Case-taking

Case-takingThe competent physician, before he attempts to give medicine to his patients, makes himself acquainted not only with the diseases which he wishes to cure, but also with the habits, and constitution of the sick man. (Cicero, De Oratore II).At various times in the initial clinical review, you have the chance to get acquainted with a stranger who is seeking your medical help. Be as inquisitive about this unfamiliar person as you are about bodily complaints. Know your patients, when patients mention important people in their lives or refer to their work or other major activities, inquire further. Give reign to your curiosity. In getting to know the person with whom you are talking, you foster a mutually satisfying relationship and you acquire data that are important for diagnosis and management.

The more we know about our patients, the better we can care for them.

I. Greeting an introducing oneselfDoctor: -Good morning, Mr. Petrov. Come and sit down. I am Dr. Myazin Roman Gennadievitch -Good afternoon, Mrs. Ivanova. Take a seat, please. I am Dr. Gonzhal Olga Alexandrovna -Good morning, Mr. Sidorov. Do sit down. I am Dr. Zamyatina Inna Igorevna

II. General information/Personal detailsDoctor: I would like to know a little more about you-your background, your work, your family. Let me ask you some specific questions. Now, I am going to ask you a series of routine questions about your body. -Whats your name?

-How old are you?

-At what age did you start working?

-Whats your job/occupation?

-How long have you been with that company?

-Why have you changed your work?

-Are you on nightshift (day-shift)? Are you doing a rotational cycle? Are you a shift-worker?

-Where do you live?-Are you married /single/divorced? Have you been married previously?- Whats your marital status?

-Do you smoke?

-How many do you smoke each day?

-(What) Do you drink? Beer, wine, brandy, whisky, cognac, vodka, champagne, rum, liqueur, moonshine, spirits/alcohol?

-Have you ever been in hospital, if yes, for what reason?

-Do you have to do a lot of overwork?

-Do you do anything for exercise?

-How do you keep physically fit?-Are you addicted to drink?-Are you allergic to any drugs?-Have you ever had diabetes mellitus?

-Are you retired? Are you on a pension?

-Have you ever been in the military?

-Do (did) you wear glasses/contact lenses?III. Immunizations-Did you get immunizations as a child?

-Measles, mumps, rubella? Polio? Tetanus and diptheria?

-Have you had a tetanus booster in the past 10 year?

-Have you had an annual flue shot?

-Have you been vaccinated for the flue?

-Have you had the pheumonia vaccine?

-Have you gotten Hepatitis B vaccine?

IV. Periodic health examination-Do you have a regular doctor?-Who is your district (your own) doctor?

-Have you consulted your own doctor about your illness?

-Have you been treated in a TB hospital?

-Are you registered in an oncological/ dispensary?

-Are you being (were you) followed up by a neuropathologist/psychiatrist/TB doctor?

-When did you last undergo prophylactic medical examination?

-How often do you get routine medical checkups?

-When was your last dental exam?

-Do you get your eyes checked?

-Have you been examined for glaucoma?

-Have you had your cholesterol measured?

-Do you check your breasts for lumps?

-When did you have your breasts checked?

-Have you gotten breast X-rays (mammograms)?

-Have you had your stools checked for signs of bleeding?V. Previous health/Past health

-How have you been keeping up now?

-Have you ever been admitted to hospital?

-Have you ever been hospitalized? What for? When? Where?

-Have you ever had (headaches) before?

-Has there been any change in your health since your last visit?

-Have you ever had any (minor/major) surgery or operations? What for? When? Where?-Have you ever been involved in a serious accident?

-Did you break any bones?

-Did you have a serious head injury?

-Have you ever required a transfusion?

-Have you ever been bedridden?

-Have you ever been confined to bed?

-How long have you been confined to wheel chair?VI. Pregnancies-Have you ever been pregnant? How many times?-Any miscarriages or abortions?

-Any problems or complications with the pregnancies?

-Did you take any hormones during the pregnancy?

-How were the births?

VII. Family history

-Are your parents alive and well?

-What did he/she die of? What caused there death? At what age?-How old was he/she?

-Does anyone else in your family suffer from this problem?

-Is there any history of cancer, stomach disorders, alcoholism in your family?

-Is there anybody in your family who has similar complaints?

- Has there been anyone in your family who is (was) insane or committed suicide?

-Do you have children? Are your children well? Do you see them?-Who are the important people in your life? Tell me about your family.

VIII. Asking about systems

-Do you have any trouble with (passing water)?

-Any trouble with your chest?

-Whats your appetite (been) like?

-Have you noticed any (blood in your stools)?

