in Relation to Genomic Nursing, a Family History Helps Nurses Quizlet

краевое государственное бюджетное профессиональное

образовательное учреждение

«Ачинский медицинский техникум»

(КГБПОУ АМТ)

Учебное пособие для студентов

по дисциплине «Иностранный язык»

Example History

для специальностей

31.02.01 Лечебное дело

34.03.01 Сестринское дело

Ачинск, 2014

Введение

Данное учебное пособие для студентов соответствует требованиям ФГОС СПО для специальностей 31.02.01 Лечебное дело, 34.03.01 Сестринское дело .

Использование информационных технологий в учебном процессе является существенным фактором практического занятия. Студенты самостоятельно находят нужную информацию, активно включаются в поисковую деятельность, применяя Интернет-ресурсы.

Задачи:

1. Развивать у студентов речевую, языковую, компенсаторную, учебно-познавательную компетенции.
2. Развивать у студентов готовность к сотрудничеству.

three. Повысить мотивацию к изучению английского языка.

Занятия в интерактивном формате дают возможность студентам приобретать знания от учителя к ученику, активно добывать их в учебном общении друг с другом.

Преимуществом данного занятия является использование интерактивной методики обучения английскому языку (сложная кооперация, использование аутентичных материалов), информационных технологий, а также технологии критического мышления.

Read and acquire the post-obit words and word combinations:

the medical history, case history

история болезни

to study

сообщать, составлять отчет

proceeds obtain

добывать, получать

refer

относиться

enable

давать возможность

analyze

вносить ясность

the impact

влияние

the comment

комментарий, отзыв

suicide attempts

попытки суицида

appreciate

оценивать

exacerbate

раздражать, обострять (боль)

siblings

единокровная сестра (брат)

the research

расследование, запрос

Taking a Medical History

Admitting a patient to hospital includes two major steps: on the one hand the medico has to accept the patient`southward medical history , where he is given the opportunity to report his complaints and to answer the physician`s questions.

The medical history or (medical) case history of a patient is data gained past a physician past asking specific questions, either of the patient or of other people who know the person and can give suitable data with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to equally symptoms, in contrast with clinical signs, which are ascertained by direct exam on the part of medical personnel. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is ofttimes lengthy and in depth, equally many details about the patient's life are relevant to formulating a management plan for a psychiatric disease.

The data obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and handling programme. The treatment plan may and then include farther investigations to clarify the diagnosis.

Instance history structure

i. Introduction

It should consist of a few articulate and curtailed opening statements, which typically include information on:

Name (pseudonym)

Age

Marital status

Occupation

Cardinal problem

2. History of Presenting Complaint

Annotate on the touch on of the disease on the patient'south life

Consider piece of work, social relations and self-intendance.

Note details of previous treatment

Include data on who administered management (when and where), what the treatment was (and preferably the dose and duration of handling), and the patient'south responses to treatment.

Integrate electric current problem and psychiatric bug

three. Past Psychiatric History

The post-obit points are relevant in this department:

details of previous episodes of illness

previous psychiatric admissions/treatment

outpatient/community treatment

suicide attempts/drug and alcohol abuse

iv. Past Medical History

In this department of the written report, y'all need to show that you a) empathize the relationship between medical weather and psychiatric symptoms, and b) can capeesh the complexity of medical problems that might be exacerbated past psychiatric weather.

Record medications. Demonstrate an understanding of the significance of drug therapy on psychological function and, if advisable, focus on medications taken past the patient that may influence the patient'southward psychological function.

five. Family History

Include details of:

Parents and siblings, nature of the relationships between family unit members

Whatever family tensions and stresses and family models of coping

Family history of psychiatric affliction (incl. drug/booze abuse, suicide attempts)

half dozen. Personal History/Development

Apply the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section:

Early development

Childhood

School

Adolescence

Occupation

Menstrual history

Sexual history

Marital history

Children

Social network

Habits

Leisure

7. Review of Systems (ROS)

In this portion of the history, all organ systems not already discussed during the interview are systematically reviewed. ROS is a final methodical research, prior to physical examination. Information technology provides a thorough search for farther, as yet unestablished, disease processes in the patient.

Following are the topics to be reviewed for each organ organisation:

7.1. Constitutional

Whatever history of contempo weight modify

Any history of anorexia (loss of appetite), weakness, fatigue, fever, chills, indisposition, irritability or nighttime sweats

seven.2. Skin

Any history of peel rashes—astute or chronic, is it unilateral or bilateral

Whatever history of allergic pare rashes

Whatever itching of the skin

Any history of unhealed lesions (probably due to: diabetes; poor nutrition; steroids and other causes of decreased amnesty, specially AIDS)

Any history of bruising, bleeding

7.3. Head

Whatever history of headaches

Loss of consciousness (may exist due to cardiovascular, neurologic causes, anxiety, metabolic causes, etc.)

