问诊

• Hello.may (can) I help you?    您好，我可以帮您吗？
• What seems to be bothering you?    您觉得哪儿不舒服？
• Do you have a record?    您有病历吗？
• I'll transfer you to the surgery department.    我给您转到外科去
• what's wrong with you?    您怎么了？
• Sit down, please.    请坐
• When did the symptom begin ?    症状是什么时候开始的？
• Are you bring anything up when you cough?    咳嗽时有痰吗？
• Have you had any chills (chest pain)?    您有发冷（胸痛）吗？
• Have you ever coughed up blood    您咳血过吗？
• All right. Let me examine you. Would you mind taking off your coat?    好吧。我给您检查一下，您不介意脱掉外衣吧？
• Take a deep breath, please    请深呼吸
• I'll take a white blood count and give you a x-ray examination.    我将给您做白细胞计数和胸片检查
• I'm sure it's pneumonia. You should be admitted to the hospital.    我可以确定您得了肺炎，应当住院。
• How long have you been like this?    这种症状有多久了？
• When did you begin to notice these symptoms?    您什么时候发现这些症状的？
• What's the trouble?    怎么啦？
• What's your trouble?    你怎么啦？
• What's the trouble with you?    你哪儿不舒服
• What's troubling you?    你哪儿不舒服
• What's your complaint?    你哪儿不舒服
• What's bothering you?    你哪儿不舒服
• What can I do for you?    你哪儿不舒服吗？
• What's up with you?    你生什么病了？
• What's the matter with you?    你哪儿不舒服？
• Is there a sense of distension and numbness?    你有胀和麻木的感觉吗？
• When did the trouble start?    什么时候开始不舒服？
• When did the pain start?    什么时候开始痛的？
• When did it happen?    什么时候发生的？
• When did your diarrhea start?    你什么时候开始腹泻的？
• What kind of pain do you feel?    你觉得怎么个痛法？
• What kind of stool did you notce, watery or mucous?    你注意大便的样子了吗？是水样的还是粘液样？
• What did you vomit, food or blood?    你吐的是什么？食物还是血？
• What kind of treatment have you had?    你过去用什么方法治疗过？
• What about your heart?    你的心脏怎么样？
• What's your stool like?    大便是什么样子？
• Where is your pain?    你觉得哪儿痛？
• Where does it hurt?    哪儿痛？
• What's your appetite?    你的胃口怎么样？
• How's your appetite those days?    近来食欲怎么样？
• How long have you been feeling like this?    你有这样感觉多长时间了？
• Have you been coughing and sneezing?    你是不是一直咳嗽和打喷嚏？
• Have you got a high fever?    你发烧吗？
• Any fever?    发烧吗？
• Have you got any chronic disease before?    你以前有过慢性病吗？
• Does it bleed often?    常出血吗？
• Do you feel short of breath?    你觉得气急吗？
• Do you feel pain after meals?    是饭后痛吗？
• Do you feel abdominal pain when you go to the toilet?    你去厕所时感到腹痛吗？
• Do you have a pain in your stomach?    你肚子痛吗？
• Do you have a cough?    你咳嗽吗？
• Do you remember how many times you went to the toilet?    你记得去过多少次厕所吗？
• Did you receive any treatment before you came to the hospital?    来医院前你接受过治疗吗？
• I'd like to listen to your chest.    我想听听你的胸部。
• I'd like to run a few tests.    我想给你做些检查。
• You must have a blood (sputum) test.    你需要验验血（痰）。
• You have the flu.    你得了流行感冒。
• You have got enteritis.    你得了肠炎。
• You have caught a chill.    你着凉了。
• You seem to have picked up some sort of infection.    你好象染上什么传染病了。
• When did you first notice it?    你什么时候感觉到的？
• What kind of pain is it?    怎样疼？
• Did you run any temperature?    你发过烧吗？
