III.Medical Examination

Choose the proper set of questions (from part B) for the following points (from part A):

Part A:

1) Identification

2) CC (Chief Complaints)

3) HPI (History of Present Illness)

4) PH (Past History)

5) FH (Family History)

6) √ (Diagnosis)

Part B (I):

1) - What is the problem?

- I have difficulty in breathing, especially at night. You know, it constantly keeps me awake. I quite often have episodes of wheezing. The shortness of breath comes more and more frequently.

2) - Are you married?

- Yes.

- Have you got any children?

- No.

- Are your parents alive?

- Yes. They are healthy.

- And what about your grandparents?

- They died of heart failure when they were elderly.

- Your uncles and aunts?

- In good health.

- Have you ever heard your relatives talk about asthma in your family?

- No, never.

3) – Your diagnosis is bronchial asthma. It is a very serious disease. I advise you a change of climate, first of all.

4) – Who are you?

- Ann Brag.

- How old are you?

- 26 years old.

- What’s your address, please?

- 32, Forest Street, Eastpoint, Missouri.

5) – What diseases did you have in your childhood?

- Measles, mumps, chicken-pox.

- Any surgery?

- No, doctor.

- Will you tell me more details about your present illness?

- Yes, of course, I started having wheezing when I was 5. My parents told me that I had had shortness of breath after attacks of children diseases.

6) – When do you think the disease began? How long has it been troubling you?

- I was taken ill when I was 5 years old. Our family doctor advised my parents to take me to the sea for a change of air.

- How did you feel there?

- Fine. I had no trouble while staying at the sea. But when we returned home my breathing ailment recurred. I don’t feel well in cold and rainy weather.

- What treatment did your physician prescribe you?

- Inhalations. But my condition became worse, more severe. You know, tobacco smoke irritates me badly. My husband is a heavy smoker.

- Oh, my dear, you need only pure fresh air. He should know this.

Part B (II):

1) - Are you married?

- Yes.

- Do you have any children?

- Yes, two boys and a girl.

- Do you have any close relatives living?

- Yes, my parents and a brother are alive and healthy.

2) – What’s your name?

- __________ (fill in the gap)

- How old are you?

- __________ (fill in the gap)

- Where do you live?

- __________ (fill in the gap)

- What’s your occupation?

- __________ (fill in the gap)

3) – What diseases have you had?

- Whooping cough, mumps, measles.

- Have you ever had pneumonia or kidney trouble?

- I often caught colds in winter and had pneumonia, that’s all I remember.

- Any harmful habits?

- I neither smoke nor drink.

4) – What’s your trouble?

- I have persistent coughing and pains in the chest.

5) – I suspect you have pneumonia as a complication after influenza. But to confirm the diagnosis you have to have your tests of blood, urine and X-ray examination made.

6) – When did you notice the first signs of the disease?

- I had influenza a week ago, but I followed the doctor’s recommendations and recovered rather quickly.

- When did you feel chest pain for the first time?

- Two days later.

- Can you relieve it by any drug?

- No.

- Do you cough up any phlegm?

- Yes, a little.

Part B (III):

1) - Are you married?

- Yes, but we are childless.

- Do you have parents? Are they well?

- My mother died of diabetes, my father of heart trouble.

- Have you any sisters or brothers?

- No, I have no relatives.

2) – Have you ever been sick?

- In childhood I had some children diseases but I don’t remember which of them.

- Have you ever been operated on?

- Five years ago I had urethral resection made.

- Any bad after-effects of the surgery?

- No, not any.

- Did you seek medical attention to clear the cause of your trouble?

- Yes, my family doctor advised me some drugs and to have a good rest, but with no effect.

3) – What’s your opinion, are these epileptic attacks?

- No, I’m sure you have been suffering from heart trouble for a rather long time. Your seizures have been connected with cardiac standstill. It is difficult to manage. I think of installing a pacemaker, with your coming for check-ups yearly.

4) – What problem do you have?

- I have been having a feeling of heaviness in my chest for more than a year.

- Any pain?

- Not any, Doctor, but three or four times when I was gardening, I had recurrent episodes of convulsions, brief seizures.

- Do you have headaches?

- No, not often.

- Do you feel worried or nervous?

5) – What’s your name?

- I’m Mrs. Gross.

- How old are you?

- I’m 50, doctor.

- Your address?

- 38, Rockland Road.

- What do you do for living?

- I’m a housewife, I have a large family.

6) – A feeling of heaviness in the chest, convulsions, tiredness, seizures, loss of consciousness.

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