-Do you ever suffer from constipation (headaches)?

-Do (bright light) bother you?

-Do you have (a cough)? Do you ever cough up blood?-Do you bring up sputum? How much? What color? How often?

-Do you have trouble sleeping/falling asleep/staying asleep?-Do you have any problems with your skin (ulcers or sores that dont heal)?

-Have you been knocked unconscious?

-Do you usually lose consciousness? For how long?

-Do you ever pass out or feel like you are about to pass out?

- Do you have any problems with enlarged glands or nodules?

-Any problems with easy bruising or bleeding?

-How for can you walk on level ground without stopping?

-Do you have to stop to rest and catch your breath?

-Can you climb two flights of stairs quickly?

-Have you noticed any tenderness in your breasts?

-Do you have any buzzing or ringing in your ears?

IX. Obtaining a Detailed Review of SymptomsInvitation to describe symptoms:-Well now, what seems to be the problem?

-Well, how can I help you?

-Would you please tell me how I can help you?

-Your GP (general practitioner) says youve been having trouble with your right shoulder. Tell me about it.

-My colleague Dr. Sanders says your left knee has been aching lately. Is that correct?

-Whats brought you along today?

-What can I do for you?

-What seems to be the problem?

-Well, whats the trouble?

-Have you had any nose bleeding?

-Have you lost weight lately?

Asking about duration

-How long have they/has it been bothering you?

-How long have you had them/it?

-When did they/it start?

-Did it start all of a sudden?

-What do you think the reason is?

-Do you think there is any explanation?

X. Preparing the patient

-I am just going to test your reflexes

-Id just like to examine your throat/abdomen-Now I am going to tap your knee

-Ill just check your blood pressure

Commenting/reassuring

-Im checking your (heart) now

-Thats fine

-OK, weve finished now

Explaining purpose of the investigations

-Im going to (take a sample of your bone marrow) to find out whats causing your anaemia)

Reassuring

-It wont take long

-It wont be sore

-Ill be as quick as I can

-It will be tickly, but it wont hurt.

-It wont be painful

-Dont worry, nothing serious.

Warning-You may feel (a bit uncomfortable) -You might find it uncomfortable, but it wont take long.

-Youll feel (a jab)

XI. Instructions for undressing:-Would you mind taking off all your clothes except your underwear? (man)

-Would you please take off all your clothes except your underwear and bra? (woman)

-You should take off your underwear too.

-Lie on the couch and cover yourself with the blanket.

-Lie on the stretcher with your shoes and socks off, please.

-Roll your sleeve up, please, I am going to examine your elbow. Roll up your shirt.-Strip off all your top things. Strip you trousers down.-Please, remove your clothes.

-Would you (strip to the waist), please?

XII. Instructions and general commands:-Lie down, please (supine position)

-Lie on your tummy, please (prone position)

-Please turn over and lie on your back again

-Roll over onto your left side and bend your knees up.

-Roll over onto your right/left side, tummy.-Sit up and bend your knees.-Keep your knees bent/firm.

-Keep your feet together.

-Lean forward.

-Get off the stretcher.

-Stand up, please.-Lie on your back with your knees bent and your legs wide apart.

-Lie on your tummy and relax.

-Let yourself go loose.

-Open your mouth, please.

-Stick out your tongue.

-Swallow, please.

-Give a cough.

-Raise your arm/leg. Raise it more.-Take a deep breath. Breathe normally, in and out through your mouth.

-Grasp my hand.

-Now try and turn both shoulders round to the right. Go back to the center again. Try the same thing and go round to the left side.

-Bear down as if you were to have a bowel movement (Valsalvas maneuver).

-Walk across the room, please. I would like to see you walking

-Get off the couch and stand up. I would like to see you standing. Put your hands by your side.-Could you bend down as far as you can with your knees straight and stop when youve had enough.

-I would like you to slide your right hand down the right side your thigh. See how far you can go.-Now, do the same on the opposite side.

-Now, just come back to standing position.

-Let your legs completely relaxed-Let me hold your right arm. Let it go quite relaxed. Try not to tighten up.

-Let me have your wrist. Let it go quite floppy.

-Put your hands on your hips, please

-Lean backwards, please.

-Would you like to sit up, Ill take your blood pressure.

-Can you (put your hands on your hips)?

-Could you bend down and touch your toes?

-Now I just want to see you (walking)

-Lift it up as far as you can go, will you?

-Let me see you (standing)?

-Keep still.

-Watch my finger.

-Sit up straight.

-Sit/Stand still.

-Look up/down.

-Extend you arm/leg.

