История болезни на английском языке пример с переводом

История болезни на английском языке пример с переводом thumbnail

Çäðàâñòâóéòå, ïðèø¸ë ïðåäâàðèòåëüíûé ÏÎËÎÆÈÒÅËÜÍÛÉ îòâåò èç Øâåéöàðèè.

À âíèçó èñòîðèÿ ìîåé áîëåçíè íà àíãëèéñêîì. Ìîæåò îòâåòÿò àíãëîãîâîðÿùèå ïîëüçîâàòåëè.

Ðàáîòàòü ìíå óæå î÷åíü òÿæåëî. Ñ ìîìåíòà ïîñëåäíèé ïóáëèêàöèè ÿ óæå ïîáûâàë â õîñïèñå, ëåæàë òàì 4 äíÿ è 10 äíåé ëåæàë â ÷àñòíîé ïñèõèàòðè÷åñêîé êëèíèêå.

Êàê îáû÷íî î÷åíü èíòåðåñíûé îïûò. Åñëè ìíå õâàòèò ñèë, ÿ âàì âñ¸ ðàññêàæó è ïîêàæó.

Letter to the Swiss organization Dignitas.

When reading this letter, please, understand that I am not asking you to take my word for it, on the contrary, in case of any doubts, please check my words. Checking in my case will not cost anything and will take very little time.

Just please note that ALL my medical tests at the moment are very good, but they are all passed under large doses of anti-parasitic drugs, so they are not the basis for any conclusions.

Hello,

I got sick 9 years ago. At that moment, I was earning $ 7.5 thousand a month. I’m a programmer. For Russia-this is a high salary. I specified this amount in oder to show that it is not a very desirable thing to be sick having such a job. Moreover, I love my job more than anything in my life.

In 2010, I felt crawling and stirring in the left part of my abdomen. My abdomen started to inflate. It had grown to enormous size in two years. I began to cough blood and defecate with thick blood.

I began to go to private clinics in Moscow. Diagnostics showed nothing. The doctors prescribed me many medications, but none of them helped. Tests on all possible parasites showed a negative result.

05.05.2012, the test on the virus Human gammaherpesvirus 4 was done. This had been the first test that confirmed that I had been seriously ill, since the results were very bad. 11.02.2013, the most important in my medical history test was done, which was duodenal intubation (biochemical study of bile). This test showed severe inflammation in the abdomen.

In February 2013, I could no longer go to work. None of medicines prescribed by doctors was not helping. That time, doctors prescribed me more than 100 drugs a day. The only thing that was helping me to soothe the inflammation (temporarily) — an ordinary food soda. In fact, if it hadn’t been for the soda, I would have committed suicide, because everything burned inside me. Something was constantly crawling in my stomach (I don’t exaggerate!!!). I defecated with huge number of black balls of different sizes from very small to a half pea, and small pieces, looked like round worms. All these balls I collected and brought to the best laboratories of Moscow, and on March 27, 2013, in one of Moscow private clinics the ONLY ONE test confirming infection with parasites was done.

Next you need to understand what it is to get sick in Russia. Therefore, the description of my life will include deviations from medical subjects, but these deviations are directly related to my trip to you.

In Moscow, there is ONLY ONE STATE institution that designed to parasitic diseases: Marcinovski Institute of Parasitology and Tropical Medicine, Sechenov University. Only the diagnosis made in this institution can be the basis for hospitalization in the state clinic. There are only two parasitologists who work in this Institution, 60-70 years old woman and man. Despite that the Institute is state, there are only paid services and the cost of these services is about 2 times higher than in private clinics. For diagnosis, tests must be taken ONLY in this clinic for a lot of money. I showed them the results of previously done tests, and they replied, quotation: «We know the doctor who did these tests, she’s an idiot and we are not going to take into consideration the results of these tests». I immediately passed the tests at this Institute, and received the answer that I DID NOT HAVE parasites!!! At that time, I took test-tubes with a solution for analysis at the Institute that allows to storage fecal matter for a long time. This detail is important for my further description.

My health continued to deteriorate at a tremendous rate. Since the state institution had not confirmed the presence of parasites, I was not prescribed anti-parasitic drugs.

And my great walk on doctors began.

