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Taking a history 1:section 1

.asking 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?

How the doctors asks how


long the problem has lasted

-How long have they been bothering


you?
-How long have you had them?

Language focus 2
How the doctor asks where the
problem is
-which part of your head is
affected?
-where dose it hurt?
-where is it sore?

How the doctor asks about the


type of pain
-can you describe the pain?
-what is the pain like?
-what kind of pain is it?

Language focus 3
How the doctor asks if any thing
relieves the
pain of headaches
-is there any thing that makes them better?
-dose anything make them worse?
Doctors often ask if anything else
affects the
problem: e.g
-what effect dose food have?
-dose lying down help the pain?

Section

2 taking notes

TAKING NOTES

O/E= on examination
B.P= blood pressure
P=
pulse
ENT= ear,nose,throat
GIS= gastero-intestinal system
CNS= central nervous system
3/7= three days
8/52= eight weeks
5/12= five months

Section3-Reading skills:

scanning a

case history

A case history is to be read.


Information to be found and
underlined
about the patient through answering
questions.

Taking a history 2:Asking about


systems

Language focus 4
How the doctor asks about the systems:
-Have you any trouble with your
stomach or bowels?
-What is your appetite like?
-Any problems with your waterworks?
-What about coughs or wheezing or
shortness of breath?
-Have you noticed any weakness or
tingling in your limbs?

Match each of the suspected problems in the first


column with a suitable question from the second
.column
Suspected problem
question
depression
have you had any pain in your
chest?
cardiac failure
do you ever get wheezy?
asthma
what sort of mood have you been
in recently?
prostate
any problem with your
waterworks?
coronary thrombosis
have you coughed up blood?
cancer of lung
have you had any shortness of
breath?

Section 2 asking about


symptoms
Language focus 5How to ask about
associating problems or symptoms-(e.g fever)(yes/no questions)
The doctor uses rising intonation for these
questions.
-any pain in your muscles?
-have you lost weight?
-have you had cough?
-have you had any pains in your chest?

Which problems in the checklist do the


following questions refer to?

Do you suffer from double vision?


Any shortness of breath?
Does light bother you?
Are your stool black?
Do you have a cold?

Study this extract from a case history,


then put the questions that you might ask
the patient to obtain the underlined
information.
A 59-year-old patient, a teacher of English,
complained of sever chest pain which occurred
on exertion and was sometimes accompanied by
sweating.He smoked 40 cigarettes a day. The
pain had first appeared three months a go and
was becoming increasingly frequent. He had
noticed some weight gain recently and also
complained that his hair had become very dull
.He felt the cold much more than he used to. He
had no palpitations or ankle oedema.

What is your job?


What has brought you along today?
1-does the pain come on at any particular time?
Apart from the pain ,do you feel anything else
wrong?
Do you smoke? how much do you smoke?
When did you first notice the pain?
Have you noticed any change in the frequency
of the pain?
How has your weight been?
Do you ever become aware of your heart
beating too quickly?
Have you had any problem with swelling of the
ankles?

Terms which a patient would easily understand as opposed to the


original medical terms
medical term
non-medical term
1-parasthesia
a-sweeling, puffiness
2-productive cough
b-indigestion
3-anaesthesia
c-coughing up phlegm or spit.
4-retrosternal chest pain
d-trouble holding your water
5-orthopnoea
e-cramp in the leg muscles which
comes and goes.
6-stress incontinence
f-numbness
7-dysmenorrhoea
g-sleeplessness
8-dyspepsia
h-out of breath,out of
puff,breathlessness
9-oedema
i-painful periods
10-intermittent claudication
j-pain behind the breast bone.
11-insomnia
k-pins and needles
12-dyspnoea
l-shortness of breath when lie
down.
The doctor may use these terms in taking history from the patient
because it is easier for the patient to understand , but in writing
medical report ,the medical terms should be used.
1 k,2 c, 3 f, 4j, 5l, 6d, 7i, 8b, 9a, 10e, 11g, 12h.

Letter of referral from a doctor to a


consultant concerning a patient.
Medical terms are used in the report or
referral letter.
Complete history regarding of the patient
illness.
Findings on examination.
Details of the treatment given.

Here is a version of consultation, complete the


doctor s questions.

Doctor ---------------------------------------------------------------Patient :well, doctor ,I have been having headaches and I have
lost a bit of weight.
Doctor------------------------------------------------------------------------------------Patient: for quite a while now.
Doctor :------------------------------------------------------------------------------------Patient : just here ,on the top.
Doctor--------------------------------------------------------------------------------------Patient: I have been off my food.
Doctor
---------------------------------------------------------------------------------------Patient : I have been having problems in starting urination.
Doctor
---------------------------------------------------------------------------------------Patient ;I have noticed it gradually over the past few months.

