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1 Taking a history

Section 1 Asking basic questions


A PERSONAL DETAILS
Personal details
To find out or check a atient!s occuation" nurses ask#
Do you $ork%
&hat do you do for a li'ing%
Patients (ay resond#
No" I!( une(loyed) No" I!( retired) *es" I $ork for a bank)
I!( out of $ork) I!( a ensioner) I $ork in a factory)
To find out or check a atient!s (arital status" nurses ask#
Do you ha'e a artner%
Patients (ay resond#
No" I!(
single)
searated)
di'orced)
I li'e $ith (y
artner)
souse)
husband)
$ife)
*es" I!( (arried)
No" I!( a
$ido$)
$ido$er) +y souse assed a$ay last year)
Note# A spouse can be a husband or $ife) A widow is a $o(an $hose
husband is no longer li'ing, a widower is a (an $hose $ife is no longer li'ing)
To a'oid saying so(eone is dead" atients (ay say that erson has passed
away)
B DR-. /ISTOR*
To find out about a drug history" nurses ask#
Details of drug and medications
Are you taking any (edication at
the (o(ent%
&hich tablets do you take%
Do you use any o'er0the0counter
re(edies or herbal or
ho(eoathic (edicines%
Compliance
Do you al$ays re(e(ber to take
it%
Side-effects and allergies
Do you get any side effects%
Do you kno$ if you are allergic to
any drug%
If the
answer is Yes: &hat
sy(to(s do you get after
taking it%
Frequency of administration
/o$
(any ti(es a day do you take it%
C 1A+IL* /ISTOR*
Note the age" health and cause of death of arents" siblings 2brothers and
sisters3" souse 2husband or $ife3" and children)
To find out about family history, nurses ask:
Do you ha'e any brothers or sisters%
Do you ha'e any children%
Are all your close relati'es ali'e%
Are your arents ali'e and $ell%
Is anyone taking regular (edication%
/o$ old $as he $hen he died%
Do you kno$ the cause of death%
Do you kno$ $hat did he die off%
Does anyone in your fa(ily ha'e a
serious illness%
D SO4IAL AND PERSONAL /ISTOR*
Record the rele'ant infor(ation about occuation" housing and ersonal
habits including recreation" hysical e5ercise" alcohol and tobacco and" in
the case of children" about school and fa(ily relationshis)
Typical questions in taking a social and personal history are:
&hat kind of house do you li'e in%
&ho shares your ho(e $ith you%
Are any of the( at nursery or school%
Do you ha'e any hobbies or interests%
Do you li'e alone%
/o$ old are you children%
&hat!s your occuation%
&hat about e5ercise%
&hat about alcohol%
&ine" beer or sirits%
/o$ (uch do you drink in a $eek%
Do you s(oke%
/o$ (any a day%
/a'e you tried gi'ing u%
Do you ha'e any financial roble(s 6 roble(s at $ork%
1.1 4o(lete the sentences) Look at A" 7" 4 AND D abo'e to hel
you)
8 Phar(acies sell a $ide 'ariety of 999)) 0 999))0 999) re(edies
as $ell as disensing rescritions fro( hysicians)
: The 9999)) is the quantity of the (edication to be taken at any one
ti(e)
; A drug 9999)) is hyersensiti'ity to a articular drug)
< A 9999)) 9999)) is a (edication reared fro( lants"
esecially a traditional re(edy)
= *our brothers and your sisters are your 9999)) )
> 9999)) is $hat you do for hysical or (ental sti(ulus outside $ork)
? 9999)) can take (any for(s# aart(ents" single roo(s" houses"
hostels)
@ The atient!s 9999)) to drug treat(ent" his $illingness or ability to
take the right dose at the right ti(e and frequency" is essential)
1.2 &rite the nurses questions) Look at 4 abo'e to hel you)
N-RSE# 283 ))9999999999999999)9999999999%
PATIENT# +y father died t$enty years ago but (y (other is in good health)
