English for doctors(醫生診療英語會話)

English for doctors：Authentic consulting－room activities for doctors, dentists, students and nursesFrom DXY.CN1 PAST MEDICAL HISTORYi "d like to ask you about your past medical history.can you me whether you have had any childhood diseases?for example chickenpox ,measles,mumps or rubellawhen i was small ,i had measles,chickenpox and whooping cough .but i don"t think i ever had rubellahave you ever been in hospitalized for anything?or have you ever had an operation well,i had my tonsils taken out when i was a childhave you had any major health problems since thenyes,i have diabeteswhen were you first diagnosed with diabetes?what were your simptomsi was diagnosed when i turned 14.i was always thirsty ,tired and depreassedare you receiving any treatment for thisi have been getting insulin shots ever sinthhave you had your vaccinationsyesgooddid your referring physician give you a letter for meyes ,here it is2 FAMILY HISTORY as far as you know,are there any illnesses that run in your family?none that i know of, doctornothing like diabetes, high blood pressure, heart disease ,stroke,cancer,mental illness or anything like that?oh i see! my father had a heart condition, and i have two my aunts who have diabetesand is your father still aliveno, he isn"thow old was your father when he diedhe was 68what did he die offhe had a heart attackdid he suffer for a long time with this heard cindition before he diedoh no, it was very suddenand your aunts? do you know what kind of diabetes they have? do they have to take insulin or tablets or are they just on a dietthey just take some pills, i thinkyou are married, i see,have you any childrenyes, a boy and a girlare they healthyyes, they are3 SOCIAL HISTORY are you working right nowno , i have just been laid offoh , i am sorry .what was your jobi was a manager for an import and export companyi see . was it an office job or were you on your feet all dayi worked behind a deskwas it managerial,did you have a lot of responsibilityyes ,i was in charge of a large departmenti see,quite stressful.now,tell me ,do you smokeyes,i do. unfortunately, quite a lotoh ,really? how muchall about 2 packs a dayhow long have you been smokingsince i was about fourteenhave you ever try to quit smokingyes , i have tried several times .but without successwhat about driking?do you drinkyes ,sometimes with my friendshow much alcohol do you drink a daylet see.a couple of glasses of beer at lunch time.a wisky in the evening.and about half a bottle of wine with my dinnerthat"s quite a bit.how old were you when you start drinkingoh,about 17 ir 18, i supposewhat about your living conditions? where do you livewe living in a small apartment.we own it .but of course we are still paying the morgage on it 4 PRESENT COMPLAINTS 4 present complaints1-4-1what"s the problem todaycan you tell me what your symptoms arehave hou ever had these complains beforewhat"s seems to bring this condition onwhen did you start feeling poorly1-4-dialogue a (1-4-dialogue b )what seems to be the problem at the moment(today)well,i have been feeling so poorly recently(ill lately)i see . feeling poorly(ill).(now)what do you mean by thati have been getting very short of breathhm...how long has this been going onfor about 18 months ,i thinkand were there any other symptoms before then or did it(this condition) start quite suddenlyi hadn"t notice anything before thenso you haven"t (didn"t have any of)experence this symptom beforeno , not that i can remember , doctori see.was there anything that seems to cause this(have caused these symptoms)well,nothing(no,not) really.except maybe it gets really bad when i go up to london(new york) to see my sisiterlet"s take a look(to begin with).i"ll listen to your heart and lungs to begin with1-4-5a .what can i do for you todayhow can i help you mr. jonesb .what do you mean by thatcan you describe that in more detailc .what are your symptomscan you describe the changes that have occurredd .did it start suddenlydid your condition change without any warninge .what brings it onwhat do you think causes your condition 5 PAIN 5 pain1-5-1headdo you have a splitting headache/throbbing/band-like/dull/aching/burning/sharp/stabbing/colicky/migraine/blinding/stress- induced/tensiontoothdo you have a sharp toothacheis your toothache dull/throbbing/stabbing/pulsatingis your tooth sensitive/aching/tenderlower backis the pain in your back slow in onsetlong in duration/dull/diffused/aching/steady/constant/severe/progressing poorly/localised/crushing/deep/mildchestis the pain in your chest burningdo you have a constricting pain in your chestbursting/choking/squeezing/griping/pressing/crusching/sticking/jabbing/sharp/knife- like/fleeting/throbbing/dull/severe/stabbing/like a weight on it/like a band across itabdomendo you fell a sharp pain in your abdomendull/aching/gnawing/burning/cramping/colicky/diffused/localised/recurrent/constant/flank/intermittent/stabbingdo you get bloateddo you feel bloateddu you have any heartburndo you have any indigestionkidneys and urinary tractdo you have a sharp paindu you have a dull achedu you have severe discomfortburning/stinging/nagging/nigging/splitting/flank/back/abdominal/steady/low gradedo you have slight discomfortextremitiesdo you have a sharp pain in your shoulderdo you have a tingling pain in your handdo you have a shooting pain in your footdull/burning /severe/pulsating/throbbingdo you have weakness in your handsdo you have numbness in your armsdo you have crampdo you have an ache on your hand1-5dialogue a (dialogue b)do you feel any painoh,yes . quite a bitcould you show me where it hurtsright here, doctor, in my chesthere,hm...is it always just in that spotno, sometimes it moves around to herei see.what kind of pain is it.can you descrie the painwell,most of the time it feels like a cramp.but occasionally it is sharp and stabbingdoes it come and go or do you have it all the timewell,it worse at times.it seems to come over me in waves.but mostly it"s there all the timedoes it start suddenly or build up slowlyit seems to build up graduallywhat do you do when you get the(feel this) painwell,there isn"t much i can do.i just have to put up with itand does anything in paticular seem to bring the pain on or make it worsewell,i find going upstairs difficult(it is more intense when climbing stairs).also when i have to cough or take a deepbreath it"s terrible like a knife stabbing me1-5-6a. can you show me where it hertsb.could you describe what the pain feels likec.how long have you had this paind.when does it come,when,does it goe.does anything relieve the symptoms or make them worthf.does the pain move to another part of your bodyg.what brings it on6 HEADACHE6 headache1-6-11 do you feel the pain at the top of your head2 do you feel any pain in your temples3 is the pain around your eyes4 is the pain at the back of your head5 do you have any pain in your forehead6 does the pain move to your face7 do you feel any pain around your ears8 does the pain spread to your neck9 does the pain seem to be comeing from your neck10 does the pain travel to your shoulders1-6 dialogue a (dialogue b)tell me about your headacheit comes and goescan you point out the painful areait seems to be on the right side of my headhow long does the headache last when you get it(it comes)it varies.it can be between half an hour and four or five hourswhen you get a headache ,does anything else happen at the same timeyes.often i feel sick(i am often nauseous).sometimes i actually vomit(throw up)does the headache ever upset your eyes,for example , does your vision get blurredit"s not blurry.but i get flashing lights that seems to be in the right eyewhat do you do when you get the headachewhll, i"m not ususlly able to carry on with what(i ususlly have to stop wtatever) i am doing,i have to go to a dark room and lie downhave you found any tablets(medication) that seems to have helpedsometimes if i take an aspirin early on ,it seems to help.at other times nothing seems to help muchdoes anybody else in your family have this type of a headacheyes,my mother used to suffer from migraines when she was youngercan you describe the (character of he ) pain.is it stabbing or more band-like, kind of pressingit throbs.sort of stabbing ,i suppose(guess)1-6-6a can you point out the painful areab how long does the headache last when you get itc can you describe the paind when you get the headache,does anything happen at the same timee what do you do when you get the headachef have you found any medican that seems to have helpedg does anybody else in your family have this type of headache7 VERTIGOHow would you describe your dizziness?It』s as if I am falling to the left.what does the disease spell constist for you?A kind of imbalance.How long does the episode of dizziness last?Sometimes an hour, sometimes a whole day.In what body position do you feel dizzy?Every time I squat or bend down and try to get up too quickly.Do you ever suffer from dizziness? (get dizzy?)Yes, quite often.When does this happen?When I get up too quickly.Do you feel as if you are falling in a certain direction?No, not really.Does this dizziness feel like spinning or is it just a kind of unsteadiness.It feels more like spinning.How would you describe it? Is it as if the room is going around or do you feel as if it』s you that"s going around.It feels as if I am going around.Do you have any other problems such as ringing in the ears.Yes, sometimes.Have you seen a consultant(specialist) about this?Yes, she prescribed some medication for it, but it didn』t help at all.Do you have any associated symptoms like blurred vision.No, but I haven"t noticed(not that I have noticed. )8 BODY TEMPERATURE AND SWEAT8 body temperature and sweat1-8 dialogue a(dialogue b)have you got a temperature(had any fever recently)yes, doctor,i have been feeling quite flushed(warm) latelyis your temperature (constantly)high all the time or does it go up and downit ususlly goes up( it is uaually higher) at night.but it is still high even during the daywhat"s the highest and the lowest it has been in the past few daysthe highest was 104.the lowest was 100and where did you take your temperature,under your arm or under your tongue(orally)under my tongue(i measured it orally)do you also have the shivers(chills)yes, sometimesdo(did) your teeth chatter(rattle) or are the shivers(chills)milder than thatoh yes, they chatter(rattle).i"ve bitten my tongue several times alreadydo(did) you take anything for the feveraspirindoes it helpno not reallyhave you been abroad( traveled) to any tropical or developing countries recentlyyes, i just came back from tailand a few months agoi see.do you perspire more than usualyes, a lot, i am afraidjust when your work hard or also at other timeswell,i never used to sweat much.but now i seems to break out in a sweat (at the drop of a hat)easily .my clothes often get soaking wetdo you feel shaky or weak at allyes , practically all the time` 9 NAUSEA AND VOMITINGDo you just feel sick /nauseous/ or have a actually vomited?/thrown up/oh, I am vomiting and it seems (I』m throwing up) all the time.When did it all started?About two months ago.And how often does this happen?About once a day, sometimes more.When are you sick? Is it in morning or after you"ve eaten.Well, it isn"t really regular.But does it get better or worse if you eat something?Worse, I think.When you vomit, do you bring up digested food, undigested food or bile?Oh, it is usually more like bilewhat colour is it? Green, black, yellow or red?It seems to be a sort of yellowish green color.Does it ever have blood in it or look like ground coffee?no, neverDo you belch a lot/burp a lot/or have a bad /a nasty/ taste in your mouth?Well, yes, doctor. I do belch a lot and I seem to suffer from a lot wind just lately. /and I have had a lot of gas lately/ 10 DYSPN(O)EADyspneaDo you have any difficulty breathing?What』s harder breathing in or breathing out?Are you short of breath when you are resting ?Can you lie flat in bed?Is it relieved by sitting up in bed?Do you have to stop frequently when you climb the stairs?Have you ever had any breathing tests?Dialogue aHow long have you had difficutly breathing ?Since last week, doctor.Is it very bad?Yes, I feel as if I can』t get enough air.Which is more difficult, breathing in or breathing out?It is harder to breathing in.Are you short of breath when you are resting or only when you doing something?When I am rest, but it is worse when I try to do anything.Can you lie flat in bed?Oh, no.How many pillows do you use?Three.Do you ever wake up night feeling short of breath?Yes, I do.(If frightens me because when i wake up feeling as if i cann"t breath.What do you do when this happens? I mean, do you sit or stand up, does some movement help?If I sit up, it helps a little.Let me listen to your chest. I can hear few crackles and it sounds a big wheezy.Dialogue BHow long have you had difficulty breezing?.Scince last week, doctor.Is it very bad?Yes, I feel like I can"t get enough air.What』s harder, breath in or breath out?It』s harder to breath in.Are you short of breath, when you are resting, or only when you are doing something physical.A little when I am resting, but it』s worse when I try to do anything physical.Can you lie flat in bed?Oh, no.How many pillows do you use?Three.Do you often wake up night feeling short of breath?Yes, I do. It』s scares me because I wake up feeling as if I can』t breath.What do you do when this happens. I mean, do you sit or stand up? Does some movement help you breathe easier?If I sit up, it helps a little.Listen to your chest... I can hear a few crackles and it sounds a big wheezy.how long have you had difficulty breathing? / how long have you been short of breath?i"ve had difficulty breathing for about two weeks.when is your breathing most diffcult?i wheeze in the early hours.which is more difficult,breathing in or breathing out?breathing out is harder.are you short of breath when you are resting or only when you are working?i"m short of breath when i"m working.can you lie flat in bed?/ can you sleep on your back?yes, i can sleep on my back.can you ever wake up at night because you are short of breath? /is your sleep disturbed?yes,i eake up several times because i"m short of breath.what do you do then?i usually get up and walk around when it happens 11 COUGH Dialogue ADo you have a cough? I have a cough, but I also seem to wheeze a lot.Is this a recent symptom, or have you had it for some time now? I』ve had it for some time, Doctor.Do you suffer form coughing fits?Yes, a lot.Do you bring up phlegm or is it a dry cough?I bring up quite a bit of phlegm, I am afraid I might have asthma.What is it like? What do you mean?Can you describe the phlegm for me? What color is it? Is it white, yellow, or greenish, and is it frothy/foamy/ or sticky?Yes, it』s yellowish and feels kind of like jelly?Does it have a strange smell or taste?No, I don』t think so.Has there ever been blood in it?Yes, just once I noticed some blood in it.Have you taken any medicine or tablets lately? Yes, I was on something to thin my blood.Dialogue BDo you have a cough?I have a cough, but I also seem to wheeze a lot. Is this a recent symptom or have you had for sometime now?I』ve had it for some time, doctor.Do you cough a lot?Yes a lot.Do you bring up phlegm, or is it a dry cough? I bring up quite a bit of phlegm. I am afraid I might have asthma? What is the phlegm like?What do you mean? Can you describe for me what colour it is, whether it is white, yellow or greenish, and what is it foamy, thick and sticky?Yes it is yellowish and feels kind of like a jelly.Does it have strange smell or taste?No I don』t think so.Has there ever been blood in it? Yes, just once I noticed some blood in it.Have you take any medication lately? Yes I was on some medication to thin my blood.Yes, it smells very bad.It is frothy!I』ve had this cough for 3 weeks.Yes, I bring up a lot of phlegm.If I sit up or use two pillows I feel better. It』s a barking cough. 12 HEART heart symptomsAwhat seems to be the problem at the moment?i seem to be getting very short of breath nowadays, so i thought it best to come in to see you. i also feel a tightness in my chest.how long has this been going on?it seems to have been getting worse over the last few weeks.are you short of breath all the time or is it just when you walk up the stairs?well, it is hard work going up the stairs,the pain feels like a knife.does the pain move to other area as well?yes, it moves to my neck, my left arm, my back and my should.do you ever feel sick or sweaty when that happens?well, i don"t feel sick but i often break out in a sweat.do you ever feel that your heart beats usually fast or slow?yes, sometimes it beats really slowly. then from time to time it skips a beat, then continues to beat very rapidly.can you tap out with a finger what the rhythm feels like to you? .. good, have you had any swelling in you ankle?yes, both my feet have been somewhat swollen.does this go down overnight or are they still swellon in the morning?oh, my feet feel much better and they aren"t as swollen in the morning.Bcan you tell me, ... what are yous complaints?i seem to be getting very short of breath lately, also i feel tightness in my chest, so i thought it would be wise to come in and see you. how long has this been going on?it seem to have been getting worse of last few weeks.are you short of breath all the time or it is just when you exert yourself?well, the pain gets worse when i exert myself,it feels kind of like a knife.does the pain radiate to other areas as well or is the pain localised.no, it moves to my neck, my left arm, my back and my should.do you ever feel sick or sweety when this happens?well, i don"t feel sick but i often break out in a sweet.do you ever feel that your heart beats unusually fast or slow?yes, sometimes it beats really slowly,then from time to time it skips a beat, then continues to be very rapidly.can you tap out with a finger what the rhythm feels like to you?.. good, have you had any swelling in you ankles?yes, both my feet have been somewhat swollen.does this go down overnight or are they still swollen in the morning?oh, my feet feel much better and they aren"t swollen in the morninghave you ever had any heart problems?i"ve never been diagnosed whit angthing, but i think something can be wrong my heart.what seems to be the problem with your heart?it beats irregually especially when i smoke.what kind of pain do you get during you exercise?i get pressure in my chest sometimes when i have to walk a long distance.do you often get short of breath?absolutely, i am alway short of breath when i go upstair.do you ever feel sweaty when this happens?yes, i break out in a really bad sweat when my chest hurts.where does the pain move?down my left arm.and have you had any swelling in your feet or ankles?yes, my ankles seem to be swollen all the time.do your feet hurt all the time?yes, the pain is fairly constant,but it helps when i put my feet up. 13 BODY WEIGHT AND DIETWhat』s your appetite like? Are you on a special diet?