Patient anamnesis

(Anamnesis Vitae)

Represents the patient’s medical biography stated consistently in such order:

Childhood: the date of birth and the birth place, what child under the account in family, material - conditions of life, physical development, when began walking and talking, when has gone to school, school results. Pastchildren's diseases (rickets, dyspepsia, infections).

Adolescence: physical development, go in for sport, study, family material - conditions of life, feature of the sex maturity: girls — menstruation occurrence, when they were established, their cycle.

Maturity: the beginning of labor activity, military service, occupation (its changes), carried out work now, its features; occupational hazard, invalidism (disability) (when received, what group, what occasion (disease)), the pensioner. Family status: married, structure of family, number of children, their age; women — number of pregnancies, parturition, miscarriage (on what month), abortions, mortinatality.

Social history at this time: the budget, apartment, municipal services, feeding (regular, chaotic, to eat food dry, propensity to sharp food. Rest (time to sleep, the way in which the patient spends his leisure time: weekend, holiday), personal interest, habits, additional works in-home, frequent business trips.

Harmful habits: smoking (how long time smokes, how many cigarettes in a day, smokes at night, on an empty stomach). Drug or alcohol abuse (in what quantity, frequently, how long time); predilection for strong tea, coffee, to tranquilizers.

Previous illnesses; describe with a chronological account illness, operations, accidence, specifying at what age has passed different disease, if sick was hardly, if was hospitalized, consequences. Is necessary to find out from each patient this diseases: rheumatism, tuberculosis, venereal diseases, viral hepatitis, HIV.

Family history: the health and age of the members of family (the wife, the husband, children) and near relatives of the patient (father and mother, brothers and sisters, the uncles and the aunts, grandparents) — if they are sick it is need to detailed disease, if died it is need to detailed course and in what age.

Residence or travel abroad: where, prophylactic medication.

Allergological anamnesis: allergic reactions to various food (strawberry, eggs etc.), medical preparations (novocaine, analgin etc.), perfumes, pollen etc.

PAST MEDICAL HISTORY (Anamnesis vitae)
Date of birth	When were you born?
Place of birth	Where were you born?
Life's condition in childhood	What life's condition did you have in your childhood?
Education	What education have you received?
Beginning of work	At what age did you begin to work?
Occupation	What is your occupation?
Past diseases in childhood	What childhood diseases were you ill with? What were you ill with before?
Adult	At what age were you ill with this disease? Were you ill with tuberculosis? Were you ill with a venereal disease? (gonorrhoea, syphilis)
Operations, traumas	Have you undergone an operation, which one? Did you have any wounds (contusions, traumas)?
Chronic poisoning	Do you smoke? Do you smoke much? How many cigarettes a day do you smoke? Do you use narcotics, which ones? Since when have you been taking opium (heroin, hashish)?
Drinking habits	Do you drink? Are you addicted to drink? Do you drink every day or just on social occasions? How much do you drink on an average every day? Do you think your drinking causes any problems?
Relatives	Do you have relatives? How many relatives do you have? How many of you are there in your family? Are your parents alive? Is your father (mother) well? What diseases did he (she) has? At what age did he (she) dye? What caused his (her) death? Are you children healthy? What diseases have they got? Do you have brothers, sisters? How many brothers, sisters do you have? Are they well? What diseases do they have? Were your relatives ill with tuberculosis, venereal, malignant (tumor), mental, endocrine diseases?
Material status	Are you single? Are you widowed? Are you divorced? Are you married? How long have you been married?
Obstetric history	At what age did you begin to menstruate? When did your periods first start? Are the menses regular (irregular)? Is your menstrual cycle regular? How often do you have your periods? How long do they last? Are the menses abundant (moderate, painful)? Are you still having your periods? When did you have your last menses? How many pregnancies have you had? Have you had abortion (miscarriages, still-born)? Was it an induced or spontaneous abortion? Did you have any trouble during pregnancy, such as raised blood pressure? Did you have any complications at delivery? Which ones? Did you have a normal delivery? How many children have you? How old are they?
Profession and living conditions	What are the conditions of your work? What harm is there at your enterprise? Do you work with lead, mercury, acids, alkalis, nickel, radioactive substances? What are your living conditions? Allergic history
Allergic history	Have you got allergic reaction?

