47. Taking a history I PROFESSIONAL ENGLISH IN USE FOR MEDICINE

PROFESSIONAL ENGLISH IN USE FOR MEDICINE

47. Taking a history I

A	A full case history A full case history covers personal details family history presenting complaint social and personal history past medical history (PMH) patient ideas, concerns and expectations drug history review of systems
B	Personal details Normally, patients’ personal details have been entered in their records by a nurse or administrative staff before a doctor sees them. However, on later consultations a doctor may wish to check details such as address, date of birth, occupation or marital status. To find out or to check a patient’s occupation, doctors ask: √Do you work? √What do you do for a living? Patients may respond: √No, I’m unemployed/ I’m out of work √No, I’m retired / I’m a pensioner √Yes, I work for a bank /I work in a factory To find out or check a patient’s marital status, doctors ask: √Do you have a partner? Patients may respond: √No, I’m single/ separated/ divorced √Yes, I’m married √I live with my partner/ spouse/ husband/ wife √No, I’m a widow/ widower/ divorced √My spouse passed away last year Note: A spouse can be a wife or husband. A widow is a woman whose husband is no longer living; a widower is a man whose wife is no longer living. To avoid saying someone is dead, patients may say that person has passed away.
C	Talking about pain Case notes are kept for each consultation. The presenting Complaint section of case notes records the patient’s symptoms. For example In this case, the patient complains of a headache. For a list of the questions the doctor asked this patient, and for patients’ descriptions of other kinds of pain, see Appendix IV.

EXERCISES

47.1	Study the case notes. write the questions the doctor asked to obtain the numbered information.
47.2	Read the continuation of the case notes for the patient in C above. Write the doctor’s questions. Doctor : Can you tell me what the problem is? Patient : I’ve got a terrible headache? Doctor : (1) ________________________________ Patient : Just here. Doctor : (2) ________________________________ Patient : Well, it’s really bad. And it throbs. Doctor : Have you had anything like this before? Patient : Yes, about every three months. I’ve had them for the last ten years or so.
47.3	Complete the sentences. 1 Gastric ulcers are associated with a ___________, ___________ pain. 2 Cystitis causes ___________, ___________ pain on passing urine. 3 Patients with a peptic ulcer may say they have a ___________, ___________ pain. 4 Recurrent abdominal pain (RAP) may be described as ___________ or ___________.

Answer key