Ce mancati? What do you eat? De exemplu: legume, fructe, carne, produse lactate, peste 27. De cat timp nu mancati? For how long have you been fasting? 4) Comportamente (fumat, alcool, ..) Chronic intoxications 28. Fumati? Do you smoke? /Ati fumat vreodata? Did you ever smoke? = Cat timp? How long? De cate ori pe zi? How many times per day? - Cite tigari pe zi? How many cigarettes per day? Cati ani aveati cand ati inceput sau renuntat? When did you start or stopped smoking? 29. Consumati bauturi alcoolice? Do you drink alcohol? ~ Cit de mult? How much? - Cate pahare pe zi de... How many glasses a dayof. De exemplu: vin, bere, trie? wine, beer, spirits? ~Dacd nu beti acum, ati baut vreodata? /f you don’t drink now, have you ever drank? 30. Sunteti dependent de droguri usoare Are you a drug addict? - De cénd? Since when? - Dac acum nu sunteti dependent de nici un drog, ati fost vreodata? if you are not @ drug addict now, were you ever one?e)M imunosupresoare lusiv preparate hormonale 31. Ce medicamente luati? What medications are you on? De cite ori pe 2i? How many times per day? 32. Urmati vreun tratament? Are you on any treatment? De exemplu: tablete, injectii 33, Aratati-mi cutille de medicamente. Show me the medicine containers, 34, Pentru ce parte a corpului luati/ati luat medicamentele? For which part of your body do/did you take it? ISTORICUL BOLI! - HISTORY OF PRESENT ILLNESS 35. Cand au inceput durerile cu ..... When did the pain start concerning -De cand a inceput? When did it start? - Durerea a inceput progresiv sau brusc? Did the pain start slowly or rapid? - Unde sunt localizate? ArStati-mi cu mana, v8 rog! Where is localized? Show me with your hand, please! ~ Cum este durerea? De la unu la zece? How is he pain? From 1-10? - Disconfort moderat, durere ascutit3, pulsatila, constrictive? Moderate discomfort, sharp pain, pulsatile constructive? A fost /este o durere constanta sau doar pe perioade? Was /Is the pain constant or in periods? - Cat timp dureaz8? How long does it last? - Ce 0 face mai puternica/ mai putin puternicd? Asezat? What makes it worse? Better? Ex. Sitting ‘Systemic inquiry 36. Ce mai faceti? How are you doing? 37. Aveti pofta de mancare? Do you have a good appetite? V-a crescut/ scézut pofta de mancare? Has your appetite increased/decreased? 38, Ce greutate aveti? What is your weight? - Afi sc&zut/luat in greutate? Did you lose / gain weight? 39, Cat de inalt sunteti? How tall are you? 40. Cum dormiti? Bine sau ru? How is your sleep? Good or bad? 41. Va simtiti lipsit de energie? Do you feel a lack of eneray? 42, Aveti temperatura/febr’? Do you have any fever? ~ Ce temperatur’ aveti? How much? - De cand? Since when? ‘© V8 rog frumos s8 va asezati pe marginea patului. Please sit on the edge of the bed. © Puteti sa vi dati bluza jos, v8 rog? Could you please take off your shirt? Trebuie s5 va examin3m/consultim. Puteti si stati asezat(5), v3 rog ? We have to examine/consult you. Can you sit down, please? V8 rog s v8 intindeti. Please lay down V8 rog si respirati normal/ adanc. Please breath normally or deeply. VA rog sa tusiti. Please cough Va rog sa spuneti 33 - trei zeci si trei Please say 33. Va rog deschideti gura. Please open your mouthOther questions: 43, 44, 45. 46. 47. 48. 49. 50. si. 52. 53. 54, 55. 56. 97. 58. 59. 60. Aveti regurgitatii acide? Do you get acid brash? De cat timp vi plangeti de aceasta? For how long have you been complaining of this? ani, luni, zile, ore Aveti regurgitatii? Do you regurgitate? Sunt acide? Sunt cu reflux? Aveti senzatia de great? Do you have nausea? Vomati? Do you vomit? Vomati des? Do you often vomit? Vomiati dupa ce mancati? Do you vomit after eating? Cand au inceput durerile? When did the pain start? ~ Lace or? At what time? = Pe ce dat8? At what date? Durerea a inceput de la sine? Did the pain start spontaneously? ~ Sau ca rezultat al unor actiuni ale dumneavoastra? Or as a result of some action by yourself? Durerea a inceput progresiv/ brusc? Did the pain begin progressively/ suddenly? Exista ceva care calmeaza durerea? Does anything help ease the pain? = pozitia, miscarea, medicamentele antialgice/antiacide position, rolling around, medicine painkillers/ antiacids Durerea radiaza? Does the pain spread? spre spate, umar, maxilare, brate, in sus, in jos to the back, shoulder, jaws, arms, upwards, downwords A fost nevoie s8 luati calmante? Did you have to take pain killers? Tusiti? Do you cough? - De cat timp? Since when? Ramaneti fara suflu? Do you get breathless? Aceasta se intampla dupa efort?/ cand mergeti? /cdnd urcati scarile? Does it occur after efort?/ when you walk?/ when you go upstairs? Ati simtit cd inima va bate repede si cu putere? Did you fee! your heart beat fast and strong? Ati avut vreodata angina pectoralé/ o crizd cardiaca? Have you ever had angina/ a heart attack? Urinati putin? Do you urinate less? Vati pierdut vreodat cunostinta? Did you ever become unconcious? - Cat timp dureaza? How long does it last? Purtati proteze? Do you have false teeth?