Gastrointestinal

— Do you have a good appetite? Do you have lack of appetite?

— When did you lose your appetite?

— Do you ever have any excessive thirst?

— Do you ever have any pain in your stomach or bowels?

— Does the pain have any relation to your meals?

— Is the pain relieved by the ingestion of food?

— Do you ever have pains on an empty stomach?

— Do you ever have hunger pains in the stomach?

— Do you ever have pain in the pit of the stomach after meals?

— Do you have belching? Is it of a sour or bitter taste?

— Do you usually belch a lot after eating? Do you suffer from a hiccup?

— Is there any burning sensation in the stomach? When? Does nausea trouble you?

How often (when) does it trouble you?

— Do you watch a diet?

— Have you ever vomited? When do you vomit?

— Have you ever thrown up blood? Do you suffer from indigestion?

— Have you ever had severe bloody diarrhea?

— Do you constantly suffer from bad constipation?

— Do you have any trouble with your bowels?

— How many times a day do you have stools?

— Do you move your bowels every day?

— What colour is the stool (light yellow, dark brown, dark green, red, black, whitish,

clay-coloured, burgundy red, tarry, discolored)?

— Have you ever noticed blood, mucus, pus in stools?

— Do you suffer from constant stomach trouble?

— Are there any night pains? What relieves the pains?

— Has a doctor ever said you had stomach ulcers?

— Have you ever had jaundice (yellow eyes and skin)?

— Have you ever had serious liver or gallbladder trouble?

— Do you ever have bellyache?

— Do you ever have abdominal cramping (colics)?

— Do the pains subside after applying a hot-water bottle?

Texts and dialogues

At the Doctor’s Consulting Room

P:May I come in, Doctor?

D: Sure. Come in, please. Sit down here.

P: Thank you.

D: Well. What is your name?

P: My name is ____.

D: ____, I must fill in your patient's card. Could you give it to me?

P: Yes of course. Here you are.

D: Well. You should answer some of my questions.

P: O.K. I am ready.

D: How old are you?

P: I am __.

D: When and where were you born?

P: I was born in 1980 in ___.

D: Are you married?

P: No, I am single.

D: I see. Now tell me, where do you work or study?

P: I am a second year student of medical University.

D: Pleased to hear that. OK, now let's talk about your condition. What do you complain of?

P: You see, doctor, I feel rotten.

D: What troubles you?

P: Oh, doctor, it is my sore throat.

D: Really? Does it hurt much?

P: Oh, yes. And I cough and sneeze too.

D: Is the cough dry?

P: Yes it is.

D: What about your temperature? Is it high?

P: Yes. I have a fever. My temperature is 38 degrees.

D: Oh, I see. Your condition is poor. And what about headache?

P: Yes I have a splitting headache and my nose is running too.

D: Do you have muscular pains?

P: Yes, I do, and I am very weak.

D: Yes, I see. Now I must examine you. Will you strip to the waist please?

P: Yes, I am ready. Will you listen to my heart?

D: Yes, and to your lungs too... Give me your arm. I'll take your blood pressure.

P: Is my blood pressure normal?

D: Yes, it is. Now I must feel your pulse. Give me your hand. OK.

P: Usually I have no problems with the heart.

D: Yes, it is in order. But...

P: What is the matter with me, Doctor?

D: I suppose it is the flue.

P: Yes, maybe. But what should I do?

D: You should stay in bed and follow my prescriptions.

P: Shall I take any drugs?

B: Sure. Here is a prescription for some drugs. Take them every 6 hours.

P: All right.

D: I'll give you a sick-leave for 6 days. You should come to me next time on Tuesday, at 10 a.m.

P: OK, Doctor. Thank you. Good-bye.

At the Polyclinics

(Situation: A patient comes to an out-patient department of his local polyclinic to his district-doctor).

Doctor: Good afternoon. What's your name?

Patient: Good afternoon. I am Vasiliy Smirnov.

Doctor: Have you ordered your patient's card from the registration department?

Patient: Yes, I have. The nurse will bring it in a minute.

