Lecture 7

 Taking History 2

English for medical purposes 1 – Hisham Badr 41

 Taking History 2
 Asking basic questions
You will read an interview between a doctor and his patient. As you read, complete the
Present Complaint section of the case notes below.
SURNAME: Hall FIRST NAMES: Kevin Doctor: Good morning, Mr. Hall. What’s
AGE: 32 SEX: M MARITAL STATUS: M brought you along today?
OCCUPATION: Lorry driver Patient: Well, you see, doctor, I’ve been
having these headaches, you see, and ….
PRESENT COMPLAINT
Doctor: Aha, and how long have they
been bothering you?
Patient: Well, they started about, well it
must have been about three months ago.
Doctor: I see. And which part of your
head is affected?
Patient: Well, it’s, it’s right across the
front here.
Now compare your notes with those made Doctor: Mm. And can you describe the
by the doctor. Explain these sections in the pain?
notes. Patient: It’s a sort of dull, dull and
throbbing kind of pain.
1. SEX M Doctor: I see, and do they come on at any
particular time?
2. MARITAL STATUS M Patient: They seem to be, they’re usually
worse in the morning. I notice them when
3. 3/12 I wake up.
Doctor: Mm. And is there anything that
4. a.m. makes them better?
Patient: Well, if I lie down for a while,
5. “dull, throbbing” they seem to get, they go away.
Why are these words in quote marks (“ “)? Doctor: Yes, and has there been anything
else apart from these headaches?
6. c/o Patient: Well, the wife, my wife, she says
that I seem to be getting a bit deaf.
Doctor: Oh? Well, Mr. Hall, I think I’ll start
by checking your ears to see if there’s any
wax.

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  Language focus 1
Note how the doctor starts the interview

1. What’s brought you along today?

2. What can I do for you?
3. What seems to be the problem?

Note how the doctor asks how long the problem has lasted

1. How long have they been bothering you?

2. How long have you had them?

Note how the doctor asks where the problem is

1. Which part of your head is affected?

2. Where does it hurt?
3. Where is it sore?

Note how the doctor asks about the type of pain

1. Can you describe the pain?

2. What’s the pain like?
3. What kind of pain is it?

 Language focus 2
Note how the doctor asks if anything relieves the pain of headaches:

1. Is there anything that makes them better?

2. Does anything make them worse?

Doctors often ask if anything else affects the problem. For example:

1. What effect does food have?

2. Does lying down help the pain?

English for medical purposes 1 – Hisham Badr 43

  Taking notes
These notes show the doctor’s findings when he examined Mr. Hall. Note the
explanations given for the abbreviations used. What do the other abbreviations stand
for?

SURNAME FIRST NAMES

AGE SEX MARITAL STATUS
OCCUPATION
PRESENT COMPLAINT

O/E
General condition obese, 1.65m tall, 85 kg

ENT wax ++ both sides

RS NAD

CVS P 80/min reg. BP 180/120 HS normal

GIS

GUS

CNS fundi normal

IMMEDIATE PAST HISTORY

POINTS OF NOTE

INVESTIGATIONS
Urine –ve for sugar and albumen

DIAGNOSIS
? hypertension

MANAGEMENT
See 1/52

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Task 4. Study this letter from a GP to a consultant. Write down the questions which a
doctor might ask to obtain the information numbered in the letter.

For example:

4. How long did it last?

8. What was the cause of death?

CLINICAL DETAILS
Date Oct 3rd 2004
Dear Dr. Scott
I would be grateful for your opinion and advice with regard to
(Name) Green, Peter

A brief outline of history, symptoms and signs and present therapy is given below:

This 42-year-old (1)salesman had a severe attack of (2)central chest pain (3)six months

ago which (4)lasted 10 minutes and was (5)relieved by rest. This has recurred several

times (6)after exertion. His father (7)died aged 56 of a (8)coronary thrombosis. Physical

examination was normal and I refer him to you for further assessment in view of his age.

Diagnosis: angina

Thank you for seeing him.

Yours sincerely

1………………………………………………………………………………….
2………………………………………………………………………………….
3………………………………………………………………………………….
5………………………………………………………………………………….
6………………………………………………………………………………….
7………………………………………………………………………………….
Angina pectoris – pain in the mid-chest that sometimes radiates to the shoulder, left arm, jaw, or abdomen.
Usually brought on by physical exertion, the underlying cause is the narrowing of a blood vessel due to
temporary spasm or build-up of plaque. The narrowing causes the heart to receive less blood (and therefore
less oxygen) than it needs.

