Урок по английскому языку "История болезни"

краевое государственное бюджетное профессиональное

образовательное учреждение

«Ачинский медицинский техникум»

(КГБПОУ АМТ)

 

 

 

 

 

 

 

 

 

Учебное пособие для студентов

по дисциплине «Иностранный язык»

Case History

для специальностей

31.02.01 Лечебное дело

34.03.01 Сестринское дело                                                             

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ачинск, 2014

 

 

 

 

 

 

 

 

 

 

 

 

 

Введение

 

         Данное учебное пособие для студентов соответствует требованиям ФГОС СПО для специальностей 31.02.01 Лечебное дело, 34.03.01  Сестринское  дело.

Использование информационных технологий в учебном процессе является существенным фактором практического занятия. Студенты самостоятельно находят нужную информацию, активно включаются в поисковую деятельность, применяя Интернет-ресурсы.

Задачи:

1. Развивать у студентов речевую, языковую,  компенсаторную, учебно-познавательную компетенции.
2. Развивать у студентов готовность к сотрудничеству.

3. Повысить мотивацию к изучению английского языка.

Занятия в интерактивном формате дают возможность студентам приобретать знания  от учителя к ученику, активно добывать их в учебном общении  друг с другом.

Преимуществом данного занятия является использование интерактивной методики обучения английскому языку (сложная кооперация, использование аутентичных материалов), информационных технологий, а также технологии критического мышления.

 

 

 

 

 

 

 

 

 

 

 

 

Read and learn the following words and word combinations:

 

 

the medical history, case history	история болезни
to report	сообщать, составлять отчет
gain obtain	добывать, получать
refer	относиться
enable	давать возможность
clarify	вносить ясность
the impact	влияние
the comment	комментарий, отзыв
suicide attempts	попытки суицида
appreciate	оценивать
exacerbate	раздражать, обострять (боль)
siblings	единокровная сестра (брат)
the inquiry	расследование, запрос

 

 

 

 

Taking a Medical History

 

Admitting a patient to hospital includes two major steps: on the one hand the doctor has to take the patient`s medical history, where he is given the opportunity to report his complaints and to answer the doctor`s questions.

 The medical history or (medical) case history of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan. The treatment plan may then include further investigations to clarify the diagnosis.

 

 

 

Case history structure

 

 

1. Introduction

 

It should consist of a few clear and concise opening statements, which typically include information on:

Name (pseudonym)

Age

Marital status

Occupation

Central problem

 

2. History of Presenting Complaint

 

 Comment on the impact of the illness on the patient's life

 Consider work, social relations and self-care.

Note details of previous treatment

 Include information on who administered management (when and where), what the treatment was (and preferably the dose and duration of treatment), and the patient's responses to treatment.

Integrate current problem and psychiatric issues

 

3. Past Psychiatric History

 

The following points are relevant in this section:

details of previous episodes of illness

previous psychiatric admissions/treatment

outpatient/community treatment

suicide attempts/drug and alcohol abuse

 

4. Past Medical History

 

In this section of the report, you need to show that you a) understand the relationship between medical conditions and psychiatric symptoms, and b) can appreciate the complexity of medical problems that might be exacerbated by psychiatric conditions.

 

Record medications. Demonstrate an understanding of the significance of drug therapy on psychological function and, if appropriate, focus on medications taken by the patient that may influence the patient's psychological function.

 

5. Family History

 

Include details of:

Parents and siblings, nature of the relationships between family members

Any family tensions and stresses and family models of coping

Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts)

 

 

6. Personal History/Development

 

Use the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section:

Early development

Childhood

School

Adolescence

Occupation

Menstrual history

Sexual history

Marital history

Children

Social network

Habits

Leisure

 

 

7. Review of Systems (ROS)

 

In this portion of the history, all organ systems not already discussed during the interview are systematically reviewed. ROS is a final methodical inquiry, prior to physical examination. It provides a thorough search for further, as yet unestablished, disease processes in the patient.

Following are the topics to be reviewed for each organ system:

7.1. Constitutional

Any history of recent weight change

Any history of anorexia (loss of appetite), weakness, fatigue, fever, chills, insomnia, irritability or night sweats

7.2. Skin

Any history of skin rashes—acute or chronic, is it unilateral or bilateral

Any history of allergic skin rashes

 Any itching of the skin

Any history of unhealed lesions (probably due to: diabetes; poor diet; steroids and other causes of decreased immunity, especially AIDS)

Any history of bruising, bleeding

7.3. Head

Any history of headaches

Loss of consciousness (may be due to cardiovascular, neurologic causes, anxiety, metabolic causes, etc.)

