PRESENT ILLNESS - Asking basic questions

Kinh Thi Thu Oct 20, 2011 11:07 am

1. Starting an interview are:

1. What can I do for you?

2. What seems to be the problem?

3. What’s brought you along today?

4. What’s wrong with you?

5. How can I help?

6. Can you tell me have you any trouble with your stomach or bowels?

A bad dose of flu

Swollen ankles

Terrible constipation (táo bón)

A pain in my stomach

A palpitation: hồi hộp đánh trống ngực

2. Asking About Duration: How long the problem has lasted:

1. How long have they been bothering you?

2. How long have you had it/them?

3. When did they/it start?

A fortnight (nửa tháng, 15 ngày)

For almost a month

3. Asking About Location: How the doctor ask where the problem is:

1. Which part of your head is affected?

2. Where does it hurt?

3. Where is it sore?

Note: “hurt” is a verb, we use it like this: my foot hurts.

“sore” is an adjective we can say: my foot is sore or I have a sore foot.

4. Show me where the problem is?

5. Which part of your (head) is affected?

6. Does it stay in one place or does it go anywhere else?

4. Asking about type of pain and severity of problem

1. What is the pain like?

2. What kind of pain is it?

3. Can you describe the pain?

4. Is it bad enough to (wake you up)?

5. Does it affect your work?

6. Is it continuous or does it come and go?

7. How long does it last?

8. What sort of mood have you been in recently?

It’s a dull sort of ache: đau âm ỉ

a feeling of pressure: đau như bóp nghẹt, đè nén

like a knife: đau như dao đâm

a burning pain: đau nóng rát

very sore: rất đau

5. Asking about relieving or aggravating factors, If anything relieves the pain, anything else effects the problem

1. Is there anything that makes it better/worse?

Better means improved or relieved. It doesn’t mean cured.

Better được hiểu là cải thiện hoặc làm dịu chứ không phải điều trị

2. Does anything make it worse or better?

3. What effect does food have?

4. Does lying down help the pain?

5. How long does it last?

6. Asking About Precipitating Factors

What seems to bring it on?

Does it come on at any particular time?

7. Asking About Systems

1. Have you any trouble with (passing water) ?

2. Any problems with (your chest)?

3. Have you noticed any (blood in your stools)?

4. Do you ever suffer from (headaches)?

5. Do (bright lights) bother you?

6. Have you (a cough)?

7. Can you tell me more about that?

8. What’s your appetite like?

9. Apart from your (head aches) are there any other problems?

To rephrase if the patient doesn’t understand, try another way of expressing the same function for example:

10. What caused this?

11. What brought this on?

Was it something you tried to lift?

8. General Information / Personal Details

What’s your name?

How old are you?

What’s your job?

Where do you live?

Are you married?

Do you smoke?

How many do you smoke each day?

Do you drink?

Beer, wine or spirits?

Beer, wine or alcohol?

9. Asking About Medication

Have you taken anything for it?

Did (the tablets) help?

10. Family History

Are your parents alive and well ?

What did she/he die of?

How old was she/he?

Does anyone else in your family suffer from this problem?

11. Previous Health /Past History

How have you been keeping up to now?

Have you ever been admitted to hospital?

Have you ever had (headaches) before?

Has there been any change in your health since your last visit?

12. Asking about other symptoms

Apart from your (headaches) are there any other problems?