XIII. Asking about location

-(Where) does it hurt?

-(Where) is it sore?

-Show me where the problem is?

-Which part of your (head) is affected?

-Does it stay in one place or does it go anywhere else?

-Does it radiate or move?

-Can you show me by putting your finger on the sore spot?

XIV. Asking about type of pain and severity of problem

-Whats the pain like?

-What kind of pain is it?

-Can you describe the pain?

-Is it bad enough to (wake you up)?

-Does it affect your work?

-Is it continuous or does it come and go?

-How long does it last?

XV. Aggravating (precipitating) and alleviating factors

-Is there anything that makes it better/worse?

-Does anything make it better/worse?

-What do you do when it happens?

-What do you think is causing this symptom?

-What seems to bring it on? What brings it on?-Under what circumstances do you get this problem?

-What were you doing when it first began?

-Does it come on at any particular time?

-Is it related to eating (before, during, or after meals; size of meals; type of food; swallowing)?

-Is it related to coughing or deep breathing?

-Is it related to body position (lying down on your back, stomach, or side; sitting up, standing or changing position (standing up, lying down, and turning over in bed)?

-Is it related to movement of separate parts of the body (arm, leg, neck) or to physical activity (walking, climbing stairs, exercise, strenuous work)?-How soon after you eat (change position) do you feel better /worse?

-Have you treated yourself with diet (rest, activity, prescription medication or over-the-counter preparations)? Has the treatment helped?

XVI. Asking about medication

-Do you use any medicines or drugs?

-What are their names? What are they for?

-How long have you been taking them?

-Do you know their size and strength?

-When do you take this medicine?

-How often do you miss a dose?

-Have you taken anything for (headaches)?

-Did (the tablets) help?

-Did you feel an instant relieve when taking those drugs?

-Have the medication helped?

-Have you had side effects?

-Do you take anything for sleep or your bowels?

-Do you take vitamins or minerals?

-Do you take birth control pills?

-Are you using any alternative or complementary therapies- treatments not traditionally prescribed by physicians such as special vitamins or minerals, herbal remedies, diets?

-Do you have any allergies?

-What kind of allergic reaction did you have?

-Have you had any allergic or adverse reactions to medicines?

Medical cost

-Do you have insurance for your medical bills?

-How will you handle the expense?

-How will you handle the loss of income (from a new disability)?

XVII. Asking about other symptoms

-Apart from your (headaches) are there any other problems?

To rephrase if the patient does not understand, try another way of expressing the same function, for example:

-What causes this?

-What brought this on?

-Was it something you tried to lift?

-What did you do when this happened?

XVIII. Diet-Are you on a special diet?-Have you tried to lose weight? How?

-Do you do anything to control your weight?

-Do you try to avoid cholesterol or saturated fats?

-How often do you eat red meat?

-How about poultry and fish?

-What about dairy products, such as eggs, butter, and whole milk?

-Fried foods?

-Have you had your cholesterol checked?

-Do you limit your intake of salt?

-Do you usually salt your food?

-What do you usually eat? For breakfast, lunch, dinner, snacks?

-Where do you eat these meals?

-Who does the cooking/the shopping?

-Do you take caffeine-containing coffee or tea? Caffeinated tonic or soda? How much?

-What about sources of fiber in your diet?

-Do you take calcium supplement?

XIX. Treatment

Advising

-I advise you to give up smoking

-Youll have to cut down on fatty foods

-You must rest

-You should sleep on a hard mattress

-If you get up, all your weigh will press down on the disc

-Dont sit up to eat

-You should take this medicine twice a day before/after meals/food

-Give up smoking.

- The best thing would be to have another scan done.

-You should have your eyes tested.

-You should get your tonsils removed.

-Do as I have advised you.

-You should consult a dermatologist

-Youd better go on a diet.

-If I were you, I would cut down on the hours you workExpressing regret

-I am afraid that (the operation has not been successful)

-I am sorry to have to tell you that (your relative has little chance of recovery)

XX. Instructions to get dressed:

-You can get dressed now. -Please get dressed.

-You can get your clothes on now.

XXI. Treatment/No treatment:

-There is nothing wrong with you.

-This will clear up on its own.

-There doesnt seem to be anything wrong with your shoulder. -I will arrange for you to go to hospital for further/more tests.- As home treatment has not been successful, you will be hospitalized to avoid any possible complications.-I will refer you to the X-ray room (for physiotherapy treatment, for exercise therapy).

-I will give you a referral to a heart specialist.

- I will put you on a sick leave. I will extend your sick leave.- Are you willing to be admitted to hospital?

-You need urgent admission to a hospital.