(Have you ever follow a diet?)(Have you tried to lose weight? )Have you had your cholesterol checked?Is your weight steady?Tell me, what』s your appetite like? / how"s your appetiti?Sometimes it』s good, but at other times I don』t feel like eating at all.How do you feel about your eating habits? / describe your eating habits to me?well,I usually eat five or six times a day. Lots of foods and vegetables, but when I am anxious /nervous / I can』t eat at all. Have you lost or put on /gained/ any weight recently or does your weight stay at same? I』ve been putting /gaining/ on quite a bit /lot/of weight likely.How many pounds have you gain do you think/ you"ve gained ? About 10 pounds or so.Over how long a /what/ period of time has this happened? Since about charismas, so in the last 6 months. Are you trying to do anything to control your weight, for example, are you on a diet?Yes, but it doesn』t seem to work. Are there any foods you dislike or is there anything that you particularly like to eat? I eat lots of pasta dishes, but I can』t have anything with nuts in them because I am allergic to most kinds of nuts. Do your eating habits change for any reason?Yes, I eat quite a bit more when I feel good.I am losing my appetite a bit.Yes, I am getting very thin. I have lost 20 pounds.I』d say, during the last 3 months or so.Yes, I can』t stand a sight of meat. 14 BOWEL MOVEMENTS Bowel movements1-14dialogue A-Do you have regular bowel movements?-No, (Yes ,but) sometimes I get constipated and sometimes I have diarrhea.-When you say you have diarrhea,do you mean the stool is very loose, or that you have to go to the toilet(bathroom) more frequently?-I have to go four or five times a day.-When you have to go, do you have to go quickly?-Yes, I have real problems holding it.-Could you describe your stool?-The last time it was loose and watery,but very dark.-Do you have any problems flushing it down at all?-No, I haven"t noticed anything like that.-Has there been any blood or mucus in the stool ?-Yes, I have noticed some blood, but no mucus.-Is it mixed in with the stool or is it just there on the paper when you wipe yourself?-It seems to be mixed in with the stool, Doctor.-I see. and when you are constipated, do you take laxative, or do you give yourself (use) anenema?-If I can"t go for three days, only the laxative helps.-Do you feel bloated when you are constipated?-Yes,occasionally. But the laxative helps with that too.Do you have any problems with excessive wind or belching (gas or burping)?No, not particularly.1-14-5AIs it actually painful to have a bowel movement? = Does it hurt when you open your bowels?BHave you ever tried taking any laxatives that you can get at a chemist"s? = Do you take anything for your bowels ?CDoes your stomach ever feel distended? = Do you ever feel bloated when you are constipated?DDo you have wind moving aroud in your bowels? = Do you feel gassy?EDo you pass wind? = Do you break wind?FDo you have a tendency towards flatulence? = Do you ever suffer from excessive wind? 15 BLOOD bloodDialogue A:A: So you say that you are having problems with bleeding or bruising?B: Yes I am.A: Can you tell me what you mean by that? Do you bleed or bruise easily?B: B: Yes,everytime I scrape myself or bump into something I get bruised.A: Have you always had this problem or is it recent development?B: I noticed the problem started about the time I started shaving.A: Do your gums bleed when you brush your teeth?B: Yes,quite a bit.A: Do you have any trouble stopping the bleeding?B: Oh,yes,even from the most minor cutsA: How long dose it take to stop the bleeding?B: At least 10 or 15 minsA: Are there any other members of your family with bleeding tendencies?B: No ,no that I know of.A: Have you ever needed the blood transfusion, or have you given blood recently?B: I don"t like needles, so I don"t give blood. But I needed a transfusion after a car accident a few years ago when I was 15.A: Do you remember how many units of blood you received?B: No,I don"t remember sorry.A: Do you know what your blood type is?B: I think it"s AB negative but I am not sure.Dialogue B A: So you say that you are having problems with bleeding or bruising?B: Yes I am.A: Can you tell me what you mean by that? Do you bleed or bruise easily?B: Yes,everytime I scrap myself for bumping to sth I get bruised.A: Have you always had this problem or is it just recent development?B: I noticed that the problem started about the time I started shaving.A: Do your gums bleed when you brush your teeth?B: Yes,quite a lot.A: Do you have any trouble stopping the bleeding?B: Oh,yes,even from the most minor cutsA: How long dose it take to stop the bleeding?B: At least 10 or 15 minutesA: Are there any other members of your family with bleeding tendencies?B: No ,not that I know of. A: Have you ever needed the blood transfusion or have you given blood recently?B: I don"t like needles so I don"t give blood.But I needed a transfusion after a car accident a few years ago when I was 15.A: Do you remember how many units of blood you received?B: No,I don"t remember sorry.A: Do you know what your blood type is?B: I think it"s AB negative but I am not sure. 16 MEDICAL EXAMINATION16、medical examination1 Now Mr Jacob, I"d like to examine you. I just want to check one or two things, your heart and your lungs and abdomen. Would you just take off your clothes/just/ down to your underwear and put on this gown with the opening at the back.2 Hop on/please get on/ the table for me, can you manage or shall I give you a hand?/ can you do it yourself or would you like me to help?3 Right, give me your wrist, will you. I am going to take your pulse. That is fine.4 Now let"s take your blood pressure. Will you straighten your arm for me, please.5 Now let"s have a look at your eyes. Look up for me. please.6 Let me check the reflexes in your arms and legs. Relax.7 Turn your head to the right to look at the wall. I want to check the pulse in your neck.8 Let me feel your windpipe… Let me just feel your glands. That』s fine.9 Stick your tongue out for me, please. Open your mouth and say 「ahh「.10 Right, now I want to listen to your heart. Just breathe out quietly 11 Now sit forward when I listen at the back, hold your breath. ... Good. Now let"s listen to your lungs. Take deep breaths through your mouth-- in ....out ... keep going.12 I』d like to feel your abdomen. Put your arms down by your side and let your tummy/stomach/ relax… that』s it. Are there any places that are tender or painful? Now I want to check your liver and spleen so take deep breath in, hold it...fine.13 I"d just like to examine your prostate and rectum. Now this will be slightly uncomfortable, but it shouldn"t hurt. Lie down on your left side and bend your knees right up to your chest…fine. I am going to insert a finger into your rectum. Don』t worry, you won"t lose any control. 17 ISOTOPE SCANNING1, you will receive an intravenous injection, make a tight fist, now open it, this injection contains the medicine which can be seen by the machine so that it is possible for us to scan your organ. you have to wait so the medicine can reach the organ. you must not move during the scan. we will sent the results to your doctor.2, have you drunk anything today? you must drink four glasses before the scan.we will give you a water tablet during the scan, after which you will have to urinate more often then usual.do you take anything to keep your blood presure down?3, a, before you get the injection you need lie on your back for ten minutes.b, now you have to inhale a vapour for the test.this has no taste or smell. you"ll need to sit in front of an inhaler, you"ll get a clip for your nose so that you breath through your mouth.4, before the examination you need drink a litre of the fluid over the period of twe hours.before we call you you should go to the toilet to empty your bladder.otherwise we cann"t scan your hip correctly.5, you"ll have to drink a sweetened solution which will contract your gallbladder, this tastes very sweet and in some people causes diarrhea6, my colleage the cardiologist will explain the procedure,after you are given the isotope injection you have to consume fatty food or drink, such as milk, cheese or sandwish. this is so that the medicine passes through your liver quickly for us to get correct picture of how the heart muscle are supplied with blood.7, you"ll get four small injection where you have changes on your skin.we"ll take three pitures. the last will be taken in 24 hours" time. we will mark the location of the lymph nodes. so please don"t wash the marks off.before the injection, you will need to a lie in a dark place for forty-five minutes with your eyes closed, only after the injection can you open your eyes.B1.you will be given an intravenous injection, make a fist, then let it go.this injection contains a substance to make necessary organs visible on the machine.there"ll be some waiting time before the actual examination. This is necessary so that the test substance can reach the appropriate organ..you must remain completely still during the examination. the results will be given to your regular physician.2. have you drunk any liquids today? you"ll have to drink about 4 glasses of fluids before the examination , you 『ll also be given the substance which will make you have to go to the bathroom frequently. What blood pressure medication are you taking ?3.A) before receiving the rejection, you should lie on your back for 10 minutes,Now you must inhale the spray.it resembles water vapour and has no taste or smell,in these cases you"ll have to sit in front of inhaler. we』ll clip your nose shut and you will have to breathe through your mouth,4.the waiting time is about 2 hours, during which you should drink approximately a liter of fluid, please go to the bathroom before you are called ,so that your bladder will be empty, otherwise we will not be able to make a precise examination of the pelvic bones.5.you will have to drink a sucrose solutions to constrict your gallbladder,it is very sweet.for many people it may cause diarrhea.6.the cardiologist will inform you about the procedure. after you have received the isotope injection. you should eat or drink something containing fat, such as cheese ,milk or sandwich,this is necessary in order to stimulate the substance being past through the liver,so that we can make an accurate image of blood supply of your heart muscle.7 you will be given four small injections around the affected areas of your skin,u we will take scans 3 times, the last of which will be 24 hours later. we will mark the location of indicated lymph gland with a stain. please do not wash this off.8,before receiving injection,you will have to lie in a dark room with your eyes shut for about 45 minutes,please do not open ur eyes until after the injection 18 PRESCRIPTIONSprescriptionyou seem to have a localized skin rash caused by a bacterial infection.this means you will have to take some antibiotics. are you allergic to any medicine?Yes ,actually, I had quite a bad reactions once when I took penicillin.i felt a choking sensation and my tongue was badly swollen.Ok,then I』ll prescribe an antibiotics without penicillin. you』ll have to take one tablet 3 times a day, preferably immedially after eating,Is there some kind of lotion that I can use on my skin?Yes,I can also prescribe an anti-inflammatory ointment or some talcum powder,both should help reducing the burning and itching sensation,I recommend the ointment,but I"ll prescribe whichever you prefer. Which would you rather use?Then I 『ll take the ointment,as you suggested.You should apply it whenver you need to. do you feel that you need some pain {blocked}ers?Yes,that would quite helpful,i havn"t been able to do anything since this started.it hurts so badly,well,that should clear it up,if everthing looks good,you won"t have to come back again. however if the symptoms don"t go away after a week, make sure you come back and see me again 19 THERAPEUTIC EFFECTS OF DRUGStherapeutic effects of drugsantiemetics,to stop or prevent vomiting.anthelmintics,to eliminate wormsanti-inflammatory drugs,to decrease inflammation,antitussives, to stop coughing,bronchodilators, to reduce bronchial spasmsdiuretic, to help the patient to preduce the urinemucolytics, to liquefy viscid bronchial mucussedative/ tranquilizers , to induce tranquility or sleepspasmolytics, to relax smooth muscles and relieve crampsanalgesic, to relieve painantibiotics, to eliminate infectionsantacids, to neutralise acid in the stomachantipyretics, to bring the temperature downantihypertensives,to bring the blood pressure downemetics, to help the patients to vomitantiasthmatics, to treat the bronchial asthmaavessel dilates ,to dilate blood vessels and improve circulationi can"t sleep at night and i"m tired when i get up in the morningmy little girl is always scratching her bottom, and i have noticed small worms in her stool.my ankles are swollen, i"m bloated around my stomach in the eveningi cough a lot but i can"t seem to cough up phlegmi often feel dizzy and i have headaches, my vision is getting worse, my blood presure usually high when it"s checked 20 SIDE-EFFECTS OF DRUGS3 side effects of drugs 2 3 2 1 . You prescribed some tablets/pills/for my pneumonia, By the evening my face was flushed and itching. And I had come/broke/ out in a rash. 2. I came down with the flu so I took the aspirin as you suggested, however, by the next morning I had an upset stomach, I』m afraid to continue with it, but I am still running a fever.3. I"ve been feeling dizzy since I started taking the new blood pressure medicine. When I bend down, I』m afraid I』ll fall over4. I"ve been feeling sick since I started taking this new medicine, I"ve had an upset stomach since then.2 3 3 1 . you prescribed some tablets for my pneumonia, by the evening my face was flushed and itching. And I had come out in a rash.Oh I』m afraid you must be allergic to that medicine, I』ll prescribe something else that shouldn"t affect you. 2. I came down with the flu so I took the aspirin you suggested, however, by the next morning I had an upset stomach, I』m afraid to continue with it but I』m still running a fever.Aspirin sometimes affects the stomach, I think you should take paracetamol instead, it doesn"t cause stomach problems.3. I』ve been feeling dizzy since I started taking the new blood pressure medicine. When I bend down, I』m afraid I』ll fall over. Your pressure has come down a little low, and that』s causing the dizziness, so we"ll adjust the dosage of your tablets. 4. I』ve been feeling sick since I started taking this new medicine for my headache. I』ve had an upset stomach since then. Oh dear! I』m sorry. We』ll have to change the tablets/pills/ to put a /stop /to the nausea. 21 ADMINISTRATION OF MEDICATIONAdministration of MedicationTake this tablet half an hour before meals.Swallow this tablet without chewing.Take a pinch of this powder and mix it with some water.Apply a thin coat of this ointment every evening and then cover with a wet dressing.Dip a cotton bud in this tincture and apply it to your gums.Pour an ampule of this solution into boiling water and inhale it for five minutes.This is a bitter tablet, so take it with some sort of juice.If you are unable to swallow this tablet/pill/, break it in half or crush it into a powder.Place this pill under your tongue and allow it to dissolve.Take this capsule with some water.Drop some mixture on a sugar cubeShake the mixture well before taking.Insert one of these suppositories into the vagina before going to bedRub a thin layer of this cream on your skin Use three drops of this eye drops every eveningApply some talcum and powder to your skin Mix 15 drops in a cup of water and gargle two or three times a day.22 GENERAL QUESTIONSunit 3 obstetrics and gynecology1 general questions3-1could you tell me when your last period wasit was about 3 weeks agodo you have a regular cycleyes, it"s quite regular. it comes about every 28 daysand how long do your periods lastusually about 5 or 6 dayswould you say that they were painfuli get some discomfort especially during the first 2 or 3 days, but it"s not too badwould you say that your periods are quite light, average or heavyi would say they are about moderate, doctordo you find you are using a lot of padsno, i can usually just manage with 3 or 4 a daynow, have you had a smear done within the last 3 yearsi had one done about 5 years ago, doctordo you remember the results of ityes, they said it was cleardo you know how often you ought to be coming /should come/ for a smear testi think it"s about every 2 or 3 yearsyes, that"s right, although if there are any abnormalities on any of the smear tests you must /should/ come back more regularly than that. do you have any pain or swelling you"ve noticed in your breastswell, i don"t have any lumps, doctor, but i"ve sometimes notice that they get a bit sore, especially just before my period. also, sometimes they feel a bit /little/ lumpy, but when i check them a few weeks later they all seem to have gone away. 23 GYNAECOLOGICAL COMPLAINTSgynecological complaintsdysmenorrheaPMT1dysmenorrheaamenorrheamenorrhagialeukorrheametrorrhagiadyspareuniaprolapsehypermenorrhea3-2-AD: what seems to be the problem?P: over the last a few months, my periods have been getting terribly painful.D: is this a new thing?P: my abdomen is alwasys a little bit sore in the first couple of days, but over the last few weeks, i have been getting really sore.i have been getting this terrible crampy feeling in my tummy /stomach/ and some back ache as well. it"s been coming on before the bleeding begins / it starts before the bleeding/ and it"s been so bad that i had to have some days off from work over the last few months. i"ve also got another problem, i get so up-tight just before my periods. i feel as though i could murder everyone. D: that sounds typical of PMT/PMS/- pre-menstrual tension. it"s difficult to treat but some people are helped by vitamin B12 or evening primrose oil. there are some self-help groups that you could join, the receptionist will give you a pamphlet if you ask her.3-2-BD: what seems to be the problem?P: my periods used to be quite/fairly/ light, doctor, but they seem to have been getting much heavier recently.D: have you been passing any clots in them?P: well, the last few times they have been one or two quite/pretty/ big clots and sometimes it"s been soaking right through the pads and into my underwear, and i"ve had to go and change quickly, it"s becoming really very embarrassing.D: i see. are your periods very painful at all?P: well, they"re worse than they used to be, but the worst thing is really just this terrible bleeding, it"s caused me awful embarrassment and trouble.3-2-CD: could you tell me when your last period was?P: well doctor, they"ve been a bit irregular. sometimes they"ve coming every two weeks, sometimes i am not getting any for 6 or 7 weeks, and when they do come they can be terribly heavy with flooding and passing clots for the first couple of days. i"m having to use sanitary towels and tampons sometimes, and they can be very very painful for the first 2 or 3 days, and for the week beforehand.D: have your periods always been irregular or has this been something recent? /did this just start?