Patient History Taking: Key Phrases and Steps for Effective Interviews
Patient History Taking: A Comprehensive Guide
Effective patient history taking is crucial for accurate diagnosis and treatment. Here are key phrases and steps to guide you through the process:
Basic Phrases and Translations
- Agree: Acuerdo
- Statements: Afirmación
- Following: Siguiente
- Answers: Respuesta
- As, as: Tanto, como
- Take: Tomar
- As: Como
- Interviewing: Entrevistando
- Patient: Paciente
- When: Cuando
- Taking: Tomas
- Should: Deberías
- Have: Tener
- Headaches: Dolor de cabeza
- Like: Como (verbo gustar)
- Put: Poner
- These: Estos
- Steps: Pasos
- Chief: Motivo de consulta
Steps for Effective History Taking
The correct way to take a patient’s history includes:
- Small talk
- Chief complaint
- History of present condition
- Past medical history
- Family history
- Social history
- Medication
- Physical examination
Improving Communication
- Making: Hacer
- What: Que, cual
- Beginning: Comenzando
- Improve: Mejorar
- Might: Podrían
- Suitable: Adecuado
Small Talk Topics
Small talk can include topics such as:
- Weather
- News
- Sports
- Family life
- Work
- Travel
- The hospital environment
Example Small Talk Phrases
- “It’s cold, isn’t it?”
- “Did you feel the earthquake?”
- “Did you watch the football match?”
- “Where did you go on vacation?”
- “How is your wife/the family? (Good/Bad)”
Key Questions and Phrases
- Looking: Ves
- Very well: Muy bien
- Still: Continuas
- Going: Yendo, ir
- Brings: Trae
- So: Entonces
- Here: Aquí
- Tell me: Dime cual
- Everything: Todo
- About: Sobre
- Can we: Puedo hacer
Common Symptoms
- Thirst: Sed
- Tiredness: Cansancio
- Lazyness: Flojo
- Losing: Perder
- Weight: Apetito
- Died: Morir
- Stroke: Ataque cerebro vascular
Example Questions
- Do you: Tu tienes
- Job: Trabajo
- Involves: Involucra
- Lot: Mucho
- Do you feel…?
- How is your…?
- What do you…?
- Get: Obtener
Specific Symptoms and Conditions
- Chest: Tórax
- After: Después
- Sure: Seguro
- You’ve: Ha estado haciendo
- Don’t you: No es cierto?
- Do you: Es cierto?
- Stabbing: Punzante
- Earache: Oído
- Both ears: Ambos oídos
- Some: Algunos
- About: Como, más o menos, hacia
- Sometimes: A veces
- Have had: Yo he estado/yo había estado
- Painless: Inholoro
- Nodule, lump: Nódulo, bulto
- Neck: Cuello
- Heartbeat: Latido cardiaco
- Typist: Mecanógrafo
- Tingling: Hormigueo
- Worse: Peor
- Weakness: Debilidad
- Finger: Palpar
- Dizziness: Mareo
- Hissing: Silbido
- Cough: Tos
- Tasting: Sabor
- Phlegm: Flema
- Sweats: Sudar
- Complaining: Queja
- Enlargement: Agrandecerse
- Thyroid lump: Nódulo tiroideo
- Breathlessness: Falta de aliento, dificultad al respirar
- Tachycardia
- Gets: Conseguir, obtener
- Ringing: Resonante, zumbido en el oído
- Lobe: Lóbulo
- Clubbing: Dedos hipocráticos
- Ache: Dolor
- To hurt: Lastimar
- Swelling: Hinchazón
- Swollen: Hinchado
- Painless: Sin dolor
- Sick/Ill: Enfermo
- Suffering: Sufrimiento
- Sore: Doloroso
- Last: Intimo, durar
Describing Pain
- Intense, excruciating: Agudísimo (dolor severo)
- Unbearable: Insoportable (dolor severo)
- Aching: Difuso (dolor leve)
- Slight: Leve (dolor leve)
Characteristics of Pain
- Stabbing: Punzante
- Annoying: Molesto
- Hot
- Tingling: Hormigueo
- Blunt, dull: Sordo, ligero
- Pressing: Insistente
Instructions for Physical Examination
- Bend down: Tocar punta de los pies
- Breathe in/out: Inhala/exhala
- Close your eyes
- Curl up: Acurrucarse
- Do this: Hace esto (imitar)
- Follow my fingertip with your eyes: Sigue la punta de mi dedo con tus ojos
- Keep your knee straight: Mantenga su rodilla estirada
- Let your wrist go floppy: Deje caer su muñeca
- Open your mouth: Abre tu boca
- Point to the finger that moves: Apuntar al dedo que se mueve
- Pull as hard as you can: Tirar tan duro como puedas
- Push as hard as you can: Empujar tan duro como puedas
- Put your head down: Poner la cabeza baja
- Put out your tongue: Poner la lengua afuera
- Sit: Sentarse
- Sit up: Levantarse de la cama
- Stand straight: Pararte derecho
- Stand up: Levantarse de la silla
- Strip to the waist: Sacarse las cosas de arriba
- Tilt your head back: Inclinar la cabeza hacia atrás
- Touch your shoulder with your chin: Tocar el cuello con el mentón