COMPREHENSION

Free from pain, painless.

Pain Aches

Aches are used in compound words: backache, earache, headache, stomachache, toothache.

For the other parts of the body we say: "I have a pain in my shoulder".

The word "ache" can also be used as a verb: "My leg aches after walking two miles".

The word "hurt" is another verb used to express injury and pain: "My chest hurt when I cough", "My neck hurts when I turn my head".

“like being in a vice”, “like an iron band round the chest”,

Detailed description "Pain".

Aching

Biting

Boating

Burning

Colicky (abdominal disease)

Crampy

Cutting (rectal disease)

Deep – diffuse aching sensation

Dragging

Drawing

Dull (headache, tumour)

Excruciating

Gnawing (tumour), pronounced gnawing

Grinding

Gripping (as in angina pectoris)

Heavy (as premenstrual)

Knife-like

Numb (lack of sensation)

Piercing (angina pectoris)

Pinching, pinch

Pressing

Prickling (like pins and needles in inflamed eyes, conjunctivitis)

Scalding (cystitis)

Severe - gip, 'It gives me the gip'

Sharp

Shooting (toothache)

Sickening

Smarting (burns)

Sore

Stabbing (indigestion)

Steady

Stinging (Guts, stings)

Stitch (spasm in side due to excessive exercise)

Straining

Sudden

Tearing

Tender

Throbbing (headache)

Tingling (return of circulation to extremities)

Twinge (sudden, sharp)

Wasp

Other words to describe pain:

acute/subacute/chronic; constant/inter-mitten; localized/diffuse, radiating, spreading; mild/severe; superficial/deep-seated; constricting; convulsive, spasmodic; darting, fleeting; intense, very severe, violent, agonising, excruciating; persistent, obstinate, stubborn.

RESPIRATORY SYSTEM

Breathing.

Medical words: respiration, expiration, inspiration Colloquial words: breathing, breathing out, breathing in Descriptive words: breathing, shortness of breathing, deep breathing, weak breathing, noisy breathing, quick breathing, rapid breathing, wheezing breathing, laboured breathing, shallow breathing

Cough

Descriptive words:

Character: dry, productive, explosive, suppressed, postural spasmodic, persistent, moist

Tone: barking, brassy, hacking, hawking (catarrhal and chronic sinusitis) wheezing (bronchitis) loud, strong, voiceless

Sputum

Medical words: sputum, to expectorate

Colloquial words: phlegm (flem), to bring up phlegm;

Descriptive words:

Quality: clear, frothy, glassy, jelly-like

Colour: black-gray, blood-stained, brown, dark-red, green, red, pinkish, rusty-brown, yellow

Odour, foetid, putrid, nauseating

DIGESTIVE SYSTEM

Vomiting

Medical words: to vomit

Colloquial words: to be sick, to bring up food

Descriptive words:

Character, residues of food, watery

Colour: black, blood, coffee-ground, green

Bowels

Medical words: faces, stools, to defecate

Colloquial words: motion, to have a bowels opened, to do to stool

Descriptive words:

Colour: black, brown, like rice-water (cholera), green, gray, pale, pea-soup-like, porridge-like (steatorrhea), white, yellow

Form and consistency: bloody, dry, fatty, hard, purulent (with pus), slimy (excess of mucus), soft, watery, well-formed

URINARY SYSTEM

Urination

Medical words: to micturate, to urinate

Colloquial words: to pass water

Descriptive words:

Character: clear, cloudy, flecked, milky, muddy, thick, slimy, smoky

Colour: amber, black, brown, blood-streaked, blue-green (as result of drugs for back and kidney), orange, pink, red, redish-brown, straw-colored (normal), yellow

Odour: ammoncical, foetid, fruity and sweet (diabetes)

Physical examination (Objective examination)

(Status praesens)

Those pathological changes which are found out at research of the patient are needed to describe, and at their absence describe a physiological condition of organs and systems.

Дата добавления: 2015-11-16