In April 2013, my stomach reached colossal proportions. I could neither eat nor sleep. I constantly coughed up blood and defecated with thick blood. I could barely get out of bed. At that time, I had already passed a huge number of tests and all they were extremely bad. The strongest ulcers appeared on my fingers, which were constantly leaking with blood, the lumps appeared in my armpits, causing a lot of pain. The doctors did not know how to help me and started to send me to a psychiatrist.

I went to a psychiatrist in a private clinic. Here again it is necessary to remind about Russia. The thing is that the situation with paid psychiatry in Russia is very unclear. Only the diagnosis made in a state psychiatric hospital matters. Russian people are extremely afraid of state psychiatric hospitals. Even if you are not very sick, once in a Russian psychiatric clinic, you are unlikely to come out healthy. Anyone can get into our psychiatric clinic, but in order to get out from there, relatives sometimes have to bribe a Chief Medical Officer (I say according to the words of my friends, who had a relative in such a hospital). Once you are in this clinic, you’re very likely to come out with a severe mental illness that will actually completely destroy your life. It will be interesting to you that this information was told to me directly in the Russian Ministry of health, categorically recommending me not to go to the state psychiatric clinic. I learned this from my own experience soon, as will be explained below.

A private psychiatrist looked at my extremely bad tests, ulcers with blood, armpits with lumps, I coughed blood in front of this doctor, and I was told that I had schizophrenia. They prescribed me psychotropic drugs. In 2013, almost any Russian pharmacy could sell any dangerous psychotropic drugs WITHOUT A PRESCRIPTION. I was taking all the medicines prescribed by the doctors according to their instructions. I never changed the dosage, and took them at exactly the appointed time. None of the drugs prescribed by the psychiatrist HELPED me!!!

Obviously, I was constantly seeking a medicine that would help me. In 2013, on one of the most difficult nights at 4 am I drove to the nearest pharmacy and bought the drug Biltricide. The active ingredient in this drug: Praziquantel. I took two capsules and fell asleep. In the morning, my stomach decreased more than 2 times, I became able to eat any food, began to recover strength. Joyful, I ran to doctors. I passed a lot of tests and they all became very good. I showed the tests to doctors and they said: this is the power of suggestion, you do not have any parasites!!! I received the same answer from ALL the doctors I had visited at that time. There were about 10 of them.

I was not happy for a long time, a month later my health began to deteriorate again. I independently repeated the drug Biltricide, but has increased the dosage to 6 pills. The result was amazing, I decided that I was completely cured. The medicine worked a little more than a month, then the condition quickly and severely deteriorated. From that moment on, I started taking 6 pills of Biltricide every month. After about 4 months, Biltricide completely stopped working. Increasing the dosage did not help. I decided to try other anti-parasite drugs.

I tried to take Albendazole — the effect was zero. I tried to take Mebendazolum — the drug worked very well, but only in large quantities, 5 pills a day. I began to search other anti-parasite drugs. It turned out that one of the most effective drugs was not available in Russia – it is Ivermectinum. I ordered Ivermectinum from China online. I received it in 2 weeks, at that time I could hardly walk. With great effort I went to the post office and took the medicine. About an hour later, I defecated with four round interconnected parasites. When I saw it, I was shocked, but unfortunately did not take a picture of these parasites, and just flushed down the toilet. I continued to take Ivermectinum 1-2 pills a day and every day I defecated with a huge number of black balls. I brought these balls the best laboratories of Moscow. The parasite tests were always negative.

Ivermectinum significantly improved my health, but recovery was out of the question.

05.05.2014 I arrived by plane to Prague. A pre-rented car was waiting for me at the airport. I drove to Germany by car , to the city of lüneburg. Being able to barely communicate in English, I managed to arrange an examination in this hospital via the Internet. Then, a few years later, I found out how lucky I was. The fact is that to get to a German hospital for not German citizen is not so easy, actually very difficult, but it is not important for my story. In lüneburg near the hospital, a beautiful interpreter was waiting for me, and I was lucky with this too. In the hospital at the reception we were told to get lost, at first gently, and then with shouts, but finally sent us to a secretary with a scandal. The secretary was very surprised at first, but after a minute said that the correspondence with me was conducted by her, and told us to sit and wait. The next day I was in a hospital in Germany. If there is a Heaven on the Earth, it is in this hospital. I stayed there only 4 days, and never in my life I had such a good rest. In the German hospital under general anesthesia (full sleep) they twice checked my ENTIRE intestine, and they found nothing.