/P: no, they were quite regular up until about a year ago,and then they gradually began to go haywire.D: do you get any bleeding in between your periods?P: yes, i sometimes get a little bit of spotting of blood just in the middle of my periods3-2-DD: do you ever find it uncomfortable to have sex?P: yes, doctor, the last few months it"s been quite painful. D: does it happen every time or just occasionally?P: almost every time, i get this really deep ache inside, it has become so bad that we haven"t been able to do it for the last few weeks.3-2-ED: can you tell me what the problem is?P: well, doctor, i got this discharge from down below.D: can you describe it to me? what color is it for instance.P: well, it"s sort of yellowish but sometimes it becomes brown.D: is the discharge foul smelling at all?P: well, sometimes it smells quite strong, doctor.D: do you have any burning or stinging when you go to the toilet?P: it sometimes stings when i spend a penny /urinate, pee/D: is your vagina itchy or sore?P: yes, a bit.3-2-FP: doctor, i"ve got something down below.D: where do you mean exactly? show me. mm. is this lump there all the time, or only sometimes?P: it only seems to come on after i"ve been to the toilet.D: is that after you"ve been to pass urine or after you have a bowel motion?P: well, sometimes both but more after i"ve open my bowels, doctor.D: are you able to push this lump back up?P: sometimes i can push it back up.D: does it ever come down and you are not able to ?P: no, doctor, it can always be pushed back up. 24 PHYSICAL EXAMINATIONphysical examinationif you can just pop /step/ go/ behind the curtains and take your trousers and underwear off / take your slacks and underwear/ and cover yourself with a blanket, i"ll be round in a minute.jump up onto the couch. /you can get on the cough/if you just slide a little bit further down a table and if you pull your knees up towards you, now, let your knees fall apartkeep your knees as relaxed as you can. put your feet wide apart in the stirrups. if you just try and relax your bottom down into the bed as much as you can, that keeps your muscles relaxed and makes it much more comfortable for you.just let me know if this hurts at all 25 PREGNANCY4 pregnancy3-4-AD: what can I do for you?P: well, I don"t seem to have had a period for several months now, D: how long has it been since your last period? (When was your last period?)P: well, I think it was about 2 or 3 months, but they"ve always been a littlebit irregularD: have you ever gone this long before without having a period?P: no, they always seem to come on after about 6 or 7 weeksD: are you sexually active?P: yes, doctorD: are you using any kind of contraception?P: Yes, he always uses a condomD: have you ever had any accidents or perhaps forgotten to use a condom? Doyou think you might be pregnant?P: well, maybe, because there was an episode a few weeks ago, now I come tothink of it, when the condom split. But we didn"t think it was so important,because it was just before my period began.3-4-BD: how long has it been since your last period?P: come to think of it, about 2 or 3 months.D: do you think you might be pregnant?P: well, I think it"s possible, doctor. the last few weeks I』ve been feeling really quite queasy in the morning, and I』ve gone off some of my favorite foods. I』ve started eating the most peculiar stuff. I never used to like tomatoes and now I can never get enough of them. I』ve also noticed that mybreasts are really tender like they get before period.D: have you felt sick or been sick at allP: well, I suppose I should have guessed myself that I might be pregnant, because the last 3 mornings I』ve been feeling really, really sick and I actually vomited this morning. I』ve also been feeling terribly tired and I keep having to rush to the loo/bathroom. I』ve also felt quite on edge and anxious. The other thing is that my breasts seem to have got/gotten bigger. I』ve always been a 32B cup up until now and I would swear that they"re getting largerD: let"s do a pregnancy test and we"ll see what it shows. .... the pregnancytest from the blood has shown that you are pregnant, can you remember exactly when the first day of your last period was?P: not exactly, but I think it must have been about 8 weeks ago.D: well, working it out roughly from the first day of your last period, it looks as though you will be having your baby at the end of October.3-4-CD: have you felt the baby move at allP: well, just a little bit. I felt this sort of fluttering feeling in my tummy/stomach, the first time I thought it was wind but then it came back again, so I think it must have been the baby kicking. D: have you had any problems, any burning or stinging when you pass urine?P: yes, it"s very uncomfortable at times. and I』ve also had /also have/ thisdischarge from down below and it"s been getting itchy and really unpleasant.D: well, we have to have a look down there and we"ll probably take a swab butit sounds as though you might have a touch of thrush which is something common in pregnancy and quite easily sorted out/fairly easily taken care of. Have you had your ultrasound scan recently? P: no, I』m due for one next week.D: they can show whether the baby is growing well. sometimes they can tell whether it"s going to be a girl or boy from the scanP: I』m not really sure I want to know 26 PAST PREGNANCIESpast pregnancies3-5-AD: is this your first pregnancyP: noD: how many times have you been pregnant?P: i have been pregnant six timesD: how many children do you have?P: i"ve got 3 children.D: were they all normal deliveries?P: i had one of them by a cesarean because i had problems with the delivery,but the other two were normal deliveriesD: what about miscarriages?P: well, i had one miscarrige quite early on before the first child, and thenmy third pregnancy ended in stillbirth, i also had a tubal pregnancy which needed an operationD: have you had any terminations/abortions?P: noD: do you have any problems at the moment?P: i"ve noticed that my hands and feet are getting a bit swollen, and my rings are getting tight.D: how did you feed your children? breast or bottle?P: i breast-fed all of them, but only managed for about the first 3 months and after that, we began to top them up with bottle milk.D: ok, that"s good. we just need to do a little internal examination now.3-5-BD: have you ever been pregnant?P: yesD: do you have any children?P: yes, i"ve got 2 boys.D: how old are they?P: 3 and 5.D: when your older child was born, do you remember if he was early or late oron time?P: well, he was about 4 weeks early, doctorD: i see, he was slightly premature then. did you have any problems during your first pregnancy?P: i had a little bit of a problem with my blood pressure. it went a bit high, and i was in/the/ hospital for a few weeks towards the end. but he was absolutely fine and it was a straightforward delivery.D: and the younger child? was he early, or late or on time?P: he was actually a week late, and they had to start him off/induce labour/,and then they need the forceps to pull him out, but since then he"s beenabsolutely fineD: ok, are they quite well now?P: yes, they"re absolutely fine. 27 PREECLAMPSIA / TOXAEMIApreeclampsiaD: we"ve noticed that your blood pressure is a little bit high on this admission. how have you been feeling?P: not too bad, apart from the odd/an occasional/ headacheD: how often have you been getting these headachesP: well, i"ve had them for the last 2 daysD: anything like dizziness or blurred vision.P: i"ve been getting some flashing lights in front of my eyes, but i just putthat down to tiredness. i"ve also noticed my rings are really tight on my fingers, and my feet are getting to be quite swollen 28 GENERAL QUESTIONS REGARDING PAST PREGNANCIESWhen you had your first child ,do you remember what kind of anesthetics you had for the delivery？I managed at first for a little while using gas and air but after that it really became too painful and I had to have an epiduralDid your start labor by yourself, or did they have to give you some help?No,it began by itself. although I remember some of the other women in the ward having to get started off/getting help, to get it started/Do you remember how long the labor went on for?It was quite long, it was at least 24 hours.And the delivery itself; was it caesarean, a forceps or was it normal?Welll, in the end have to use forceps to help get the baby out because he wasbeginning to get a bit tired as well.Did you have any problems after that?he went to the special care unit just for a few hours because I think he was a little bit tired and after that his head leaned to one side for a week or2 but then he was all right.What kind of feeding did you use for the first child? did you breast-feed or bottle-feed him?He was breast-fed for the first six weeks, but after that he didn』t seems tobe getting enough milk and health visitor suggested we top him up with bottles/formula/. eventually we just gradually change him over to bottle feeding. I also had to express milk for a while because after he tried the bottle he was lazy about sucking at the breast. 29 MISCARRIAGEHave you ever been pregnant at all apart from having these 2 children?Well,I did have a miscarriage in between them.Do you remember how many weeks on you were/what week you were in/, when youmiscarried? that was quite early on, about ten weeks.and were there any problems afterwards ,did you need D and C or anything?Yes ,I had a quick DNC afterwards,but there weren』t any further problems.Had you been pregnant at any other time apart from the ones you mentioned?well,when I was much younger,I did have a terminateon ,an abortion,when I was about 19,do you remember how many weeks on you were/what week you were in/ when it happened?I am not sure,but I think it was about 2 month,I just went into the hospitaland they did an operation, and that was that. 30 DILA(TA) TION & CURETTAGE dilatation & curettageThe patient is given a general anesthetic and placed in a lithotomy position.the perineum and vagina are washed with Betadine solution and the legs and surrouding area covered with sterile drapes.The patient is then examined by bimanual pelvic examination to determine thesize of the uterus,the direction of the uterus.and any adnexal pathology.The cervix is then visualized using a Simss speculum and the anterior lip of the cervix is grasped with a vulsellum. The cervix is dilated using Hegar dilators of increasing size.the cavity of uterus is then evacuated usually by suction curettage.in other circumstancesit is emptied using simply sponge forceps.the cavity of uterus is then checked using a curette to ensure that it"s entirely empty.The operation is then complete.First we will put you to sleep,then we will exam your womb to see how big it is and whether its position is normal. we will then have/take/ a look at the cervix__ the neck of your womb to check it out. after that, we』ll stretch it gradually, then we』ll use suction to clear up what is in the womb, finally, we』ll just give the inside wall a gentle scrape to check that it"sclear. 31 DELIVERY 10 delivery 3-10-awell, looking at the dates of your pregnancy your baby is really quite overdue now. it should have been here about 10 days ago. and we really don"t like to leave them much longer than 2 weeks over the due date, so what we will do is bring you to/the/ hospital tomorrow and get the delivery started. the way we usually do this is to bring you in in the morning and just pop/apply/ some gel up by the cervix, and see if that gets things started off, that should make the cervix softer and easier to open up. And if you still haven"t gone into labor by yourself, we can put a drip up, that will cause the uterus to begin to contract, and so when your cervix is open a little bit, we can break the waters around the baby and that should get things started.3-10-bD: have your waters broken yet?/ have your water broken?P: yes, about half an hour ago.D: are you getting any tightening or regular contractions.P: well, i"ve been feeling this sort of tight feeling across the top of my tummy/stomach.D: how often are your contractions coming?P: about every 10 minutes at the moment.D: are they getting any stronger or closer together?P: they"re gradually getting a little bit stronger. they used to be about 20 minutes apart, and i definitely feel them coming on harder. D: how long do they last when they come?P: just about a minute at the moment.D: are they very painful or do you just feel a tightening across the tummy/stomach?P: they"re really becoming quite sore now...D: now you"ve been doing very well. it won"t be long before your baby"s here. the head is coming now. don"t push, pant like a dog until the head emerges. P: ha....D: now one last big push. P: ha...D: congratulations, you have a lovely baby boy, here he is. now push one last time for/the/ afterbirth.P: habefore starting the procedure,the patient should be examined. on abdominal examination there should be no head palpable abdominally. the cervix should be fully dilated and the bladder should be emptied. the position of the fetal head be determined and the maternal pelvis felt to be adequate for delivery vaginally. the perineum is then washed down with an antiseptic solution and the legs and surrounding areas covered with sterile drapes. it"s essential that the mother have adequate analgesia whether this is by epidural and aesthesia or perineal infiltration or a pudendal block. when the uterus is not contracting well, the forceps are applied. during the next contraction the mother is asked to actively push while traction is applied on the forcops. the should be no more than three moderate pulls required to delived the baby. an episiotomy is usually required, and it is recommended that it should be a right mediolateral episitomy. following delivery of the baby, the placenta is delivered either by maternal effort or controlled cord traction. the vagina is then examined for any further tears the episiotomy is required in layers usuallu with Vicryl. which is a synthetic absorbable suture. hemostasis should be achieved by this and the rectum should be checked by digital examination to ensure none of the sutures have reached the rectal mucosa.we are going to have to give the baby a little help. because it is getting a little distressed. what we are going to do is to give you something to help with the pain. then we"ll use a catheter to empty the bladder. after that we"ll get hold of the baby"s head with some forceps. at the next contraction, while you are pushing we will be giving a little pull. we shouldn"t need to do this for more than three contractions then everything will be fine.32 CONTRACEPTION[生詞摘錄] coil避孕環 cap/diaphragm 子宮頸帽 coitus interruptus 性交中斷, 體外射精 mini pill 小劑量口服避孕丸 IUD/ intra-uterine device 宮內避孕器 [原文] Have you thought of what sort of contraception/contraceptive/ you"d like to use? Well, I wondered about a pill.That"s quite a good idea, there are different types of pill that you need to think about and they all work differently, there"s what we call the mini-pill which has a single hormone in it but you do need to be more careful about when you take it because it only has a three hour gap in which it is safe and if you take it any later than that then it"s not working reliably.the combined pill on the other hand has two types of hormones in it , and it has much wider range, you can be up to 12 hours late and it"ll still work reliably. However some people do find that they have problems with both types of pills, For example, they get headaches or migraines or put on weight and some people also has problems with their blood pressure, so it is not always suitable. another option is to have a coil; however, we don』t normally recommend this to woman until they"ve had at least one child, because some studies have shown that although the coil it isn"t necessary associated with causing infections , if you do have any pelvic inflammatory diseases , it can be made worse, and it can increase the risk of infertility . therefore it usually only given to woman after they"ve had at least one child. the cap or diaphragm has its advantage in that it doesn"t involve any hormones , therefore, you"re not mucking/ messing/ around with your body"s cycle and it also means that it can be put in before you have your intercourse not like sheath or anythings so it』s in and out of the way and out of your mind, however, you do have to have it quite carefully fitted and you need to be quite confident with your own boby in learning how to put it in. if you are at all embarrassed, it can be very difficult.if you absolutely certain that you"ve finished your family or you"re not planing on having any children, it』s possible to be sterilised or as it is sometimes called "have you tubes tied". it normally involves just minor operation. you are just in for a day, we look inside you tummy with a telescope and cut and tie off each your tubes to stop the egg from reaching the womb, and it stops you from getting pregnant, it"s a very, very reliable method, it has a very low failure rate , but it"s main drawback is that should be regarded as being absolutely irreversible, and once it"s done you really can"t have it changed back. so you have to be very sure that you don』t want any more children.coitus interruprus, also called the rhythm method, is a very unreliable method of contraception, where the man withdraws from the female just before he comes/ ejaculates/ reachs orgasm/, however, there is often a small quantity of sperm released even before the man comes, and, therefore, it"s an extremely unreliable mathod.condoms or sheaths are quite a safe reliable mathod of contraception , the main disadvantage is that they have to put on during or shortly before intercourse, and this can, therefore, interrupt the spontaneity of love making. however, they do have the advantage of protecting against sexually transmitted disease ( STD). 