N-RSE# 2:3 ))99999999999999)999999999999%
PATIENT# I $as still at school) /e $as forty0one)
N-RSE# 2;3 ))999999999999999999)99999999%
PATIENT# /e had a heart attack)
N-RSE# 2<3 9999))9999999999999999)999999%
PATIENT# I!'e got a sister of forty0fi'e and a brother $ho!s thirty0si5)
N-RSE# 2=3 ))99999999999999999999)999999%
PATIENT# No" I had an elder brother but he died $hen he $as forty t$o)
N-RSE# 2>3 99999999999999)))999999999999%
PATIENT# Like (y father" a heart attack)
N-RSE# 2?3 99999999999999999999999)))999%
PATIENT# Not that I kno$ of)
N-RSE# 2@3 As far as you kno$ )999999999999999)))99%
PATIENT# Aart fro( (e" no)
N-RSE# 2A3 99999999999999)))999999999999%
PATIENT# *es" a boy and a girl) /e!s fourteen and she!s t$el'e)
TALBIN. A7O-T PAIN
Patients description
of pain
!planation
aching 6 an ache a general ain" often in (uscles or Coints
boring like a drill
burning $ith heat
colicky an inter(ittent ain $hich 'aries in intensity"
co(es and goes in $a'es
cra(y 6 cra( an in'oluntary sas(odic (uscle contraction
crushing a feeling of ressure
dull a background ain" oosite of shar
gna$ing biting
griing a feeling of tightness
scolding like boiling $ater
shar acute
stabbing like a knife
stinging shar" burning" like an insect sting
throbbing $ith a ulse or beat
"anguage focus 1
Note ho$ the nurse starts the
inter'ie$#
- Whats brought you along today
Other $ays of starting an inter'ie$ are#
- What can I do for you
- What seems to be the problem
Note ho$ the nurse asks ho$ long the roble( has lasted#
- !ow long ha"e they been bothering you
Another $ay of asking about this is#
- !ow long ha"e you had them
Note ho$ the nurse asks $here the
roble( is#
- Which part your head is affected
Other $ays of finding this out are#
- Where does it hurt
- Where is it sore
Note ho$ the nurse asks about the
tye of ain#
- #an you describe the pain
Other $ays of asking this are#
- Whats the pain like
- What kind of pain is if%
Note ho$ the nurse asks if anything relie'es the ain of headaches#
- Is there anything that makes them better
Si(ilarly she can ask#
- $oes anything make them worse
Nurses often ask if anything else affects the roble() 1or e5a(le#
- What effect does food ha"e
- $oes laying down help the pain
% &etter (eans impro"ed or relie"ed' It does not (ean cured'
1.# 4o(lete the sentences)
8 .astric ulcers are associated $ith a 999999" 999)999
ain)
: 4ystitis causes 999999)" 999999) ain on assing urine)
; Patients $ith a etic ulcer (ay say they ha'e a 9))9)" 9))99)
ain)
< Recurrent abdo(inal ain (ay be described as 9999 or 9)9))9 )
= +igraine is often described as a 999999) ain)
> Peole $ith osteoarthritis often co(lain of a dee 999)))))
centered in the Coint)
? Bidney stone ain is sudden" se'ere and 999999) )
@ Angina is usually described as a crushing or hea'y or 99))99) ain)
Section 2 Asking about syste(s
REDIE&IN. T/E S*STE+S
$pen-ended questions
&hat!s your aetite like%
/o$!s you 'ision%
4an you tell (e about9%
4an you tell (e (ore about that%
&hat haened then%
&hat $as that like%
/o$ did that feel%
/o$ $as that for you%
Closed questions
/a'e you eaten today%
Is your 'ision e'er blurry%
ASBIN. A7O-T T/E 4ENTRAL NERDO-S S*STE+
8 Do you suffer fro( headaches%
: /a'e you e'er had a blackout%
; &hat about fits%
< /a'e you had any diEEiness
= Do you get ringing in the ears%
> /a'e you e'er e5erienced any nu(bness or tingling in you hands or
feet%
? Do you ha'e any roble(s sleeing%
P/RASAL DER7S IN /ISTOR*0TABIN.
