- •Case history/medical documentation
- •I.Basic Parts of Case History
- •II.Taking Medical History
- •III.Medical Examination
- •IV.Abbreviations Used in Clinical Notes
- •V.Medical Kits
- •VI.Reading Medicine Labels
- •VII.Practising Medicine – Case History
- •VIII.Practising Medicine: Case Report
- •IX.Medical Record
- •X.Problem Solving
III.Medical Examination
Choose the proper set of questions (from part B) for the following points (from part A):
Part A:
Identification
CC (Chief Complaints)
HPI (History of Present Illness)
PH (Past History)
FH (Family History)
√ (Diagnosis)
Part B (I):
1) - What is the problem?
- I have difficulty in breathing, especially at night. You know, it constantly keeps me awake. I quite often have episodes of wheezing. The shortness of breath comes more and more frequently.
2) - Are you married?
- Yes.
- Have you got any children?
- No.
- Are your parents alive?
- Yes. They are healthy.
- And what about your grandparents?
- They died of heart failure when they were elderly.
- Your uncles and aunts?
- In good health.
- Have you ever heard your relatives talk about asthma in your family?
- No, never.
3) – Your diagnosis is bronchial asthma. It is a very serious disease. I advise you a change of climate, first of all.
4) – Who are you?
- Ann Brag.
- How old are you?
- 26 years old.
- What’s your address, please?
- 32, Forest Street, Eastpoint, Missouri.
5) – What diseases did you have in your childhood?
- Measles, mumps, chicken-pox.
- Any surgery?
- No, doctor.
- Will you tell me more details about your present illness?
- Yes, of course, I started having wheezing when I was 5. My parents told me that I had had shortness of breath after attacks of children diseases.
6) – When do you think the disease began? How long has it been troubling you?
- I was taken ill when I was 5 years old. Our family doctor advised my parents to take me to the sea for a change of air.
- How did you feel there?
- Fine. I had no trouble while staying at the sea. But when we returned home my breathing ailment recurred. I don’t feel well in cold and rainy weather.
- What treatment did your physician prescribe you?
- Inhalations. But my condition became worse, more severe. You know, tobacco smoke irritates me badly. My husband is a heavy smoker.
- Oh, my dear, you need only pure fresh air. He should know this.
Part B (II):
1) - Are you married?
- Yes.
- Do you have any children?
- Yes, two boys and a girl.
- Do you have any close relatives living?
- Yes, my parents and a brother are alive and healthy.
2) – What’s your name?
- __________ (fill in the gap)
- How old are you?
- __________ (fill in the gap)
- Where do you live?
- __________ (fill in the gap)
- What’s your occupation?
- __________ (fill in the gap)
3) – What diseases have you had?
- Whooping cough, mumps, measles.
- Have you ever had pneumonia or kidney trouble?
- I often caught colds in winter and had pneumonia, that’s all I remember.
- Any harmful habits?
- I neither smoke nor drink.
4) – What’s your trouble?
- I have persistent coughing and pains in the chest.
5) – I suspect you have pneumonia as a complication after influenza. But to confirm the diagnosis you have to have your tests of blood, urine and X-ray examination made.
6) – When did you notice the first signs of the disease?
- I had influenza a week ago, but I followed the doctor’s recommendations and recovered rather quickly.
- When did you feel chest pain for the first time?
- Two days later.
- Can you relieve it by any drug?
- No.
- Do you cough up any phlegm?
- Yes, a little.
Part B (III):
1) - Are you married?
- Yes, but we are childless.
- Do you have parents? Are they well?
- My mother died of diabetes, my father of heart trouble.
- Have you any sisters or brothers?
- No, I have no relatives.
2) – Have you ever been sick?
- In childhood I had some children diseases but I don’t remember which of them.
- Have you ever been operated on?
- Five years ago I had urethral resection made.
- Any bad after-effects of the surgery?
- No, not any.
- Did you seek medical attention to clear the cause of your trouble?
- Yes, my family doctor advised me some drugs and to have a good rest, but with no effect.
3) – What’s your opinion, are these epileptic attacks?
- No, I’m sure you have been suffering from heart trouble for a rather long time. Your seizures have been connected with cardiac standstill. It is difficult to manage. I think of installing a pacemaker, with your coming for check-ups yearly.
4) – What problem do you have?
- I have been having a feeling of heaviness in my chest for more than a year.
- Any pain?
- Not any, Doctor, but three or four times when I was gardening, I had recurrent episodes of convulsions, brief seizures.
- Do you have headaches?
- No, not often.
- Do you feel worried or nervous?
5) – What’s your name?
- I’m Mrs. Gross.
- How old are you?
- I’m 50, doctor.
- Your address?
- 38, Rockland Road.
- What do you do for living?
- I’m a housewife, I have a large family.
6) – A feeling of heaviness in the chest, convulsions, tiredness, seizures, loss of consciousness.