33 CLIMACTERICClimacteric.Have you had any problems since your last period?Actually, my last period was about a years ago, I haven』t had one for about a years now.Have you had any bleeding at all since then?No, I haven』t had any bleeding at all.Have you had any problems with the "change"?I used to have some problems with these terrible hot flushes/flashes/, I would wake up in the middle of the night absolutely drenched with sweat, my bed clothes and nightie would be soaked through, they seem to be getting a bit better, but, I"m still awfully tired.Mu, have you felt unwell?Not really. Apart from the terrible sweats.How often do you get them?perhaps once or twice a night, it』s really disturbing my sleep.Apart from lack of sleep, has it effected your life in any other way?Well, I haven"t as much energy and it takes much longer for me to get through my work, I fell tired all the time and... it"s interfering with our sex life a bit because my vagina is so dry.34 HYSTERECTOMY[生詞摘錄] Hysterectomy fallopian tube estrogen progesterone hormone osteoporosis incision endometriosis fibroid malignant ovary droop biopsy patch growths[原文] We need to remove your womb, to give you a hysterectomy, we』ll put you to sleep under a general anaesthetic, we』ll either make a cut in your tummy or perform the operation through vagina. In your case, unfortunately, we』ll have to remove not only the womb but also the tubes and ovaries. I』m afraid we have to do this to prevent the disease from spreading. After the operation, you won』t have any periods and sadly you won』t be able to have any children. because we have to remove the ovaries there is a possibility that you might get hot flushes, and night sweats and dryness of the vagina --- all symptoms of the menopause, but this doesn』t always happen. This is because your estrogen and progesterone hormone levels drop. Your ovaries produce these hormones, if you do have problems we can always help by giving you HRT (hormone replacement therapy ) in the form of pills or a patch. However, to prevent osteoporosis we also recommend this HRT to patients without symptoms, you may also feel a bit low and depressed but usually it soon passes, and you may also get a bit of a problem with your weight. A lot of people seem to put on weight after a hysterectomy. You will have to stay in hospital for about 6 days where we can keep you comfortable with pain killers necessary, then you will have to take it easy for a while and get plenty of rest. You can gradually start doing things again. It takes about 6 to 8 weeks to really get over the operation. After 6 week, I』ll want you to come in for check-up just to see that everything is ok. If you have any questions regarding this operation, don』t be shy about asking me.What you have is fibroids. These are growths in the womb. they can be very large but yours aren』t too bad, that』s what』s causing your pain and heavy bleeding, but don』t worry it』s not cancer. You have a drooped womb, what has happened is that the muscles in your pelvis aren』t holding it in place any more and it has slipped down into your vagina.the problem is called endometriosis, the lining in your womb, that』s called the endometrium, has started to grow outside the womb itself.I』m afraid you have a pelvic infection , your ovaries are infected and inflamed. sometimes it can affect the fallopian tubes and the womb as well, but in your case , it』s just the ovaries at the moment. With all the excessive bleeding it looks like have a real menstrual disorder. The biopsy shows that there is cancer of the uterus and possibly the ovaries are affected.35 NEONATAL HISTORY [生詞摘錄]Caesarean section.[原文]pediatrician,neonatal historyHow old were you when the baby was born?How many times have you been pregnant?What number pregnancy was this child?How many children do you have?Are you and your husband blood relatives?Were there any problems like bleeding or an illness?Was your pregnancy planned?Did the baby arrive at the expected time?Was the baby born mormally or did you have to have forceps or a section or anything like that?Good morning, Mrs smith, I』m Dr o』Hare. I am a consultant pediatrician. I』d like to ask you for a little background information about James. First of all, if you don』t mind, I』d like to take you right back to the beginning. Could you tell me about your pregnancy? How old were you when the baby was born?Twenty seven.How many times have you been pregnant?Three.What number pregnancy was this child?This was my third pregnancy.How many children do you have?Three, with this one.What are the ages of your other children?Two and three.Are you and your husband blood relatives?No.Were you unwell/well/ during your pregnancy? Were there any problems like bleeding or an illness, or did you take any medication?No, there were no problems.Would you mind me asking, Mrs, Smith, whether the pregnancy was planned?Yes, we had been trying for six months.Did the baby arrive at the expected time?Well, in fact, he came three weeks early.Was the baby born normally or did you have to have forceps or a section or anything like that?Yes, I had to have the baby by Caesarean section.Do you know why the baby had to be delivered by section?Yes, because there were signs that the baby was getting distressed in the womb, so I was advised that he had to be delivered immediately.36 BABY"S CONDITION AT BIRTHBaby』s condition at birthHow was the baby at birth? Did he have any problem? How was he in the first few days of life? Did the baby stay with you or did he need to go to special care or to the nursery for any reason?Yes, he was taken to special care unit because he was very small and he was getting cold and needed to be given oxygen.Was the baby premature-- preterm, appropriate for dates. overdue?He was three weeks early.What did he weigh?Only five pounds.Was the jaundiced?__Yellow when he was born?Yes, he had photo therapy for jaundice.Do you know, Mrs. Smith, whether James had to have any assistance with his breathing? Was he on the ventilator, for example, or was he just on oxygen in his incubator?He had to be ventilated .Did he had have any transfusions ?Yes, he also had an exchange transfusion.Did he had any other problem that you are aware of, such as infections or any need for resuscitation while he was in the special care unit?No, I don』t think so, Doctor, but they are recorded in his special care baby notes. 37 NEWBORN COUNSELLING[生詞摘錄]spatula n.(塗油漆, 塗藥等)抹刀, 壓舌板Nystatin n.[微]制黴菌素,制真菌素(一種抗黴菌葯)thrush n.畫眉, [醫]鵝口瘡, [獸醫](馬的)蹄叉腐疽鵝口瘡swabs n.拖把, 藥籤vt.拭抹, 擦洗nappy/ diaper/ n.尿布cot death 嬰兒猝死綜合症duvet n.<法> 用羽毛, 絨毛等製成的棉被umbilical cord n.臍帶[原文]Newborn counsellingWhat I』d like to do know, Mrs. Smith, is just have a look at James and check thing out, like his heart and chest. What I』m doing now is I』m just having a look at reflexes to make sure that they are in place I would expect them to be, now I am going to have/take/ a gentle look in his mouth/gently/ with this wooden spatula, now looking in his mouth I can see that he has a little bit of thrush so I』ll give you something called Nystatin for that, to help it go away. Could you tell me, Mrs Smith, whether you have any concerns about James?Well yes, doctor, I』m little bit concerned about his cord because I would have expected to have come off by now.Will, in fact, Mrs. Smith, this can take a week to ten days but if there were any signs that the separation of the cord is delayed or if it was becoming infected then I』d just give you some alcohol swabs so that you can clean around the belly button at bath time or when you change him.Hello, Mrs Smith, would you like to undress James? I』d like to see how his weight has been progressing in the last couple of weeks…. Three hundreds grams, /12 ounces/ that』s fine, isn』t it? Now I』ll just examine him and have a look at how things are going. Are you happy with your breast-feeding? How』s that going?Fine, I think, although he always seems to be hungry and I wonder sometimes whether he』s got some pain in his tummy.Well, it』s always worthwhile checking whether he』s got any wind/gas/ that』s giving him discomfort in his tummy. You don』t need to give him anything for this. It』s just a question of letting him sit upright a little while after a feed. How often does he have a dirty nappy/ diaper/?About once a day, usually after a feed.What does the stool look like? Is it yellow or green? Does it smell strong?Well, it』s very pale but it doesn』t smell too much.That seems ok. Can you tell about James』s immunizations?Yes, he』s had his triple, doctor.Good, how are things generally? any anxiety about James.?No, not really, I』m a bit worried about taking him out in this cold weather there.Well, It』s a good idea to taking him out in the fresh air. But you must obviously dress appropriately for the temperature.What would you advise, doctor, about dressing him at night time for sleep, because I』ve heard different views on this.Yes, that』s quite true, Mrs. Smith, there is quite a lot of evidence to demonstrate that it』s wise not to overwrap your baby at night time as there』s a clear disadvantage from this with respect to things like cot death. So, what I would advise is you never use a duvet / padded blanket/ with a new baby. It』s not recommended for a baby because babies are not able to lose enough heat if they are covered with duvet.38 NEWBORN DISEASES Newborn dieasesMrs brown, I just had a look at brown』s hips during my examination, I feel that we need be sure that his hip is developing normally and there"s plenty of room for the top of the hip to fit into the pelvic bone. As I have some doubts as to whether there is more movement in the hip then I would expect, I think it would be wise for me to arrange for Brain to have an x-ray of his hips, and also to ask a colleague who is an orthopaedic surgen to come and have a look and see whether he feels that we need to take any action along the lines of doubling up his nappies or applying a small splint until the hip stabilises.So, John had respiratory problems, some breathing problems in the first few days of life. Could you tell me about those?Well, we were told that his lungs were very immature because he was preterm, and he needed to have help with his breathing with a machine. I do know, Doctor, though, that he had extra problems because he had an infection and he also became jaundiced, and at that time the doctor explained to me that they thought he may had developed jaundice both because he was premature and also because he had some bleeding in his brain.Do you know how they established that he had had some bleeding in his brain, Mrs Green?Yes, he went for an ultrasound scan of his brain when he was two days old and that confirmed it.Do you know if he had any injuries during the delivery.No, there was no problems there.And also, do you know whether he had any congenital abnormalities noticed after delivery?Well, doctor, the doctor explained to us that John had been born with some of things that should have been in his tummy up in his chest.Do you know if he had an infection?Do you know if he became jaundiced?Do you know if he had any bleeding in his brain?Do you know if he went for an ultrasound scan of his brain?Do you know if he had any injuries during the delivery?Do you know if he had any congenital abnormalities?39 FEEDING [生詞摘錄]Farex 亨氏公司生產的一種嬰兒麥片Boots 英國一家保健連鎖店feedingCould I ask you, Doctor, what your advice would be if I were to breast-feed my baby? How often should I do this?What I would recommend is that you feed on demand. Particularly in the first few days of life as this will allow James to get your feeding pattern adjusted to his needs. By give him feeds/by feeding him/ on demand, he』ll gradually develop a regular feeding rhythem.Did you bottle-feed your baby or did you breast-feed?I breast-feed.And how did that go?I had to give up breast-feeding because I didn』t have enough milk and I packed it in / gave up/ after about three or four weeks. I didn』t have any milk. The baby was not satisfied so I decided put him on the bottle.How many ounces does he tend to take with any one feed?Four ounces.How often does he feed?Every three or four hours.How does his feeding go? does he take a long time to finish his bottle?Not too long, about fifteen to twenty minutes.How long does the baby spend in the incubator?I don』t really know, Doctor.When was your baby allowed to go home?When he was three weeks old.Was he tube-fed in the incubator or were you able to breast-feed him?He was tube-fed at first, but then he was able to put him on the breast.How long were you able to breast-feed him?Only for three weeks, I am afraid.At what stage did you wean the baby?When he three months.What sort of things did you offer him when you started wean him?I started him on Farex with some egg, and some Boots baby food in tins/ cans/jars/.Has the baby been receiving any medication, any vitamin drop or iron?Yes, he has vitamin drop.40 PSYCHOMOTOR DEVELOPMENTPsychomotor developmentDo you have any concerns about the way James sees or any concerns about his eyes? Does he turn to the light? does he fellow your face? Does he fellow a light?What about his hearing? Is he aware of noise? Does he turn his head when he hears a noise? Does he recognize your voice?How is he getting on with moving about? Is he able roll over?Is he getting up to crawl?Is he pulling himself up?Is he trying to get onto his knees?Is he holding onto furniture to stand and cruise /move/ around?When could he sit up by himself?How old was James when he started to walking completely on his own?What do you think about the noise that James makes to communicate with you? Does he cry? does he babble ? does he have any oohahh or gaga noises? Does he use them to attract your attention?Does he get hold of /grab/ grasp/ things with his hands yet?Does he reach with both hands or only one?Does he pass things between his hands?Can he feeding himself with a spoon or with his hands?Can he get hold of/grab/ grasp/ a drinking cup? 41 INFANT COMPLAINTS Infant complaintsI gather, Mrs Smith, that you have some concerns about James, could you tell me what they are and when they started?Well, after a feed him, doctor, he seems to be in discomfort and draws his knees up to his tummy and cries. Sometime he does it between his bottles.How long after he』s finished his feed, does he do this?Well, it tends to be about twenty minutes after he』s finished his bottles, but he can also be restless and cries throughout the night.Do you think he』s gaining weight all right?Yes.Well, having a look at James here, I feel quite happy that there』s nothing abnormally going on in his tummy and I think what』s probably happening is that he is experiencing colic. Although it』s very awkward for you and James, it』s not going to do him any term harm. And now I would advise that you try very sample measures such as a drop of phenol gripe water.42 FEBRILE CONDITION [生詞摘錄]Calpol 撲熱息痛syrup n.糖漿, 果汁, 糖漿劑Febrile adj.發燒的,熱病的[原文]Febrile conditionDoctor, I』m very worried about James because he seems to have a high temperature and I can』t get it to settle.Do you know how high his temperature is?No exactly.What measures have you taken to try and get his temperature down?Well, doctor, I have tried a number of things. I took his clothes off, and give him some Calpol and I also try sponging him with tepid water.Well, that is quite the right approach. if you could slip James』s clothes off I』ll just have a wee look and see if we can establish the cause of his temperature…. Well, that didn』t take a long to establish. I』m afraid James』s got tonsillitis, which is certainly a good enough cause for his temperature. so what I』ll do is I』ll giving you an antibiotic syrup, give him one teaspoonful three times a day and that should settle it, I』d like you give him the full course so carry on giving him teaspoonful three times a day until the bottle is finished.43 PYLORIC STENOSISPyloric stenosisCould you tell me when James was born?About a month and a half ago.So he』s six weeks now. So when did your concern about him start?Well, I』ve been concerned about him for two days now because he seems to be vomiting after every feed.Could you describe what the vomiting is like Mrs Smith, For example, does it clear your lap and land on the floor?Well, his vomiting is very strong, doctor, he throws the vomit right across the room.And, what is in the vomit? Do you ever see any green material or any blood? Has he had any upset of his bowels?Yes, it』s often white, but there』s no blood.Could you tell me how often he is opening his bowels/ has bowel movement/ ? whether the stool looks any different from normal?It』s yellowish and quite hard.How do you think James is behaving? Do you feel he』s behaving normally?No, I don』t, doctor, he seems very irritable and upset and cries a lot.Well, what I propose to do is to examine his tummy while he』s taking a feed. So if you pop /put/ him on your lap and just put him to the breast... Well, While I』m feeling his tummy, I can feel a little lump underneath my fingers and what that indicates to me is that he』s got some overgrowth of the muscle at the exit of the stomach, and that is blocking the material like his milk draining from his stomach, so I think that it』s likely that what we need to do is a small operation to cut through the muscle and relax it.44 DIARRH(O) EA DiarrheaGood morning, Doctor, I』m concerned about my son. He』s now eight months old and he』s been unwell, he』s had a temperature and he also had diarrhea.Could you tell me a little bit more about the diarrhea? How often is it occurring in the day, and what does the stool look like?It was watery?Could you see any bits of food in it?/did it have any food pieces observable in it?