Anamnesis holistic doctor

Tugas MKWU bahasa inggris

Oleh
Timothy isa pranata Siregar
1710313063

Jurusan Kedokteran
Program studi profesi Dokter
Universitas andalas
Padang
2018
Doctor and pasien dialogue’s

I. Medical History Interview

Doctor : good morning,sir

Patient : good morning,too doc

Doctor : I am Timothy, your doctor for today. May I know your name,sir?

Patient : my name is Viraj kumar

Doctor : ok,sir. Would you mind to tell me your problem?

Patient : recently I am having a weight loss about 3 KG in this month,and I easily get tired

Doctor : well.. I see.what is your job at this time sir?

Patient : I work as a junior high school teacher,Doc.

Doctor : then, how old are you mow?

Patient : I am 30 years old,Doc

Doctor : where do you live in?

Patient : I live in bukit tinggi on a housing site

Doctor : and with whom do you live ?

Patient : I live with my two children ; my wife has passed six months ago on labor.

Doctor : I am sorry for that,sir; do you have any siblings ?and does your parents still alive?

Patient : I have one younger brother and both of my parents still alive , Doc

Doctor : does anyone in your family have a serious illness ?

Patient : as long as I know there isn’t any of my closest relatives have a serious illness,Doc

Doctor :then do you smoke or drink any alcohol,sir?

Patient :I quit smoking about 2 years ago and so long I didn’t drink any alcohol

Doctor : ok sir thank you for your time lets continue to the next examination

Patient : your welcome ,Doc

 II. Physical examination

Doctor : now we,re going to have a physical examination; please have a sit on the bed and relax

Patient : ok Doc

Doctor : what we’re going to do is to examine any disorder in your neck sir, so I will have to
inspect your neck but I won’t take too long, are you pleased for that,sir?

Patient :yes I am ,Doc

Doctor : please turn your head to the left side… and the to the right side and…..

Patient : (following the doctor instruction willingly)

Doctor : ok sir that’s all it’s over thank you for your cooperation

Patient : thank you for you,too Doc

III. Diagnose, management plan , lifestyle advice and prognosis

Doctor : Sir, from our anamnesis,physical examination and the results from the laboratory.

I would say that you’ve suffering a mild hypertiroidsm

Patient : where is that statement come from,Doc ?

Doctor : from the symptoms that you say. You’re having a variant weight loss recently and
when you saying that you’re getting tired more easily now. The physical examination results is
that you’re having a mild Enlargement of the Tiroid’s Gland. While in laboratory we found an
increasement of tiroid hormones index in vascular.

Patient : then what is the therapy should I take ?

Doctor : because of you experiencing a easily tired function, we’re suggesting you to limit your
physical work. We’re gonna giving you a fixed dietary plan based on the hipermetabolism
syndrome and we’re gonna focusin on farmacologists therapy such as oral PTU to limit the
problems.

Patient : is there a thing that I should change about my lifestyle,Doc?

Doctor : since you’re not smoking or drinking alcohol, we’re suggesting that you should relieve
your stress and live a more happily life.
Patient : so what about the disease? Can I get back to the normal condition?

Doctor : you shouldn’t worry much about it. I expect the treatment will reduce your pain and
improve your healthiness Vanish it Completely without disturbing your daily activities. If only
you obey the instruction and routinely exercise every day.

Patient : okay , Doc thanks a lot.

IV. Medical Treatment based on your scenario

PROPILTHYOURASIL
INDICATION: HIPERMETABOLISM
CAUTIONS: AVOIDED CONTACT WITH EYES
SIDE OCCASIONAL ALERGY AND REDUCING EAT APPETITE
EFFECTS:
DOSE: APPLY ORAL 3 TIMES A DAY

V. CASE PRESENTATION

SECTION LANGUAGE EXAMPLE

INTRODUCTION I’D LIKE TO PRESENT MY SELF TO MR. VIJAY
AGE AND OCCUPATION A 30 YEAR OLD TKANG BISNIS
DURATION AND WEIGHT LOSS IN ABOUT ONE MONTH
PRESENTING SYMPTOMS
ASSOCIATED SYMPTOMS HE ALSO COMPLAINED ABOUT EASY TIREDNESS
POST MEDICAL HISTORY NO RELEVANT PAST HISTORY
SOCIAL HISTORY HE DOESN’T SMOKE OR DRINK ANY ALCOHOL
FAMILY HISTORY NO RELEVANT FAMILY HISTORY
EXAMINATION’S FINDING I CAN FOUND THAT THERE IS AN
ENLARGEMENT ON TIROID GLAND
INVESTIGATION RESULTS REDUCED TIROID’S HORMONE IN LABORATORY
DIAGNOSE I THOUGHT PATIENT SUFFER A
HIPERTIROIDSM
TREATMENT ON GOING FARMACOLOGISTS THERAPY “PTU ”
OUTCOME TREATMENT COULD TERMINATE THE DISEASE
TOTALLY