Phrasal 'erbs are often used in infor(al soken English)
P%rasal &er' !ample (eaning
bring on Is there anything secial that
brings on the ain%
cause" induce
bring u &hen you cough" do you bring
up any hleg(%
e5ectorate" 'o(it
carry on #arry on taking the ain killers
for another $eek)
continue
co(e on &hen does the ain come on% co((ence
gi'e u +y ad'ice is to gi"e up s(oking) sto
ut on I!'e put on a lot of $eight in the
last (onth or so)
gain $eight
turn out She had all the tests and it
turned out to be cancer)
haen in the end
turn u The rash Cust turned up out of
no$here)
aear une5ectedly
1.) +atch each of the susected roble(s in the first colu(n $ith a suitable
question fro( the second colu(n)
Suspected problem
8 deression
: cardiac failure
; asth(a
< rostate
= coronary thro(bosis
> cancer of the lung
Question
a3 /a'e you had any ain in your chest%
b3 Do you e'er get $heeEy%
c3 &hat sort of (ood ha'e you been in recently%
d3 Any roble( $ith your $ater$orks%
e3 /a'e you e'er coughed u blood%
f3 /a'e you had any shortness of breath%
1.* +atch the features of the stool 280?3 $ith the nurse!s questions 2a0g3)
Feature
8 blood
: bo$el habit
; change in bo$el habit
< bulk
= colour
> consistency
? offensi'eness
Question
a3 /o$ often do you oen your bo$els%
b3 Are you going to the toilet (ore often
than nor(al%
c3 Are the (otions hard or loose%
d3 Do the (otions ha'e an unusual s(ell%
e3 &hat about the aearance of the stools%
f3 /a'e you assed black stools%
g3 Is the siEe or the a(ount of the stool
nor(al%
1.+ +atch the atient!s descritions of their sy(to(s 280?3 $ith the (edical
ter(s 2a0g3)
Desciption
8 I ha'e to ee e'ery hour or so)
: I get a scolding ain $hen I ass $ater)
; I ha'e to get u se'eral ti(es to ass $ater
at night)
< I ha'e to rush to go to the toilet)
= I ha'e trouble getting started)
> I can!t hold (y $ater)
? I assed so(e blood in (y urine)
Medical term
a3 dysuria
b3 frequency
c3 hae(aturia
d3 hesitancy
e3 nocturia
f3 urgency
g3 incontinence
Section # Asking and talking about sy(to(s
"anguage focus #
&hen $e ask *es6No questions like these" $e nor(ally use rising
intonation#
- (ny pain in your muscles
- !a"e you lost any weight
- !a"e you had a cough at all
- Is there any blood in it
- !a"e you had any pains in your chest
1., Study this e5tract fro( a case history)
The atient $as a =A0year0old (an" head of a small
engineering firm )*+, $ho complained of central chest pain 2:3
$hich occurred on e,ertion )-+ and $as sometimes
accompanied by sweating 2<3) /e smoked ./ cigarettes a day
2=3) The ain had first appeared three months pre"iously 2>3
and $as becoming increasingly frequent 2?3) /e had noticed
so(e weight gain recently 2< kg3 2@3 and also co(lained that
his hair had beco(e 'ery dull and lifeless) /e felt the cold
(uch (ore than he used to) /e denied any palpitations 2A3 or
ankle oedema )*/+'
&hat questions (ight a nurse ask a atient to obtain the infor(ation in
italics in the case history% -se the question tyes studied in this unit) *ou
(ay ask (ore than one question for each iece of infor(ation) 1or
e5a(le#
8 &hatFs your Cob%
: &hatFs brought you along today% &hich art of your chest is affected%
1.- +atch each of the (edical ter(s for co((on sy(to(s in the first colu(n
$ith a ter( $hich a atient $ould easily understand or (ight use" fro( the
second colu(n)
Medical term
8 araesthesia
: roducti'e cough
; anaesthesia
< retrosternal chest ain
= orthonea
> stress incontinence
? dys(enorrhoea
@ dysesia
A oede(a
8G inter(ittent claudication
88 inso(nia
8: dysnoea
Non-medical term
a3 s$elling" uffiness
b3 indigestion
c3 coughing u hleg( or sit
d3 trouble holding your $ater
e3 cra( in the leg (uscles $hich co(es
and goes
f3 nu(bness
g3 sleelessness
h3 out of breath" out of uff" breathlessness
i3 ainful eriods
C3 ain behind the breast bone
k3 ins and needles