/No.was there any mucus or blood or anything unusual with the diarrhea?Yes, there was both mucus and blood.How much has the baby been drinking?I』m afraid not very/too/ much.Well, James seems to be quite dry and I think he』s probably not been keeping enough fluids in. So what we』ll need to do is to set up an intravenous infusion to get the fluids directly into his circulation to bypass the problem that he』s having by losing fluids through his diarrhea and his vomiting.Good morning, Mrs smith, would you like to sit down and tell me what your concerns are about James?Well, he』s vomited several times this morning and he』s also had diarrhea, and I think he』s also expressing some tummy ache and he』s very lethargic tired.Has he had a temperature?Yes, I think he has.Have you noticed any blood in his stool?No, I haven』t, the stool is just loose.How is he managing to drink?Well, he』s managing quite well, he』s quite keen to drink but, unfortunately, he』s not able to keep it down and it』s all being vomited back up.Well, let』s have a look him then. Could you pop/take/ his cloths off and I』ll have/take/a little look first all at his tummy… Well it』s all very reassuring, I can』t find anything wrong looking at his tummy and he seems to be keeping plenty of fluids in, so you are being successful with your encouraging him to drink. I think what』s probably happened is he』s got an infectious diarrhea and what would be a sensible thing to do would be to collect a sample of his stool and sent it off for bacteriology analysis, we』ll have the results in three or four days』 times.Well, What should I do in the meantime, doctor?Well, the important thing is to make sure that he has sufficient fluids. So, as long as he』s happy to drink, then he won』t get into too much difficulty, and then once he』s feeling a little bit better, you could start introducing a gentle diet.45 ASTHMA (Obstructive bronchitis)AsthmaCould you tell me, Mrs smith, when James started coughing?Well, it started a week ago and it』s particularly bad at night, he keeps the whole family up.Do you think he』s having any problem with choking?Well, he seems to be experiencing quite a lot of trouble getting his air in and getting his breath/ catching his breath/.Is it the first time that James has found it difficult to get it breath?No, this has happened three times before.How frequently do you think it occurs?Well, as I said, it happened about three times.Have you noticed any relationship to the time of the year? Is it more likely to happen in the spring, for instance, rather than in the winter?No, if anything, it』s slightly more likely to happen in winter.And have you noticed anything else that brings it on?Yes, I have, it always seems to be associated with a cold.Have you noticed anything else, such as, does it start when he』s running about or when he』s been in contact with animals or anything like that?No, I haven』t, although I must admit he』s not very athletic and he does complain sometimes when he』s running about a lot. It makes him cough and particularly in cold weather.Has he had any treatment for this?Yes, he has had some treatment every now and then, he has had an inhaler which has helped a little bit.What about the present episode? What treatment has he had for this?Well, he』s not had anything for this one because I was hoping it would just settle on its own.And with the present episode, how difficult has it been to get it breath? Has he been able to talk to you all right?It』s been so difficult to catch his breath that he couldn』t speak clearly to me.Has he looked blue or pale?No, not that I remember.And how long did the last?I』d say it lasted around five minutes. It was very scary.Has this been difficulty that』s made him lose time from school?He hasn』t been to school for three days this weeks. 46 ACCIDENTS Accident,Well, Mrs smith, could you tell me what happened?Well, I』m afraid that James followed his dad up the step ladder and fell off.How long ago was that?A good half an hour ago.Do you know what kind of height he might have fallen from?About two meters/ six feet/.Was he knocked out?Yes, I think he was knocked out, not entirely. maybe just for a couple of minutes.Was there anything else unusually about him? did he look pale or limp?Yes, he looked very pale.Did he have any jerking of his limbs, was he sick?No.Did he seem to be like himself when he came round / recovered / (or did he seem disoriented or unwell) was he all right or disoriented? 原文答案He seemed very confused when he came around.Have you noticed any bleeding from his nose or ears or any bruising occurring?No.…Well, I think what we need to do is to get an x-ray of his skull and in view of the fact that he hasn』t been to well since he fell off the ladder, and that he had a period when he lose consciousness, I think it would be wise for us to admit him overnight just to keep him under observation.Can you tell me how the burn happened?Well, I think what happened was he reached out for a cup of coffee that I was carrying?How long ago was that?Half an hour ago.What action did you take once you』d realised this happen?Well, I stripped his clothes off and I ran cold water onto the burnt area.Well, Doctor, I』m really not sure what has happened, when I went out to the shops and when I came back I found Joe lying there very pale and clearly unwell.Where did you find him?In his grandma』s bedroom.Did his grandma have any medication? Have you noticed any of it missing?Yes, we have, it looks as if there are some red pills missing from one of her bottles.And do you know what kind of medicine his grandma took?Well, it』s certainly something to help strengthen her heart.Well, I think the safest thing to do would be to try and wash out Joe』s tummy/ have his stomach pumped/ so that we can get the remaining tablets out, before they are absorbed into his system. 47 MENINGITISMeningitisDoctor, I am worried about James because he has a high fever and he』s vomited a lot (he』s been vomiting) since yesterday. He』s very restless and he』s been crying all the time.Could you tell me a little bit more about the vomiting?Yes, he』s vomited five times, and while he is vomiting, he holds his head as if it』s hurting him and I think he』s probably got a very bad headache.Well, Mrs Smith, I think that I need to establish whether or not James has got meningitis, and I suggest this because of his history of temperature and vomiting and also because he』s finding it uncomfortable when I try to flex his neck. Now it』s quite straightforward to establish whether he』s got meningitis, and we』ll do this with a lumbar puncture. It』s very quickly undertaken and it shouldn』t be too upsetting for him. It will tell us very quickly whether what we』re dealing with is meningitis. And if it is, than we』ll be able to start appropriate antibiotic therapy straight away. 48 FEBRILE CONVULSIONS Febrile convulsionsHad he been unwell before this?Which part of his body was involved in the jerking?Was it his whole body or only one side?Did his color change?Did he seem to have any difficulty (with his) breathing?How long do you think the episode lasted?Did he wet or soil himself?Did he have a cold and a temperature?Does anyone else in your family have anything similar?Well, Mrs smith, could you tell me what』s happened to James?Well, half an hour ago he suddenly went rigid and blue and started jerking.Had he been unwell before this? / has he been sick before this?Yes, he had had a bad cold and he spiked a temperature /had a high fever/ just before the episode.Which part of his body was involved in the jerking? Was it his whole body or only one side?His whole body.Did his color change?He went grey/gray.Did he seem to have any difficulty with his breathing?Yes, he wasn』t breathing.How long do you think the episode lasted?Around 3 minutes.Did he wet or soil himself?No.Does anyone else in the family have anything similar?Yes. I know when I was a little girl I did have some febrile fits when I had tonsillitis.What I would suggest, Mrs, smith a sensible approach, is to try and keep James temperature down in the event of further fevers, In order to see if we can prevent him having another fits with his fever. so, avoid overdressing him, particularly, as you have a temptation to pile clothes on him when he has a temperature. Because he may look cold and trembling, but don』t overdress him. In fact, if anything, take his clothes off down his nappy/diaper. You can sponge him with a tepid water and you can also give him some Paracetamol. Whatever you do, you must not put him in cold water, or in a cold bath because all that would do is increase the temperature in his body. so it must be tepid /lukewarm/ water that you sponge him down with.49 HENOCH-SCHONLEIN PURPURAHenoch-schnlenin purpuraCould you tell me what』s been worrying you, Mark?Well, doctor, I』ve developed these funny rashes on my arms and my legs, it just came on suddenly yesterday.Is there anything else about them? Are they itchy or uncomfortable or sore?No, they aren』t sore, but they seem to be getting worse and worse and they also seem to be getting bigger.Have you noticed anything else?Yes, I have, when I go to the toilet, I think I』v got some pink in my wee /pee/.And have you had a tummy ache?Only a little bit.Was there any blood in you poo (poo-poo, doo-doo)?No.Was there any swelling of your wrist, elbows or ankles?No.Well, What I』m going to do is I』m going to listen to your breathing. so, could you take a deep breath for me? Right, that is fine. You can just breathe normally now. now I』m going to listen to you heart, just lie down. I』ll just have a look at your tummy. Now what we also need to do is have a little look at you pee, so could you put a little bit into this pot here? 50 BEDWETTING BedwettingSo, Mrs Smith, could you tell what your concerns are?Well, James is 9 years old now, and he』s still wetting the bed.Can you tell me whether he』s always wet the bed or whether he had a period when he was dry and then he started wetting again?Well, Doctor, he』s wet the bed nearly from the word go/ from the very beginning.And what about during the daytimes? Does he have any problems wetting during the day time?No, he』s fine then.Is it every night or does he sometimes have periods when he』s dry?No, it is every nightAnd what kind of measures have you taken yourself to see if you can improve up it.Well, we』ve done the usual things we』ve made him get up during the night, we restricted the amount that he drinks after tea time/ in the evening, after supper/.Has your doctor given you anything for it?No, we』ve never tried anything. 51 BENIGN PROSTATE HYPERPLASIA Urology.Benign prostate hyperplasiaSo you have problems with your waterworks/urination, urinary tract ?Yes.And do you have to go more often than usual?Yes.How often do you actually go during the day?About fifteen - twenty times on some days.What about during the night?I have to get up at least three or four times each nightWhen you do pass water, do you have difficulties starting?Sometimes.Do you have any difficulties stopping? When you think you have stopped, do you have to go a bit more?Yes, yes, that』s it exactly.After you have stopped urinating, do a few extra drops continue?No.What』s the stream like? Is it the same as it used to be?No, It seems to be just a trickle nowadaysDo you think you are passing more or less than you used do?I』m not sure, doctor.Do you have any stinging or burning when you urinate?Yes, Sometimes.Have you noticed any difference in the color of the urine? Is it any darker or have you ever noticed any blood in it?No, I don』t think it』s any darker and I haven』t noticed any blood in it.Do you drink a lot of water?No, not really.52 ADVANCED STAGE OF BPHAdvanced stage of the benign prostate hyperplasiaSo, I understand that you are here because you』ve had trouble with your waterworks.Yes, my waterworks are not as good as they used to be, I am getting up an awful lot and I am running to the toilet all the time.Do you have much in the way of urgency? That is when you need to go to the toilet can you hold on until you get there?Yes, very time I go to the toilet I need to get there quite quicklyDo you ever not get to the toilet on time? does it ever leak or dribble before you reach the toilet.That happened to me twice, doctor.Well, When you go to the toilet, does it take some time to begin or do you begin quite quickly?It usually starts quite quickly, doctor. Sometime it starts before I get there.When you pass water, does it come away with good force, is the stream good?No, it is not as good as it used to be, it is not as good as when I was younger, It just dribbles, Doctor.Does it stop in start when you』re passing water?Yes, it stops and starts or it sprays when I go to toilet, it is not a good streamWhen you stop, does it dribble on at the end? Does it continue to leak after you pass water?Yes, I always wet my pants, doctor, I always leaks into my pants.Does this happen immediately after or does it happen after say five-ten minutes?It happens a few minutes afterwards.Do you feel you empty your bladder fully, or after a short time do you feel you need to pass water again?Yes, when I get up in the morning, I pass water and then I need to go half an hour later to pass water again.How much do you pass? Do you pass a lot of water or just a little?A little.How frequently are you passing water during the day and how frequently are you passing water at night?I have to pass water every hour night and day.Is it worse during the night or worse during the day?It is bad during both night and day.53 CHRONIC INTERMITTENT PROSTATITIS chronic intermittent prostatitisYour doctor has asked me to have a word with you because he believes that you have had trouble with your prostate. He thinks you have had some prostatic infection. Do you feel you have had any trouble with your prostate?Yes, doctor. I have a lot of pain. Every few months I have another bout of severe discomfort, it feels like a lot of pressure and burning sensation just above my groin.Do you have any problems with your urinating? What』s the flow like?It』s good but sometimes when I have these bouts it is quite slow.When you feel you need to pass water can you postpone going to the toilet, or do you really need to go quite quickly?Normally, doctor, I』m all right, but again if I have an infection I need to get there quite quickly and I』m going to the toilet quite a lot at that time.When you start to pass water, is the stream continuous or does it stop and start?It』s always continuous, Doctor.Are you able to stop passing water quite well, or does it dribble on?It dribbles a little, but not very much, Doctor.When you pass water, do you feel you empty your bladder fully?Yes, I don』t have any trouble with that unless I have an infection, when I am running back and forth to the toilet all the time, and I only pass a little amount of urine each time.How about the water, does it smell or is it discoloured at all?Not really.Are you up much at night to pass water?Normally once at night if I have a drink before I go to bed, But otherwise not particularly frequently.I』m going to examine your abdomen and do a rectal examination. So please get up on the bed. Now I』m just going to pass a finger into your back passage to feel your prostate gland. .. is that uncomfortable at all? does it hurt? … Now we』ll massage the prostate and if there is any fluid discharged from you penis we』ll collect it and send it off to the lab for an investigation to see if there is any infection in it. What I』m going to do is swab the urethra which is the lining of the inside of the penis. This will be a little uncomfortable but wouldn』t last very long.54 PROSTATECTOMYProstatectomyIn older man it is quite common for the prostate to enlarge and cause the symptoms you』ve been experiencing. To relieve these symptoms, it maybe necessary to remove the prostate but there are some drugs which may help. Before doing anything we need to do some tests on your waterworks/ urinary tract/. Unfortunately, I don』t think the drugs will help in your case so we』ll have to operate.Before your operation, I would like to explain what happens when your prostate gland is removed, you』ll have a few tests before your operation, like blood and urine tests, heart tracing, a chest x-ray and sometimes an IVP - intravenous pyelogram, which means we』ll inject some contrasting dye into your vein which will pass through the kidneys and then we』ll take some x-rays of your kidneys. You will speak to an anesthetist who will decide on your type of anesthesia - a general- when you would be completely asleep or an epidural which only numbs the lower part of your body.There are two ways of removing the prostate. One is by operating after inserting a telescope through the penis or by making a cut in the lower abdomen. I』ll decide which method to use after I』ve examined you.After the operation your urine would be drained by a tube called an in-dwelling catheter. You may have some blood in the tube, your bladder would be washed with water. You』ll also have a tube in your arm called an IV which may supply you with saline or blood.It』s recommended that you start drinking large quantities after the operation. you can have tea, coffee, squash or water but fizzy drinks are not recommended. This will speed up your recovery and wash away the blood in the catheter.The bladder tube will be removed two to five days after the operation, you should continue to drink as much as possible and pass water every two or there hours, depending on your recovery, you are usually allowed home after about five days. Drink a lot liquids at home and we』ll give you stool softener to avoid constipation. if you have any problems, call your doctor.Your sex life will change a little. You can have intercourse a few weeks after the operation, but you will not emit any semen from your penis at sexual climax. Your semen will flow into your bladder and your urine may be cloudy after intercourse. You are unlikely to produce any further children but should not rely on this as safe contraception.55 CYSTITISCystitisYour doctor asked me to have a word with you regarding the urinary symptoms you』ve been having. What kind of symptoms have you had?Oh, Doctor, I have to pass water all the time and I』m running back and forth to the toilet, and it』s burns and stings every time.How often does the happen? Does this happen all the time, or is it an intermittent thing?I have good days and have bad days, sometimes when I get a bad infection it can floor me /last/ for a weeks, but at other times in between it never quite feels right but it』s, you know, I can live with it when I don』t have a bout of infectionHave you noticed any blood or discoloration in your urine?Yes, I passed blood on one occasion, but normally I don』t pass any blood. Sometimes when I have an infection, my urine is smelly, it smells foul.Is it cloudy at that time?Yes it』s ( quite of cloudy. )How is your health otherwise, apart from this? do you have any trouble with diabetes, heart disease, blood pressure?No.Are you on any other medication?I』m taking aspirin for my arthritis.Has your doctor given you any antibiotics for this?Yes, he gives me some tablets/pills/ whenever I get an infection, but in the meantime, in between times, I』m not on any tablets for it.Now, in the first instance, what I』d like to do is to examine you, examine your abdomen and then afterwards we』ll organize some tests, I』d like you to get undressed and put a gown on so that I』m able to see your abdomen. would you please get up on the table and I』ll come round and examine you…. That』s fine. You can get down, Now, about the tests. I』ll send some of your urine off to be examined in the laboratory to see if there』s any infection present. We would advise you in the meantime to drink plenty of fluids and carry on/continue/ taking any antibiotics your own doctor prescribed for you. We』d like to organize routine x-ray and an ultrasound scan to assess renal tract further. An ultrasound scan is simple scan, and it doesn』t involved any radiation, it involves you attending the x-ray department for a few hour and they scan over your tummy with a probe which allows them to visualize the kidneys and the bladder, it』s not a painful or unpleasant procedure. Once we have all the tests, we may call you in to have an inspection of the inside of your bladder, we call it a cystoscopy. 