Explaining=what the doctor is


going to do to the patient.
Instructing=what the doctor wants
the patient to do.
Reassuring=to decrease the worry
or fear of the patient about the
procedure to be done.

Section-1 Explaining, Instructing, and


Reassuring.
Language focus 8:Note how the doctor
starts the examination (Eye
Examination);I would you just like to examine your eye.
-could you just look at the chart
for me?
How the doctor indicates the examination
is finished:
-Right ,thank you very much indeed.

Examining a patient-language
focus 6

Section 1 Giving instructions

How the doctor instructs the patient what to do:


( e.g. examination of the back)
-now I want to see you standing.
-could you bend down as far as you can?
-keep your knees and feet steady.
Instructions to change positions or remove clothing:
-would you slip off your top things, please.?
-now I would like you to lean backwards.
Preparing the patient for the next part of the
examination
-I am just going to find out where the sore spot is.

Doctor's explanations and


expressions of reassurance-add
.one word in each gap

1 Now I am .to put this thing on your chest.


2 It isa stethoscope.
3 It.be a bit cold.
4 OK?First.all, I listenyour front and ..your
back.
5 well..you did not move at all.
6 Now I would.to see your tummy,.will you lie on the
bed for a minute?
7 Now while.lying there,feel your neck and under
your arms.
8 Are you.?
9.the top of your legs.
10 That is .very quick,.

Language focus 7
How the doctor marks the end
of each stage of examination.
-he pauses.
-he uses expressions such as
OK, FINE, THAT IS IT.

Match the part to be examined from the first


column with the appropriate instruction from
the second column.

Examination
The throat
shoe.
The ears
clothing.
The chest
The back
The foot
The nasal passage

instruction
remove your sock and
remove your top
turn your head this way.
open your mouth
tilt your head back.
stand up.

What do you think the doctor is examining


?by giving each of these instructions

I want you to push as hard as you can against my hand.


Breath in as far as tou can. Now out as far as you can.
Say 99.Now whisper it.
Could you fix your eyes on the tip of my pen and keep
your eyes on it?
I want you to keep this under your tongue until I
remove it.
Would you roll over on your left side and bend your
knees up?
I want to see you take your right heel and run it down
the front of your left leg.
Put out your tongue. Say Aah.

How to play the role of a


doctor

( E.g :Eye examination)


Greet the patient.
Indicate that you have had a letter of referral.

Ask about the patient occupation.


Ask about the effect on his occupation.
Indicate that you would like to examine him.
Ask him to read the chart.
Ask about the right eye.
You change the lens-dose it make any difference?
You try another one.
Indicate that the examination is over.

Ask about the duration of the problem .

INVESTIGATIONS
EXPLAINING AND DISCUSSING INVESTIGATIONS
EXPLAIN WHAT THE DOCTOR IS GOING TO DO AND
WHY.E.G now I am going to take some fluid off
your back to find out what is giving you these
headaches.
INSTRUCT THE PATIENT TO TAKE UP THE CORRECT
POSITION. E.g-now I want you to move right to
the
edge of the bed.
REASSURE THE PATIENT ABOUT THE
INVESTIGATION
E.g-it will not take very long.
-now I am going to give you a local
anaesthetic so it willnot be sore.

Order of explanation to a patient to do sternal


marrow
investigation
1-First of all,I am going to wash the area with a bit
of antiseptic.
2-Now the next thing I am going to do is to put a
towel,over the area.
3-Now I am going to give you an injection of local
anaesthetic.First into the skin and then into the
bone.
4-Now we are ready to do the actual test.
5-Now I am going to remove the actual cells from
your bone.
6-Just going to remove the needle from your bone.
7-Then we will put a dressing over the area.

Sequence of instructions by
physiotherapist
-first of all ,you lie down
-now place your hands on your back
How the physiotherapist advice the
patient
-you should do these exercises three times a
day, 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 jerking your body.

Expressions used between doctors in discussing a choice of


.investigations

Essential

should, must be+required


essential
important
indicated
E.g:-the patient shuold be given an

x-ray
-it is important to give an x-ray
-an x-ray is indicated.

Possibly usefulcould
Not required ---need not be, not necessary
not required
not important
Essential not to doshould not
must not
be+contraindicated.

Making a diagnosis
Expressions used between doctors in
discussing a diagnosis:
Certain
Yes

Is
Must
e.g HF

No

Cannot , Exclude
Definitely not
Rule out

.e.g HF

Fairly
certain
Seems
Probably
Likely
Unlikely

Uncertain
Might
Could
May
Possibly
A
possibility

Little information to base adiagnosis=we can


say;the pt.might have cervical spondylosis.
Or cervical spondylosis is a possibility.
Some diagnoses become more likely while
others become less likely;e.g he seems to
have temporal arteritis.
There is no neck stiffness.It is unlikely that
he has got cervical spondylosis.
Stronger evidence for final diagnosis
E.g=raised ESR makes temporal arteritis
very likely.
-normal MRI excludes space occupying
lesion.
Finally,following the biopsy,we can say;
-he must have temporal arteritis.