History of seizures. Are they general (with or without loss of consciousness) or focal? Are there any motor movements?

Is there any history of head injury?

7.4. Eyes

Check for vision, history of glaucoma ( could cause pain in the eyes), redness, irritation, halos (seeing a white ring around a light source), blurred vision

 Any irritation of the eyes, excessive tearing, which can be associated with frequent allergic symptoms?

7.5. Ears

Any recent change in hearing

Any pain in the ears or ringing in the ears (tinnitus)? discharge?

 Any history of vertigo (dizziness)?

7.6. Lymph Glands

Any history of lymph glandular enlargement in the neck or elsewhere? Are they tender/painless? How were they first noticed?

Are they freely mobile or are they adherent to the underlying tissues?

7.7. Respiratory System

History of frequent sinus infections

Postnasal drip

Nosebleeds

Cough (with/without expectoration)

Color of sputum, when present

History of sore throat

History of shortness of breath on exertion or at rest

Any history of wheezing (may be due to asthma, allergies, etc.)

Hemoptysis (blood in the sputum): may be due to dental causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral stenosis or CHF (congestive heart failure). Determine if it is a blood-tinged sputum or there is frank blood in the sputum.

Any history of bronchitis, asthma, pneumonia, emphysema, etc.

7.8. Cardiovascular System

History of chest pain or discomfort

History of palpitations: were the palpitations associated with syncope (loss of consciousness)?

History of either hypertension or hypotension

Does the patient experience any paroxysmal nocturnal dyspnea (shortness of breath during sleep, in the middle of the night)? Is there any SOB in relation to exercise or exertion?

Any history of orthopnea (shortness of breath when lying flat in bed)? Does the patient use more than one pillow to sleep? Has this always been the case, or has the patient recently started using more pillows?

History of edema (site of edema—legs, face, etc.)

Any history of leg pains, cramps? Are they relieved by rest (this is suggestive of intermittent claudication) or is it unremitting? (this is muscular)

Any history of murmur(s), rheumatic fever, varicose veins?

Any history of hypercholesterolemia, gout, excessive smoking, i.e., conditions which can lead to or worsen heart disease

7.9. Gastrointestinal System

History of bleeding gums, oral ulcers or sores

History of dysphagia (can the patient point out and describe where the difficulty swallowing exists?)

History of heartburn, indigestion, bloating, belching, flatulence

History of nausea: is it related to food? Is it one of the many symptoms due to GI (gastrointestinal) disease?

Vomiting: is there any associated weight loss, psychosocial factors, or are medications causing it?

Hematemesis (vomiting blood). Ask for associated ulcer history, food intolerance, abdominal pain or discomfort

Jaundice: is there a viral cause, gallstones, associated family history?

History of diarrhea/constipation

Any change in color of stools

7.10. Genitourinary

History of polyuria (excessive urination) due to diabetes, renal disease, unknown cause, etc. Check if this has been a recent change

History of nocturia (getting up at night to go to the bathroom). Is this a recent change?

 History of dysuria (painful urination). If it is because of urinary tract infection (UTI), the patient will experience frequency and urgency in addition to dysuria. STD will also be associated with similar symptoms (was treatment for STD completed?)

History of renal stones, pain in the loins, frequent UTIs

7.11. Menstrual History

Date of LMP (last menstrual period). Always precede this question by informing the patient that she has to get x-rays done, so you need to know if she is pregnant; thus, the need to know her LMP

Any history of menorrhagia (heavy periods)

History of use of birth control pills

7.12. Musculoskeletal System

History of joint pains—determine location: is it acute or chronic? Unilateral or bilateral? More in the morning or evening? Are there associated systemic symptoms?

Any history of rheumatoid arthritis, osteoarthritis, gout, etc.

7.13. Endocrine System

History of symptoms due to diabetes, i.e., polyuria, polydypsia, polyphagia1, weight change

History of thyroid symptoms: heat/cold intolerance, increased/decreased heart rate, goiter, etc.

 History of adrenal symptoms: weight change, easy bruising, hypertension, etc.

1 Polyuria — excessive urination; polydypsia — excessive thirst; polyphagia — excessive appetite

7.14. Nervous System

History of stroke, CVA, TIA

History of muscle weakness, involuntary movements: they may be tremors, seizures, or anxiety, etc.