56 CYSTOSCOPYCystoscopyMr, abbot, we』ll do a flexible cystoscopy, far a flexible cystoscopy I』ll bring you into /the/ hospital, and we"ll pass some local anesthetic jelly down through the penis which will anesthetize the entrance to the bladder and then we』ll pass a very fine, flexible tube into your bladder that will allow us to see the lining of the urethra and lining of the bladder. It also allowes us to examine the size of the prostate.Why are you asking for a cystoscopy?Because we want to have a look inside the bladder. we』ll get you into a hospital, and under a local anesthetic we』ll anesthetize the entrance to the bladder and have a look inside your bladder, this is not a very uncomfortable procedure, that simply involves you being in hospital for a few hours.If we feel we need to call you back for a cystoscopy, we』ll probably do that under a general anesthetic. we』ll bring you into the hospital for a day. we』ll take you to the theatre, pop you off/put you/ to sleep for no more than a few minutes, than we』ll pass a small telescope into the bladder through the urethra and inspect the lining of the bladder. At that time, we may also need to take some biopsies but you should be allowed home later that same day.57 RENAL STONERenal stoneYour doctor asked me to have a discussion with you concerning the symptoms you』ve been having, your doctor thinks perhaps that you have some trouble with stones in your kidney. When did you first notice the symptoms?I』ve had them on and off for about three months, but it was only last week that I had such a severe bout of pain that it made me to go to my doctor immediately. He gave an injection for the pain that』s made things settle down somewhat since then. But I still have got this nagging discomfort that』s occasionally quite bad on my right sideHave you had any trouble in the past with kidney stones or any history of kidney diseases at all?No, I was fine until the last few months.Where exactly is the pain that you get?I get it in the right side of my back.Does the pain go anywhere else?Yes, it radiate down to my groin on the right and sometimes to my testicles.What type of pain is it?It』s a sharp pain that comes and goes in waves. It』s very severe when it comes on.Does it make you feel sick or nauseated when you have the pain?Yes, I feel sick. I was sick once.How severe was the pain? How would you describe the pain? Was it one of the worst pains that you』ve had?Yes, it』s a very severe pain.Do you have any associated changes in your urine, such as discoloration or grit in your urine?Yes, I have noticed a change in the color, and my doctor says that when he tests the urine there was some blood in it, but I didn』t notice that, I couldn』t see any blood in my water.What I』d like you to do is to sit up on the bed, first of all if you could take off your shirt and loosen your trousers and lie down, please?Lie on my back?If you lie on your back, I』ll examine your abdomen first of all, and then I』ll examine your genitalia, and after that I』ll ask you to turn over onto your left-hand side and I』ll examine prostate through the back passage. first of all, I am going to have a general feel of your abdomen and after that I』ll examine you to see if I can feel your kidneys, your liver and spleen…... I』d like to examine your genitalia. That might be a little uncomfortable but hopefully wouldn』t be too painful for you… was it uncomfortable?.... that feels fine, I can』t feel anything unusual in your abdomen, and external genitalia feel normal. There is no abnormality…. and now I』d like you to turn over on your left-hand side… can you hold your right knee up towards your chest and I』ll examine the back passage….. if you could try and relax it』ll make it slightly less uncomfortable for you. I』ll put some cold jelly on my finger… Can you feel that? ….Is there any pain or tenderness there?It』s just a bit uncomfortable, doctor.Now you can get up and get dressed and come back in about a quarter of an hours. 58 INFERTILITY EXAMINATIONInfertility examinationYour doctor tells me that you』ve been trying to have a family for the last four years now. and so far you』ve been unsuccessful. I』d like you to spend a few moments answering this questionnaire. I』ll just go through the questions with you quickly.How often do you have sexual intercourse?How long have you been married?Do you live together?Have you any history of infections?Have you ever been in the army?Have you ever had a medical investigation?Have you ever had any operations on your external genitalia, on the scrotum, any hernia, any circumcision or vasectomy?Have you had any infections in the water works?Have you had any sexually transmitted diseases?Have you ever had any children by any other partners?Have you ever been investigated anywhere else for a similar problem?When you have completed it, come through into the office....Now I』d like to examine the external genitalia. If you pop up/sit/ on the bed, then I』ll examine your abdomen and groin regions. The examination may certainly be a bit uncomfortable but it shouldn』t be too painful.Now I』d like to get a blood sample for hormone levers which will be sent off to the lab, and we』d like to get a semen sample in order to analyse it under the microscope in the lab. what I』d like to do is to take these two pots away, and after three days of not having any intercourses, put a sample into this pot by masturbatine not using a condom, because the condom effects sperm count, and then bring it into this lab fresh on the same morning of collection. we usually have two samples, one week apart and thereafter we』ll see you back in the clinic in a couple of weeks" time to see you with the results. If you have a low sperm count, we arrange for blood tests to check the hormone circulating in your body. sometimes we may have to do a testicular biopsy by bringing you in as an inpatient just to stay for one day, and then under a general anesthetic, we"ll take a small biopsy of the testicle to look at under the microscope. this tells us how well it is functioning. you』ll be allowed home the same day.It』s not a painful procedure as you are asleep on the table when the procedure is done. 59 EXAMINATION OF THE EAR Ear nose and throatExamination of earLet me examine your ear, now I』m looking for any ulcers or other abnormalities of your ear, I』m stroking your ear with my thumb in front to detect any scarring. I』m now looking behind your ear to see if you have any scars there.Now let me pull this part of your ear out so that I can put the speculum in to look inside with my light, …..very good. I』m going to puff a little bit of air with this balloon into your ear… very good. Now I』m going to have a look with the magnifying otoscope, and if we need to later we can use the operating microscope to see your eardrum in more detail.I』m going to call out some numbers, repeat the numbers I say, I』m going to put my hand across your eyes so you can』t read my lips, and my finger in your other ear and wiggle it slightly so that we』re only testing this ear. Now I』m two feet away from you at my arm』s length. I』m going to call out some numbers. repeat the numbers I say: Eighty, sixty, forty-two, sixteen, sixty, eighteen, eighty, twelve. what did I say? Did you hear anything? Tell me when you can no longer hear it, now I』ll turn you around and I』ll do the same with the other ear, I』ll cover your eyes again, this time I』ll blocking the other ear, repeat the numbers I say again.60 DEAFNESS DeafnessDoctor, I』m having problems with my hearing.I see, well, I』d like to test your hearing now. Which is your better hearing ear? Which is your worse hearing ear?I don』t know, I』m all right one to one, but in a crowd I』m useless. I can』t hear the doorbell, I can』t hear people speak on the phone. Everyone complains that I have the television on too loud. If I go out into a crowd, I』ve had it. I hear all the noise behind me.My baby is six months now, doctor, but he doesn』t seem to hear me.Does he smile? Does he know you?If he sees me, yes, but he never seems to hear me and he is not talking at all.Does deafness run in your family?Well, I think my grate grandma was deaf, but I』m not sure.Was it a normal birth?No, he was born ten weeks early and went to a special care baby unit. He had meningitis then, but he looked as if he was normal.I think we』d better do some special hearing tests to check out your baby』s hearing 61 PATIENTS" COMPLAINTSPatient』s complaintsI had a bad head cold last week, and since then I can』t hear, my ears feel clogged up. Last night I was ill, I had a fever and had a terrible earache, just terrible. It went on and on. It throbbed and suddenly my ear burst.My ear always feels blocked up and I can』t get the blockage out/ it cleared out/. I put cotton buds/ balls/ in and pulled this stuff out. but it only seems to get worse. It itches terribly and sometimes I think I』m going deafDuring rugby yesterday, this prop fell on me and hit the side of my head. It has been bleeding since but now it』s stopped and I think I』ve gone a bit deaf.I was serving at a bar in a pub, when someone took a dislike to me and hit me on my ear. I』ve been deaf on that side ever since.I was in a car accident last week, and my head hit the side of the car and since then I can』t hear in this ear. I was in Angel hospital overnight and x-rayed my skull. They don』t think I』ve fractured it.I』ve worked in the steelworks for thirty year now. Whenever I get home at night, there』s a ringing in my ears and I have the television on very loud. I think I am going deaf.Little John hasn』t been well, he has been ill, he has had a headache. He』s been terrible, he has been crying half the night and now his ear started running, and he』s been feeling sick.Every since I had scarlet fever when I was seven, my ears have been running on and off. It happens several time during the winter, I just feel my ear pouring/ I can feel my ear draining/, and it get worse, sometime is smells terrible. 62 TINNITUS TinnitusMy ears are always ringing day and night, I can』t sleep.Which is your bad ear?My right ear hurts.Does is run as well?Yes.Has your hearing got worse lately?It』s been bad while is been running.Do you hear noises in your ears?Yes, I』ve got running in my right ear.What』s it like? Is it high-pitched or is it low?It』s a high-pitched whistling, like machinery.Do you have it all the time or does it come and go? Does it throb with your pulse?I have it most of the time, doctor.Do you got dizzy at all?Yes.When you』re dizzy, do you mean everything goes round and round in circles or do you just feel wobbly on your feet?Everything spins round and round.Does it make you feel sick or are you sick?/ does it make you feel nauseous or do you actually throw up?I』ve been sick for the last two days, but now I just feel sick. I』m not actually vomiting./ I』m not actually vomiting, but I feel nauseous./Do you have a headache with this?Yes, it』s there.I』d like to test your hearing with this tuning fork, I』ll strike this tuning fork, and put it on your forhead. Where do you hear it? Do you hear it in the middle or only in one of your ears.It』s in the right ear.Very good. Now I strike it again, and hold it next to your left ear, do you hear it?Yes.I put it behind your ear. Is it louder of softer?Louder behind.Very good. Now the other ear, I』ll strike the tuning fork and hold it up to your ear. Do you hear that?Yes.Louder or softer?Louder.Right. 63 WAX PLUG IN THE EXTERNAL EARWax plug in your external earMy ear feels all blocked up, doctor, and I』ve been deaf since yesterday when I was having a bath.Does it hurt?No.Does it run/drain?No. I just can』t hear.Right, sit down, turn around, let me look into your ear. ..aha, it』s full of quite hard wax. Do you get a lot of wax?I suppose I do….This wax is too hard for us to got out now. You have to put some almond oil or olive oil from the supermarket in your ear. Warm it slightly before you put it into your ear and come back next week. We』ll take the wax out.Well, the wax looks quite soft, so well syringe it. Now lean slightly over, put this apron around you so you don』t got wet, and I』ll put it kidney bowl/basin/ under your ear. I』ll fill up this big syringe, right to the top. I』ll put a nozzle into the upper part of your ear, the water is warm, so you shouldn』t feel dizzy, here we go.Lie down on this cough here, under the microscope, put your head on the pillow there, turn slight away form me, that』s good. I』m bring in this microscope in your ear and focusing it on your ear. I』m putting a speculum in your ear. Now you』ll feel some tickling and itching, I』m using a little hook to get the wax out. Here it comes, we』ve done. 64 OTITIS EXTERNAOtitis externaMy ear is itching all the time, doctor.Do you keep poking it with your finger?I know I shouldn』t, but I do, and I scratched it and made it worse.Have you had any ear drops from your doctor?No.Let me take a look.A.Aha, you』ve got what we call an outer ear infection, you have a mixture of wax and skin in your ear canal, because you』ve been scratching and because you』ve an infection in your ear, it』s itching. I』ll clean it out with suction/ sucker/ and give you some ear drops.Will my hearing get better, doctor?Yes, it will, it』s not the ear drum, the hearing part of your ear, just the outer earBYou』ve got furuncle or otitis externa. you』ve got an outer ear infection, you』ve got boils, that is why it』s so tender like a boil anywhere else on your body, we are going to put a dressing in to draw it, come back on Friday, we』ll take it out to see if they』ve come to a head.come to a head 膿點成熟 65 OTITIS MEDIA otitis mediaI』ve been having trouble with my ears, I have a terrible earache. I can』t seem to hear well at all and I』ve had a temperature on and off for a week.You』ve got an ear infection, there is pus behind your ear drum, we』d like to let it out. What we will do is put some cream in your ears, an anaesthetic, let it work for half an hour, and then we』ll make a nick in your ear drum and let the pus out.66 FOREIGN BODY IN THE NOSEForeign body in the noseDoctor, we think our little girl』s got a bead up her nostril. it』s missing for my necklace and her nose has been running since. We think we can see it.Right, nurse, would you come here? ... sit on mummy』s lap. Lie back, let』s put this sheet round you, well done. The nurse is going to hold your nose, that』s lovely. Now I』ve got this little magic light, I』m going to look in your nose. Well done, I haven』t looked up your nose before. Now wait, I』m putting this little hook down it. Ohh, now it』s out. Here we are. Now promise never to do it again.67 NOSEBLEEDSNosebleedI have a lot of nosebleeds, doctor.When you blow your nose too hard?Well, yes. Sometimes it just happens anyway.Have you ever broken your nose?No.Do you bruise easily?No.Have you ever had trouble with your blood pressure?Not, as far as I know.Let me look up your noses, tilt your head back. It』s the right side that bleeds more, isn』t it?Yes.You』ve got some weak blood vessels here, they are very prominent in what we call 「little』s area」, I think that』s where you』re bleeding from. I』d like to cauterize/cauterize/ those. Now I』m going to spray this area with some local anesthetic, open your mouth and breathe through your mouth while I do it, it doesn』t taste very good, now wait a couple of moments. Has the taste gone? Good, Let me see your nose again. I』m putting the speculum in, I』m going to touch this area with the stick, we can cauterize it. Ahh, you』re bleeding slightly now from that weak point, I』ll hold the stick on it for a minute, good it』s stopped, now, there are a few other areas. I』ll do the same.we』ve cauterized your nose here, we』ve made a scab where it was bleeding , it will be weak for a few days, so don』t blow your nose hard, put some vaseline in your nose over the area for the next week while it heals.Which side is bleeding more? It』s your right, is』nt it? Is much of the blood going down into your mouth?No, it isn』t.That』s good. Do you ever have trouble with your blood pressure?No.Do you bruise easily? Yes, you do. Your skin』s getting thinner as you get older, isn』t it? Now, we』ll be as quick as we can, sit here on this chair, well done. Let』s put this apron around your neck, breathe through your mouth. There. we』ll be shining a light up your nose, holding it open with a speculum. We』ll be using some sucktion. I』m going to put some spray on your nose, it doesn』t taste very good… breathe through your mouth while we do it, very good. I』ll be pulling out this blood clot, well done. I can』t see where it』s bleeding from, I』ll I put the bandage in your nostrils to stop it and you need to stay with us overnight. Bear with us, I』m putting this tape in your nose, it』s ribbon gauze with some BIPP on it. Keep going, the worst is over now. a few more layers of it, very good. Has it stopped now? good. we』ll put this little bolster over your nose to keep the dressing in. stay in hospital overnight, and stay in your bed all the time because if you strain or cough or lift things or move around, you may start the bleeding again. 