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Frustrated, I left Germany. What pleasantly surprised me: the prices for medical services were 10 percent higher than in Moscow hospitals, but not more. I paid 3 thousand Euros for 4 days, two years later I received a letter that they wanted you to return my unused deposit. On my second visit to Germany, I was returned about 2 200 Euros.

16.11.2014 I made my first suicide attempt. I went out of the city by a car, wrapped the front seat with plastic, and made 4 incisions on my left arm. As it turned out it’s necessary to inflict itself more a serious harm for a suicide. An hour later, the bleeding stopped, and I went to a first-aid station, where I was quickly and well sewn up. While I was in the car bleeding, I had an epileptic fit.

Further I continued the search for anti-parasitic drugs. I realized that Biltricide and Ivermectinum helped me, but temporarily. I could not live without these drugs. On the Internet I stumbled upon a cure for animals Praziver. This medicine included both Biltricide and Ivermectinum, but it was for animals. I bought this medicine, mixed it with dumplings and took a dose exceeding the dose for a human in several dozen times. After sleeping for a day, I woke up completely healthy person. I defecated with a flat slug with tentacles and suckers. I fished this slug out of the toilet, and I put it in a capsule with a solution from the Institute of Parasitology. First I met with a friend and showed him a slug, to which he replied that it was definitely a living organism. For three days I gained 10 kilos of weight, as I was able to eat normally, the muscles began to grow by leaps and bounds, but after three days again a rapid deterioration began again. I started constantly taking Praziver.

19.05.2015 I received the result of an analysis of the slug: PARASITES are not DETECTED.

In July 2015, I decided on a second suicide attempt. I flew to Greece and almost immediately went drowning in the sea. The thing is, I’ve never been able to swim. As a child I was taught many times, but to no avail, although I grew up next to the sea. I almost drowned several times in my childhood. But this time, instead of drowning, I learned to swim for the first time in my life. That didn’t stop me. When it got dark I jumped from a small cliff and swam away from the shore. I swam for a long time, then decided to drown, but could not. I always came up after diving. In the end, I realized that it was useless and swam back to a shore. One man on the shore realized that I went to drown, and while I swam, he watched from the shore. When I swam back, he left quickly.

30.01.2016 after taking too much medications Praziver, I was in intensive care. Even here I was lucky. I live alone and after taking this medicine, I, without realizing what I was doing, opened the front door and passed out. My neighbor, having heard that I left and apartments, decided to talk to me (miracles). He found me unconscious and called an ambulance. The ambulance took me to the First City Hospital named after N. I. Pirogov in the psychosomatic department. I am very grateful to the doctors of this hospital, because most likely they saved my life. This is where my gratitude ends. If there’s a branch of hell on the Earth, it’s in this hospital and this ward. Maybe everything has changed, and now it’s paradise, but in 2016 — it was hell.

I was in a ward where patients could not walk on their own. And in general they are terminally ill people, I think. I was transferred from intensive care to a ward. I was fully conscious and feeling fine. It was forbidden to leave the ward, mobile phones were forbidden. After a while I asked permission to go to the toilet, to which I received the answer: soil yourself!!! Finally, they let me go the toilet. One of the patients, who could not walk, asked to take him to the toilet, the staff refused to do it. This patient crawled out of bed and he fell. For several hours he lay naked on the floor and shouted at the top of his voice. For several hours no one approached him. Patients were tied to their beds for the whole day in order to not let them crawl somewhere. Once a day there was a change of linen, while the rest of the time patients soiled themselves. Linen change was accompanied by such a swearing, which is rarely where you will hear especially in such quantity.

I was discharged quickly, thank God, but with a diagnosis of alcohol withdrawal syndrome. I drink alcohol about once a year, and about three bottles of beer. The second diagnosis that I was given was epilepsy. I was in a Russian state hospital for the first time. And at the moment I have two official state diagnosis of the alcoholic and the epileptic.