• Have you seen anybody about it?    你找医生看过吗？
• I think you need some examinations first.    我想您首先需要做一些检查。
• You'd better take an X-ray picture to see if there is a fracture.    你最好拍张X片子，看看有没有骨折。
• I'd like to give you an X-ray.    我想给你透视一下。
• The X-ray reveals a dislocation of your elbow.    X光片显示你的肘关节脱位。
• I'll give your some medicine.    我给您开点药。
• I'm afraid you have to receive an amputation.    恐怕你需要截肢。
• It is the only way to save your life.    这是挽救您生命的唯一办法。
• My diagnosis is that you have a malignant tumor osteogenic sarcoma.    我的诊断是您得了恶性骨肉瘤。
• The fractured leg must be kept in plaster.    必须把骨折的腿打上石膏。
• Open your mouth, please.    请张开嘴。
• It's too worn out to be filled.    这颗牙坏得太历害了，无法补了。
• Have you ever had an injection of procaine(pencillin) before?    你以前打过普鲁卡因(青霉素)吗？
• Does it hurt when you eat anything sweet or sour?    你吃甜的或酸的东西时疼吗？
• I'll be cleaning them now. let me know if it hurts.    我现在给你洗牙，疼就说一声。
• The wound hasn't healed enough yet.    伤口还没完全愈合。
• You'll have to wait for one more month, or they won't fit properly.    你得再等一个月，要不然装上也不会合适。
• What kind of material do you prefer?    你想要什么材料的？
• Would you like to have a look at some of the samples?    你要看一看样品吗？
• You can try the gold-alloy ones.    你可以试一下合金的。
• You've got to come five times before the work can be finished.    你得来五次才能做好。
• Shall I fix you a plastic crown?    我给你装一个塑料牙套好吗？
• We'll give you an X-ray to find out the condition of the root.    我们要给你拍一张X光片，看看牙根的情况。
• You'll have to leave your old denture here.    你得把原先的假牙留下。
• You should leave your denture in your mouth all day.    你应该整天戴着你的假牙。
• How are your periods? Are they heavy?    你的月经怎么样？量多吗？
• Have you had any pain in this area during your menstruation?    你来月经时间时这一部位疼吗？
• How about your menstruation cycles?    你的经期准吗？
• Have you had any discomfort?    有什么不舒服吗？
• When was your last menstruation?    你上一次月经是什么时候？
• How long is your period usually?    通常你的月经周期多长？
• Have you had any bleeding, watery discharge or pain in your lower abdomen?    你有过阴道出血、水性分泌物以及下腹部疼痛的情况吗？
• How long has this been bothering you?    这种不适感有多久了？
• Did you feel contractions regularly?    你感觉到过有规律的宫缩吗？
• What's the amount of beeding? Is it profuse?    出血量多少？很多吗？
• Do you mind if I examine you briefly?    我简单地给你检查一下，你介意吗？
• Please take off your shoes and panties and lie on the examining table.    请你脱去鞋和裤子，躺到检查床上。
• I'll run some tests on you.    我要给你做些化验。
• That's due to your heavy period.    这是因为你月经过多造成的。
• I think it's carcinoma of the breasts.    我认为是乳腺癌。
• We'll send her to the delivery room for further observation.    我们想把她送到产房进一步观察。
• Do you see dimly from distance or close by?    您看远不清还是看近不清？
• Do you see objects dimly?    您看东西模糊吗？
• What kind of pain do you have?    怎么痛法？
• Is there much secretion from your eyes?    眼里的分泌物多吗？
• Does light affect your eyes?    您的眼睛怕光吗？
• Do you see an object as if there were two that overlap?    您看东西有重影吗？
• Do you see my hand moving?    您看见我的手在动吗？
• Try not to blink.    不要眨眼。
  

