Taking Case History

I. Words and word combinations to be remembered:

taking the patient’s case history, family history, past history, the history of the present illness, to take a
history, to give a history, to admit, admission, the ward doctor, the attending doctor, to include the
information, cause of the disease, to be ill with tuberculosis, mental or emotional impairments, compose,
trauma, blood group, sensitivity to antibiotics, findings, to complain of, complaints, laboratory tests, the
course of the disease, the administered medicines, the produced effect of the treatment, to consist of, to
prescribe, description, describe, exact and complete information.

II. Read and translate the text:

The patient’s case history consists of 3 main parts: the family history, the past history and the history
of the present illness. As soon as the patient is admitted to the in-patient department the ward doctor fills
in the patient’s case history.
First of all the doctor must know the information about the patient’s parents – if they are living or not.
If they died, the doctor must know if any of the family has ever been ill with tuberculosis or has had any
mental or emotional impairment. This information composes the family history.
Then the doctor asks the patient to give his history, i.e. the diseases which the patient had both being
a child and an adult, the operations which were performed, any traumas he had. The patient’s blood group
and his sensitivity to antibiotics must be determined and the obtained information must be written down
in the case history. These findings compose the past history.
The attending doctor must know what the patient’s complaints and symptoms are. He must know how
long and how often the patient has had these complaints. The information on the physical examination of
the patient on his admission to the hospital, the results of all the laboratory tests and X-ray examination,
the description of the course of the disease with any changes in the symptoms and the condition of the
patient, the administered medicines in their exact doses and the produced effect of the treatment – all
these findings which compose the history of the present illness must always be written down the case
history. The case history must be written very accurately and consist of exact and complete information.

Active words and word combinations:

the patient’s case history – история болезни больного
the family history – семейный анамнез
the history of the present illness– история настоящего заболевания
to make a history – собрать анамнез
to give a history – рассказать о перенесенных заболеваниях
to include the information about ...– включать информацию о ...
a cause – причина
to cause – вызывать, причинять
to be ill with tuberculosis – болеть туберкулезом
mental and emotional impairments – умственные и эмоциональные
нарушения
sensitivity to antibiotics – чувствительность к антибиотикам
to determine – определять, устанавливать
to obtain the information – получать информацию
to write down in the case – записывать в истории болезни
to compose – составлять
the ward doctor – палатный врач
the attending doctor – лечащий врач
to complain of – жаловаться на ...
complaint – жалоба
physical examination – физикальное обследование
X-ray examination – рентгенологическое обследование
the administered medicines – назначенные лекарства
exact and complete information – точная и полная информация
IV. Translate into English:
1.История болезни больного состоит из трех основных частей: семейного анамнеза, жизненного
анамнеза и истории настоящего заболевания.
2. Врач должен знать все о родителях больного: если они умерли, он должен знать в каком
возрасте и по каким причинам они умерли.
3. Данные о болезнях, которые больной перенес, об операциях, которые ему сделаны, о травмах,
которые он имел, составляют жизненный анамнез.
4. Следует определить группу крови больного и его чувствительность к антибиотикам.
5. Лечащий врач должен знать жалобы и симптомы больного.
6. Информация о физикальном осмотре, результаты всех лабораторных тестов и
рентгенологического обследования, описание течения заболевания, назначенные лекарства – все
эти данные составляют историю настоящего заболевания.
7. История болезни должна быть составлена очень внимательно.