English for medical purposes 1 – Hisham Badr 45

Task 5. The hospital consultant made these notes of her interview with Mr. Green.
Complete as many of the gaps as you can.

Then listen to the recording and complete the remaining gaps. Use the abbreviations you
have studied in this unit.

SURNAME………………...... (1) FIRST NAMES Peter

AGE……………………(2) SEX M MARITAL STATUS M
OCCUPATION………………………………..(3)
PRESENT COMPLAINT
………………………………...(4) chest pain radiating to L arm. Started with severe attack t
dyspnoea. Pain lasted ……………………(5) relieved by rest. Has occurred since on exertion.

O/E
General condition

ENT

RS Chest …………………….(6)

CVS ………………(7) 70/min …………………..(8) 130/80 …………………..(9) normal

GIS

GUS

CNS

IMMEDIATE PAST HISTORY

POINTS OF NOTE

INVESTIGATIONS

DIAGNOSIS

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Doctor: Come in, Mr. Green. Come and sit down here. I’ve had a letter from your doctor
and she tells me that you’ve been having pain, pain in your chest.
Patient: Yes, and in my arm, and also tingling in my fingers and …
Doctor: Yes, now when did you first notice this pain?
Patient: Well, I suppose about six months ago.
Doctor: And can you remember when it first came on?
Patient: Yes, well I remember, I got a bad pain in my chest when I was shopping. It was so
bad I couldn’t breathe and …..
Doctor: And where, in which part of your chest did you feel the pain?
Patient: Well, right across my chest.
Doctor: And how long did it last?
Patient: Ooh, about ten minutes.
Doctor: And what did you do when it happened?
Patient: I had to stop and wait for it to go away.
Doctor: So, have you had this, the pain again since then?
Patient: Yes, I often get it when I overdo things, and when I …..
Doctor: Well, I think at this stage I’d like to examine you, your chest. So if you could strip
to your waist.
Patient: Right. There we go.
Doctor: That’s fine. I’ll just check your pulse first of all. Fine. That’s fine. It’s quite normal,
seventy per minute.
Patient: Right.
Doctor: Now your blood pressure. Fine. That’s quite normal too. 130 over 80.
Patient: Oh, I’m pleased to hear it.
Doctor: Now I’m going to listen to your heart, so I want you to breathe normally … Mm,
your heart sounds quite normal.
Patient: Well, that’s a relief.
Doctor: Well now, I want you to take deep breaths in and out while I check your lungs. In.
out. In. out. Fine. They’re completely clear. Well, Mr. Green, the pain you’ve been having
sounds very much like the pain of what we call angina, and this, well, this occurs when not
enough oxygen is getting to the heart. Now I’d like to check a few tests, and, following that
I’ll be able to advise some treatment for you….

English for medical purposes 1 – Hisham Badr 47

  Reading skills: Scanning a case history
Read the following case history and find and underline this information about the
patient as quickly as you can.
1. Previous occupation
2. Initial symptoms
3. Initial diagnosis
4. Condition immediately prior to admission
5. Reason for emergency admission
6. Duration of increased thirst and nocturia
7. Father’s cause of death
8. Alcohol consumption

Case History
Mr. Wildgoose, a retired bus driver, was unwell and in bed with a cough and general
malaise when he called in his general practitioner. A lower respiratory tract infection
was diagnosed and erythromycin prescribed. Two days later, at a second home visit,
he was found to be a little breathless and complaining that he felt worse. He was
advised to drink plenty and to continue with his antibiotic. Another 2 days passed
and the general practitioner returned to find the patient barely rousable and
breathless at rest. Emergency admission to hospital was arranged on the grounds of
“severe chest infection”. On arrival in the ward, he was unable to give any history
but it was ascertained from his wife that he had been confused and unable to get up
for the previous 24h. He had been incontinent of urine on a few occasions during
this time. He had been noted to have increased thirst and nocturia for the previous
2 weeks.
His past history included appendicectomy at age 11 years, cervical spondylosis 10
years ago, and hypertension for which he had been taking a thiazide diuretic for 3
years. His father had died 62 years of myocardial infarction and his mother had had
rheumatoid arthritis. His wife kept generally well but had also had a throat infection
the previous week. Mr. Wildgoose drank little alcohol and had stopped smoking 2
years previously.

