Taking a case history

As soon as the patient is admitted to the in-patient department the ward doctor fills in the patient’s case history. It must include the information about the patient’s parents – if they are living or not. If they died, the doctor must know at what age and of what caused their death. The doctor must know if any of the members of the family has ever been ill with tuberculosis, has suffered from a stoke or heart attack or has had any mental or emotional impairments. This information composes the family history (семейный анамнез).

The patient’s medical history must include the information about the diseases which the patient had both being a child and an adult, about the operations which have been performed, about any traumas he had. These findings compose the past history (жизненный анамнез). The patient’s blood group and his sensitivity to antibiotics must be determined and the obtained information is written down in the case history.

The attending doctor (лечащий врач) must know what the patient’s complaints and symptoms are. He must know how long and how often the patient has had these complaints.

The information on the physical examination of the patient on his admission to the hospital, the results of all the laboratory tests and X-ray examinations, the course of the disease with any changes in the symptoms and the condition of the patient, the administered medicines in their exact doses and the produced effect of the treatment - all these findings which compose the history of the present illness must always be written down in the case history.

The case history must always be written very accurately and consist of exact and complete information.

IX. Read and translate the medical terms: