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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):

1. 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

2. 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

3. 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