PROFESSIONAL ENGLISH IN USE FOR MEDICINE
48. Taking a history 2
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A
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Drug
history
Here is an extract from a medical
textbook
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It is essential to obtain full
details of all the drugs
and medications taken by
the patient. Not infrequently patients forget to mention, or forget the
name of the drugs they take. Some may be over-the-counter remedies unknown to the general
practitioner. The significance of others, such as herbal remedies or laxatives,
may not be appreciated by the patient.
It is necessary to determine
the precise identity of the drug, the dose
used, the frequency of administration
and the patient’s compliance
or lack of it.
It is important to ask about
known drug allergies or
suspected drug reactions
and to record the information on the front of the notes to be obvious to
any doctor seeing the patient. Failure
to ask the question or to record the answer properly may be lethal.
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To find out about drug history, doctors
ask:
Details of drugs and medications
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a
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Are you taking any medication
at the moment?
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b
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Do you use any
over-the-counter remedies or herbal or homeopathic medicines?
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c
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Which tablet do you take?
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Frequency administration
Compliance
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a
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Do you always remember to take
it?
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Side effects and allergies
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a
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Do you get any side effects?
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b
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Do you know if you are
allergic to any drug?
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If the answer is YES: What symptoms do you get after taking
it?
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B
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Family
history
Note the age, health or cause of death of parents, siblings (brothers and
sisters), spouse (husband
or wife), and children. To find out about family history, doctors ask:
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√
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Do you have any brothers and
sisters?
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√
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Is anyone taking regular
medication?
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√
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Do you have any children?
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√
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How old was he when he died?
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√
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Are all your close relatives
alive?
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√
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Do you know the cause of the
death?/ What did he die of?
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√
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Are your parents alive and
well?
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√
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Does anyone in your family
have a serious illness?
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C
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Social
and personal history
Record the relevant information about occupation, housing and personal habits including
recreation, physical exercise, alcohol and tobacco and, in the case of
children, about school and family relationships. Typical questions in taking
a social and personal history are:
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√
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What kind of house do you live
in?
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√
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Do you smoke?
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√
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Do you live alone?
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√
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How many a day?
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√
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Who shared your home with you?
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√
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Have your tried to giving up?
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√
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How old are your children?
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√
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What about alcohol?
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√
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Are any of them at nursery or
school?
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√
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Wine, beer or spirits?
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√
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What’s your occupation?
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√
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Can you give up alcohol when
you want?
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√
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Do you have any problems at
work?
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√
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How much do you drink in a
week?
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√
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Do you have any financial
problems?
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√
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What’s the most you would
drink in a week?
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√
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Do you have any hobbies or
interests?
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√
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Are you aware of any
difference in your alcohol consumption over the past fiver years?
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√
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What about exercise?
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EXERCISES
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48.1
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Complete the sentences. Look at A, B and
C above to help you.
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1
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Pharmacies sell a wide variety
of __________-__________-__________ remedies as well as dispensing
prescriptions from physicians.
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2
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The __________ is the quantity
of the medication to be taken at any one time.
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3
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A drug __________ is
hypersensitivity to particular drug.
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48.2
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Write the
doctor’s questions. Look at B above to help you.
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48.3
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Study the social history of Mr Black. Write
the questions the doctor asked to obtain the numbered information. Look at C
above to help you.
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Answer key
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