• Are you near-sighted or far-sighted?    您是近视眼还是远视眼？
• Come back in a week for a re-examination of your eyes.    一周以后来复查您的眼睛。
• I'll send you some medicine (pill, ointment).    给你开些内服药（丸药，膏药）。
• I'll give you some tablets.    我给你一些药片。
• I'll make up a prescription for you.    我给你开一张药方
• I'll write out a prescription for you right now.    我马上给你开张药方。
• I'll give you a prescription. Take it to the chemist's     我给你一张处方，到药房去配药。
• I think you'd better take Chinese traditional medicine.    我认为你最好服用中药。
• Take the medicine according to the instruction.    请按医嘱用药。
• I'd like to put you on some medicine and have you come back in several days.    给我开点药，几天以后你再来。
• One tablet each time, three times a day after meals.    每日3次，每次1片，饭后服。
• Take one capsule every four hours.    每4小时服用一胶囊。
• Take a dose three times a day.    每天服3次，每次一剂。
• ut the ointment on the sore once a day.    把软膏涂在患处，每日1次。
• Shake well before using it.    使用之前要摇匀。
• The medicine will relieve your pain.    这种药会给你止痛。
• This medicine can keep your fever down.    这种药可给你退烧。
• This is for oral administration.    这是口服药物。
• This lotion is for external use only.    这种洗剂只可外用。
• You're suffering from acute appendicitis and must have an operaton.    你得的是急性阑尾炎，要动手术。
• I'm sorry to say you'll have an immediate operation.    很遗憾，你得快动手术。
• Your meals should be frequent but small in quantity.    应该少吃多餐。
• Your meals should be light and digestible.    吃的东西要清淡容易消化。
• You should take some more vitamines    你应该多吃些维生素。
• You should go on a diet.    你应该节食。
• You can't touch anything sweet.    你一点甜食也吃不得
• Fatty food will do you harm.    高脂肪食物对你有害处。
• Avoid eating greasy food.    不要吃油腻食物。
• Drink plenty of water.    要喝大量的水。
• You are scheduled to have a GI and a GB test tomorrow morning.    您预定明天早上作胃肠检查和胆囊检查。
• lease don't eat or drink anything until the test is over. I'm sorry but you have to have an absolute empty stomach.    要检查结束之前请不要吃喝任何东西。我很抱歉，您得完全空着胃。
• This test is done on a 24 hour basis from 6 in the morning until 6 in the following morning.    这个检查是以早晨六点到第二天早上六点的二十四个小时为单位进行的。
• You may have something to drink whenever you wish.    你可以随意喝你想喝的东西。
• lease use this container for your urine.    请将尿放进这个容器内。
• Breathe in deeply. That'll do.    深呼吸，好了。
• Now take a breath.    现在吸气。
• Now take a deep breath with your mouth open.    现在嘴张开作深呼吸。
• Now turn around, please.    现在请转过去。
• Take it easy and don't move.    放松点，别动。
• Show me exactly where it is.    请告诉我准确的地方。
• Show me your tongue, please.    请把舌头伸出来。
• Show me which one it is?    告诉我是哪个？
• Show me where it hurts the most.    告诉我哪儿最疼。
• You'd better have a chest X-ray.    你最好透视一下胸部。
• Your tongue is rather coated.    你的舌苔比较厚。
• Dull tongue with whitish and greasy coating.    舌质暗，苔白腻。
• How do you feel now?    现在你觉得怎么样？
• Where does it hurt?    哪儿痛？
• Which of your arms is sore?    你哪个胳膊痛？
• Do you feel weak?    你感到身体虚弱吗？
• Do you have any pain in your belly?    你腹部痛吗？
• Does it hurt here?    这儿痛吗？
• You are scheduled to have an operation.    您要预定动手术。
• First of all, we will prepare you by shaving.    首先，我们要给你备皮，做手术前的准备工作。
• I will give you an NG tube right now.    我马上给你插鼻胃管。
• Urinating after an operation is very hard.    手术后排尿很困难。
• Did you pass any wind by rectum?    有气从肛门排出吗？
• You can lie on your side more often.    您可以经常翻身。
• You look a little better today.    今天看来你精神好一些。
• You can get out of bed today.    你今天可以下床了。
• Shall we limit the amount of visitors?    要不要限制访客的人数呢？
  