Doctor: What do you complain of?

Patient: I have discomfort in the chest and general malaise. I get tired very quickly and don't sleep well.

Doctor: When did you first feel bad?

Patient: Well, I think it was a month ago.

Doctor: Was the onset sudden?

Patient: 1 cannot say it for sure. I had tonsillitis and after that 1 first felt some discomfort in the chest and palpitation.

Doctor: Have you ever had any trouble before?

Patient: No_, I haven't. I used to go in for sports and was seldom ill. Do you thinkit is serious?

Doctor: I don't know it yet. You'll have to undergo a thorough examination and have all necessary analyses made.

Patient: What analyses shall I have to go through?

Doctor: You must have your blood samples and electrocardiogram taken. Did you take your temperature?

Patient: I first took my temperature a week ago. It was 37.2°C and has been like that since.

Doctor: I shall give you a sick leave and you will have all the necessary analyses made within a week.

Patient: That's all right doctor. When should I come again?

Doctor: Come next Monday at 2 p. m. Good-bye.

Summoning a Doctor

(Situation: Tom is talking to a clerk of the registration department on the telephone)

Tom: Good morning.

Clerk: Good morning.

Tom: May I call in a doctor?

Clerk: Certainly. What's the matter with you?

Tom: I've got a very high temperature, a bad cough and a splitting headache.

Clerk: What is your full name?

Tom: I am Tom Smith.

Clerk: Where do you live?

Tom: Tower Street, 15, flat 20.

Clerk: Your local doctor will come in the afternoon.

Tom: Thank you, good-bye.

Clerk: Good-bye.

(The doctor comes to Tom's place)

Doctor: Good afternoon.

Tom: Good afternoon.

Doctor: You are Tom Smith, aren't you? What do you complain of?

Tom: I've got a splitting headache and muscular pains. My temperature is over 38°C. My nose is running.

Doctor: When did you fall ill?

Tom: I felt rotten two days ago. But as my temperature was normal I didn't consult a doctor.

Doctor: Strip to the waist. Let me examine you. May I have a look at your throat? Open wider. Say "Ah".

Tom: Ah!

Doctor: Very well, your tonsils seem all right. Give me your hand. I'll feel your pulse. It's accelerated a little. Let me listen to your heart and lungs. I can hear moist rales. I think you've got bronchitis. You should stay in bed. I'll give you a sick leave for three days and after that you'll come to the polyclinic.

Tom: That's all right, doctor.

Doctor: Here is your prescription for antibiotics, order them at the chemist’s.

Tom: Thank you, I'll do everything you've told to me.

Talk between a Mother (M), her Son (S) and the Doctor (D)

M: Your nose is clogged up, your voice is hoarse and your face is flushed. You must have a cold. I’m sure. I hope it’s nothing more. Where did you manage to get it?

S: I don’t know myself. I must have caught cold last night after a game of football when I felt so hot that I even took my jacket off.

M: How thoughtless (careless) of you, the evening was chilly and windy. Now you’ll have to stay in. Here’s the thermometer, take your temperature.

S: Oh, I’ll be all right in a few hours.

M: Now, you do what you are told. Put the thermometer under your arm (in the armpit)... Oh, it’s thirty eight point three. You’ll have to stay away from classes today. I’ll call the doctor (I’ll have the doctor in).

(She phones to the local out-patient hospital and is told that the doctor will call while making his daily round of the district. Some time later the doctor comes)

D: What do you complain of, my boy?

S: I have a bad (splitting) headache and a sore throat. I feel a sort of feverish.

D: Let me feel your pulse. Open your mouth, please. I see your tongue is coated and your throat inflamed. Now, strip to the waist, please. (The doctor sounds the boy’s lungs.) Take a deep breath...

(To the mother.) Your son is to keep his bed for three days. Here is the prescription. The medicine is to be taken three times a day before meals, two tablespoonfuls each time. It will help to keep the fever down.

(To the son.) Blow your nose gently, young man, or else you’ll have an earache... Nothing serious, but don’t get up before Wednesday, as there might be complications (bad after-effects).