History of seizures. Are they general (with or without loss of consciousness) or focal? Are at that place whatever motor movements?

Is in that location any history of head injury?

7.four. Eyes

Check for vision, history of glaucoma ( could cause hurting in the optics), redness, irritation, halos (seeing a white ring around a low-cal source), blurred vision

Any irritation of the eyes, excessive tearing, which can be associated with frequent allergic symptoms?

seven.5. Ears

Any recent alter in hearing

Any pain in the ears or ringing in the ears (tinnitus)? belch?

Any history of vertigo (dizziness)?

7.6. Lymph Glands

Any history of lymph glandular enlargement in the neck or elsewhere? Are they tender/painless? How were they get-go noticed?

Are they freely mobile or are they adherent to the underlying tissues?

7.7. Respiratory System

History of frequent sinus infections

Postnasal drip

Nosebleeds

Cough (with/without expectoration)

Colour of sputum, when present

History of sore throat

History of shortness of breath on exertion or at rest

Any history of wheezing (may be due to asthma, allergies, etc.)

Hemoptysis (blood in the sputum): may be due to dental causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral stenosis or CHF (congestive heart failure). Determine if information technology is a blood-tinged sputum or there is frank claret in the sputum.

Any history of bronchitis, asthma, pneumonia, emphysema, etc.

seven.viii. Cardiovascular Organization

History of chest pain or discomfort

History of palpitations: were the palpitations associated with syncope (loss of consciousness)?

History of either hypertension or hypotension

Does the patient experience whatever paroxysmal nocturnal dyspnea (shortness of breath during sleep, in the middle of the nighttime)? Is there any SOB in relation to exercise or exertion?

Whatever history of orthopnea (shortness of breath when lying flat in bed)? Does the patient employ more than i pillow to sleep? Has this always been the case, or has the patient recently started using more pillows?

History of edema (site of edema—legs, face, etc.)

Any history of leg pains, cramps? Are they relieved by rest (this is suggestive of intermittent claudication) or is information technology unremitting? (this is muscular)

Whatever history of murmur(s), rheumatic fever, varicose veins?

Whatever history of hypercholesterolemia, gout, excessive smoking, i.e., atmospheric condition which can lead to or worsen heart disease

seven.nine. Gastrointestinal System

History of bleeding gums, oral ulcers or sores

History of dysphagia (can the patient signal out and describe where the difficulty swallowing exists?)

History of heartburn, indigestion, bloating, belching, flatulence

History of nausea: is it related to nutrient? Is information technology one of the many symptoms due to GI (gastrointestinal) disease?

Vomiting: is there any associated weight loss, psychosocial factors, or are medications causing it?

Hematemesis (airsickness claret). Inquire for associated ulcer history, food intolerance, abdominal hurting or discomfort

Jaundice: is there a viral crusade, gallstones, associated family unit history?

History of diarrhea/constipation

Any change in color of stools

7.10. Genitourinary

History of polyuria (excessive urination) due to diabetes, renal disease, unknown crusade, etc. Check if this has been a recent change

History of nocturia (getting upward at night to get to the bath). Is this a contempo change?

History of dysuria (painful urination). If it is because of urinary tract infection (UTI), the patient volition experience frequency and urgency in addition to dysuria. STD volition as well exist associated with similar symptoms (was handling for STD completed?)

History of renal stones, pain in the loins, frequent UTIs

7.11. Menstrual History

Appointment of LMP (final menstrual period). Always precede this question by informing the patient that she has to get x-rays done, so you need to know if she is pregnant; thus, the need to know her LMP

Whatsoever history of menorrhagia (heavy periods)

History of employ of birth control pills

7.12. Musculoskeletal System

History of joint pains—determine location: is it acute or chronic? Unilateral or bilateral? More in the morning or evening? Are there associated systemic symptoms?

Any history of rheumatoid arthritis, osteoarthritis, gout, etc.

7.13. Endocrine Organisation

History of symptoms due to diabetes, i.due east., polyuria, polydypsia, polyphagia1, weight change

History of thyroid symptoms: rut/cold intolerance, increased/decreased heart rate, goiter, etc.

History of adrenal symptoms: weight change, easy bruising, hypertension, etc.

