Case report

When we are ill, we call the doctor. He examines us and diagnoses the illness or disease.

If we cannot get better at home, we must go to hospital. After examining the patient the doctor fills in case report. All the medical documentation is put in order by a nurse of admissions department.

She fills in the title-page of in-patient card. She enters in it identification data: name, full name. date of birth, age, home address, number of medical insurance policy, unit number, occupation, education, pension, marital status (married, single, divorced, widow, widower), home circumstances, religion: beliefs and practices, special needs. Then she carries out history taking: family history (FH) / hereditary history, social history (SH), allergological history,

past history (PH), harmful patient’s habits, occupational hazards

Patient's characteristics:

Age 22 Height 1, 7 m Sex: M Weigh: 70kg Main symptoms:

• pain in the right lower quadrant (sporadic and colicky in nature)

• began in epigastrium 2 days ago.

— moved to periumbilical region and right lower quadrant.

Other symptoms:

fever, vomits (3), anorexia, constipation for two days

(no bowel movement). No diantidea.

Past history: none Family history: none Toxic habits: none Medications: none Physical finding:

— patient well oriented as to time, place and person;

— well nourished;

— extreme tenderness to palpation mainly over Mc'Bumey's point;

— guarding, muscle regidity, rebound tenderness;

— difference: axillary — rectal temperature;

— bowel sounds: absent.

— Diagnostic procedures:

urinalysis (-) CBС WBС

sed rate:

Т Hg and ht: normal

Differential diagnosis:

acute pancreatitus, acute cholecystits, myocar-dial infarction, gastroduodenal ulser, perforation of an ulcer

Exercises

1 Answer the questions.

1.Where does a doctor write downPhysical finding?

2. Who puts in order all the medical documentation?

3.What kinds of data does a nurse enter in the title-page of in-patient card?

4. How is out history taking carried out?

2. Представьте больного соответственно следующим све­дениям:

1) full name; 2) age; 3) family status; 4) occupation; 5) place of employment; 6) principal complaints; 7) the onset of disease 8) operations undergone if any; 9) the state of health of his next of kin (ближайшие родственники).

Заполните историю болезни больного задавая ему сле­дующие вопросы:

1) What is your full name?

2) How old are you? (When were you born?)

3) Are you married or single?

4) What is your occupation? (What are you?)

5) Where do you work?

6) What is your home address?

7) What are you complaining of?

8) When did you fall ill?

9) Was the onset sudden or gradual?

10) What were the first symptoms of your disease?

11) What diseases did you suffer from in childhood?

12) Have you undergone any operations? What for?

13) Are you parents alive? What did they die of?

14) Does any of your next of kin suffer from tuberculosis? Diabetes? Alcoholism? Psychic diseases?

15) Are there any hereditary (наследственный) diseases in your family?

.Give Russian equivalents:

identification data: name, full name. date of birth, age, home address, number of medical insurance policy, unit number, occupation, education, pension, marital status (married, single, divorced, widow, widower), home circumstances, religion: beliefs and practices, special needs. Then she carries out history taking: family history (FH) / hereditary history, social history (SH), allergological history, past history (PH), harmful patient’s habits, occupational hazards

3.Translate into English.

карта стационарного больного- medical card, in-patient card

собирание анамнеза- history taking

семейный / наследственный анамнез- family history (FH) / hereditary history

социальный анамнез- social history (SH)

анамнез болезни - history of present illness

анамнез жизни- life history / past history (PH)

вредные привычки больного - harmful patient’s habits

индивидуальные характеристики больного- a patient’s personal details

паспортные данные- identification data

домашний адрес - home address

дата рождения- date of birth

возраст

имя, полное имя

ближайшие родственники- next of kin

инвалидность - disability

образование- education

профессия - occupation / profession

семейное положение (женат / замужем, не замужем / холост(ой), разведен / разведена, вдова, вдовец)- marital status (married, single, divorced, widow, widower)

.