History of sensory loss of any kind: anesthesia, paresthesias, or hyperesthesias2

Is there any change in memory, especially recent change.

2 Anesthesia → no sensation; paresthesia → altered sensation, commonly a pins and needles sensation; hyperesthesia → increased sensation

 

8. Concluding History

 

It is important at this point to collect the relevant data about the patient (all positive findings) and construct a logical framework of the case.

 

 

EXERCISE 1.Найдите в тексте эквиваленты следующих слов и словосочетаний:

Поступление в больницу; информация, полученная врачом; с целью получения информации; обеспечение медицинского ухода; сообщенные пациентом; формулировка плана лечения; поставит диагноз; самолечение; предыдущее лечение; злоупотребление алкоголем; оценка сложности медицинских проблем.

 

EXERCISE  2. Ответьте на вопросы по тексту:

1.     What is the medical history?

2.     How  do medical histories vary?

3.     What does the introduction include?

4.     What integrate History of Presenting Complaint ?

5.     What is a final methodical inquiry?

EXERCISE  3. Дополните следующие предложения:

1.     The medical history of a patient is information … by a physician by asking specific questions.

2.     The medically relevant complaints are referred to as symptoms, which are ascertained by direct … on the part of medical personnel.

3.     … … … would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc.

4.     The treatment plan may then include further investigations to clarify … .

5.     History of Presenting Complaint Include information on who administered … , what the treatment was, and the patient's responses to treatment.

6.     Past Medical History demonstrates an understanding of … of drug therapy on psychological function and, if appropriate

7.      Family History includes details of nature of the relationships between family … .

8.     …  provides a thorough search for further, as yet unestablished, disease processes in the patient.

9.      

 

EXERCISE 4.Прочитайте диалог. Запишите вопросы доктора.

 

 

EXERCISE 5.Найдите предложения, в которых сказуемое стоит в страдательном залоге и переведите их.

 

EXERCISE 6. Составьте ментальную карту «Структура истории болезни».

 

EXERCISE 7. Изучите истории болезни (см. Приложение 2). Ответьте на вопросы.

 

 

 

Заключение

 

Учебное пособие для студентов предназначено для проведения вводного занятия по теме «Case History». Оно основано на материалах учебников и сайтов Великобритании и США и  включает в себя интерактивные упражнения для работы с лексикой и текстами, презентацию , обучающую программу

Занятие рассчитано на студентов с  разным уровнем знаний, умением работать в парах и малых группах в интерактивном формате  и пользоваться Интернет-ресурсами. Задания составлены с учетом индивидуальных особенностей студентов, т.е. на основе дифференцированного, личностно-ориентированного подхода и соответствуют требованиям ФГОС СПО для специальностей 060101  Лечебное дело,  060501 Сестринское  дело.

 

 

 

 

 

 

 

Библиографический список

1.     A c k e r m a n, Terrence & Carson S t r o n g. A Casebook of medical ethics. New York, Oxford: Oxford University Press, 1989.

2.     G l e n n d i n n i n g/ H o l m s t r ö m. English in Medicine, course book. Klett, 1998.

3.     G r o s s, Peter. Medical English. Stuttgart: Thieme, 2000.

4.     L o n g m o r e / W i l k i n s o n / T ö r ö k. Oxford Handbook of Clinical Medicine. Fifth

5.     Edition. Oxford: Oxford University Press, 2001.

6.     P a r k i n s o n, Joy. A Manual of English for the Overseas Doctor. Edinburgh: Churchill Livingstone, 1998.

7.     S a n d l e r, P.L. Medically speaking. English for the medical profession. BBC English by Radio & Television, 1982.

8.     T h i e m e L e x i m e d Pocket Dictionary of Medicine – English-German/ German-English. Stuttgart: Thieme Verlag, 2002.

9.     D o r l a n d`s Illustrated Medical Dictionary English-English, pocket. W.B. Saunders Co., 2000.

10. S t e d m a n`s Medical Dictionary, Student Value Pack (Book with CD-ROM) – English-English. Williams & Wilkins, 2000.

11. http://nswhealth.moodle.com.au/DOH/DETECT/content/02_scenario_breathe/scenario_breathe_02.htm

 

 

 

Приложение 1

 

 

1) Introducing oneself/ Specific Greetings

 

- Good morning, Mr. Bradford, my name is Anne Golding. I am a medical student (you may say: “student doctor”) doing a clerkship on this ward.1 I heard about the problems you have with your

heart. Would you mind if I examined your chest again?