1 Polyuria — excessive urination; polydypsia — excessive thirst; polyphagia — excessive appetite

7.14. Nervous Arrangement

History of stroke, CVA, TIA

History of muscle weakness, involuntary movements: they may be tremors, seizures, or feet, etc.

History of sensory loss of any kind: anesthesia, paresthesias, or hyperesthesias2

Is there any alter in memory, especially contempo alter.

two Anesthesia → no sensation; paresthesia → altered sensation, usually a pins and needles sensation; hyperesthesia → increased sensation

8. Concluding History

It is important at this point to collect the relevant data about the patient (all positive findings) and construct a logical framework of the instance.

EXERCISE 1 . Найдите в тексте эквиваленты следующих слов и словосочетаний :

Поступление в больницу; информация, полученная врачом; с целью получения информации; обеспечение медицинского ухода; сообщенные пациентом; формулировка плана лечения; поставит диагноз; самолечение; предыдущее лечение; злоупотребление алкоголем; оценка сложности медицинских проблем.

Practise two . Ответьте на вопросы по тексту:

1. What is the medical history?

2. How do medical histories vary?

3. What does the introduction include?

4. What integrate History of Presenting Complaint ?

5. What is a final methodical research?

EXERCISE 3. Дополните следующие предложения:

1. The medical history of a patient is information … by a dr. past asking specific questions.

2. The medically relevant complaints are referred to equally symptoms, which are ascertained by direct … on the part of medical personnel.

3. … … … would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc.

4. The treatment plan may then include farther investigations to clarify … .

5. History of Presenting Complaint Include information on who administered … , what the treatment was, and the patient's responses to treatment.

6. By Medical History demonstrates an agreement of … of drug therapy on psychological function and, if appropriate

7. Family History includes details of nature of the relationships betwixt family unit … .

8. … provides a thorough search for farther, every bit yet unestablished, disease processes in the patient.

EXERCISE 4 .Прочитайте диалог. Запишите вопросы доктора.

Exercise 5. Найдите предложения, в которых сказуемое стоит в страдательном залоге и переведите их.

Practise vi. Составьте ментальную карту «Структура истории болезни».

EXERCISE 7. Изучите истории болезни (см. Приложение 2). Ответьте на вопросы.

Заключение

Учебное пособие для студентов предназначено для проведения вводного занятия по теме « Instance History ». Оно основано на материалах учебников и сайтов Великобритании и США и включает в себя интерактивные упражнения для работы с лексикой и текстами, презентацию , обучающую программу

Занятие рассчитано на студентов с разным уровнем знаний, умением работать в парах и малых группах в интерактивном формате и пользоваться Интернет-ресурсами. Задания составлены с учетом индивидуальных особенностей студентов, т.е. на основе дифференцированного, личностно-ориентированного подхода и соответствуют требованиям ФГОС СПО для специальностей 060101 Лечебное дело, 060501 Сестринское дело .

Библиографический список

1. A c 1000 e r m a n, Terrence & Carson S t r o n g. A Casebook of medical ethics. New York, Oxford: Oxford University Printing, 1989.

2. G l e northward n d i n n i northward grand/ H o l m due south t r ö m. English in Medicine, form volume. Klett, 1998.

3. G r o s south, Peter. Medical English. Stuttgart: Thieme, 2000.

4. L o due north g thou o r e / W i l g i n s o northward / T ö r ö k. Oxford Handbook of Clinical Medicine. Fifth

5. Edition. Oxford: Oxford University Press, 2001.

6. P a r k i northward s o n, Joy. A Manual of English language for the Overseas Doctor. Edinburgh: Churchill Livingstone, 1998.

7. S a n d 50 due east r, P.L. Medically speaking. English for the medical profession. BBC English past Radio & Tv, 1982.

8. T h i e m e L e 10 i m e d Pocket Dictionary of Medicine – English-German/ German language-English language. Stuttgart: Thieme Verlag, 2002.

9. D o r 50 a due north d`s Illustrated Medical Dictionary English-English, pocket. West.B. Saunders Co., 2000.

10. S t e d one thousand a northward`s Medical Dictionary, Student Value Pack (Book with CD-ROM) – English-English. Williams & Wilkins, 2000.

11. http://nswhealth.moodle.com.au/DOH/Observe/content/02_scenario_breathe/scenario_breathe_02.htm

Приложение 1

one) Introducing oneself/ Specific Greetings

- Good morning, Mr. Bradford, my proper noun is Anne Golding. I am a medical student ( you may say : "educatee dr.") doing a clerkship on this ward.1 I heard about the problems you have with your

heart. Would you listen if I examined your chest over again?