• Hello, Ms. Smith. Let me introduce myself. My name is Dr/Nurse X. I’m a doctor/nurse here in the hospital. It is nice to meet you. I would like to ask you a few questions and do a physical exam. So let’s get started.
  

• First, I need to ask you some questions. Then I’ll do a physical exam. After that, we’ll discuss everything, and I’ll be glad to answer any questions that you may have.
• So, what caused you to come in today?
• Please show me exactly where the pain is.
• Does the pain ever move anywhere else?
• How would you describe the pain/feeling/discomfort?
• On a scale of 1 to 10, if 10 is the worst pain you’ve ever had, where is the pain on this scale?
• How bad is the pain on a scale of 1 to 10?
• Have you ever had (anything like) this before?
• When did this problem start?
• How often do you have this?
• Do you have any idea of what might have brought this on?
• Was anything different or unusual happening when this first started?
• Has the pain changed any over time ? How?
• Does anything make it worse?
• Does anything make it better?
• In addition to your headache/ Beside the , have you noticed anything else? How about ?
• OK ,Ms. , now I need to ask you some questions about your health in general . Have you ever had problems with ? How about?
• Have you had any recent injuries or accidents?
• Have you ever had surgery?
• Do you have any allergies (strange reactions), such as to medications, foods, animals, or plants?/ Are you allergic to anything?
• Are you taking any medication?
• Have you had any changes in your urinary habits?
• Have you had any changes in your bowel habits?
• Have your eating habits changed in any way?
• Has your weight changed any?
• Have you noticed any changes in your sleeping pattern?
• When was your last menstrual period?
• Have you ever been pregnant? Yes
• How many times?/How many children have you had?
• Have you ever had a miscarriage or abortion? (If miscarried, in what trimester?)
• Do you use any method of birth control?
• Now I need to ask you some important questions about your personal habits .Whatever you tell me will be kept confidential.
• Are you currently sexually active?
• Do you use condoms/other contraceptives consistently?
• How many sexual partners have you had over the past 6 months?
• Do you have one sexual partner , or more?
• Are you sexual partners men, women, or both?
• Have you ever had a sexually transmitted disease?
• Tell me about your work situation? Is there physical strain?
• Is it stressful?
• Are you exposed to hazardous materials?
• It will be helpful for me to know something about your lifestyle/ home life.
• Have you ever used tobacco in any form?
• How many packs per day and for how long?
• Do you drink alcohol?
• Do you use any recreational drugs?/ Do you ever inject drugs?
• Has anyone in your family ever had this same problem? How about ?
• In addition to that, are there any serious illnesses or conditions in your family?
• Thanks for answering all these questions, now I need to do a physical exam. So I’ll just wash my hands.
  

• OK, Ms. Smith. Now I’d like to talk over what I’m considering so far. First, let me summarize. You told me that you have had___ over the past month; you’ve also___. You said that___ and that___. Your sister and mother have both been treated for___. In the physical exam, I observed that___ and ___. So, Ms. Smith, I think that this problem may involve your ___. It’s most likely ___.”
• Based partly on this , I think you may have . Of course, I need to run some tests to find out for sure . I need to have , and . . As soon as I study the results, let’s meet again to go over everything. At that time , I’ll explain the details, and we’ll talk about your options for treatment , Okay?
  

Obtaining a Patient History and general patient assessment
Chief Complaint

• -What seems to be the problem?
• -How can I help you?
• -What brings you here?
  

History of present illness

• After the patient tells you his/her chief complaint
• -Please tell me about it
• If it is a chronic problem, you might want to start here:
• -When were you last well?
• or
• -How long have you been ill/sick?
• If the patient has many problems and you want to ask about  the most important one
• -What seems to bother you the most?
• During history taking, if a patient stops talking, you might want to stimulate your patient to continue.
• -Go on, I’m listening.
• If you need a  patient to talk more about a particular aspect:
• -Can you elaborate on what you said about ____?
• If what your patient told you isn’t clear:
• -Tell me what you meant by feeling …..
• or
• -You said you were feeling …., What do/did you mean?
• If the patient says something that is sad or is embarrassing, you can say:
• -I understand.
• or
• -I know how you feel.
• or
• -I know what you must have felt.
• If you want your patient to tell the history in steps:
• -What happened next?
• -What then?
• During ‘History of present illness’ or ‘Systematic Review’
  

Past medical history

• 1. Have you ever had ____?
  

• ex.  –pain in your chest?
•       -tuberculosis?
•       -hepatitis?
•       -angina?
• Present medical history
• The question below is to ask about current symptoms and is not asking about what disease a person suffers. This question might be asking about small things that are annoying the patient.
• 2. Have you been troubled with _____?
• ex. –wheezing?
•      -coughing?
•      -headaches?
•      -hiccups/hiccoughs?
• This question is used to ask about current symptoms that are causing the patient to really suffer?
• 3. Have you been suffering from ______?
• ex. –diarrhea
•      -constipation
•      -stomach pain
• This question is used to ask if the patient has been noticing something different about themselves but it isn’t necessarily causing them to suffer or to be in pain.
• 4. Have you recently noticed_________?
• ex. –lumps in your breasts?
•      -weight loss?
•      -tremors in your hands?
•      -Have you recently had trouble sleeping?
•      
• You don’t always have to ask complete/full sentences. It can be very short phrases like:
• 5. Any-shortness of breath?
•              -pain in your stomach?
•              -blood in your urine?
•              -other problems?
  

Past Medical History

• -Have you had any serious illnesses/accidents in the past?
• -What did the doctor say?
• -Where were you treated?
• -Have you had any operations?
  