l3 shortness of breath $hen you lie do$n
"anguage focus )
Talking about sy(to(s#
Symptom Meaning Patients say
tiredness
lethargy
fatigue
lassitude
loss of energy I feel tired all the ti(e)
I feel co(letely worn out)
Lately I!'e been feeling co(letely
e,hausted at the end of the day)
(alaise general feeling of
being un$ell
I feel un$ell)
I don!t feel $ell)
I!'e been feeling off-colour for)))
I ha"ent been feeling myself for9
I!'e been out of sorts for9
anore5ia loss of aetite +y aetite is 'ery poor)
I!'e been off my food for9
$eight gain increase in $eight I!'e put on @ kilos in the last year)
I!'e gained = kilos)
$eight loss decrease in $eight I!( not eating any less than usual but
I!'e lost a lot of $eight recently)
constiation hard" infrequent faeces +y motions are 'ery hard)
I!'e been quite constipated recently)
I!( not 'ery regular)
2 E5a(ining a atient
Section 1 .i'ing instructions and e5laining
DER7S -SED IN INSTR-4TIONS
bend do$n ut your head do$n
ut out your tongue
breathe in
breathe out
raise your leg
close you eyes roll on to your back6front
roll o'er
roll u your slee'e
curl u sit
sit u
do this slide your hand do$n
your side
follo$ (y fingerti $ith your
eyes
sli of your coat
kee your knee straight stand straight
stand u
let your $rist go floy take off your to things
lie on your side6back
lie on the bed6couch
lie do$n
tilt your head back
look straight ahead
look at so(ething
touch your shoulder $ith your chin
oen your (outh turn your head to the left
turn on your side
oint to the finger that (o'es $t%er instructions.
rela5
sho$ (e $hat (o'e(ents you can (anage
tell (e if it hurts
ull as hard as you can
ush as hard as you can
E5a(ining a atient
8 Brief t%e patient on /%at %e0s%e s%ould e!pect.
Do you kno$ $hat $e are
going to do this (orning%
&hat $e!re going to do today is 9
I!( going to e5a(ine your 999 so I can find out $hat!s causing this 9
&hat $e do is 9 &hat haens is that 9 I!ll ask you to 9
Are you ready% Ok%
: 1%en e!amining a patient2 polite forms are often used for t%e
initial instruction.
4ould you bend for$ard as far
as you can%
If you could cross your ar(s in front of
your chest)
&hat I!d like to do is e5a(ine you standing u)
After t%at direct instructions may 'e used.
Stand $ith your feet together) Lie erfectly still)
3o soften an instruction.
4an you Cust turn to the side again% 4ould you Cust lie on the couch%
; S%o/ sensiti&ity to t%e patients needs and respond to discomfort2
reasurring if appropriate.
*ou (ight feel a bit of disco(fort) This (ight hurt a little but I!ll be quick)
Tell (e if it hurts) Let (e kno$ if it!s sore) It $ill be o'er 'ery quickly)
It $on!t take long) *ou!re doing 'ery $ell)
< 3al4 t%e patient t%roug% t%e procedure.
I!( Cust going to9 1irst I!ll9 Then I!ll9 No$ I!( going to9
*ou!ll feel9 &hen it!s o'er" I!ll9 That!s it) All o'er)
= S%are your findings /it% t%e patient.
&ell" I!( fairly certain you!'e got a9 One ossibility is it could be
$hat $e call9
I ha'en!t found anything to suggest any roble(s)
Examinations
8 the throat
: the ears
; the chest
< the back
= the foot
> the nasal assage
Instructions
a3 Re(o'e your sock and shoe)
b3 Re(o'e your to clothing)
c3 Turn your head this $ay)
d3 Oen your (outh)
e3 Tilt your head back)
f3 Stand u)
2.1 &hat do you think the nurse is e5a(ining by gi'ing each of these
instructions%
8 I $ant you to ush as hard as you can against (y hand)
: 7reathe in as far as you can) No$ out as far as you can)
; Say AA) No$ $hiser it)
< 4ould you fi5 your eyes on the ti of (y en and kee your eyes on it%
= I $ant you to kee this under your tongue until I re(o'e it)
> &ould you roll o'er on your left side and bend your knees u% This
(ay be a bit unco(fortable)
? I $ant to see you take your right heel and run it do$n the front of your
left leg)
@ Put out your tongue) Say Aah)

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