Health became worse and worse. I kept looking for a cure. One fine day, on the forum seriously ill people a man sent a message to me and advised the drug Triclabendazole. I knew nothing about this drug. I methodically began to call all my friends with a request to find and buy me this medicine. It was impossible to buy it in Russia. Several of my friends were able to find this medicine for animals in Germany, but tehy couldn’t buy it without a prescription. One of my unfamiliar girl was able for an expensive gift to a doctor to get a prescription from a German doctor (forgive me God for this information – I mean the gift), and the girl brought me this drug by an airplane. That time I already couldn’t leave house.

I mixed Praziver and Triclabendazole and took a huge dose. That girl was right next to me. It was evening. I fell asleep, and she went home. In the morning I woke up and decided that nothing had changed. A few hours later I went to the doctors with this girl, after the doctors, I realized that something began to change greatly in the body. I asked to stop a taxi in the city center and walked to the office of my friends, which was 15 km from the place where I left the taxi. I went this way without stopping, but I still did not feel healthy.

Back home, I started taking Triclabendazole periodically. Then I noticed that the disease returned when I ate starchy and sweet food. I stopped eating starchy and sweet food. After about two months, I felt that I could already eat without any anti-parasitic drugs. Very slowly I got better and better. I didn’t take any more medicine.

During this not long period of temporary recovery, I was the first time when I understood what did it mean to be a healthy person and how well the brain could work. My performance had increased in many times. In addition to programming, I began to study physics, chemistry, microbiology and history on my own. I’ve always been interested in space.

At the end of 2016, I felt a sharp improvement in health. In a few days, it became even better, and in a week something happened in my stomach. I began to rush around the apartment and open all the windows, as I did not have enough air, and after a few minutes something rearranged in the body with great force.

The first thing that had changed – my appearance. My clothing size literally increased by three sizes, especially the shoulders. After three days, I didn’t fit a single t-shirt, shirt or jacket. The muscles of the arms began growing rapidly. My brain worked perfectly.

I was healthy only three days!!! On the third day, I began to eat fried food, then starchy foods and sausages. And three days later, I had a blast my head (figuratevily). I barely took the medicine Praziver (fortunatelly, I had it), but I didn’t have Triclabendazole since I foolishly threw away the remnants.

In a few hours, I turned into a goner. My shoulders instantly deflated and it was a start of the process that eventually led me to you.

Even though I lost the battle with the disease, these events changed my life forever. I realized that I was born a physically strong man with excellent health. From my earliest childhood I assumed that I was infected with something. My parents and teachers assumed it too. I have an excellent memory and I remember well what happened in my life from early childhood.

I can not say exactly how old I was, but it was still attending a school. I got seriously sick, and already then the doctors did not understand anything. My temperature rose very quickly to 41 degrees, I was convulsing. The whole family was there, the doctors didn’t know what to do. The temperature was kept almost all night, during the night an ambulance came to us three times, but they didn’t take me to hospital. Then the disease began to decline. When I got better, grandmother gave me a laxative and I defecated. The fecal matter was liquid as water. The design of a toilet allowed to see the feces. It was a black liquid in which hundreds of pinworms (Enterobius) floated. I showed it to my grandmother and lost consciousness a minute later, my father picked me up when I fell, he was also there.

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Once at school, I felt something bad in my stomach, fell and began to convulse. All this happened in front of a teacher. The teacher was shocked. He called a doctor, then parents. Nobody understood the reason.

When I was about 19 years old, I felt bad and went to visit my grandparents. I lay down on a bed and did not get out of bed within almost a month. I was getting worse and worse. A month later, grandfather bought me medicine against parasites, I was surprised why did I need them. Grandfather said: just take it. And again I defecated with hundreds of pinworms, and my health began to improve every day. Now I recall all these events and understand that my relatives, too, guessed that my disease related to parasites.

Since the beginning of 2017, I could no longer eat without antiparasite medication.

03.06.2017 I came back to Germany for Triclabendazole.

From 04.01.2018 to 27.01.2018 I was in Germany and managed to get in a German psychiatric clinic in Hamburg for three days. Then it was already clear that I would not have a future. My representative in Germany was the same girl who helped me to buy Triclabendazole. The German clinic insisted that this girl would sign papers that she born responsibility for me, including monetary. I categorically forbade her to do it, paid 1 600 Euros for three days in the hospital and moved out.