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  Case History
Complete the personal details and present complaint section of the case notes below.
SURNAME Hudson FIRST NAMES William Henry
AGE SEX MARITAL STATUS
OCCUPATION
PRESENT COMPLAINT

Doctor: Ah good morning, Mr. Hudson. I see from your card that you’ve just moved into the area
and perhaps you could tell me a little about your previous health as I won’t get your records for
another month, month or two, and then we can deal with your present problem.
Patient: Well, I’ve actually, I’ve always been very fit up till now but ….
Doctor: Have you ever been in hospital?
Patient: Oh, only when I was a child. I had an appendicitis when I was eight.
Doctor: Aha, and what’s your job, what do you do?
Patient: Well, I’m a, I work for the post office. I’m a postmaster.
Doctor: And I see that you’re what, 58, now, and have you?
Patient: Yes.
Doctor: Have you always been with the post office?
Patient: Yes, well apart from my time in the army you know ….
Doctor: I see. And you’re married. Any family?
Patient: Yes, two girls and a boy.
Doctor: Fine. That’s fine. Now can you tell me what seems to be the problem today?
Patient: Well, it’s this terrible pain. I’ve got this terrible pain in my back. I’ve had it for more than
a week now and it’s …..
Doctor: I see, and can you show me exactly where it is?
Patient: it’s down here, here.
Doctor: And does it go anywhere else?
Patient: Yes, it goes down my left leg. And I feel pins and needles in my foot.
Doctor: I see, and is it there all the time?
Patient: Yes, yes it is. It’s keeping me awake, awake at night and I can’t get out into the garden.
I’ve been taking aspirins but the pain, it just comes back again.
Doctor: And was there anything that started it off?
Patient: Well, yes, yes. I’ve been trying to sort out the garden at my new house and I don’t know,
I may have been overdoing things a bit.

English for medical purposes 1 – Hisham Badr 49

  Language focus 3
Note how the doctor asks about the systems:

1. Have you any trouble with your stomach or bowels?

2. What’s your appetite like?
3. Any problems with your waterworks?
4. What about coughs or wheezing or shortness of breath?
5. Have you noticed any weakness or tingling in your limbs?

Task 6. Match each of the suspected problems in the first column with a suitable
question from the second column.

Suspected Problem Question

1. Depression a. Have you had any pain in your chest?
2. Cardiac failure b. Do you ever get wheezy?
3. Asthma c. What sort of mood have you been in recently?
4. Prostate d. Any problem with your waterworks?
5. Coronary thrombosis e. Have you ever coughed up blood?
6. Cancer of the lung f. Have you had any shortness of breath?
Task 7. Match each of the medical terms for common symptoms in the first column with
a term which a patient would easily understand or might use from the second column.

Medical term Non-medical term

1. paraesthesia a. swelling, puffiness
2. productive cough b. indigestion
3. anaesthesia c. coughing up phlegm or spit
4. retrosternal chest pain d. trouble holding your water
5. orthopnea e. cramp in the leg muscle which comes and goes
6. stress incontinence F. numbness
7. dysmenorrhoea g. sleeplessness
8. dyspepsia h. out of breath, out of puff, breathlessness
9. oedema i. painful periods
10. intermittent claudication j. pain behind the breast bone
11. insomnia k. pins and needles
12. dyspnoea l. shortness of breath when you lie down

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  Study this extract from a case history
The patient was a 59-year-old man, head of a small engineering firm (1), who complained
of central chest pain (2) which occurred on exertion (3) and was sometimes accompanied
by sweating (4). He smoked 40 cigarettes a day (5). The pain had first appeared three
months previously (6) and was becoming increasingly frequent (7). He had noticed some
weight gain recently (4 kg) (8) and also complained that his hair had become very dull and
lifeless. He felt the cold much more than he used to. He denied any palpitations (9) or ankle
oedema (10).

