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Translate the following word combinations paying your attention to the word formation:
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To present a set of complaints - presenting symptom - reason for presenting, to affect the organ - the affected person, to swallow rapidly – ankle swelling, to find the cause – to find out by using hands – X-ray findings, to weigh 10 kg – weight loss, short distance – to shorten the route - shortness of breath, to exert the muscles – exerted on the walls of blood vessels – on exertion, to digest the food – digestive tract – the process of digestion - indigestion, to examine the patient - examiner - physical examination, to provide with blood – provided data - primary care provider, to evaluate the condition - evaluating objective anatomic findings - evaluation of general patient appearance, abnormal findings - abnormality in the body systems, to assess the patient’s status - a health assessment, to test the organ system – blood test.
5. Translate the following word combinations into Russian:
The major health problem or concern, a short statement describing the symptom, problem or condition,
obtaining further information about the patient's symptoms, appreciated only by the affected person, supported by physical signs observable to the examiner, a set of ordered questions about each major body system, generally follows the taking of the medical history, investigates the body of a patient for signs of disease, develop a baseline assessment to identify normal versus abnormal findings, includes evaluation of general patient appearance and specific organ systems, may reflect abnormalities in the body systems, the process of evaluating objective anatomic findings, reviews the appearance for signs of any potential conditions, to feel for abnormalities during a health assessment, a list of potential causes of the symptoms, further investigations to clarify the diagnosis.
6. Think of the patient examination and answer the following questions:
ü What is a physical examination?
ü Who examines the patient?
ü What kinds of examination do you know?
7. Watch the video ‘Abdominal examination’ and put down types of physical examination shown:
https://www.youtube.com/watch?v=O1ajZJvrITg
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8. Read the text and check your answers:
History and Physical Examination
The chief complaint (CC) or presenting complaint (PC) in Europe and Canada is the major health problem or concern forming the second step of medical history taking. It is sometimes also referred to as reason for encounter (RFE), presenting problem, presenting symptom, problem on admission or reason for presenting. The chief complaint is a short statement describing the symptom, problem, condition, diagnosis, or other reason for a doctor’s visit.
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A patient typically presents a set of complaints to the medical professional who then performs a diagnostic procedure, which generally includes obtaining further information about the patient's symptoms, previous state of health, and so forth. In the broad sense, the word symptom is used to label any manifestation of disease. In the diagnostic sense, however, symptoms are thought to be only subjective, appreciated only by the affected person. Pain and itching are pure symptoms. Signs are detectable by another person, i. e. they are objective. Pulmonary rales are pure signs. Fever and swelling are symptoms and signs as the same time. A symptom can never be a diagnosis: a headache is a symptom, even if you call it cephalalgia. Most clinical diagnoses will be comprised of a syndrome, supported by physical signs observable to the examiner, and correlated with laboratory and roentgenological findings.
Following the presenting complaints, a review of systems (ROS) or systems inquiry, which is a set of ordered questions about each major body system, is made by the healthcare provider. Secondary complaints are based on the review of systems. A medical professional may find symptoms that the patient had forgotten about or identify secondary, unrelated problems.
General symptoms: weight change (loss or gain), change in appetite, fever, malaise.
Respiratory symptoms: cough, sputum, shortness of breath, wheeze, chest pain.
Cardiovascular symptoms: shortness of breath on exertion, chest pain, palpitations, ankle swelling.
Gastrointestinal symptoms: indigestion, abdominal pain, nausea, vomiting, constipation.
Urinary symptoms: polyuria, dysuria, haematuria.
Neurological symptoms: headaches, dizziness, weakness, tremor, fits, faints.
Locomotor symptoms: aches, pains, stiffness, and swelling.
Skin symptoms: ulcers, rashes, itch.
Physical examination generally follows the taking of the medical history. A physical examination, medical examination, or clinical examination (more popularly known as a check-up) is the process by which a medical professional investigates the body of a patient for signs of disease. Together with the medical history, the physical examination aids in determining the correct diagnosis and forming the treatment plan. There is no real dividing line between history and examination. It may be performed by a family practice physician, physician assistant, a certified nurse practitioner or other primary care provider. Nursing professionals such as Registered Nurse, Licensed Practical Nurses develop a baseline assessment to identify normal versus abnormal findings. These are reported to the primary care provider.
A complete physical examination includes evaluation of general patient appearance and specific organ systems. In practice the vital signs of temperature, pulse, and blood pressure are usually taken first. Respiratory rate is checked too. Vital signs may reflect abnormalities in the body systems.
Physical examination is the process of evaluating objective anatomic findings through the use of observation or inspection, palpation, percussion, and auscultation. A general examination generally starts at the head and finishes at the extremities.
The first part of examination is to observe. A medical professional reviews the appearance for signs of any potential conditions. A patient may sit or stand during this part of the examination. This includes the estimation of: face expression, constitutional type, gait abnormalities, skin color, hair, nails, visible mucous membranes, subcutaneous fat, presence of edema, lymph nodes, muscles, bones, joints.
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In a physical examination, there are many things that the healthcare provider can find out by using hands to feel, stethoscope and ears to listen. The patient is lied down and the healthcare provider inspects the consistency, location, size, tenderness, and texture of the individual organ using:
Palpation. The examiner uses their hands to feel for abnormalities during a health assessment (lymph nodes, chest wall, abdomen) checking the presence of masses or lumps.
Percussion. The examiner uses hands to "tap" on an area of the body. The "tapping" produces different sounds. Depending on the kind of sounds the healthcare provider may determine anything from fluid in the lungs, or a mass in the stomach.
Auscultation. The healthcare provider listens to heart, lungs, neck or abdomen, to identify if any problems are present. Auscultation is often performed by using a stethoscope.
With the clues obtained during the history and physical examination the healthcare provider can formulate a differential diagnosis and a list of potential causes of the symptoms. Specific diagnostic tests generally confirm the cause. Primary care provider can form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated. The treatment plan may then include further investigations to clarify the diagnosis, e.g. additional screenings or imaging tests, blood tests, etc.
Choose the right variant:
Multiple Choice Test
1. Chief complaint is
o the minor health problem or concern
o the major health problem or concern
o the major syndrome
2. Symptom is thought to be
o associative
o subjective
o objective
3. Sign is thought to be
o causative
o subjective
o objective
4. Review of systems is
o a set of ordered complaints about each major body system
o a set of ordered questions about each minor body system
o a set of ordered questions about each major body system
5. Physical examination is
o process by which a medical professional investigates the body of a patient for signs of disease
o process by which a medical professional investigates the body of a patient for symptoms of disease
o process by which a medical professional investigates the body of a patient for signs of symptom
6. Complete physical examination includes
o evaluation of specific organ systems
o evaluation of general patient appearance and specific organ systems
o evaluation of general patient appearance and specific cell systems
7. Observation is
o the review of the symptoms for signs of any potential conditions
o the review of the internal organs for signs of any potential conditions
o the review of the appearance for signs of any potential conditions
8. Palpation is
o the use of feet to feel for abnormalities during a health assessment
o the use of hands to feel for complaints during a health assessment
o the use of hands to feel for abnormalities during a health assessment
9. Percussion is
o the use hands to "tap" on an area of the body to determine a sounds
o the use hands to "tap" on an area of the body to determine a fluid or a mass
o the use ears to "tap" on an area of the body to determine a fluid or a mass
10. Auscultation is
o listening to heart, lungs, neck or abdomen performed by using a stethoscope
o listening to heart, lungs, neck or abdomen performed by using a otoscope
o listening to heart, lungs, neck or abdomen performed by using a microscope
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