68 SINUSITISSinusitisAI』ve got the patient sitting on a chair upright, breathing through his mouth, I』m using the Bull』s eye lump, shinning it on head-mirror focus on his nose. We』re going to perform a test (proof) puncture of the antrum using a Tilly-lichtwitz trocar and cannula. We』ve prepared the nose with a local anaesthetic using twenty five percent cocaine paste on the cotton-wool on a silver cocainizing wire. If the patient should faint, the silver will bend as they collapse, which is why we use silver wire.The local anesthetic has been there for some ten minutes to shrink the mucosa in the inferior meatus and also for local anesthesia. He』s now got some anesthesia in the region of the antero-superior alveolar nerve. It』s numb over the incisor and canine teeth on that side, so we』ll remove the cocainizing wire. Now, holding the nostril open with the speculum in my left hand, I』m passing the trocar and cannula under the inferior meatus. The meatus』s attachment is somewhat curved so I』ll pass it back until I feel resistance and I pull back slightly, turn the point towards the tragus of the ipsilateral ear and I』m entering the antrum with a slight boring action. I』ve put my index finger out to stop me from penetrating too far. Then I enter the antrum, now I』ll advance slightly further, pull back the trocar until the tip of the cannula is in the middle of the antrum. First, we』ll aspirate pus using an ordinary 10 ml syringe.Now we』ve taken a specimen of pus, and we』ll send it for microscopy culture and sensitivity. Now we』ve going to irrigate the antrum using the Higginson』s syringe. We put some warm water in a basin. The Higginson』s syringe is a rubber syringe with a central bladder, and piping at both ends which we』ll attach through an Iver___ lock connector to the cannula, and we』ll place the other end in the water. Then pumping the bladder, the sinus is irrigated. We are using suction from the hospital supply to suck out excess fluid as it returns.BDoctor, I had this bad head cold, it』s gone, but now I』ve got this pain in my left side of my cheek and around my eyes. It』s throbbing behind my eyes.Do your teeth hurt?Yes, they do, now that you mention it. The pain goes round to my ear as well, it』s terrible. If I lean forward it throbs. I』ve had some muck (-colloquial )/drainage/ coming out.Have you had any medicine?Yes, I』ve had some Vibramycin, and some nose drops.Any benefit?I』m not really sure.Sit up in this chair, I』ll turn on the light to look up your nose. I』m holding your nostril open with this speculum. Now I』m looking up with my light. Are you tender here on your cheek and around your eye?Yes.You』ve got a nasty left-sided sinus infection. Now it hasn』t got better just with the antibiotics. The X-ray shows here you』re full of pus on that side. We』d better drain it. Now we don』t need to put you to sleep for this, we』ll do it with you awake. I』ll put this anesthetic on this cotton wool on this silver wire, put it in your nose. Now wait there a few minutes. .. Are your teeth going numb?Yes, they are, it』s odd.Right, then it should』ve worked. Now I』ll take this out. You should shut your eyes for this. I』m holding your nose open with my speculum again, and I』m passing this up your nose. It』s a bit like syringing up the inside of your cheek. Here we are. I』m going to push now. wait, right, now we』re in. well done, that』s the worst part over, now we』ll suck this out. Ah see, you』ve got pus. Very good. I』m almost finished. Now I』m going to syringe through it. I』ve got a bowl of water here and a Higginson』s syringe. Right. Now you』ll feel as though it』s being scratched. Open your mouth wide. Breathe through your mouth. You』ll feel water going in and out through your nose. Just let it drop out and we』ll suck it out. Keep through your mouth, just let the water run out of your nose. Well done, it』s coming back clear now. we can stop.69 DEVIATED NASAL SEPTUM Deviated nasal septumDoctor, I can never breathe out of my left nostril.Have you ever broken your nose?Yes, last year.Have you had any bad colds or high temperature lately?No.Are you otherwise well?Yes.Do you get hay fever in the summer?No.What』s your job?I work in an office.Is it very dusty?No, not really.Do you sneeze or have watery stuff coming out of your noses or get an itchy noses?Not really.Do your eyes run?No.Do you get any pus out of your noses?No, not really. I just can』t breathe through it and I snore.Do you tend to breathe through your mouth all the time?Yes, I do. And doctor, in the morning my mouth』s terribly dry.I think that』s because you』ve been mouth-breathing all night and you』ve dried your mouth out. Can you smell?Well, I can』t smell at the moment.Does your nose bleed at all?Sometimes, it bleeds on this blocked side, especially when I blow my nose hard.Now, sit down. I』d like to look up your noses. Sniff for me, sniff on the other side. Now I』ll shine this light up your nostril and hold your nostril open with this speculum, and now the other side, very good. Well, Mr. Williams, it is the left side of your nose that』s blocked.Yes, since I broke it last year.You』ve got a deviate nasal septum, this part of your nose is cartilage, and instead of being straight it』s twisted and the twist is blocking you on the left side. I』m pleased to say we can fix it for you. We can put it right with/correct it by / an operation to straighten up your nose, as there are no medicines or tablets really that will help.Is it a big operation?No, not too big, it』s quite common. If you agree, we』ll bring you into the hospital the day before the operation, you can usually go home the day after your operation, or possibly the second day after that. We do it under a general anesthetic. It』s done through your nostril, there is no cuts on your face.No black eyes.Not for this operation. When you wake up from the anesthetic, you』ll probably have a bandage up both nostrils overnight so, you see, you』ll have to breathe through your mouth that night. Would you like the operation?Will it work?Yes, we can see that we can make things a lot better than they are now.That doesn』t sound too bad. I』ll have it done, please. 70 PHARYNX-LARYNX EXAMINATIONPharynx and larynx examinationI』m going to examine your mouth, open your mouth wide for me. let me put these tongue depressor/blades/ under your lips to look from side to side. stick your tongue out, lift it up to the roof of your mouth… down again…to your right….to your left. I』m going to look at your vocal cords. Can you take out any false teeth you have. Sit up straight, lean very slight forwards, I』d like to loot deep into your throat with this mirror. I』ve warmed it with a burner, you can see it』s not hot, I can touch it, and it doesn』t hurt. Open your mouth wide, stick your tongue out, I』m going put a swab round it and hold it. Breathe steadily through your mouth, I』m passing this mirror to the back of your mouth and now say 「ee」.BEvery day when I wake up, my mouth』s dry and I can』t talk. I have to have a few drinks or something to get mouth working. As the days goes on, my voice tires as well and I get hoarse.I』d like to look down your voice box /larynx / with this mirror, open your mouth wide. That is lovely. put your tongue out. Let me hold it with a swab. I』ve warmed the mirror slightly on the Bunsen burner. It』s not hot, you can see that, Breathe through your mouth, sit up straight, leaning very slightly forward lovely. Let me put this to the back of your mouth, keep your tongue down, that』s super and say 「hay 」….You』ve got laryngitis, your vocal cords, your voice box/larynx/, they are all sore. Do you smoke?Yes.Do you use your voice a lot, do you shout a lot?Yes, I am a school teacher.You must rest your voice as much as you can. You really should stop smoking. Take care with hot and spicy food or cold drinks. 71 CANCER OF THE LARYNXCancer of the larynxI』ve been hoarse for about a month.Do you smoke?Yes.How much?Twenty a day?Does that mean forty a day?It』s might.Do you drink much?Well, I like a glass of whiskey when I go to bed at night.Does any thing bother you?Well, hot food hurts my throat.Do you have any difficult swallowing?Sometimes.Do you get any pains in your ears?Yes, when I swallow my ear hurts.Now, I』m going to look at your larynx, your voice box…. You』ve got some trouble with you larynx, I』m not quite sure what it is but you have been rather harsh on your voice, it might be something nasty. We really will need to get you into the hospital, put you to sleep to look at it while you are asleep. We』ll take a biopsy and see what it is. Then see if we need to do anything.72 FOREIGN BODY IN THE PHARYNXForeign body in the pharynxI was eating this haddock yesterday, and I am sure I felt something stick there. I think I』ll never eat fish again.Can you eat and drink?I can, but whenever I do I』ll feel it there.Where is it? Point it out to me.Here, over on one side.Right, now let me have a look at you. Sit down, open your mouth. Head slightly forward. Let me put this tongue depressor on your tongue. I』m shining this light in. hah, there is a fish bone in your tonsil. Now hold steady, breathe through your mouth, and I』ll put this forceps in, hold it ….well done. That』s out. That』s out. Try to swallow, do you feel better now? 73 TRACHEOSTOMY TUBE CHANGETracheotomy tube changeWe need to change your tracheotomy tube. We』ve got the new one ready here with an introducer. Let』s untie these tapes around your neck and bring them round. That』s good. we have the suction running in case we need it. We have to suck your tracheotomy before we take old tube out in case you have a lot of mucus. We bend the suction tube (as we) put it in, it』ll only suck as we pull it out. Now take a deep breath for me, and we』ll pull the tube out. Right, we are putting a new tube in. it』s in. let』s take out the cannula. very good, you may breathe. Let』s put these tapes in and tie them back again. 74 GOOD AND BAD NEWS Good and bad newsGood morning, Mr Gorden, sit down, is your voice better?/Clears throat/ Yes, Mr Marleod, not prefect, but at least I can talk. Do you have my results?Yes, I do. I』m pleased to say there』s no sign of cancer, but …Oh, Thank God, no sign of cancer, no sign at all?Yes, that』s right, but listen for a moment. You』ve done your voice a lot of damage with smoking, and a lot of overuse at work. I could』t be sure it wasn』t cancer until we had the results. In the future you really must try to stop smoking, as long as you keep smoking you can get more trouble with your voice, and one day it could turn nasty.Oh, yes, doctor, I』m trying. I』ve cut down a lot, but you know, it』s not easy.Well, do your best. Today it』s good news for you. But I do want us to see you again in a month, and keep an eye on you for the present.Good morning, Mr Duncan. How』s is your voice?Much the same. Perhaps a little better.Now, Mr Duncan. Please listen carefully. We』ve got the result of your biopsy. And I』m afraid we will need to give you more treatment of your voice. The report』s come back saying that some of the sample looks nasty. There is some cancer there, not a lot, but some.So it is cancer, doctor?Yes, Mr Duncan, but we』ve caught it early and there is treatment, and does it work well. If you are going to get a cancer anywhere, your larynx is one of the best places to get it, we can give you treatments, and many people do very well.Is it taking my larynx out, doctor?Not in your case. We』ll get you seen by the x-ray doctors next week. The treatment is x-rays.I』ve cut out the cigarettes, doctor.That』s very good. You』re certainly doing your part. Our part is to get the treatment started as soon as possible. I』ll arrange your appointment at the radiotherapy clinic. Would you like me to speak to your wife?No, I』ll tell her. 75 INJURIES InjuriesADoctor, I』ve cut my hand.Let me see. Where have you cut your hand, Mr Smith?Just here.How did it happen?I was using a saw to cut some wood and the saw slipped and sliced my finger.Has there been a lot of bleeding?Yes, the blood was spurting out at first and it has soaked through my handkerchief.Can you bend your finger?Yes.Can you feel me touching the tip of your finger?Just/barely /just barely /Does it feel normal?No.In what way does it not feel normal?It feels numb compare with my next finger.When did you last have an anti tetanus injection?I haven』t had any.BDoctor, I』ve injured my hand. I think I may have broken a bone.Tell me, Mrs Johns, how did you injure your hand?I slipped on some ice, and fell and landed with my hand out in front of me.Can I see your hand? Show me how well you can move your fingers?It』s painful when I bend my middle finger.Your hand is more swollen and tender in the palm... I think you may have broken a bone. I like you to have an x-ray.CDoctor, I』ve a painful, swollen right knee.How did it occur?I twisted my knee playing football yesterday, I was unable to continue to playing the game and since then my knee has become more swollen and painful.Can you move the knee?When I try to move it』s painful, and I』m unable to fully straighten the knee.DCome in, Miss Miller and sit down. What』s the matter?Doctor, I sprained my ankle getting off the bus yesterday, and now I find it very difficult to walk.Let me see it. Can you move your ankle? Move it up and down. I want to check if you have torn ligaments.Oh, doctor, that』s sore.I』m sorry. I』ll be more gentle. Miss Miller, there is swelling and tenderness over the outside of the ankle. I think you are right, you』ve sprained your ankle. I recommend that you wear the bandage and have some physiotherapy. 76 DIAGNOSISDiagnosisHere you can see a fracture through the third bone which is called the metacarpal. you can see that the bone is bent and in order for you be able to use your hand normally. I think we ought to give you an anaesthetic to put you to sleep in order to straighten the bone. We should be able to hold it straight with a plaster, but it』s possible we might need to put wires in the bone to hold it in place. So that you don』t feel any pain, we』ll need to anesthetize your hand. This can be done by injection to make either your hand or your whole arm go numb but if you prefer you could go off to sleep under general anesthetic.The knee is very swollen and it』s possible there may be some bleeding within the joint, you are tender over the inside of the knee and are unable to fully straighten the joint. I』m sure you have torn the cartilage over the inside of the knee. You』ll require an operation. I advise an arthroscopy under a general anesthetic. This is the insertion of an arthroscope into the knee through a very small opening, we are able to see the inside of your knee on a television screen and I am certain we』ll find you have torn the cartilage. If that is the case, at the same time, we』ll go ahead and remove the torn part of the cartilage. This will relieve the pain and swelling in your knee and allow you to return to football in the few week』s time.Mrs Smith, I』d like to examine your shoulder. Please show me how far you can move it, can you raise your arm over your head? Farwards and now to the sides. Can you touch the back of your head? Now can you touch the middle of your back with your hand? That』s good.How well can you move your elbow? Can you bent it up and straight it? Now stop me from bending it and stop me from straighten it. Now, I』d like to examine your wrist. Cock your wrist up and now bent it down. Can you twist it, as though you were turning a key, first one way and then other, now, I like to examine your hand, please squeeze my fingers. Can I examine each finger in turn? Touch your thumb with each of your fingers. Now pinch your index finger and your thumb together and stop me from separating them.77 TREATMENTDamien, I』ve put the plaster/cast/ on to keep your bone in the right position. It』s very important that you don』t get the plaster wet, because then it will become soft and the bone may move. I』d also like you to come back to hospital straight away if your finggertips feel tingly or numb or if your fingers go pale or blue. This would suggest that the plaster is too tight and we"d need to split it to relieve the pressure. In order to avoid swelling within the plaster, I recommend that you keep your hand up so that the swelling can drain away. You"ll need to be in the plaster for six weeks altogether, but we"ll need to get some x-rays done before then, to make sure the bones haven』t moved.Damien, I"m pleased to say that your facture has healed in a very good position and now we can take the cast off, I』m going to use a special sort of saw to cut through the cast. It makes a loud noise but it』s very safe. It vibrates, so will not cut your skin even though it cuts through the plaster. 78 SCOLIOSISScoliosisDoctor, I』ve noticed that my daughter』s spine has become crooked.When did you first notice this, Mrs Black?It was during the summer when my daughter was wearing a t-shirt. I noticed that the right side of her back appeared very prominent.And since you first saw that, has there been any change in the shape of your daughter』s back?No, not really, although it may have become slightly more curved over the last few months.How is Mary』s health?She is usually a very fit girl. She has suffered from asthma in the past, but doesn』t take any medicine regularly.Is there anyone else in your family who suffered from curvature of the spine?Yes, my brother, that』s Mary』s uncle, was quite severely disabled by curvature of the spine when he was in his teens.I see, so you』re obviously concerned that the same thing may happen to your daughter.Yes, doctor, that』s right.What I』d like to do now is to examine Mary if that』s all right with you.Yes, please go ahead.Mary, what I』d like to do first is (to) examine you standing up. Please, could you take your clothes off for me… thank you, would you please stand as straight as possible... That』s good, now walk across the room…. That』s fine. Now stop and turn around and come back towards me…. Ok, come and stand in front of me again, now stand with your back to me. now lean forward as far as you can. Now lean back. Now stand straight again, now lean over to the right, and now lean to the left. What I』d like to do now is examine your legs. Would you lie on the couch for me please Mary…. I need to get some x-rays of your spine. These would be taken with you standing, from the back and from the side. and I』ll see you again after they』ve been done.Marry, I』m pleased to say that your scoliosis, which is curvature of your spine, is not very severe and the treatment I recommend is physiotherapy. I think it』s best for you to have exercises to improve your posture which will include some in the hydrotherapy pool.Emma, you have scoliosis, I』m pleased to say that you won』t need an operation to put this right. Mrs Thomas, scoliosis is curvature of the spine, no one is quite sure what causes it but we can be certain that a curve of the amount that Emma has will not progress enough to require an operation. However, in order to stop it deteriorating, I recommend that Emma is put in a plastic brace which she should wear day and night for the next few months. We』ll need to keep a close eye on Emma』s spine to make sure that the curve doesn』t get worse. 