English for MedicineHistory Taking.ppt

1、English for MedicineHistory Taking,Lee Chee Siong Department of Cardiology Kaohsiung Medical University Tel: 7738 Email: ,在臺灣看診為什麼要學用英文？,病歷記錄與書寫 病人是本國人需要英文嗎？ 病人是外國人時又如何？ 國際醫療、與國際接軌,甚麼是 “History Taking？,回想一下你自己看病的經驗，看診過程的大部份 時間醫師在做甚麼？,Developing a Management Plan for a Patient,Establish a relationshi

2、p with a patient,Gather information History Physical examination Investigation,Make a diagnosis if possible,Formulate a management plan,Explain and discuss this with the patient,The Medical History,“.the interview is potentially the most powerful, sensitive instrument at the command of the physician

3、” George Engel 1973,“ Listen to the patient. They are giving you the diagnosis” Rene Laennec 19th century French physician,Contribution of history, PE and investigations to final diagnosis,Diagnosis made on history alone Diagnosis changed after investigations Diagnosis changed after physical examina

4、tion,Beginning an Interview,Establishing Rapport,Gathering Information,Taking a Medical History,The Structure of a Medical History,Basic information about the patient Description of presenting problem History of presenting problem Review of body systems Past medical history Family history Social his

5、tory,Basic Information About the Patient,Patients name Gender Address Age Occupation Marital status Nationality (Ethnic),想一想，遇到阿豆仔病人，如何開啟第一個問題？,What can I do for you? How can I help you? Whats bothering you? Please tell me about your problem,Chief Complaint 主訴,常見的主訴有那些，英文又該如何描述呢？,主訴,皮膚出疹 Skin rash 噁

6、心 nausea 嘔吐 vomiting 腹瀉 diarrhea 出血 bleeding,疼痛 Pain, -ache, sore, -algia 發燒 fever 咳嗽 cough 呼吸短促 shortness of breath 腫脹 swelling,Terms Related to Pain,Headache Toothache Chest pain Abdominal pain Epigastralgia Joint pain (arthralgia) Lumbago Sorethroat Muscle sore Dysuria Dysmenorrhea,主訴,不適 Epigastr

7、ic discomfort, chest discomfort .感覺 Oppressive sensation in the chest A heavy feeling in the head A feeling of foreign body in the throat .困難 Difficulty in walking Trouble breathing,discomfort,Feeling (sensation) of,Difficulty (trouble) in ,主訴,無法 Unable to concentrate Inability to urinate Inability

8、of voiding 喪失 Loss of appetite Loss of energy Body weight loss 減少. Decrease in sexual desire, decreased libido Increase in abdominal girth 不規則 Irregular pulse Irregularity in menstrual period,Inability (unable ) to .,Loss of .,Decrease in .,Irregularity in ,Chief complaints,醫生阿，我那個肚子很不舒服！還有腰也會痛。我是不是

9、腰子壞了，最近都很疲勞。晚上睡不好，頭都暈暈的呦！昨天還吃什麼就拉什麼。醫生啊，這怎麼辦？ 他到底是為何而來？,Principles of recording the Chief Complaint,Select the most important symptom Use patients own words rather than medical terms The duration, frequency or interval of the main symptom Use simple phrase,How to Describe Breathing Abnormalities,Dif

10、ficulty in breathing Shortness of breath Breathlessness Dyspnea Exertional dyspnea Dyspnea on exertion,Feeling of Discomfort,General discomfort (malaise) Sensation of heaviness in the head Foreign body sensation in the throat Oppressive sensation of anterior chest Epigastric discomfort (distress) Se

11、nsation of fullness in the upper abdomen Lower abdominal fullness,How to Describe the Chief Complaint of Chest Pain,Chest pain today Chest pain for 2 hours Precordial pain for 2 hours Excruciating precordial pain for 2 hours Sudden onset of excruciating precordial pain 2 hours ago Sudden onset of ex

12、cruciating precordial pain 2 hours ago during exercise,Examples of Chief Complaint,Increasing shortness of breath for 2 months Frequent episodes of anterior chest pain in the past 3 months Persistent fever and headache for 3 days Sudden onset of high fever today Left lower abdominal pain with diarrh

13、ea for 2 days Cough with yellowish sputum (phlegm) for the last 5 days Intermittent ankle swelling in the past 4 months,Examples of Chief Complaint,Sudden onset of difficulty in walking . Difficulty in voiding for 2 days Loss of vision. Loss of appetite Decrease in sexual desire (libido) Decrease of

14、 urine amount,Commonly Used Adjectives,Severe; moderate; mild, progressively worsening. Sudden; acute; insidious; gradual; progressive. Persistent; intermittent; fluctuating; (例如：pain with fluctuating severity). Sharp; vague; crampy; stinging; tingling. Generalized; diffuse; localized; scattered. De

15、creased; lessened; diminished; subsided; reduced; declined; lowered; get better; improved. Increased; worsened; progressed; degenerated.,How to Describe the Presenting Symptom in Present Illness,Duration and frequency Mode of onset Site and radiation Character Severity Aggravating or relieving facto

16、rs Associated symptoms Placed in chronological order Current treatment The impact of the illness,Patients Presenting Problem,WHAT What does it feel like ? What brings it on ? What else ?,WHERE Show me where it is,WHEN When did it start ? When does it occur ? How often ? How long for ?,HOW How bad is

17、 it ? How is it altered by .,WHY Why do you think youve got it ?,WHO Who is affected by it ?,Commonly Used Questions (I),Does this happen often? Is this the first time youve had this symptom? When did you find this? When did you notice this? When did you first feel it? How long have you had this pro

18、blem? When did this start? Is this symptom getting better or worse? Was there any possible cause? Can you think of any reasons?,Commonly Used Questions (II),Have you ever had any serious illness? Have you ever had any operation? Do you have any allergies? Are you allergic to anything? Do you smoke?

