أسالكم بالله للي يعرف يترجم يدخل يساعدني

1. History and physical examination


2. 2-Diagnosis :

السلام عليكم ورحمة الله
أسألكم بالله ساعدوني في الترجمة هذه المصطلحات عليها ثلاثون درجه وأنا لا أعرف الانجليزي ولا ترجمة

History and physical examination

The primary purpose of a history and physical examination is to assist the physician in establishing a diagnosis on which to base the care and treatment of the patient. In addition to the history and physical examination he usually needs the re- sults of several laboratory tests and possibly x- rays before he can arrive at a diagnosis. If the history and physical examina- tion is done by an intern it should be signed by him and countersigned by the resident and/or attending physician. If the attending physician does not agree with what is recorded he should add his own findings and pertinent observations be- fore signing. Patients admitted to the house staff service of the hospital are under the care of the resident staff but must by supervised by the chief of the service or a physician em- ployed to supervise the resident house staff and who must countersingn the history and physical examination as well as the diagnoses recorded.
The history should be a record of the in formation provided by the patient (fig.3)in the event that areliable history can-not be elicited from the patient the history must be obtained from the person best able to relate the facts. The physical examination (fig) is usually performed after the history has been taken. This entails a thorough examination by the physic- can and states the findings resulting from a complete assess- ment of all the systems of the body.
Accrediting agencies recommend that history and physical examination records be prepared to fit the case prepared tofit the records through the use of stereotyped forms. Either of two forms will usually meet their requests: the blank sheet and the outline form. The out- line form provides a reminder list so that essential factors will not be overlooked by the intern resident or attending physi- cian. The order followed by physicians when doing a history and physical examination differs somewhat in the various medical schools but the end result is the same since they cover the same essentials. To maintain uniformity in the medical records of a hospital. Each institution should adopt a standard outline to be used. The essential facts should be recorded within 24 hours in a concise and progressive manner. The terms negative and normal are opinions and not facts and should not be accepted unless used when summarizing stated facts.
Outline for history and physical examination
A- chief complaint: brief statement of nature and dura- tion of the symptoms that caused in that caused the patient to seek medical attention as stated in the patients own words.
B- present I llness: detailed chronological description of the development of the partientis illness from the ap- pearance of the first symptom to the present time.
C- past history: a summary of all illnesses such as acute in fectious diseases accidents operations allergies drug sensitivies. In women the number of pregnancies and abortions would be noted.
D- personal history: statements of marital status habits social history and occupation and environment.
E- family history : a record of diseases among relatives in which heredity or contact may play arole such as allergies infectious diseases mental metabolic endo- crine cardiovascular or renal diseases or neoplasms the health of immediate relatives ages at death and causes of death should be recorded.
F- Review of systems: the purpose of this systemic in- ventory is to reveal subjective symptoms which the pa- tient either forgot to describe or which at the time seemed relatively unimportant. Generally an analysis of the subjective findings as related by the patient will give a clue to the diagnosis and will indicate the naquired. The following data should be included:
1- General: nutrition fever night sweats falling hair weight gain or loss and any occupation or habit that might have a bearing on the development of the disease.
2- Skin: a record of eruptions cyanosis jaundice or other skin conditions.
3- Head: headache (duration severity character lo-cation)
4 - Eyes: eyestrain pain diplopia photophobia lacri- mation glasses (date last checked)inflammation blurring scotomata.
5- Ears: deafness discharge tinnitus dizziness pain.
6- Nose : head colds epistaxis discharges obstruct-tion postnasal drip sinus pain.
7- Throat: soreness redness hoarseness difficulty in swallowing.
8- Respiratory: chest pain hemoptysis expectora- tion dyspnea cough night sweats date of last chest film.
9- N****muscular: motor weakness joint pain paresthesia varicosities deformities.
10- Cardiovasculaa r : chest pain asthma palpitation tachycardia faintness vertigo edema.
11- Gastrointestinal: appetite, thirst, nausea, vomiting, hematemesis, melena, colic, jaundice, constipation, diarrhea, food idiosyncrasies.
12- Genitourinary: dysuria, frequency, nocturia, in-continence, pyuria, hematuria.
13- Menstrual: periods (frequency, type, duration)dysmenorrhea, menorrhagia, symptoms of meno- pause, contraceptive pills or devices.
14- Psychological status: personality type, emotional state, headaches, convulsions, paralysis, "nervous breakdown" environmental stress, memory loss, in- somnia, nightmares, sociopathic behavior.
G-physical Examination:
Vital signs: weight, height, temperature, pulse, respira- tion, blood pressure.
1- General: posture, nutritional state, apparent age, severity and acuteness of illness, emotional state, and appearance of patient.
2- Skin: color, texture, pigmentation, ecchymosis, petechiae, hair distribution, nails, myxedema, sweat- ing, lesions, icterus, etc.