I could not consume food anymore without antiparasite drugs. Any food consumption without antiparasite drugs led to severe deterioration of health in a few hours. The first thing that turned down was legs, then everything else.

On 26.09.2019 I’m taking antiparasite drugs at least 10 times a day. Each dose contains Praziquantel, Ivermectinum and Triclabendazole.

During my illness, I worked exclusively at home. I rarely go out. I’m a programmer.

During almost ten years of my illness, I was able to write a financial program for Tashir, the largest Russian commercial organization. The program works so well that other programmers can hardly believe that it was possible to write such a program.

I am immensely grateful to my employers, as they know about my state of health and about suicide attempts, and have always supported me in everything.

I am sure that I have never suffered from any mental illness. My sanity is to be envied. Before my illness, I was active in sports and achieved great success. I raised 100 kg barbell 10-15 times and during the day I did 10-15 approaches three days a week and more.

Before my illness, I had a girlfriend who supports me so far, but I can only live alone and this is my choice. I’m useless to the family.

At the moment, ALL my medical tests are perfect, but they are all done under huge doses of antiparasite drugs. I can eat only once in three days, and only with antiparasite drugs which necessarily must be mixed with starchy and sweet food, otherwise they don’t work at all.

I’m sure you have a lot of doubts about me. My words are very easy to verify. Which happened recently in one of Moscow private psychiatric clinics. I went there and stopped taking my antiparasite medication. After three days, I could hardly walk and almost lost my eyesight, and I had to urgently return home and start taking antiparasite medicine. This clinic categorically refused to give an opinion on my illness, as they simply do not know what to write.

On 26.09.2019 I was refused by ALL paid clinics in Moscow, except one hospice in Moscow region. Even money is not important to them in my case.

Doctors in public and commercial clinics in Moscow categorically refuse to record the situation from my words.

I filed two reports to the police, where I specified that I had never taken drugs and very rarely drunk alcohol, while I was diagnosed with alcoholism. I attached negative tests for drugs, nicotine and ethanol to the application.

In the second report I specified that doctors refused to write down that happens to me and write to me from my words I diagnosed me without any its confirmation.

The police even came to my house and treated me very well and offered to immediately resolve the issue with my hospitalization in a public hospital, not a PSYCHIATRIC one. I refused because there was nothing they could help me with.

I have repeatedly appealed to Russian television and many Russian newspapers to tell my story. I have never asked for any help, but now I am asking you.

At the moment, it is impossible to cure me, so I ask you to help me die in peace. My friend will take me from Moscow to Switzerland by a car. I won’t be able to drive myself, because my legs and hands almost don’t function.

Источник

Примеры из текстов

История болезни. Мужчина семидесяти пяти лет, очень ослаблен, с трудом добрался до клиники. В начале 1986 года диагностирован костный рак. Проходил лечение облучением и химиотерапию, но закончить курс отказался.

History 75-year-old male almost completely debilitated, barely able to get into the clinic, has undergone chemotherapy and radiation and refused any further treatment, having been diagnosed with bone cancer.

Дуглас, Уильям / Целительные свойства перекиси водородаDouglass, William Campbell / Hydrogen Peroxide H2O2 Medical Miracle

Hydrogen Peroxide H2O2 Medical Miracle

Douglass, William Campbell

© 1990, 1992, 1995, 1996, 2003 by William Campbell Douglass, MD

Целительные свойства перекиси водорода

Дуглас, Уильям

© ООО «Питер Пресс», 2007

Но в истории болезни нет ни слова о том, что он когда-то служил в банке.

There’s no record at the hospital that he ever worked at First Union.

Паттерсон, Джеймс / Розы красныеPatterson, James / Roses Are Red

Roses Are Red

Patterson, James

© 2000 by James Patterson

Розы красные

Паттерсон, Джеймс

© James Patterson, 2000

© Издательство ЭТП, 2003

Пролистать эту книгу — все равно что познакомиться с историей болезни, заведенной на семью Гамильтонов.