Family History

• -Does anyone in your family have any illnesses that I should know about?
• -Is there any family history of _____?
• -diabetes?
• -hypertension/high blood pressure?
• -heart disease?
• or
• -Has anyone in your family had_____?
  

Personal History

• -Where do you come from originally?
• -What work do you do?
• -Are you married?
• -Are you living with someone?
• -Do you have any children?
• -Do you smoke? How many times a day/week?
• -Do you drink alcohol? How much? How long have you been drinking?
• -Do you have unprotected sex?
  

Medication History

• -Are you taking/on any medications at the moment?
• -Are you allergic to any medication?
• -What are your reactions to these medications?
• -Are you addicted to any drugs?
  

• Physical Examination
• 1. Asking for something
• -Could you please _____
• or
• -Can you_________
• ex. Can you please breathe in and out slowly and deeply?
• 2. An  instruction
• -Just breathe in and out.
• or
• -Breathe in and out.
• If the patient does what he/she is told, say:  “Good
• -Let me examine you, please
• or
• -Can I examine you?
• -OK!, I’d better have a look.
• or
• -Let me have a look.
• -Can you please get on the exam table and lie down?
• or
• -Lie down and make yourself comfortable.
• -Let me have a look at your ______ (body part).
• -Can I take your blood pressure?
• -Let me feel your pulse?
• -Can I take your temperature?
• -Look up please.
• -Open your mouth wide, well done.
• -Stick your tongue out.
  

Cardiovascular System

• -Could you please remove/take off your shirt?
• -Let me listen to your heart.
• -Now turn on your left side.
• -Please lean forward.
• -Take a deep breath and hold it in.
• -Just breathe out and hold it.
• -Now breathe normally.
  

Respiratory System

• -Just sit up straight, please.
• -Please take deep breaths in and out.
• -Now breathe in and out through your mouth.
• -I’m going to tap on your back now.
• -Say one, two, three.
  

Abdominal Exam

• -Just let me examine your stomach.
• -Can you please undo your skirt/pants and take them down a little? Thank you.
• -Put your arms by your side.
• -Is it painful anywhere?
• -With one finger just point to where the pain is.
• -Can you tell me where it hurts?
• -Let me feel your stomach/tummy.  (Tummy-is a word for stomach used with children).
• -My hands are a little cold, sorry.
• -Let me know if it hurts.
• -Is this tender? (tender = hurt)
• -I’m going to press a little harder.
• -I’m pressing down now. Tell me if it hurts when I let go.
• -Can I listen to your bowel sounds?
• -Please cough.
• -Please turn to your left/right.
• -Let me help you up.
• Rectal exam
• -May I examine your rectum/back passage? Please turn on your left side and bend your knees.
• -This may be a little uncomfortable.
• -It won’t take too long.
• -Just bear down a little, well done.
• -Push down as though you want to poo/move your bowels.
• Neurological Exam
• CNS
• I. -Please close your eyes-sniff and tell me what it is.
• II. -May I have a look into your eyes please?
• -Just look straight ahead.
•       III, IV, VI -Just look at the spot on the wall.
•            
•                       -Now look at my nose and tell me when you can see my fingers moving.
•            
•            -Look to your left/right.
• -Look up/down.
• -Follow my finger with your eyes.
•        V -Clench your teeth hard.
•        VII -Can you raise your eyebrows?
•    
• -Can you please frown?
• -Close your eyes tight and don’t let me open them.
• -Show me your teeth.
• -Now blow out your cheeks, like this.
•         IX, X –Open your mouth wide and say ‘aah’
•         XI–Can you shrug your shoulders?
• -Now keep them up and don’t let me push down.
• or
• -Keep your shoulders up and don’t let me push them down.
• -Can you turn your head to the left against my hand?
•        XII –Please stick your tongue out.
• PNS
• -Hold your arms up-don’t let me push them down.
• -Bring your arm up.
• -Push my hand away.
• -Make a fist and don’t let me push it down.
• -Squeeze my fingers tight.
• -Spread your fingers apart and don’t let me push them together.
• -Lift your leg up straight. Don’t let me push it down.
• -Try to part your legs against my hands.
• -Now try to bring your legs together.
• -Bring your knee up please. Can you bend your knee please?
• -Now stop me from straightening your leg.
• -Straighten your leg against my hand.
• -Push your foot up against my hand.
• -Push your foot down against my hand.
• Coordination
• -Could you please touch my finger and then touch your nose?
• -Could you please run your heel up and down the front part of your other leg?
• -Now change sides.
• Sensory
• -Tell me if this is sharp or dull.
• -Tell me if this is hot or cold.
• -Say ‘yes’ when you feel me touching you.
• -I’m going to move your toe up and down. Tell me if it is up or down.
• Plantar response
• -I’m going to run my finger along the sole of your foot. It may tickle.
• Knee jerk
• -Just rest your knee on my arm. Try to relax and don’t tense up.
• Biceps
• -Put your hands on your chest.
• -Bend your elbow slightly-well done.
• Internal Medicine
• Fever
• The patient might say:
• -I have fever/temperature.
  