• head –Eye s:-3

a- skull and scalp: configuration, scars.
b- lids: edema, ptosis, lid lag.
c - sclera: jaundice, hemorrhage.
d- conjunctiva: pallor, injection, petechiae.
e- cornea: scars, ulceration.
f- pupils: size, shape, equality, reaction to light and accommodation.
g - vision: acuity, visual fields.
h - ophthalmoscopic: optic discs, vessels, exudates, hemorrhage.
4- Ears: tympanic membranes, canals, hearing, dis- charge, etc.
5 - Nose: airways, mucosa septum, sinus tenderness, discharge, bleeding, smell, etc.
6 - mouth: breath, lips, teeth, gums, tongue, salivary ducts, etc.
7- throat: tonsils, pharynx, palate, uvula, postnasal drip, etc.
8- neck: stiffness, masses, thyroid, vessels, trachea, lymph nodes, salivary glands.
9- lymphatics: location of palpable nodes;size, con- sistency, mobility and tenderness.
0- thorax: shape, symmetry, respiration, etc.
1- breasts: masses, discharge, nipples, tenderness, etc.
2- lungs: fremitus, breath sounds, adventitious sounds, friction, spoken voice, whispered voice, etc.
3- heart: apical impulse, thrill, pulsation, rhythm, sounds murmurs, gallop, friction rub, etc.
4- Blood vessels: pulses, quality, vessel walls, etc.
5- Abdomen: contour, peristalsis, scars, rigidity, ten-derness, spasm, masses, fluid, liver kidneys, spleen, hernia, etc.
6- Genitourinary: scars, lesions, discharge, penis, scrotum, epididymis, varicocele, hydrocele, etc.
7- Rectal: fissure, fistula, hemorrhoids, sphincter tone, masses, prostate, seminal vesicles, feces, etc.
8- vaginal: external genitalia, skeneis and bartho-linis glands, vagina, cervix, uterus, adnexa, etc.
9- musculoskeletal: deformities, swelling, redness,tenderness, limitation of motion,etc.
0- Extremitremities: color, edema, tremor, clubbing, ul-cers, varicosities, etc.
1- n****logical: cranial nerves, coordination, re-flexes – biceps, triceps, patellar, Achilles, abdomi- nal, cremasteric, Babinki, Romberg, gait, sensory, vibratory, etc.

2-Diagnosis :

a- summary: a brief summarization of the case based on the subjective findings as related by the objective findings as found by the physician, together with recommenda- tions for treatment.
b- diagnostic impression; a tentative or provi- sional diagnosis made by the intern, resident, or physician examining the patient. This early diagnosis reflects the physicianis impression of the patientis condition. But it is made before any of the tests have been completed and a final diagnosis has been reached.
c- Differential diagnosis: a comparison of symp- toms and physical signs of several diseases from which the patient may by suffering. The present illness determines whether or not differential diagnoses are indicated. By the process of elimi- nation of differential diagnoses the provisional diagnosis may be determined.