 

- Hello, Mrs. Rutherford, my name is Robert Weiss. I am a Seniormedical student. The doctor will be here shortly, may I ask you a few questions meanwhile?

 

- Good morning Mr. Hewling, it’s nice to see you. Please come in and have a seat. What has brought you along today? What seems to be your problem? Could you describe it for me, please?

 

- Good afternoon, Mrs. Johnson. I see from your chart that you came to us complaining of pain in the stomach. Is there anything else you want to tell me before we look at your stomach more

closely?

 

- Hello, Mr. McLeod. We met last week, didn`t we? Well, I have been going over some of the results of your tests with a colleague of mine and we are pleased with your progress.

 

- Good morning, you are Christopher, aren`t you? I heard a lot of nice things about you. But your Mum told me you have a tummy ache. Is that right? Now, Chris, I want you to tell me all about it.

 

- Hello, Mr. Smith. Could you please roll up your sleeve and let me take your blood pressure?

 

- Hello again, Mr. Wright, I have come to take a blood sample. Could you please roll up your sleeve? It might be a bit uncomfortable. It is like a sharp scratch.

 

GATHERING INFORMATION

 

I) Personal Data: Time of assessment (!)

Name (surname/ Christian name)

Age (DOB)

Sex Occupation Marital Status2

 

II) c/o (= complaining of = Chief Complaint)

Try to find a short phrase describing the patient`s problem. Do not give a diagnosis!

 

III) HPC (= History of the presenting complaint)

When did the problem begin?

How long has it been bothering you? DURATION

How did it start? (gradually/ suddenly)MODE OF ONSET

How often does it come on? FREQUENCY

Have you ever had anything like this before?

What brings it on?

Does anything make it better/ worse?

Does it occur in certain positions? RELIEVING/ AGGRAVATING FACTORS

Does anything go along with it? E.g. Are you feeling sick, are you sweating? ASSOCIATED SYMPTOMS

Where does it hurt?

Is it a constant pain/ does it come and go?

Does it interfere with your daily activities? PAIN

Questions

 

What is the pain like?

 Is it ...biting?

...stabbing?

...pinlike?

...sharp?

...pinching?

...cramping?

...throbbing?

...blistering?

...burning?

...sore?

...wrenching?

...stinging?

...numb?

...gnawing?

...dull?

...excruciating?

 

IV) PMH (= Past medical history)

Apart from your present complaint how is your general health?

What previous illnesses have you had?

Do you remember any childhood diseases?

Have you ever been seriously ill?

Have you ever been hospitalised/ had an operation?

What about broken bones?

Do you suffer from any chronic disease?

V) Med (= Medications)

Are you taking any medicines/ tablets?

Are you on the pill?

Do you need sleeping tablets?

 

VI) All (= Allergies)

Have any medicines ever upset you?

Are you allergic to penicillin, contrast agents,

foods or anything else?

Have you been immunised against tetanus/ polio/ influenza/ hepatitis A, B/ pertussis /

diphtheria?

 

VII) FH, SH (= Family history, social history)

Does anyone in your immediate family suffer from a chronic disease?

Are your parents (other members of the family) alive and well?

Ask for the circumstances of the patient’s accommodation, education, job, leisure interests.

Ask whether he is married/ has children.

 

VIII) Alcohol, tobacco, recreational drugs

Do you smoke?

How often do you drink alcohol?

Do you take any kind of drugs?

Приложение 2

Case Histories

Case History I: A Patient with Abdominal Pain

 

The patient was a 33 year old salesman, who came to the emergency room because of

“bellyache”. He had been in good health until the previous evening, when he went to a party.

There he had several bottles of beer. He sampled the chili and ate custard. About an hour after

the meal of chili he suddenly felt an excruciating abdominal pain, accompanied by nausea. The pain appeared to arise from the area under his belly button. He broke out in a sweat and had to lie

down. After about 5 min the pain was completely gone and he felt fine again. He even engaged in a match of volleyball later that evening. When playing in the front row close to the net he jumped and stretched for the ball. Immediately thereafter, the abdominal pain recurred. Since then he had been restless; his pain never let up completely. In the last 2h he had not had any desire for food; he had been nauseated 6 times and vomited 4 times. Each attack was accompanied by worsening of his sharp abdominal pains. The pain was now located in the left abdomen and under the umbilicus. It worsened after coughing or sneezing. The patient`s last bowel movement had been 2 days ago.