History Taking

• -Tell me about your fever.
• -How long have you been feeling unwell?
• -What time of the day do you have your fever?
• -Have you been shivering?
• -Is there a pattern to your fever?
• -Do you have it everyday or every other day?
• -Have you been travelling?
• -Where have you been recently?
• -Do you have cough or a cold?
• -Do you have a headache too?
• -Do you have aches and pains in your joints?
• -Do you have a rash?
• -Do your calves ache?
• Tired/No Strength
• The patient might say:
• -I don’t have any energy.
• -I feel tired all the time.
• -I just don’t feel right.
• -I feel awful. I feel run down.
  

History taking

• -Do you have a fever?
• -How has your weight been?
• -Have you gained or lost weight recently?
• -Do you feel sweaty all the time?
• -Have you noticed your eyes turning yellow?
• -Do you have any weakness in your arms and legs?
• -Do you sleep well at night?
• -What time do you get up in the morning?
• -Are you worrying a lot?/Do you have a lot on your mind?
• -Do you think you are overworked?
• -Do you have diarrhoea?
• Weight loss
• The patient my say:
• -I’ve been losing weight.
• -I’ve lost weight.
  

History Taking

• -Are you eating normally?
• -How’s your appetite?
• -Have you lost your appetite?
• -Do your hands shake?/-Do you have any tremors in your hands?
• -Do you have any stomach pains?
• -Is there any blood with your stool?
• -Are you always thirsty?
• -Do you urinate more frequently/often and a large amount of each time?
• or
• -Are you going to the toilet to pee/pass water more often and a larger amount each time?
• Nausea/Vomiting
• The patient might say:
• -I’ve been feeling so sick/I’ve been feeling nauseous.
• -I’ve been throwing up./-I’ve been vomiting.
  

History Taking

• -Can you keep anything down?
• -Do you vomit blood?
• -Do you vomit digested or undigested food?
• -Do you vomit only when you cough?
• -Do you have indigestion?
• -Do you suffer from peptic ulcer?
• -When was your last period?
• -Have you been taking any pain killers?
• -Have you been eating seafood?
• -Have you been eating anything you should not?
  

Diarrhoea

• The patient might say:
• -I’ve got diarrhoea.
• History taking
• -How often do you go to the toilet?
• -Is it watery?
• -Does it have a strong smell?
• -Is there any mucus or blood?
• -What colour is your stool/diarrhoea?
• -Does anyone else in your family have diarrhoea?
• -Do you also have cramps in your stomach?
• -Do you feel tired and run down?
• -Are you thirsty all the time?
• -Have you got flatulence? Are you passing wind/gas?
• Coughing
• The patient might say:
• -I’ve been coughing.
  

Patient history

• -Is your cough a dry or productive cough?
• -Is there any phlegm?
• -What is the colour of the phlegm?
• -Do you cough up blood?
• -Is your throat sore?/Do you have a sore throat?
• -Do you have a runny nose?
• -Do you have any shortness of breath?
• -Do you have pain in your chest?
• Chest Pain and Related Symptoms
• The patient might say.
• -I’ve got pain in my chest./I’ve got chest pain.
  