To look through Dr. Gunn is to know the Hamiltons’ medical history.

Стейнбек, Джон / На восток от ЭдемаSteinbeck, John / East Of Eden

East Of Eden

Steinbeck, John

© John Steinbeck, 1952

© renewed Elaine Steinbeck, Thom Steinbeck, and John Steinbeck IV, 1980

На восток от Эдема

Стейнбек, Джон

© Издательство «Правда», 1989

Как‑то заполучил историю болезни Аманды и привёз ее на ленч, это же надо!

Somehow laying hands on Amanda’s medical records and bringing them to lunch, for heaven’s sake.

Кинг, Стивен / История ЛизиKing, Stephen / Lisey’s story

Lisey’s story

King, Stephen

В истории болезни следует отметить результаты пальпации живота — наличие болезненности и объемных образований в брюшной полости.

The presence of abdominal tenderness or mass should be noted.

© 2001-2006 Инфосеть «Здоровье Евразии» и Американский международный союз здравоохранения

система «памяток», включая используемые во время визита пациента истории болезни, протоколы, а также другую медицинскую документацию (в том числе и хранящуюся в компьютерных базах данных).

reminder systems, including checklists, protocols, and more simple paper or computerized reminders used at the time of the patient visit.

© 2001-2006 Инфосеть «Здоровье Евразии» и Американский международный союз здравоохранения

Но вопрос «Как Скотт добыл историю болезни Аманды?» остался без ответа. Тут Лизи не могла утолить своё любопытство.

How Scott had obtained the records might be another point upon which Lisey’s curiosity would never be satisfied.

Кинг, Стивен / История ЛизиKing, Stephen / Lisey’s story

Lisey’s story

King, Stephen

служащие отдела должны также включать в историю болезни записанные ими под диктовку врача отчёты по состоянию здоровья пациента;

the preparation of dictated reports from the patient’s physicians to be included in the medical record;

© 2001-2006 Инфосеть «Здоровье Евразии» и Американский международный союз здравоохранения

Из истории болезни я знал, что у него случаются приступы гнева, но сейчас он регулярно принимал валиум лошадиными дозами.

I knew from the nursing charts that he had a violent temper, but that he was on a truckload of Valium now.

Паттерсон, Джеймс / Розы красныеPatterson, James / Roses Are Red

Roses Are Red

Patterson, James

© 2000 by James Patterson

Розы красные

Паттерсон, Джеймс

© James Patterson, 2000

© Издательство ЭТП, 2003

– Если бы вы дочитали историю болезни до конца, – заметил Линдхольм, – вы бы узнали, что эти новые симптомы появились всего четыре дня назад.

«If you had read further into the report,» Lindholm said, «you would have discovered these new symptoms arose four days ago.

Роллинс, Джеймс / Печать ИудыRollins, James / Judas Strain

Judas Strain

Rollins, James

Печать Иуды

Роллинс, Джеймс

© 2007 by Jim Czajkowski

© С. Саксин, перевод, 2009

© ООО «Издательство «Эксмо», издание на русском языке, 2009

доступ к истории болезни пациента при соответствующем согласии для получения оправдательной информации;

access to patient records with the appropriate consent for release of information;

© 2001-2006 Инфосеть «Здоровье Евразии» и Американский международный союз здравоохранения

В некоторых клиниках заключаются письменные контракты, но вполне достаточно подробной записи в истории болезни о проведенной с пациенткой беседе на эту тему.

Written contracts are used in some clinics but a well-documented discussion in the medical record is adequate.

© 2001-2006 Инфосеть «Здоровье Евразии» и Американский международный союз здравоохранения

Если верить историям болезни — через месяцы.

Months sometimes, according to the case files.

Уоттс, Питер / Ложная слепотаWatts, Peter / Blindsight

Ложная слепота

Уоттс, Питер

© 2006 by Peter Watts

© Д.М.Смушкович, перевод, 2009

© ООО «Астрель-СПб», 2010

Из истории болезни Сьюзен Лиза даже узнала его фамилию: Эпплгейт.

From Susan’s medical history, Lisa even knew the patient’s name now. Applegate.

