Professional Documents
Culture Documents
The competent physician, before he attempts to give medicine to his patients, makes himself
acquainted not only with the diseases which he wishes to cure, but also with the habits, and
constitution of the sick man. (Cicero, De Oratore II).
At various times in the initial clinical review, you have the chance to get acquainted with a
stranger who is seeking your medical help. Be as inquisitive about this unfamiliar person as you
are about bodily complaints. Know your patients, when patients mention important people in
their lives or refer to their work or other major activities, inquire further. Give reign to your
curiosity. In getting to know the person with whom you are talking, you foster a mutually
satisfying relationship and you acquire data that are important for diagnosis and management.
The more we know about our patients, the better we can care for them.
I. Greeting an introducing oneself
Doctor: -Good morning, Mr. Petrov. Come and sit down. I am Dr. Myazin Roman Gennadievitch
-Good afternoon, Mrs. Ivanova. Take a seat, please. I am Dr. Gonzhal Olga Alexandrovna
-Good morning, Mr. Sidorov. Do sit down. I am Dr. Zamyatina Inna Igorevna
II. General information/Personal details
Doctor: I would like to know a little more about you-your background, your work, your family.
Let me ask you some specific questions.
Now, I am going to ask you a series of routine questions about your body.
-Whats your name?
-How old are you?
-At what age did you start working?
-Whats your job/occupation?
-How long have you been with that company?
-Why have you changed your work?
-Are you on nightshift (day-shift)? Are you doing a rotational cycle? Are you a shift-worker?
-Where do you live?
-Are you married /single/divorced? Have you been married previously?
- Whats your marital status?
-Do you smoke?
-How many do you smoke each day?
-(What) Do you drink? Beer, wine, brandy, whisky, cognac, vodka, champagne, rum, liqueur,
moonshine, spirits/alcohol?
-Have you ever been in hospital, if yes, for what reason?
-Do you have to do a lot of overwork?
-Do you do anything for exercise?
-How do you keep physically fit?
-Are you addicted to drink?
-Are you allergic to any drugs?
-Have you ever had diabetes mellitus?
-Are you retired? Are you on a pension?
-Have you ever been in the military?
-Do (did) you wear glasses/contact lenses?
III. Immunizations
-Did you get immunizations as a child?
-Measles, mumps, rubella? Polio? Tetanus and diptheria?
-Have you had a tetanus booster in the past 10 year?
-Have you had an annual flue shot?
-Have you been vaccinated for the flue?
-Have you had the pheumonia vaccine?
-Have you gotten Hepatitis B vaccine?
IV. Periodic health examination
-Do you have a regular doctor?
-Who is your district (your own) doctor?
-Have you consulted your own doctor about your illness?
-Have you been treated in a TB hospital?
-Are you registered in an oncological/ dispensary?
-Are you being (were you) followed up by a neuropathologist/psychiatrist/TB doctor?
-When did you last undergo prophylactic medical examination?
-How often do you get routine medical checkups?
-When was your last dental exam?
-Do you get your eyes checked?
-Have you been examined for glaucoma?
-Have you had your cholesterol measured?
-Do you check your breasts for lumps?
-When did you have your breasts checked?
-Have you gotten breast X-rays (mammograms)?
-Have you had your stools checked for signs of bleeding?
V. Previous health/Past health
-How have you been keeping up now?
-Have you ever been admitted to hospital?
-Have you ever been hospitalized? What for? When? Where?
-Have you ever had (headaches) before?
-Has there been any change in your health since your last visit?
-Have you ever had any (minor/major) surgery or operations? What for? When? Where?
-Have you ever been involved in a serious accident?
-Did you break any bones?
-Did you have a serious head injury?
-Have you ever required a transfusion?
-Have you ever been bedridden?
-Have you ever been confined to bed?
-How long have you been confined to wheel chair?
VI. Pregnancies
-Have you ever been pregnant? How many times?
-Any miscarriages or abortions?
-Any problems or complications with the pregnancies?
-Did you take any hormones during the pregnancy?
-How were the births?
XIX. Treatment
Advising
-I advise you to give up smoking
-Youll have to cut down on fatty foods
-You must rest
-You should sleep on a hard mattress
-If you get up, all your weigh will press down on the disc
-Dont sit up to eat
-You should take this medicine twice a day before/after meals/food
-Give up smoking.
- The best thing would be to have another scan done.
-You should have your eyes tested.
-You should get your tonsils removed.
-Do as I have advised you.
-You should consult a dermatologist
-Youd better go on a diet.
-If I were you, I would cut down on the hours you work
Expressing regret
-I am afraid that (the operation has not been successful)
-I am sorry to have to tell you that (your relative has little chance of recovery)
XX. Instructions to get dressed:
-You can get dressed now.
-Please get dressed.
-You can get your clothes on now.
XXI. Treatment/No treatment:
-There is nothing wrong with you.
-This will clear up on its own.
-There doesnt seem to be anything wrong with your shoulder.
-I will arrange for you to go to hospital for further/more tests.
- As home treatment has not been successful, you will be hospitalized to avoid any possible
complications.
-I will refer you to the X-ray room (for physiotherapy treatment, for exercise therapy).
-I will give you a referral to a heart specialist.
- I will put you on a sick leave. I will extend your sick leave.
- Are you willing to be admitted to hospital?
-You need urgent admission to a hospital.
-Ill admit you to the hospital as soon as we have a vacant bed (if you get worse)
Vision
-I cant see properly
-Everything is fuzzy
-I cant see with my left/right eye.
-My eye is itchy.
-My eye is stinging/ burning
-What have you done with you eye?
-Whats happened to your eye?
Skin
Rash
Lump
Pruritus
Itch
Scar
Bruising
Spots
Blackhead
Blister
Moles
Swelling
Puffiness
Tingle
Gastrointestinal System
Abdominal pain
Nausea
Vomitus/Vomit
Diarrhea
Constipation
Flatulence
A coated tongue
Abdomen soft, non-tender
No nausea or vomiting
No abnormalities in stool patterns or characteristics
No change in dietary patterns
Bowel sounds present
To take food piecemeal