 

Questions

What diagnostic possibilities would you consider at this point and what would you do to work them up?

 

Case History II: A policeman with chest pain

 

A 47 year-old policeman was taken to the emergency room because of substernal chest

pains. The attack began 45 min before admission, while he was on the phone. The

pain radiated to his back and did not budge until admission. It was accompanied by

shortness of breath, dizziness, and nausea; he vomited once.

The patient`s wife reported that he had had a similar attack 2 hours before while lifting a

case of beer. Furthermore, on the morning of this day the patient had had a fainting spell, followed by palpitations and restlessness. The patient had a past medical

history of high blood pressure. Family history: his father died suddenly at 51 years of age.

 

Question

What possible diagnoses do you think of and what would you doto confirm them at this point?

 

Case History III: A Dying Adolescent

 

Lucy was fifteen years old and one of four children. Her mother was a registered

nurse and her father a machine operator in a local factory. She was admitted to

the hospital with a two- day history of nausea, vomiting, and persistent

abdominal pain. A gastrointestinal X-ray series and a gastroscopy confirmed an obstruction in the initial portion of the small intestine. Exploratory surgery revealed a large tumor which appeared to arise in the pancreas and had penetrated the intestine. The tumor

had also spread to regional lymph nodes, the liver, and one kidney. Pathological examination of specimens removed at surgery confirmed the diagnosis of carcinoma of the pancreas.

Within two weeks after surgery, an intensive six-week course of chemotherapy with three drugs was undertaken. After this course, there was a marked regression of the tumor in the

pancreas. All other tumor had disappeared entirely. A second six week cycle of treatment was initiated, but by the end of this course, X-ray and physical examination revealed that the tumor

was again growing rapidly and metastases were appearing. Throughout the early period of treatment, the patient was very interested in how treatment was going. She was also very cooperative through a series of difficult procedures. She often expressed to the nurses a concern about the impact of her illness on her parents and siblings. However, she was also usually very

reserved in interchanges with hospital staff members, and she never initiated discussions of her condition. In addition, the patient’s mother was very protective of the child and, as the

health professional in the family, assumed the decision-making role. At all times, the family, particularly the mother and the patient, appeared to be very close-knit and loving.

After failure of the first regimen of chemotherapy, a different anticancer drug therapy was attempted. However, two weeks later the patient was admitted to the hospital with acute

gastrointestinal bleeding. Endoscopic examination revealed bleeding in three sites in the initial portion of the small intestine, suggesting that the tumor was eroding blood vessels. Over the

next three days the gastric bleeding continued, and the patient occasionally vomited large clots of blood. The patient’s blood volume was kept stable by daily administration of red cells.

Generalized abdominal pain was controlled with a moderate dose

of intravenous morphine. The physician visited the room each day to discuss the patient’s

condition with the family. These discussions were held at the bedside and were focused on day-to-day changes in her condition.

The patient remained awake and alert during this period, but she was always very quiet. She did not ask whether she might soon die, and the issue was not raised with her. On a couple of occasions, the mother expressed a concern outside the room about conducting discussions of her daily condition in the patient’s presence. But in private conversations with the nurse

practitioner, the child said that she was aware that she might not become well enough to return home, although she would like to do so. She expressed further concern about her parents. She also said she believed God would make her well again. One week after hospitalization the patient’s prognosis was discussed privately with her mother. The mother inquired about

the availability of other chemotherapeutic agents. She was told that no other drugs with established dosages or effectiveness were available for the treatment of pancreatic cancer, although some experimental agents might be tried. It was emphasized that the

chance for regression of the tumor was slight, and at best life could be prolonged only briefly. At any rate, chemotherapy could not be administered until the bleeding abated and the physician

said that it would probably not be possible to stop the bleeding. He suggested that it might be appropriate not to send the patient to the intensive care unit should her condition worsen; doing so might subject her to needless discomfort. He also raised the possibility of discontinuing the blood transfusions. The mother was unprepared to accept either suggestion, asked that the

transfusions be continued at their present rate, and held out the hope that additional chemotherapy might be possible. Finally, the question raised about involving the patient in the decision-making process. But the mother also firmly resisted this possibility, indicating that she did not wish to intensify the anxiety and

suffering of her daughter.

 

Question

Point out the physician’s dilemma and try to evaluate the options he has.

 

 

Приложение 3