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
11430-83185003845560-83185
00

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:
What is the medical history?
How do medical histories vary?
What does the introduction include?
What integrate History of Presenting Complaint ?What is a final methodical inquiry?
EXERCISE 3. Дополните следующие предложения:
The medical history of a patient is information … by a physician by asking specific questions.
The medically relevant complaints are referred to as symptoms, which are ascertained by direct … on the part of medical personnel.
… … … would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc.
The treatment plan may then include further investigations to clarify … .History of Presenting Complaint Include information on who administered … , what the treatment was, and the patient's responses to treatment.
Past Medical History demonstrates an understanding of … of drug therapy on psychological function and, if appropriate
Family History includes details of nature of the relationships between family … .… provides a thorough search for further, as yet unestablished, disease processes in the patient.
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
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.
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.
G r o s s, Peter. Medical English. Stuttgart: Thieme, 2000.
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
Edition. Oxford: Oxford University Press, 2001.
P a r k i n s o n, Joy. A Manual of English for the Overseas Doctor. Edinburgh: Churchill Livingstone, 1998.
S a n d l e r, P.L. Medically speaking. English for the medical profession. BBC English by Radio & Television, 1982.
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.
D o r l a n d`s Illustrated Medical Dictionary English-English, pocket. W.B. Saunders Co., 2000.
S t e d m a n`s Medical Dictionary, Student Value Pack (Book with CD-ROM) – English-English. Williams & Wilkins, 2000.
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 moreclosely?
- 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