Examination of the Patient

Before treating the patient it is necessary to make a correct diagnosis of the disease and to determine its aetiology, i.e. the causes of the disease. The doctor must know well the pathogenesis of any disease, i.e. the way and mechanism of its development, as well as the symptoms by which it can be revealed.

A number of different procedures is used to establish a diagnosis: history- taking, physical examination, which includes visual examination, palpation, percussion, auscultation, laboratory studies, consisting of urinalysis, blood, sputum and other analyses; instrumental studies, for example, taking electrocardiograms or cystoscopy, X-ray examination and others. For determining a disease it is very important to know its symptoms such as breathlessness, edema, cough, vomiting, fever, haemorrhage, headache and others. Some of these symptoms are objective, for example, haemorrhage or vomiting, because they are determined by objective study, while others, such as headache or dizziness are subjective, since they are evident only to the patient.

Taking a Case History

Case histories are biographical accounts of a patient by his doctor containing all information about his past and present that helps the physician understand the patient's health problems. A patient is asked to give such an account upon his first visit to a doctor or admission to a hospital. If he comes with a specific complaint he will, of course, be asked to tell his symptoms, any treatment or medicine he is taking and how long he had the complaint. If he comes for a check up, the interview may begin with a series of more general questions about the patient's home, work and marital status.

When enquiring into the history, the physician must inform himself about the health of other members of the family (family history), paying particular attention to the incidence of tuberculosis, mental disease, malformations, metabolic diseases, and syphilis.

From the patient's statements, information should be obtained as to past illnesses (children's diseases, poliomyelitis, rickets, wounds, accidents, operations, internal diseases), his occupation (there may be reason to recommend a change of work), his habits (alcohol, smoking) and any venereal disease.

The history, consisting of the hereditary and family history, the personal history and the present complaint must be entered accurately on a case-sheet for the information of thephysician and other investigators.

In most hospitals there is a form which includes, among other things, the special points about which questions must be asked, which depend on the specialty dealt with.

General symptoms, such as pronounced gain or loss of weight, continuously high temperature, pain, loss of appetite, disturbances of sleep, abnormal thirst, and digestive disturbances should be dealt with first, going on to the special symptoms afterwards. Questions about the special symptoms should deal with the individual systems (respiratory, digestive, urogenital, peripheral and central nervous systems, locomotor system, etc.). Examination begins after taking the history.

Asking about the Present Complaints

D: Hello Mr. Nicol, I haven't seen you for a long time. What seems to be the problem?

P: I have been having these headaches, doctor.

D: Which part of your head?

P: Mostly along here, along this side.

D: Oh, I see, the left side. How long have they been bothering you?

P: Well they started about three weeks ago. At first I felt as if I had the flue because my shoulders were aching, you know, pains in the joints and I had a bit of a temperature.

D: I see, and did you take anything for the headaches?

P: I took some aspirin but it didn't seem to make much difference to me.

D: When do they come on?

P: They seem to be there all day long, and at night I just can't get to sleep.

D: So they are bad enough to keep you awake?

P- Yes.

D: And how do you feel in yourself?

P: Very weak, and I'm tired of course. I think I've lost some weight.

D: Have you had headaches in the past?

P: Just one or two, but never anything like this.

Аsking about Pain Characteristics

D: Good morning, Mr. Hall. What's brought you along today?

P: Well, you see doctor, I've been having these headaches, you see, and ...

D: And how long have they been bothering you?

P: Well, they started about, well, it must have been about three months ago.

D: I see. And which part of your head is affected?

P: Well, it's, it's right across the front here.

D: And, can you describe the pain?

P: It's a sort of dull, dull, and throbbing kind of pain.

D: I see, and, do they come on at any particular time?

P: They seem to be…, they're usually worse in the morning. I notice them, when I wake up.

D: And is there anything that makes them better?

P: Well, if I lie down for a while, they seem to get, they go away.

D:Yes, and has there been anything else apart from these headaches?

P: Well, the wife, my wife, she says that I seem to be getting a bit deaf.