- Hello, Mrs. Rutherford, my proper name is Robert Weiss. I am a Seniormedical pupil. The doctor volition be here shortly, may I inquire you a few questions meanwhile?

- Good morning Mr. Hewling, information technology's nice to run into you. Delight come up in and accept a seat. What has brought you forth today? What seems to be your problem? Could you depict it for me, please?

- Skilful afternoon, Mrs. Johnson. I see from your nautical chart that you lot came to united states of america lament of pain in the stomach. Is at that place anything else you want to tell me before we expect at your tum more

closely?

- Hello, Mr. McLeod. Nosotros met last week, didn`t we? Well, I have been going over some of the results of your tests with a colleague of mine and we are pleased with your progress.

- Skillful forenoon, you are Christopher, aren`t you? I heard a lot of squeamish things about you. But your Mum told me you accept a tummy anguish. Is that correct? Now, Chris, I want yous to tell me all about it.

- Hullo, Mr. Smith. Could you please ringlet up your sleeve and let me take your blood pressure level?

- Hello once more, Mr. Wright, I have come to accept a claret sample. Could you please roll up your sleeve? It might be a chip uncomfortable. It is like a precipitous scratch.

GATHERING INFORMATION

I) Personal Information: Time of assessment (!)

Name (surname/ Christian name)

Age (DOB)

Sex Occupation Marital Status2

Ii) c/o (= lament of = Chief Complaint)

Try to find a brusque phrase describing the patient`s problem. Exercise non give a diagnosis!

III) HPC (= History of the presenting complaint)

When did the trouble begin?

How long has it been bothering you? DURATION

How did it starting time? (gradually/ suddenly) Way OF ONSET

How oft does it come on? FREQUENCY

Have you always had anything like this before?

What brings information technology on?

Does anything make it ameliorate/ worse?

Does it occur in certain positions? RELIEVING/ AGGRAVATING FACTORS

Does anything keep with it? East.g. Are yous feeling ill, are y'all sweating? ASSOCIATED SYMPTOMS

Where does information technology hurt?

Is information technology a constant hurting/ does it come up and go?

Does it interfere with your daily activities? PAIN

Questions

What is the hurting like?

Is it ...biting?

...stabbing?

...pinlike?

...sharp?

...pinching?

...cramping?

...throbbing?

...blistering?

...burning?

...sore?

...wrenching?

...stinging?

...numb?

...gnawing?

...dull?

...excruciating?

Four) PMH (= Past medical history)

Apart from your present complaint how is your general wellness?

What previous illnesses have you had?

Do you remember any childhood diseases?

Have yous always been seriously ill?

Have you e'er been hospitalised/ had an operation?

What well-nigh cleaved bones?

Do you endure from whatever chronic affliction?

V) Med (= Medications)

Are you taking whatsoever medicines/ tablets?

Are you on the pill?

Exercise yous demand sleeping tablets?

VI) All (= Allergies)

Have whatsoever medicines ever upset you?

Are you allergic to penicillin, contrast agents,

foods or anything else?

Have yous been immunised against tetanus/ polio/ influenza/ hepatitis A, B/ pertussis /

diphtheria?

VII) FH, SH (= Family unit history, social history)

Does anyone in your immediate family suffer from a chronic disease?

Are your parents (other members of the family unit) alive and well?

Ask for the circumstances of the patient'southward accommodation, education, task, leisure interests.

Ask whether he is married/ has children.

8) Alcohol, tobacco, recreational drugs

Practice you smoke?

How often do you beverage booze?

Do you have whatever kind of drugs?

Приложение 2

Case Histories

Case History I: A Patient with Abdominal Pain

The patient was a 33 twelvemonth former salesman, who came to the emergency room because of

" bellyache". He had been in good health until the previous evening, when he went to a political party.

In that location he had several bottles of beer. He sampled the chili and ate custard. About an 60 minutes later on

the meal of chili he suddenly felt an excruciating abdominal hurting, accompanied past nausea. The hurting appeared to arise from the area under his omphalus. He broke out in a sweat and had to lie

down. Later nearly 5 min the pain was completely gone and he felt fine again. He fifty-fifty engaged in a match of volleyball later that evening. When playing in the front end row close to the net he jumped and stretched for the ball. Immediately thereafter, the abdominal pain recurred. Since then he had been restless; his pain never let up completely. In the last 2h he had non had whatsoever desire for food; he had been nauseated 6 times and vomited 4 times. Each assail was accompanied by worsening of his precipitous abdominal pains. The pain was now located in the left abdomen and nether the belly button. It worsened later on coughing or sneezing. The patient`s last bowel movement had been 2 days ago.

