- •Case history/medical documentation
- •I.Basic Parts of Case History
- •II.Taking Medical History
- •III.Medical Examination
- •IV.Abbreviations Used in Clinical Notes
- •V.Medical Kits
- •VI.Reading Medicine Labels
- •VII.Practising Medicine – Case History
- •VIII.Practising Medicine: Case Report
- •IX.Medical Record
- •X.Problem Solving
Case history/medical documentation
Составители: старшие преподаватели кафедры иностранных языков Санкт-Петербургской Государственной Педиатрической Медицинской Академии И.Л.Гальфанович, М.Ю.Дайнеко, Н.А.Мордвинова.
Рецензент: доцент кафедры романской филологии факультета иностранных языков РГПУ им. А.И.Герцена, кандидат педагогических наук В.Д.Макаричева.
Ответственный редактор: заведующая кафедрой иностранных языков Санкт-Петербургской Государственной Педиатрической Медицинской Академии, кандидат филологических наук доцент И.И.Могилёва.
Учебное пособие “Case History/Medical Documentation” предназначено для работы по подготовке студентов разных медицинских специальностей в рамках элективного курса, посвящённого паспортизации пациента.
Данное пособие имеет чёткую направленность на формирование навыков самостоятельной работы аудиторного и внеаудиторного планов и способствует выработке у студентов навыков классификации, анализа и синтеза, логически осмысленного чтения, выделения ключевых моментов в описании клинических случаев.
Учебное пособие состоит из 10 мини-модулей, содержащих задания по различным частям основного документа пациента – карте больного. Упражнения представляют собой вариативный материал – от элементарного заполнения бланков до креативной работы по самостоятельному созданию истории заболевания на основе информации по клинической картине. Структура пособия подразумевает последовательность комплексности, что позволяет использовать его при работе со студентами с разноуровневой подготовкой по программе школьного курса.
Dear medical student!
You are starting a medical career. You are going to become a doctor. There is a great variety of areas of medicine you can later choose. But whatever branch of medicine you will take, you will have to deal with medical documentation, fill in lots of special forms. The wide open world you live in will make you need to take part in international scientific or doctors’ conferences and meetings, to discuss current medical problems with foreign doctors or patients asking for your help. Three English languages of medicine will be necessary for you to do it, they are: the language medical professionals speak to each other, the language of their talks with patients and the language of medical documents. Medical documentation is written with abbreviations, letters and shortened word forms which every doctor understands. This book will help you to master the basics of the three medical English languages, the language of English medical documentation in particular, and to translate to and from these languages.
I.Basic Parts of Case History
Fill in the Case History of Mr./Mrs./Ms./Miss N according to the plan given below (use the special boxes (A, B, C) for details) (some gaps can be left without any information):
Hospital
Register № _____
Department _____
Doctor _____
Admitted to the hospital on _____
Hospitalization days number _____
Discharged from the hospital on _____
Transferred to _____
Died on _____
A)
-
2nd February
Specialized Sanatorium, Sherwood
24
John Smith, MD
Department of Cardiology
2 weeks
B)
-
Tropical Dermato-Venereology Department
Professor Nick Swan
2 weeks
23rd August
25NS
C)
-
Doctor Anna Cornex
Trauma
TD6-01/02/2011
Car injury on 1st February
The injured unconscious person has been brought from Perlax Street
Identification of a patient
Name _____
Surname _____
Sex _____
Age _____
Citizenship _____
Place of employment _____
Profession _____
Diagnosis on admission _____
Chief complaints _____
History of present illness _____
Past History _____
Family History ______
A)
-
Female
Tram driver
Lobar pneumonia
Irish
No cases of pneumonia
Persistent dry cough, pains in the chest, fever
Jane
State Tram Company
Half a year ago – series of colds
3 weeks of non-stopping cough
35
Stompson
B)
-
Peru
Frequent cases of gum and nose bleeding among family members
P.Lumumba University student
Acute form of gangrenous stomatitis
Ulceration of the mucous membrane of the cheek, profuse salivation
Male
20
Tumbu-Hadgeru
The disease developed gradually after some hot days of bad hygiene and started from a burning sensation in the mouth
C)
-
Male
Closed skull injury is suspected
Not known
There is considerable displacement of bone fragments
No information
The patient has some open fractures
Urgent case, no history
Approximately 35 years old
The patient is severely wounded
The patient has multiple soft tissue bruises
System Review and Physical Examination
Laboratory tests/instrumental invesstigations _____
Clinical diagnosis _____
Complications _____
Surgery notes _____
Surgeon _____
Anaesthetist and anaesthetic used _____
Postoperative treatment _____
Doctor’s recommendations _____
A)
-
Blood test – high level of leucocytes
No liquid found in the pleural cavity
No sequalae
Clinically confirmed lobar pneumonia
Adequate airway should be maintained
B)
-
To rinse the mouth with a warm solution of sodium bicarbonate
Clinically confirmed gangrenous stomatitis
There is a facial asymmetry on account of swollen soft tissue
Reddened and edematous mucosa
Treat the oral cavity with antiseptics
C)
-
Operation under general anesthesia
Artificial respiration is being performed
The patient is unconscious
Pupils are dilated, no reaction to light
The patient has depressed respiration
Overdosage should be avoided