19、Do you drink alcohol? Are you taking any medicine regularly? What is your blood type? What is your average blood pressure? When did you have your last physical examination?,History of the Presenting Problem,Obtain a detailed history which is complete, accurate and relevant Find out the patients perc

20、eption of what is wrong Establish their attitudes to the problem Determine what effect the problem has on their day-to-day life and relationships,Physical / Psychological / Social,Duration of the Symptom,The duration of chest pain was around 5 to 10 minutes The pain lasted for . The symptom persiste

21、d until Suffer from alternating diarrhea and constipation for 2 weeks in succession The attacks of chest pain tended to be more prolonged than usual Several episodes of fainting occurred over a 2 month period The attacks of palpitation recurred at intervals of 1 to 2 months, and were always sudden i

22、n onset, lasting 10 to 20 minutes,Mode of onset,Occurred abruptly Sudden onset of Have an abrupt onset of Gradually Insidiously Begin slowly Unexpectedly,Examples,The patient experienced an abrupt onset of breathlessness He had a sudden onset of high fever with shaking chillness She noticed a gradua

23、l onset of general weakness There was an insidious loss of 6 kg in body weight,Aggravating or Relieving Factors,The patient began to experience retrosternal chest pain associated with shortness of breath upon effort The chest pain was closely related to position, movement and deep breath Pedal edema

24、 persisted unrelated to postures Lower abdomnal pain persisted unaffected by meals or bowel movements Change in position had little effect on the intensity of the pain The patient felt short of breath soon on climbing stairs The heartburn sensation usually appeared on lying down and became minimal o

25、n getting up The patient became dizzy when he rose suddenly from lying or sitting position,The Past History,Past illnesses Medical illness: Dx? When? Where? Symptom? Complication? Operation: What? When? Who? Where? Complication? Admissions to hospital: Why? Where? How long? Dr.? Complication? Childh

26、ood illness Obs and Gyn problems Past treatment and medications Which drug? How long? Dosage? Steroid, NSAID, oral contraceptives, antihypertensive agents, chemotherapy, radiotherapy,Poor Example of a Past History,DM ( + ) H/T ( + ) CVD ( + ),Examples of Past history,DM type 2: 5 years; regularly fo

27、llowed by Dr. Lee; 2 drugs, bid; well controlled (AC sugar 100-120) or poorly controlled due to non-compliance, and hospitalized 3 times, the last one in 3/2003 for 20 days at, operated for. CVA: 5 years ago, right hemiplegia since, walks with cane, with slurred speech; or recurrent, 5 and 2 years a

28、go, bedridden since, incontinent with Foley catheter, admitted for infected bed sores and recurrent UTI x 3 over the last 12 months.,Examples of Past History,No past history of serious illness, operation or hospitalization Unremarkable except for acute appendicitis, appendectomy at KMUH at the age o

29、f 12 without complication Hospitalized for 2 weeks because of myocardial infarction at CGMH, treated with PCI 2 May 2000 Treated by Dr. Hwang XX for hypertension since 45 years old,Social and Personal History,Education and occupation Marital status Habits: Smoking, drinking, betel nut, illegal drugs

30、, diet, eating habit Sexual history Travel history History of contact with animals, sick people Interpersonal interactions Family life,Smoking History,Smokes 20 cigarettes a day for 25 years Daily consumption of tobacco has been 10-20 cigarettes for 10 years Had been smoking more than 2 packs of cig

31、arettes a day since 18 y/o, quit 3 months ago Smoke 10 cigars daily for 5 years Smokes a pipe on occasion,Alcohol Drinking,What type? How much? How often? Exact meaning of social drinking,Never used alcohol in any form Seldom drinks alcoholic beverages Drinks alcohol only on social occasion (one can

32、 of beer once/month) Taiwan beer one bottle / day in recent 4 years,History of Allergy,Shrimps (urticaria), tomato (pruritus); Penicillin (positive skin test at KMUH, or urticaria, or probable anaphylactic reaction Allergic to an injection at a clinic (fainted, or skin rashes, or other symptoms).,Fa

33、mily History,Number of brothers and sisters Parents, uncles, aunts Any similar illness in the family members Causes of death and ages of death of the parents and siblings Cancer (breast, colon), DM, heart diseases, hypertension, CVA, gout, liver diseases, hepatitis B and C, TB, etc.,Family Tree,Syst

34、emic ReviewCommon symptoms and 3 or 4 common disorders,Cardiovascular System Any pain or pressure in the chest, neck or arm? Short of breath on exertion? How much exertion is necessary? Woke at night with short of breath? How many pillows to sleep on? Heart racing or beating? Legs pain on exercise? High BP? Heart attack? Rheumatic fever?,Systemic ReviewCommon symptoms and 3 or 4 common disorders,Respiratory System Short of breath? Cough? Cough up anything? Blood? Wheeze when short of breath? Fever? Night sweats? Pneumonia or TB history?,Systemic ReviewCommon symptoms an