What question might a doctor ask a patient to obtain the numbered information in the
case history? You may ask more than one question for each piece of information. For
example:

1. What’s your job?

2. What’s brought you along today? Which part of your chest is affected?

3……………………………………………………………………………………………………………………….
4……………………………………………………………………………………………………………….………
5……………………………………………………………………………………………………………………….
6……………………………………………………………………………………………………………………….
7……………………………………………………………………………………………………………………….
8……………………………………………………………………………………………………………………….
9……………………………………………………………………………………………………………………….
10……………………………………………………………………………………………………………………..

English for medical purposes 1 – Hisham Badr 51

Task 8. You will read a discussion between a general practitioner and a consultant.
Complete the case note below.
SURNAME FIRST NAMES
AGE SEX MARITAL STATUS
OCCUPATION
PRESENT COMPLAINT

GP: Hello, Jim. I wonder if you could see a patient for me?
Consultant: Certainly, John. What’s the story?
GP: Well, it’s Mr. Alan Jameson, a 53-year-old carpenter. He’s been an infrequent attender
in the past but he came to see me this morning complaining of pain in his right leg and in
his back (a).
Consultant: And when did this start?
GP: Well, it came on about six weeks ago (b) and it’s become gradually more severe over
the past couple of weeks.
Consultant: Was the pain localized?
GP: No, poorly. At first he thought he’d just pulled a muscle. But it’s got so bad that he
hasn’t been able to do his work properly. It’s also been getting to the stage where the pain
is waking him up at night (c), it’s been so severe, and he’s also noticed some tingling in his
right foot (d). He’s having difficulty in carrying on with his work (e). He’s also lost three
kilos (f) and has become quite depressed.
Consultant: Has he had anything similar in the past?
GP: No, not exactly, but he also suffered from intermittent pain in the back (g).
Paracetamol gave some relief (h) but didn’t solve the problem completely.
Consultant: Apart from that, any other problems with health in the past?
GP: No, perfectly OK.
Consultant: Did you find anything else on examination?

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GP: Yes, as well as the pain he has numbness in his toes and on the right foot.
Task 9. Look at the information in italics in the transcript above. What questions might
a doctor ask to obtain this kind of information from a patient? For example:
…… it came on about six weeks ago (b)
Question: When did you first notice the pain?
(a)……………………………………………………………………………………………………………………….
(c)……………………………………………………………………………………………………………….………
(d)……………………………………………………………………………………………………………………….
(e)……………………………………………………………………………………………………………………….
(f)………………………………………………………………………….…………………………………………….
(g)……………………………………………………………………………………………………………………….
(h)……………………………………………………………………………………………………………………….
 Case history: William Hudson
You will hear an extract from a consultation with Mr. Hudson. The doctor has not seen
him for seven years. He has just retired from the Post Office. As you listen, complete the
Present Complaint section of the case notes below.

SURNAME Hudson FIRST NAMES William Henry

AGE 65 SEX M MARITAL STATUS
OCCUPATION Retired postmaster
PRESENT COMPLAINT

Here is an edited version of the consultation. Complete the doctor's questions. Then
check your answers with the recording and the Tapescript.

Doctor: Good afternoon, Mr. Hudson. Just have a seat. I haven't Seen you for a long time.
………………. (1) brought you here today?

English for medical purposes 1 – Hisham Badr 53

Patient: Well, doctor, I've been having these headaches and I've lost a bit of weight.

Doctor: And how long .............(2) the headaches ...............(3)bothering You?

Patient: Well, for quite a while now. The wife passed away four months ago. I've been
feeling down since then.

Doctor: ..............(4) part of your head is affected?

Patient: Just here, on the top, it feels like a heavy weight pressing down on me.

Doctor: .............(5) they affected your eyesight at all?

Patient: No, I wouldn't say so.

Doctor: They…………(6) made you……………(7) sick?

Patient: No.

Doctor: Now, you’ve told me you've lost some weight.…………….(8) your

appetite……………(9) like?

Patient: I've been off my food.

Doctor: .............(10) about your bowels, ……………..(11) Problems?

Patient: No, I'm quite all right.

Doctor: What …………….. (12) your waterworks?

Patient: Well, I've been having problems getting started and I have to get up two or three
times at night

Doctor: ……………….. (13) this ...............(14) on recently?

Patient: No, I’ve noticed it gradually over the past few months.

Doctor: ………………… (15) pain when You................(16) water?

Patient: No.

Doctor: ………………(17) you …………………… (18) any blood?

Patient: No.

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