Роллинс, Джеймс / Печать ИудыRollins, James / Judas Strain

Judas Strain

Rollins, James

Печать Иуды

Роллинс, Джеймс

© 2007 by Jim Czajkowski

© С. Саксин, перевод, 2009

© ООО «Издательство «Эксмо», издание на русском языке, 2009

Врач взял историю его болезни, пришпиленную к дощечке в ногах постели, и просмотрел листочки.

The doctor took the medical chart off the foot of the bed. He riffed it through.

Чайлд, Ли / ЛовушкаChild, Lee / Tripwire

Ловушка

Чайлд, Ли

© 1999 by Lee Child

© Перевод. В. Гольдич, И. Оганесова, 2009

© Издание на русском языке. ООО «Издательство «Эксмо», 2009

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история болезни1/2

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case history

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  1. 1.

    medical history / case history

    Hx. — to be short.

Словосочетания

психиатрическая история болезни

history of psychiatric care

описание собственной истории болезни

autopathography

запись истории болезни

case taking

заполнение истории болезни

case taking

ведение истории болезни

clinical recording

последующая запись в истории болезни

follow-up note

архив историй болезни, реализованный на ЭВМ

health data bank

выписка из истории болезни

case record

заполнение истории болезни

case history filling

бланк истории болезни

medical card

журнал с историями болезней

casebook

Источник

краевое государственное бюджетное профессиональное

образовательное учреждение

«Ачинский медицинский техникум»

(КГБПОУ АМТ)

Учебное пособие для студентов

по дисциплине «Иностранный язык»

CaseHistory

для специальностей

31.02.01 Лечебное дело

34.03.01 Сестринское дело

Введение

Данное учебное пособие для студентов соответствует требованиям ФГОС СПО для специальностей 31.02.01 Лечебное дело, 34.03.01 Сестринское дело.

Использование информационных технологий в учебном процессе является существенным фактором практического занятия. Студенты самостоятельно находят нужную информацию, активно включаются в поисковую деятельность, применяя Интернет-ресурсы.

Задачи:

1. Развивать у студентов речевую, языковую, компенсаторную, учебно-познавательную компетенции.
2. Развивать у студентов готовность к сотрудничеству.

3. Повысить мотивацию к изучению английского языка.

Занятия в интерактивном формате дают возможность студентам приобретать знания от учителя к ученику, активно добывать их в учебном общении друг с другом.

Преимуществом данного занятия является использование интерактивной методики обучения английскому языку (сложная кооперация, использование аутентичных материалов), информационных технологий, а также технологии критического мышления.

Read and learn the following words and word combinations:

the medical history, case history

история болезни

to report

сообщать, составлять отчет

gain obtain

добывать, получать

refer

относиться

enable

давать возможность

clarify

вносить ясность

the impact

влияние

the comment

комментарий, отзыв

suicide attempts

попытки суицида

appreciate

оценивать

exacerbate

раздражать, обострять (боль)

siblings

единокровная сестра (брат)

the inquiry

расследование, запрос

Taking a Medical History

Admitting a patient to hospital includes two major steps: on the one hand the doctor has to take the patient`s medical history, where he is given the opportunity to report his complaints and to answer the doctor`s questions.

The medical history or (medical) case history of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient’s life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan. The treatment plan may then include further investigations to clarify the diagnosis.

Case history structure

1. Introduction

It should consist of a few clear and concise opening statements, which typically include information on:

Name (pseudonym)

Age

Marital status

Occupation

Central problem

2. History of Presenting Complaint

Comment on the impact of the illness on the patient’s life

Consider work, social relations and self-care.

Note details of previous treatment

Include information on who administered management (when and where), what the treatment was (and preferably the dose and duration of treatment), and the patient’s responses to treatment.

Integrate current problem and psychiatric issues

3. Past Psychiatric History

The following points are relevant in this section:

details of previous episodes of illness

previous psychiatric admissions/treatment

outpatient/community treatment

suicide attempts/drug and alcohol abuse

4. Past Medical History

In this section of the report, you need to show that you a) understand the relationship between medical conditions and psychiatric symptoms, and b) can appreciate the complexity of medical problems that might be exacerbated by psychiatric conditions.

Record medications. Demonstrate an understanding of the significance of drug therapy on psychological function and, if appropriate, focus on medications taken by the patient that may influence the patient’s psychological function.