D:Well, Mr. Hall, I think at this stage I'll start by checking your ears to see if there' s any wax...

At the Cardiologist’s

D: Come in, Mr. Green, come and sit down here. I've had a letter from your doctor and he tells me that you've been having pain, pain in your chest.

P: Yes, and in my arm, and also tingling in my fingers and …

D: Yes, now when did you first notice this pain?

P: Well, I suppose about six months ago.

D: And can you remember when it first came on?

P: 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...

D: And where, in which part of your chest did you feel the pain?

P: Right across my chest,

D: And how long did it last?

P: About ten minutes.

D: And what did you do when it happened?

P: I had to stop and, wait for it to go away.

D: So, have you had this, the pain again since then?

P: Yes, I often get it when I overdo things, and when I...

D: Well, I think at this stage I'd like to examine you, your chest. So if you could strip to your waist. I'll just check your pulse first of all. That's fine. It's quite normal, seventy per minute. Now your blood pressure. Fine. That's quite normal too. 130 over 80.

P: I'm pleased to hear it.

D: Now I'm going to listen to your heart, so I want you to breathe normally. Your heart sounds quite normal.

P: Well, that's a relief.

D: Well now, 1 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 like the pain of what we call angina, and this occurs when not enough oxygen is getting to the heart. I'd like to check a few tests, and, following that I’ll be able to advise some treatment for you...

Asking about the Personal History & the Present Illness

D: 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.

P: Well I've actually, I've always been very fit up till now but...

D: Have you ever been in hospital?

P: Only when I was a child. I had an appendicitis when I was eight.

D: And what's your job, what do you do?

P: Well, I'm a, I work for the post office. I’m a postmaster.

D: And I see that you're… what,… 58 now, and have you...?

P: Yes?

D: Have you always been with the post office?

P: Yes, well apart from my time in the army you know...

D: I see. And you're married. Any family?

P: Yes, two girls and a boy,

D: Fine. That's fine. Now can you tell me what seems to be the problem today?

P: 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...

D: I see, and canyou show me exactly where it is?

P: It's down here, here.

D: And does it go anywhere else?

P: Yes, it goes down my left leg. And I feel pins and needles in my foot.

D: I see, and is it there all the time?

P: 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.

D: And was there anything that started it off?

P: 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.

System Review

D: Now Mrs Brown, can you tell me, have you any trouble with your stomach or bowels?

P: Well, I sometimes get a bit of indigestion.

D: I see, and could you tell me more about that?

P: Well, it only comes on if I have a hot, something spicy, you know, like a curry.

D: I see, well that's quite normal really. And what's your appetite like?

P: Not bad.

D: And any problems with your waterworks?

P: No, they're, they're all right.

D: And are you still having your periods regularly?

P: No, they stopped, must have been five years ago.

D: Any pain in the chest, palpitations, swelling of the ankles?

P: Not really, Doctor.

D: And what about coughs or wheezing or shortness of breath?

P: Only when I've got a cold.

D: Have you noticed any weakness or tingling in your limbs?

P: No, no I can't say that I have really.

D: What sort of mood have you been in recently?

P: I've been feeling a bit down. You know, I'm not sleeping well.

Details of the Present Condition

D: And how long, how long have you had this temperature?

P: Oh, I don't know exactly. About two months on and off…

D: And does, is the temperature there all the time or does it come on at any particular time?

P: Well, sometimes I'm all right during the day but, I wake up at night and I'm drenched in sweat…, drenched, and sometimes my whole body shakes and...

D: And how have you been feeling in general?

P: Well, I don't know, I've been feeling a bit tired, a bit tired and weak. And I just don't seem to have any energy.

D: And have you noticed any, any pain in your muscles?

P: Yes, well… actually I have a bit, yes.

D: And what about your weight? Have you lost any weight?

P: Yes, yes I have, about a stone (6,4 kg).

D: I see, and, what about your appetite? What's your appetite been like?

P: Well, I've really been off my food this last while. I just haven't felt like eating.

D: And have you had a cough at all?