-Ill admit you to the hospital as soon as we have a vacant bed (if you get worse)

Common phrases used by patients, and their meaningWhen a patient says.The doctor understands

I cant breath or Im stuffed or my chest is tightDyspnea

Everything is spinningVertigo

It itches mePruritus

It stings when I peeDysuria

I cant eat or Ive lost my appetiteAnorexia

I dont feel like doing anythingAsthenia

HeadacheCephalgia

My nose is drippingRhinorrhea

Ive vaginal drippingLeukorrhea

Im having my periodMenstruation

My hair is falling outAlopecia

I cant remember a thingAmnesia

My skin looks yellowJaundice

I cant move a limbParalysis

I cant see anythingBlindness

Bad breathHalitosis

Ive a cavityCaries

It hurts when I swallow. I cant swallowOdynophagia. Dysphagia

I spit out phlegm (when I cough)Sputum

Cough up bloodHemoptysis

My stomach is burningEpigastralgia

I wheezeWheeze

Ive prickly sensation. I feel pins and needlesParesthesia

I feel like I am going to throw upNausea

Im always running to the bathroomPolyuria

I always feel like I have to peeTenesmus

Im always thirsty or Im always dryPolydipsia

I have a rashErythema

My ankle is swollenEdema

I have a burning sensationPyrosis

My skin looks blueCyanotic

My chest feels constrictedThoracic pain

My mouth is always wateringSialorrhea

I cant breath when I lie downOrthpnea

My stool is blackMelena

My stool is whiteAcholia

My urine is darkCholuria

I cant sleepInsomnia

I cant go to the bathroomAnuria

BruiseHematoma

ToothacheOdontalgia

Common Symptoms AreasPain

Questions:-Which part of your (head, arm, face, chest) is affected?-Where does it hurt?

-Where is it sore?

-Can you describe the pain?

-What is the pain like? What does it look like?-Is your pain severe?

-What kind of pain is yours?

-Is there anything that makes it better?

-Does anything make it worse?

-Does anything relieve the pain?

-What effect does food have?

-Does lying down help the pain?

-Has the pain gone?

-Does the pain persist?

-What relieves the pain?

-What is the pain relieved by? By rest, drugs, particular food, fasting?

-Is this the first occurrence of pain?

-Do you feel pain when bending/walking?

-Does it disrupt your sleep?

Describing the characteristics of pain:A dull sort of painA feeling of pressure

Very sore, like a knife

A burning pain

A gnawing kind of pain

A sharp, stabbing/piercing pain

Raw

The pains gone

A sharp pain

I ache all over

I am in a lot of pain

Ive got a very sore arm.

I have a sore back

Fasting pain

Generalized pain

Tightening/Pressing pain

Sudden pain

Marked/Pronounced pain

Crampy/ cramp-like/cramping pain

Long-standing pain Intermittent pain

Night/Noctural pain

Constant/Persistent/Continuous pain

Girdle pain

Throbbing pain

Severe pain of sudden onset

Slight pain

Dull pain

Pains of unknown origin

Pain on defecation/urination

Abdominal pain

Rest pain

Increased pain/Exacerbation of pain

Tenderness

FeverI think I have a temperatureI think Im running a fever

High/bad fever

When do you have the highest temperature?

Do you shiver?

Were you cold last night?

When does your temperature come down?

Do you cough/sneeze?

There is a new rise in temperature.

Something should be taken to keep the fever down/to drop the temperature

Sickness

I feel sick/queasy

I think I am going to vomit

I think I am going to throw everything up

I think I am going to bring up

I feel dizzy

Hes feeling giddy

She is feeling faint

Weakness

-I feel weak

-I am tired

-I am not in the mood for

-Are you hungry?

-Ive lost weight

-Do you still feel very weak?SleepDo you feel sleepy?

Do you sleep deeply?

I wake up too early.

I have trouble sleeping lately.

Do you snore?

Vision

-I cant see properly

-Everything is fuzzy

-I cant see with my left/right eye.

-My eye is itchy.-My eye is stinging/ burning

-What have you done with you eye?

-Whats happened to your eye?

Skin

Rash

Lump

Pruritus

Itch

Scar

Bruising

Spots

Blackhead

Blister

Moles

Swelling

Puffiness

Tingle

Gastrointestinal System

Abdominal pain

Nausea

Vomitus/Vomit

Diarrhea

Constipation

Flatulence

A coated tongue

Abdomen soft, non-tender

No nausea or vomiting

No abnormalities in stool patterns or characteristics

No change in dietary patterns

Bowel sounds present

To take food piecemeal