Questions

What diagnostic possibilities would yous consider at this point and what would you practise to work them up?

Case History Two: A policeman with chest hurting

A 47 yr-quondam policeman was taken to the emergency room because of substernal chest

pains. The attack began 45 min before admission, while he was on the phone. The

hurting radiated to his back and did non budge until admission. It was accompanied by

shortness of breath, dizziness, and nausea; he vomited in one case.

The patient`south wife reported that he had had a like assault 2 hours before while lifting a

case of beer. Furthermore, on the morn of this mean solar day the patient had had a fainting spell, followed by palpitations and restlessness. The patient had a past medical

history of high blood pressure. Family unit history: his father died suddenly at 51 years of age.

Question

What possible diagnoses do you lot retrieve of and what would you doto confirm them at this point?

Case History Three: A Dying Adolescent

Lucy was fifteen years sometime and ane of four children. Her mother was a registered

nurse and her father a automobile operator in a local factory. She was admitted to

the hospital with a ii- day history of nausea, airsickness, and persistent

abdominal hurting. A gastrointestinal Ten-ray serial and a gastroscopy confirmed an obstruction in the initial portion of the small intestine. Exploratory surgery revealed a large tumor which appeared to arise in the pancreas and had penetrated the intestine. The tumor

had also spread to regional lymph nodes, the liver, and one kidney. Pathological examination of specimens removed at surgery confirmed the diagnosis of carcinoma of the pancreas.

Within 2 weeks subsequently surgery, an intensive six-week course of chemotherapy with three drugs was undertaken. After this course, there was a marked regression of the tumor in the

pancreas. All other tumor had disappeared entirely. A 2d half-dozen calendar week cycle of treatment was initiated, merely by the end of this course, Ten-ray and physical examination revealed that the tumor

was again growing apace and metastases were appearing. Throughout the early menses of treatment, the patient was very interested in how treatment was going. She was also very cooperative through a serial of difficult procedures. She oft expressed to the nurses a concern most the bear on of her illness on her parents and siblings. Still, she was as well commonly very

reserved in interchanges with infirmary staff members, and she never initiated discussions of her condition. In addition, the patient's mother was very protective of the child and, as the

health professional in the family, assumed the controlling role. At all times, the family, particularly the mother and the patient, appeared to be very close-knit and loving.

After failure of the kickoff regimen of chemotherapy, a dissimilar anticancer drug therapy was attempted. However, two weeks after the patient was admitted to the hospital with acute

gastrointestinal bleeding. Endoscopic test revealed bleeding in three sites in the initial portion of the small intestine, suggesting that the tumor was eroding blood vessels. Over the

adjacent three days the gastric bleeding continued, and the patient occasionally vomited large clots of blood. The patient'southward blood volume was kept stable by daily administration of crimson cells.

Generalized abdominal pain was controlled with a moderate dose

of intravenous morphine. The doctor visited the room each day to discuss the patient'due south

condition with the family unit. These discussions were held at the bedside and were focused on solar day-to-day changes in her condition.

The patient remained awake and alert during this menstruation, simply she was always very tranquility. She did not enquire whether she might shortly die, and the issue was not raised with her. On a couple of occasions, the female parent expressed a concern outside the room nearly conducting discussions of her daily condition in the patient's presence. But in individual conversations with the nurse

practitioner, the child said that she was aware that she might non become well plenty to return abode, although she would like to exercise so. She expressed farther concern about her parents. She also said she believed God would make her well again. I week after hospitalization the patient's prognosis was discussed privately with her mother. The mother inquired about

the availability of other chemotherapeutic agents. She was told that no other drugs with established dosages or effectiveness were bachelor for the handling of pancreatic cancer, although some experimental agents might be tried. It was emphasized that the

take chances for regression of the tumor was slight, and at best life could be prolonged but briefly. At any rate, chemotherapy could not be administered until the bleeding abated and the doc

said that it would probably not be possible to stop the bleeding. He suggested that it might be appropriate not to send the patient to the intensive care unit should her status worsen; doing so might discipline her to needless discomfort. He as well raised the possibility of discontinuing the claret transfusions. The mother was unprepared to accept either proffer, asked that the

transfusions be continued at their present rate, and held out the hope that additional chemotherapy might exist possible. Finally, the question raised about involving the patient in the decision-making process. But the female parent also firmly resisted this possibility, indicating that she did non wish to intensify the anxiety and

suffering of her daughter.

Question

Point out the md'south dilemma and try to evaluate the options he has.

Приложение 3

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