History –taking

Taking the history is an important part of the examination and often a diagnosis may be made from the history alone. All possible information should be obtained and organized logically to tell the story of the patient’s illness.

The recorded history should begin with the time the patient first noted any symptoms of sickness, body changes, or a departure from good health. Symptoms and events up to the present time should be included. The dates or times at which various symptoms appeared should be noted as precisely as possible. The patient should be encouraged to talk freely, without interruption. Specific leading questions should be asked.

Some questions that will help the patient to give the history are:

• How did your illness start?

• What was the first symptom you noticed?

• How long have you had this?

• How and where does it affect you?

• What followed?

It is important to be specific about the main symptom or symptoms, such as pain in the abdomen or severe headache. Time should not be wasted on vague symptoms such as tiredness, weakness, and loss of appetite. These non-specific symptoms are a part of almost every illness. The patient should be asked if he has experienced similar symptoms or had the condition or problem before. He should be asked for the diagnosis of any similar situation in the past, the treatment that was prescribed and the medicaments he had taken. Also, any medicaments that the patient is currently taking should be noted, because his present illness might be a reaction to medication (for instance, allergy to penicillin or another drug.

2. Remember the following expressions

Тщательно составленная история болезни – carefulhistory

Запись в истории болезни – recordinacasereport

Заполнение истории болезни – fillinginapatient’scard

Жалобы больного- patient’scomplaints

Настоящая жалоба – present complaint

Основная жалоба – chief complaint (CC)

Типичная жалоба – typical complaint

Жалоба на – complaint of smth.

Жаловаться на – complain of smth.

Паспортные данные больного – patient’s passport/identification data

Совокупность сведений о больном и развитии болезни, анамнез – history

Заполнять историю болезни – to fill in a history

3. Answer the questions below.

1. Why is the history-taking is so important?

2. When should the history-taking be started?

3. What aspects should be taken into account while history-taking?

4. Why is it so important to be specific about major symptoms?

4. Make up dialogues using the following expressions

1. На что жалуетесь? – What is your complaint?

2. Что случилось с Вами? – What is the matter?

3. Что еще беспокоит? – What else is wrong with you?

4. Как Вы себя чувствуете? – Howdoyoufeel?

5. Есть еще какие-нибудь жалобы? – Anyotherproblems?

6. Когда появились первые признаки заболевания? – Whendidthefirstsymptomsappear?

7. Как давно Вы болеете? – How long have you been ill?

8. Вы лечились по поводу своей болезни? – Wereyoutreatedforyourillness?

9. В чем состояло лечение? – What was the treatment?

10. Какими болезнями Вы болели в прошлом? – What diseases have you had in the past?

11. Какие болезни Вы перенесли в детстве? – What diseases did you have as a child?

12. Какими детскими болезнями Вы болели? – What childhood diseases did you have?

13. Вы болели скарлатиной (корью, ветряной оспой, краснухой, коклюшем, инфекционным паротитом)? – Have you ever had scarlet fever (measles, chicken pox, rubella, whooping cough, mumps)?

14. Вы болели венерическими заболеваниями (малярией, сахарным диабетом)? - Have you ever had a venereal disease (malaria, diabetes mellitus)?

15. У Вас не было инфекционных заболеваний (туберкулеза, сифилиса, сердечных приступов, припадков)? - Have you ever had an infectious disease (tuberculosis, syphilis, heart attacks, fits)?

16. Вы болели какими-нибудь серьезными заболеваниями прежде? – Haveyoubeenseriouslyillbefore?

17. У Вас есть повышенная чувствительность к каким-нибудь лекарствам? – Areyouallergictoanydrugs?

18. У Вас была (есть) необычная реакция на лекарства, сыворотки? – Have you had (have you) any unusual reaction to any drug, serum?

19. Вы курите? Сколько сигарет в течение дня Вы выкуриваете? – Doyousmoke?How many cigarettes a day do you smoke?

20. У Вас есть пристрастие к наркотикам (спиртным напиткам, какому-нибудь лекарству)? – Have you a narcotic habit (an excessive drinking habit, some drug habit)?

21. Какое количество наркотиков Вы употребляете в течение суток? – Whatamountofnarcoticsdoyoutakedaily?

22. В Вашей семье кто-нибудь (был) серьезно болен? – Isanyoneinyourfamilyseriouslyill?(Has anyone in your family been seriously ill)?

23. В Вашей семье были (есть) больные туберкулезом (сифилисом, раком, сахарным диабетом, заболеваниями почек, сердца, желудка, бронхиальной астмой, сенной лихорадкой, эпилепсией, гипертонией, алкоголизмом)? – Is there any history of tuberculosis (syphilis, cancer, diabetes mellitus, kidney disorders, heart diseases, stomach disorders, heart diseases, bronchial asthma, hay fever, epilepsy, hypertension, alcoholism) in your family?

24. У Вас в семье есть (были) душевнобольные или покончившие жизнь самоубийством? – Has there been anyone in your family who is (was) insane or committed suicide?

25. В Вашей семье еще кто-нибудь имеет подобные жалобы? – In there anybody in your family who has similar complaints?

5. Read and translate the text, remember the points to be specified when requesting radio medical advice