History Taking

• -What was your chest pain like?
• -How would you describe the pain?
• -How long do they last?
• -How often are you getting them?
• -Do they come on at any particular time?
• -Have you ever had the pains at night?
• -Do you feel sick when you have these pains?
• -Does it hurt all the time?
• -Can you tell me exactly where it hurts?
• -Did it stay right there or did it travel anywhere else?
• -Did it go down your left arm to your fingers?
• -Did it go up to your jaw?
• -Was it crushing or was it stabbing?
• -Did you pass out when you had the pain?
• -Do you get tired easily?
• -Do you get out of breath easily?
• -Do you have palpitations?
• -Have you ever had dizzy spells?
• -Does it come on only when you breathe in deeply or cough?
• -Did it get better when you rested?
• -Does it come on when you are hungry?
• -Does it come on when you’ve got an empty stomach?
• -Do you get it after a heavy meal?
• -Is it brought on by exercise?
• -Do you get shortness of breath when you walk or climb stairs?/Do you have trouble climbing stairs?
• -Do you get out of breath if you lie flat?
• -Do have difficulty breathing?
• -At night do you have to get up suddenly and gasp for a breath?
• -Do you have pain in your calves when you walk? Does it get better if you rest?
• -Are your ankles swollen?
• -Do you wheeze when you breathe?
  

Stomach Ache

• The patient might say:
• -I’ve got a stomach ache.
• -I’ve got pain in my abdomen/stomach/belly.
  

History Taking

• -Tell me where the pain is exactly.
• -Is it beneath your breast bone?
• -Is it constant or does it come and go?
• -Is it sharp or dull?
• -Does it move/go anywhere else?
• -Does it move/go through to your back?
• -Do you burp/belch a lot?
• -Do you like spicy foods?
• -Is it worse after a spicy meal?
• -What makes it better?
• -What makes it worse?
• -What brings it on?
• -Is it related to food?
• -Do you like fatty food?
• -Do you get up in the middle of the night because of it?
• -Have you been taking any steroids?
• -Do you suffer from an ulcer?
• -Do you have indigestion?
• -Is it getting worse?
• -Is it so bad that you have to bend over?
• -Have you ever had heartburn?
• -Does it hurt if you move?
• -Does it help if you lie still?
• -Is it worse after eating?
• -Does it feel like a hunger pain?
• -Is it worse if you move around?
• -In which position are you most comfortable?
• -Have you taken any medications for it?
• -Do you eat your meals regularly?
• -Have you felt any lumps in your stomach?
• -Has it happened to you before?
• -When? How many times and what did you do then to make it better?
• -When was the last time you passed wind/gas?
• -When was the last time you opened your bowel?
• -What is your colour is your stool?
• -Have you lost weight recently?
  

Neurology

• Fainting/Passing out/Blacking out
• -Tell me what happened.
• -Was there anyone with you at the time?
• -Were you standing at the time?
• -Did you hit your head?
• -Have you fainted before? …. How often?
• -What were you doing when it happened?
• -Were you straining?
• -When did you last have anything to eat?
• -Were you feeling sick or sweaty before you fainted?
• -Could you remember the events just before fainting?
• -Do you feel dizzy if you look upwards?
• -Do you suffer from epilepsy?
• -Did you have any chest pain just before you fainted?
  

Headache

• -Tell me where it hurts.
• -Is it at the front or the back of your head?
• -Is it throbbing?
• -Is it like a tight band around your head?
• -Does it feel like a stabbing pain?
• -Does your headache start in the temple on one side and then spread to the whole side?
• -Did it come on suddenly and explosively?
• -How often do you get your headaches?
• -How long does it (the headache) last?
• -What seems to bring your headache on?
• -What makes it better?
• -Do you see flashing lights before your eyes?
• -Do you have any blurred vision?
• -Do you see double?
• -Have you noticed any strange/funny sensations deep in your eyes?
• -Is it worse when you bend or cough?
• -Do you feel as if your head is going to burst/explode?
• -Do you have any pain behind your eyes if you move them around?
• -Does it make you vomit?
• -Do bright lights hurt your eyes?
• -Have you been drinking?
• -Is it difficult for you to concentrate?
  

• Numbness
• Common symptoms
• -My legs feel like ‘jelly’
• -I can’t feel my legs.
• -My legs just give way.
• -I can’t put any weight on my legs.
• -I’ve got numbness in my fingers.
  

History taking

• -When did it happen?
• -What were you doing?
• -Did the weakness come on suddenly or gradually over a week or several months?
• -Have you been drinking heavily?
• -Were you drunk?
• -Have you had a back injury before?
• -How long did the weakness last?
• -Have you got any feeling in your fingers and toes?
• -Do you have pins and needles in your arms/legs?
• -Do you have numbness and tingling in your arms and legs?
• -Any trouble with your balance?
• -Do you suffer from high blood pressure or diabetes?
• -Do you get muscle fatigue easily after some exercise?
• -Do you choke on your food?
• -Do you chock if you drink some water?