5. Family History

Include details of:

Parents and siblings, nature of the relationships between family members

Any family tensions and stresses and family models of coping

Family history of psychiatric illness (incl. drug/alcohol abuse, suicide attempts)

6. Personal History/Development

Use the list in Bloch and Singh (2001:93) as a guide for selecting and organising the information in this section:

Early development

Childhood

School

Adolescence

Occupation

Menstrual history

Sexual history

Marital history

Children

Social network

Habits

Leisure

7. Review of Systems (ROS)

In this portion of the history, all organ systems not already discussed during the interview are systematically reviewed. ROS is a final methodical inquiry, prior to physical examination. It provides a thorough search for further, as yet unestablished, disease processes in the patient.

Following are the topics to be reviewed for each organ system:

7.1. Constitutional

Any history of recent weight change

Any history of anorexia (loss of appetite), weakness, fatigue, fever, chills, insomnia, irritability or night sweats

7.2. Skin

Any history of skin rashes—acute or chronic, is it unilateral or bilateral

Any history of allergic skin rashes

Any itching of the skin

Any history of unhealed lesions (probably due to: diabetes; poor diet; steroids and other causes of decreased immunity, especially AIDS)

Any history of bruising, bleeding

7.3. Head

Any history of headaches

Loss of consciousness (may be due to cardiovascular, neurologic causes, anxiety, metabolic causes, etc.)

History of seizures. Are they general (with or without loss of consciousness) or focal? Are there any motor movements?

Is there any history of head injury?

7.4. Eyes

Check for vision, history of glaucoma ( could cause pain in the eyes), redness, irritation, halos (seeing a white ring around a light source), blurred vision

Any irritation of the eyes, excessive tearing, which can be associated with frequent allergic symptoms?

7.5. Ears

Any recent change in hearing

Any pain in the ears or ringing in the ears (tinnitus)? discharge?

Any history of vertigo (dizziness)?

7.6. Lymph Glands

Any history of lymph glandular enlargement in the neck or elsewhere? Are they tender/painless? How were they first noticed?

Are they freely mobile or are they adherent to the underlying tissues?

7.7. Respiratory System

History of frequent sinus infections

Postnasal drip

Nosebleeds

Cough (with/without expectoration)

Color of sputum, when present

History of sore throat

History of shortness of breath on exertion or at rest

Any history of wheezing (may be due to asthma, allergies, etc.)

Hemoptysis (blood in the sputum): may be due to dental causes; lung causes like bronchitis, tuberculosis; cardiac causes like mitral stenosis or CHF (congestive heart failure). Determine if it is a blood-tinged sputum or there is frank blood in the sputum.

Any history of bronchitis, asthma, pneumonia, emphysema, etc.

7.8. Cardiovascular System

History of chest pain or discomfort

History of palpitations: were the palpitations associated with syncope (loss of consciousness)?

History of either hypertension or hypotension

Does the patient experience any paroxysmal nocturnal dyspnea (shortness of breath during sleep, in the middle of the night)? Is there any SOB in relation to exercise or exertion?

Any history of orthopnea (shortness of breath when lying flat in bed)? Does the patient use more than one pillow to sleep? Has this always been the case, or has the patient recently started using more pillows?

History of edema (site of edema—legs, face, etc.)

Any history of leg pains, cramps? Are they relieved by rest (this is suggestive of intermittent claudication) or is it unremitting? (this is muscular)

Any history of murmur(s), rheumatic fever, varicose veins?

Any history of hypercholesterolemia, gout, excessive smoking, i.e., conditions which can lead to or worsen heart disease

7.9. Gastrointestinal System

History of bleeding gums, oral ulcers or sores

History of dysphagia (can the patient point out and describe where the difficulty swallowing exists?)

History of heartburn, indigestion, bloating, belching, flatulence

History of nausea: is it related to food? Is it one of the many symptoms due to GI (gastrointestinal) disease?

Vomiting: is there any associated weight loss, psychosocial factors, or are medications causing it?

Hematemesis (vomiting blood). Ask for associated ulcer history, food intolerance, abdominal pain or discomfort

Jaundice: is there a viral cause, ga