Language focus 9
How the doctor reassures the patient
by explaining
what she is going to do and indicating
that verything
is all right:
Can I have a look at you to find out
where your bad
cough is coming from?..that is fine.

Language focus 10
How doctor uses a rephrasing technique to
encourage the patient and give him time to
answer.

E.g have you been here long?

In this house,have you been here long?

how long have you been living in High

Street?
The rephrased question is often preceded by
an expression like DO YOU REMEMBER E.G
-Do you remember where this is?where is this
place?

Examples of The rephrasing with the


corresponding
test question.
A-question do you remember when you were born?
what ..was the year of your birth?
can you remember that?
B-q
do you remember what time of the
month?
what ..was that day?
Qc.how old will you be now?
Qd ..what year is this year? Do youknow that?

Qe ...fine and what month are we in?


well,tell me is summer or winter?
Qf do you remember what day of the week it is?
or do the days not mean a great deal to you
now that you arenot working?

Mental impairment
measurement

Ask the patient the following questions.


Sore 1 for correct answer,0 for an error.

1-What is the name of this place?


2-what day of the week is it today?
3-what month is it?
4-what year is it?
5-What age are you?
6-in what year were you born?
7-in what month is your birth day/
8-what time is it?
9-how long have you been here?

8 or9 normal, 5 to7 moderate


impairment,1 to 4 sever impairment, o
complete failure.

Reading skills: Reading Articles


Headings commonly used in articles.
Title
Authors
Editor note
Summary
Introduction
Materials and methods
Results
Comment
References

REASSURANCE WITH
WARNING
IT SHOULD NOT BE PAINFUL,BUT YOU WILL
BE AWARE OF A FEELING OF PRESSURE.
THIS MAY FEEL A LITTLE BIT
UNCOMFORTABLE,BUT IT WILLNOT TAKE
LONG.

Language focus 17
Describing causes and effects. E.g:
cause
effect
bending the knee
off the nerve
straighten it

the tension is taken


the nerve goes taut.

We can link a cause and an effect like


this:
if we bend the knee, the tension is taken off
the nerve.
if we straighten it, the nerve goes taut.

Link each cause and effect to make


a simple statement used in
explanation to a patient.
If the stomach produces too much acid, it
may cause stomach pain
If a woman gets German measles during
pregnancy, the baby may be born with
deformities.
If you vomit several times in quick
succession, you may burst a blood vessel
in the gullet.
If your blood pressure remains high, you
may have stroke.

The patient would expect his


doctor to answer the following
.questions after the diagnosis

What is the cause of my problem?


How serious is it?
What are you going to do about
it?
What are the chances of a full
recovery?

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

How the patient must conduct


himself 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
weaker and the pain will heal worse.
-don't wait until the pain is out of control

How to advise each of


these patients
A hypertensive 50-year-old
director of small company.
A 65-year-old schoolteacher
with osteoarthritis of the hip.

Some abbreviations used in


medicine

Mitte give
Sig. write /label
Tab. tablet
P.c after food.
6 hrly-every six hour.

Doctor instructions to his patient


regarding his treatment

Tablets which you are going to


take two of every six hours
.Try to take them after food if
possible in case they cause
you indigestion. You can take
them during the night as well
if you are awake with the
pain.

Medical abbreviations
CABG=coronary artery bypass
graft.
LADA= left anterior desending
artery
RCA = right coronary artery.
OM1=FIRST OBTUSE MARGINAL.
LV =left ventricle.
LA =left atrium.
B.P = blood pressure.

A free text

Drug preparation
Treatment
Baldness
Limb
Stroke
Heart attack
Bleeding nose
Athlete foot
Boils
Blood poisoning
Cancer
Miscarriage

MeSH(medical subject heading) TERM

pharmaceutical
therapy, therapeutics
alopecia
extremities
cerbrovascular accedent
myocardial infarction
epistaxis
tinea pedis
furunculosis
septicemia
neoplasms
abortion,spontaneous

Reading skills: using an online database


Preparing a search, the search strategy
involves:
1-Posing the search question. e.g how
effective paracetol in controlling pain after
surgery?
2-Identifying the main topics. e.g=the main
topics will be;paracetamol,,and pain following
surgery.
3-Deciding how to search for the main topics.
By using Medical Subject headings,MeSH.
E.G=neural pathways, analgesics, digestive
system disease.
4-formulating the search query..
e.g=paracetamol and pain,postoperative