P: Oh yes, I have. Nearly all the time. I sometimes bring up a lot of phlegm.

D: And is there… have you noticed any blood in it?

P: No, not always… but yes, sometimes.

D: Have you had any pains in your chest?

P: Only if I take a deep breath.

Disorders Accompanying the Main Disease

D: Good afternoon, Mr. Hudson. Just have a seat. I haven't seen you for a good long time. What's brought you along here today?

P: Well doctor. I've been having these headaches and I seem to have lost some weight, and...

D: I see, and how long have these headaches been bothering you?

P: Well, I don't know. For quite a while now. The wife passed away, you know, about four months ago. And I've been feeling down since then.

D: And which part of your head is affected?

P: Just here. Just here on the top. It feels as if there were something heavy, a heavy weight pressing down on me.

D: I see, and have they affected your vision at all?

P: No, no, I wouldn't say so.

D: Not even seeing lights or black spots?

P: No, nothing like that.

D: And they haven't made you sick at all?

P: No.

D: Now you told me that you've lost some weight. What's your appetite been like?

P: Well… actually, I haven't really been feeling like eating. I've really been off my food for the moment and...

D: And what about your bowls, any problems?

P: No, no they're, I'm quite all right, no problems.

D: And what about your waterworks?

P: Well, I've been having trouble getting started and I have to, I seem to have to get up during the night, two or three times at night.

D: And has this come on recently?

P: Well, no, not exactly. I think I've noticed it gradually over the past, the past few months.

D: And do you get any pain when you're passing water?

P: No, no.

D: And have you noticed any blood, any traces of blood?

P: No, no, I can't say that I have.

Examining the Patient

(Giving Commands)

D: Would you slip off your top thing, please. Now I just want to see you standing. Hands by your side. You're sticking that hip out a little bit, aren't you?

P: Yes, well, I can't strengthen up easily.

D: Could you bend down as far as you can with your knees straight and then stop when you have had enough?

P: Oh, that's the limit.

D: Not very far, is it? Stand up again. Now I would like you to lean backwards. That's not much either. Now stand straight up again. Now first of all I would like you to slide your right hand down the right side of your thigh. See how far you can go. That's fine. Now do the same thing on the opposite side. Fine. Now just come back to standing straight. Now keep your feet together just as they are. Keep your knees firm. Now try and turn both shoulders round to the right. Lock right round. Keep your knees and feet steady.

P: Oh, that's sore.

D: Go back to the center again. Now try the same thing and go round to the left side. Fine. Now back to the center. That's fine. Now would you like to get on to the couch and lie on your face?

I'm just going to find our where the sore spot is.

Consilium on Investigations

A: An ECG is essential because it will show any changes in the heart: axis, ischaemia, left ventricular hypertrophy.

B: I think a chest X-ray is also very important to see the size of the heart and the extent of any hypertrophy. I would also check the creatinine to see if there's any damage to the kidneys.

С: An intravenous pyelogram is essential because a renal cause is very likely.

B: As an initial investigation?

C: No, after urea and electrolytes and after the creatinine.

B: It's essential if the creatinine shows something wrong with the kidneys.

C: Yes.

A: Yes, both creatinine and urea and electrolytes are required. In this case I think they're more important than the ECG and chest X-ray because the patient is young, 43, and the hypertention is very high.

C: Urine analysis too in this case. It's very important.

B: Yes, it's routine,

C: We can see if there's any glomerular damage. We may find blood, albumin, casts...

A: Yes, it's very important.

B: What about radioisotope studies of the kidneys?

C: Not essential, but we could do this to check the function of the kidneys.

A: We can see this from the criatinine and urine.

C: I know. It's not essential, but it could be useful.

B: Serum cholesterol?

A: Not essential. We're thinking of another type of hypertension here. But possibly useful.

B: Skull X-ray?

C: Not required. It's of no value in this case.

B: Serum thyroxine?

A: Absolutely no connection with hypertension.

B: Barium meal?

C: Not required.

B: Uric acid?

A: Not necessary. If the uric acid is raised, there would be other symptoms.