79 CONGENITAL DISLOCATION OF THE HIP Congenital dislocation of the hipHello. Mrs Smith. my name is doctor Jones. I』m one of the orthopaedic surgeons at the hospital. And I』d like to examine little John』s hips. This is a routine procedure which we perform on all newborn babies.Situation oneI』m afraid, Mrs Smith, that one of the John』s hips clicks. This is quite a common finding and really causes problem in the long term, it doesn』t need any special treatment at the moment, but I would like to reexamine john in four weeks.I』m afraid, Mrs Smith, that one of John』s hips came out of joint when I examined them. This will need treatment now, but because it has been detected so soon it shouldn』t cause any problems in the long term. I recommend that John wear double nappies/diapers/ to start with and I wish to reexamine his hips in four weeks.Mrs Smith, I』m afraid that one of Jones』s hips is out of joint and his right leg is shorter than the left. I would like to get an x-ray.Mrs, Smith, I』m sorry to say the x-ray confirms Jones』s hip is out of joint. If It is left in this position then the hip will not develop properly but if we treat it at this early stage then he stands every chance of developing normally. The treatment, first of all, is to wear this plaster device called a Pavlik harness, but if this is unsuccessful then Jones may need an operation to put this hip back into joint. 80 DISLOCATION OF THE HIP AS A LATE COMPLICATIONDislocation of the hip as a late complicationHello, Mrs Wallis. My name is doctor Trelawney. Come in and sit down. I have a letter here from your doctor but I』d like to ask you a few questions, as well. How old are you?I』m thirty-five years old.What』s your occupation?I』m a shop assistant/store clerk/.What problems are you having at the moment?My right hip is sore and I』m having difficulty walking.How long have you had these problems?I』ve had them for many years.How did they begin? Was it sudden or gradual?I』ve really had the problems for as long I can remember, but they』ve been getting gradually worse over many years.Do you remember an accident at the start of your trouble?No, the problems seemed to develop for no good reason.What are you prevented from doing by your sore hip at the moment?I』m able to do very little, I struggle to walk just a few hundred meters.Where is your pain?It』s mainly my left hip, but my right knee is also slightly sore.When do you get the paint?I have the pain most of the time, but it gets worse towards the end of the day, especially if I』ve been on my feet all day.Do you limp?Yes, I limp very badly.Do you need to use a stick or crutches to get around?Yes, I have a walking stick which I hold in my left hand.Do you find it』s getting harder to get around?Oh yes, certainly.Does your hip cause you any problems?Yes, it』s so stiff I can』t bend over to tie my shoe laces.Do any problems run in the family?Yes, my mother also had a stiff hip and she had a limp. She needed an operation when she was only forty to give her a new hip.Now, I』d like to examine you. Can you please take your clothes off. That』s good. And now stand up. I』d just like to measure the length of your legs. Good. Now if you could lie on the couch. That』s good. Show me how well you can move your hip. Good, now I』d like to move it. I』ll bend it down and straighten it again. Now move it across to me. And now to the other side, now turn it in and turn it out. That』s good, I need an x-ray of both hips and pelvis.Mrs Wallis, I have the results of your x-rays. These show you have severe osteoarthritis of you left hip. This is due to a congenital dislocation of the hip which you』ve had since birth. I think the best treatment for you would be an operation to replace your left hip.Tell me, doctor, is that a major operation?Yes, it is undoubtedly. But you are having so much trouble I do not think there is any other alternative.I』m very worried about this, doctor. What does the operation involve?It is a major operation which would require you to be in hospital for about two weeks. You』ll come into hospital a day or two day before surgery so that we can examine you and check that you are fit for an anaesthetic. The operation itself involves quite a long cut on the outside of your thigh and then the worn part of you hip will be cut away and replaced with a metal and plastic joint. This should make you more comfortable, any your hip less stiff. But of course, as with any operation, there is a small risk of complications.What are those complications, doctor?The main complication are the serious ones which can occur during any anaesthetic. There is also a small risk of infection of the new joint, or the new joint coming loose. If either of these occur, then you may need a series of operations to put the problem right/ correct it/. 81 RHEUMATOID ARTHRITIS [生詞摘錄]Gold[=concentrated marijuana]濃縮大麻rose hip 野玫瑰Achilles』 tendon. 跟腱/ Achilles" tendon阿希利斯(氏)跟腱:足跟後的強韌肌腱,小腿三頭肌即以此附著於跟骨粗隆untitussive / tussive咳嗽housebound 居家不出drowsy 昏昏欲睡get about，To be out of bed and beginning to walk again, as after an illness.可以走動：離開床並開始走動，通常指病後at times，On occasion; sometimes. 有時；間或[原文]Rheumatoid arthritisWhat problems do you have with your joints?I get a lot of pain and stiffness.Has this been getting worse recently?Yes, over the past four months I』ve noticed a general deterioration in symptoms.Which joints are mainly affected?It usually involves my hands, knees and shoulders, but some days I feel generally sore all over.Is there any time of day when your symptoms are worse?Yes, I feel very stiff in the morning when I get up.How long does this last?Oh, at least an hour. Sometimes longer.Have you noticed anything that makes the symptoms worse?Yes, if I』ve had a busy day or I』m doing heavy housework my arthritis is much worse.Do you get a lot of pain at night, and if so, does it disturb your sleep?Recently I』ve found that I wake up whenever I turn over because this makes my shoulder pain worse.What tablets are you taking at present?I』m taking ibuprofen.Have you had any problems with them?I sometimes get indigestion and heartburn.Have you had other treatments in the past?I tried Gold injections before but it was stopped after developed itching and a rash.How does your arthritis affect your life?I found it difficult sometimes to dress and washing can be a problem. It』s sometimes difficult to comb my hair and I found housework difficult at times.I always drink rose hip teaI have very little movement in my hip.I』ve torn my Achilles』 tendon.The pain is only in my right hip.It』s always worse in the morning.I have to use two sticks to get about.It』s always worse when I』ve done a lot.Gentle exercise is not a problem.Yes, I』m taking untitussives.Yes, I』m taking muscle relaxants.It makes me housebound.It makes me drowsy. 82 PHYSIOTHERAPYPhysiotherapyDoctor, you recommend that I saw a physiotherapist for my tennis elbow when I last visited you. She mentioned a treatment called iontophoresis, what does this involve?Well, Mr Foster, that involves putting some cream on the skin over the elbow and then using a special electrical devices to encourage it to penetrate the skin.Well, Mr Foster, this involves putting electrodes on the skin over the muscle and stimulating the electrodes to make muscle twitch. This has the advantage of straightening the muscles, and it』s more comfortable than when you try to contract the muscle yourself. And furthermore, the stimulation can give you stronger and contraction than you are able to manage at the moment.Doctor, the physiotherapist recommended ultrasound treatment for my ankle. Do you thank this is a good idea?Yes, very much. The ultrasound is a very special kind of pulse waves encourage the healing of the tissue of you ankle, this is very effective.Doctor, the physiotherapist recommended exercise for my shoulder, do you think this is a good idea?Yes, the physiotherapy will move the joint herself through as big a range of movement as possible without causing you too much discomfort. She will also encourage you to move the joint yourself .83 FLAT FEETFlat feetbunion 姆囊炎(大趾內側的腫炎)corn [醫]雞眼Come in, Mr Scott and have a seat. My name is doctor Jones. How can I help you?Doctor, my feet terribly sore and my legs ache. It』s particularly bad at the end of a long day and I tire very easily. I can』t stay on my feet for long at all.How long have you had this problem, Mr Scott?I』ve had it for several months but it』s been getting a lot of worse recently.Stand up for me, please. Stand up straight. That』s good. Now stand on your tiptoes, now on your heels. Walk on the outer edges of your feet. Mr Scott, you have flat feet. I think the best treatment is an insole to reinforce the arch of your foot, I noticed also that you have a number of other minor foot problems, you have corns on your second and third toes, and you are beginning to develop a bunion near your toes. I think the best treatment for this is to wear some broad, comfortable shoes.84 RICKETSRicketsDoctor, I』m very worried, my son』s legs are bent.Yes, I can see that. How long ago did the problem start?It began when he was about two years old and it』s been getting worse since.How old is your son now?He』s four.Does he have any other problems?Yes, his chest is a rather odd shape.Has your son ever had any abdominal or kidney problems? Does he have an unusual diet?He does eat poorly and as an infant he was investigated for failure to thrive. ..Mr Mohammed, your son has rickets. This is a softening of the bone caused by a lack of vitamin D. The treatment is to add some vitamin D supplements to your son』s diet and also to get some fresh air and sunlight. 85 THYROIDISMThyroidismDoctor, I』ve got swelling in my neck.How long have you had the swelling?Roughly three months.Is it getting larger?It』s slowly getting bigger.Is it giving you trouble with breathing?Very occasionally/rarely/.Have you noticed any changes in your voice?No, but sometimes I find that food sticks.Have you noticed any changes in you weight?I』ve lost several pounds over the past couple of months since the swelling began.Do you like hot weather or cold weather?Well, I prefer cold weather. I feel more comfortable then.Do you feel hot and sweaty?Yes, I even feel sweaty when it』s cold.Do you get palpitations?Yes, I often feel my heart pounding.May I examine you? Well, it appears to me that your thyroid gland is a bit enlarged. We must administer some blood tests to check on the function of the thyroid gland itself. It well help to find out if it is overactive or underactive. We』ll also perform some scans. One of these will involve the use of some radioiodine. These would mean you』ll get a little drink of a very low lever of radioactive iodine. We』ll then scan the thyroid gland so see whether it』s taking up a lot of the isotope or not enough of the isotope. This gives us an indication of how well the thyroid is functioning. Since you have swelling of the gland we』ll do an ultrasound scan as well; this is like using echo sounds and it』ll give us some idea of whether the swelling you have in your gland is solid or cystic.AA middle-aged lady, about forty years old, has noticed an enlargement in the front of her neck. She has also noticed that at the same time she was losing weight. She was having night sweats, tremors of the hands, and from time to time noticeable palpitation which could be described as feeling her heartbeat. The duration of her symptoms is about three years and she consulted her doctor about this some six weeks ago. The doctor observed the loss of weight, rapid pulse, the smooth skin and thyroid swelling, and has referred her for the consultation.BFollowing some routine blood tests, notably, for hemoglobin levels, white cell counts and for thyroid hormone levels she will almost certainly be advised to have an operation. Drug therapy is advised in toxic nodular goitre. She is also advised that she will need to be admitted to a hospital/ hospitalized / fairly soon, in other words, within a matter of three or four weeks, if possible, for the operation to be performed. She is told that the operation removes the enlarged portion of the gland, but will leave her with a sufficient amount of thyroid tissue for normal metabolism.CThe general physical examination of this lady, which concludes the consultation, reveals that she has a weight of only fifty nine kg, she has in the past been as heavy as sixty five kg, so there has been a significant weight loss. Her blood pressure is somewhat raised/elevated/in view of her age, just over forty. Her resting blood pressure is one hundred and forty over ninety and she has a constantly rapid pulse in the range of eighty eight and ninety six, whereas one would hope for it to be in the range of seventy two to eighty.dThe rest of her history is non-contributory. She is a married woman with two small children aged eight and ten. She』s had no serious previous illnesses and she』s not noticed any other symptoms apart from a slight increase in appetite which rather surprised her in spite of her weight loss, there is no family history of thyroid enlargement. She』s accepted the advice and will come in for an operation when sent for in about a month』s time.EShe is given an operation for subtotal thyroidectomy in which the exploration of the neck is carried out under general anesthesia. The usual preoperative antithyroid drug is employed to bring the patient into the euthyroid state before operation.FThe incision of the skin is made transversally in the crease line of the neck which results in a virtually invisible scar after a period of two to three years. 86 PROBLEMS OF THE (O)ESOPHAGUS Problems of esophagusDoctor, I』ve been having trouble eating. When I swallow food it seems to get caught in my chest.Do you find it difficult to swallow solid food or do you have to take liquids or can you not even manage liquids?I find that thing like meat or potato stick, and I have to take a drink to wash it down.How long have you had this problem?For about three months, but I』m finding it increasingly difficult to swallow food.Has there been any associated pain or vomiting with this?When I eat solid food, I find it sticks but after I』ve brought it up the pain goes away.In the past have you had any problems with burning in the chest, especially when lying down or after a large meal?I』ve had heartburn after I』ve eaten a lot or at night, or after some kinds of food, for about ten years.Have you lost weight or had loss of appetite?Yes, I』ve lost about four kilos over the last three months.When you eat do you feel as if you are choking, or do you cough a lot afterwards or do you feel tight around your chest?No, I don』t get anything like that.Can you please get into a gown and I』ll examine you…. With these symptoms I think we need to find out whether there is a blockage in the food pipe or the esophagus. We can do this in a number of ways. One way is to put a tube down your throat which can look into the esophagus and down into your stomach. Another way is to give you a barium meal, you have to drink a thick liquid called barium which will outline if there is any blockage. The blockage may be due to a number of factors. It could be due to a growth or from a tightening of the esophagus due to acid going up into it. This is called reflux. after these two tests we can decide upon a treatment plan.87 GALLBLADDER DISEASE [生詞摘錄]chip [pl. ]油炸[煎]土豆片Gallbladder diseasesWhat brings you in to see me today?I』ve developed this very severe pain which came on very quickly last night after I had fish and chips for my supper. I called my doctor out and he gave me an injection, and the pain got better but I still do have a dull ache under my ribs.Have you had the pain before when you』ve eaten fat food?Yes, but never as badly as this.Does the pain move anywhere or do you feel it anywhere else?I feel it on the top of my right shoulder, and it』s gone through to my back.Have you been sick, or have you felt sick? /have you vomited or been nauseous?/Yes, I vomited several times during the night, although that doesn』t make the pain much better.Has anyone in your family had gallstone?Yes, my sister has a lot of trouble with her gallbladder.I think I』ll need to examine you now. Could you please put on a gown and I』ll be back…. Um, I think you might have problems with your gallbladder. We are going to do some blood tests to determine if the liver function has changed in any way, and we are going to do an ultrasound scan. It involves a machine placed over the right side of the stomach and sound waves are produced which will show if you have stone or not. Depending upon what these test show we may recommend removing the gallbladder. If the test do not show stones, we need to look for other reasons for the pain. 88 APPENDICITIS Appendicitissick leave 病假What brings you in to see me today?Well, I』ve been having pain around the right side of my stomach.Have you felt sick or been sick? /have you vomited or been nauseous?No.Can you describe the paint? Where it began and where it is now?The pain started yesterday around my belly button and then move down to the right side. It』s a dull achy kind of pain.Do you feel hungry? have you eaten today?I don』t feel hungry now although I had breakfast earlier this morning.Have you had any hot shivery turns or chills? Any problems with your urination? Any back pain? Any change in your bowel motion/movements?No. I』ve had none of those.Have you had any colds or trouble with your chest over the past week?No, I haven』t.Have you had any diarrhea over the past few days?No.Can you please get into a gown and I』ll return and examine you. Does it hurt when I press here?Ouch!Does it hurt when I let it out?Ouch!I think that there is a good possibility that you have appendicitis, although one can』t be sure. We』ll get some blood tests looking your white blood count, however, based on your symptoms. I think it would be wise to admit you to the hospital, and put you on a drip/start you on an IV /, and if you don』t improve, then I think we should remove the appendix.I』ve got a right back pain.I』ve got a pain on the right side of my lower abdomen.I』ve got a general abdominal pain.I am always seasick on the boat trip.I』ve been on sick leave for two days.I haven』t felt nausea or vomited.It』s a stinging, burning sensation.It』s a cramping, stabbing pain.It』s a back pain.It moved up my shoulder and then I had a headache.It traveled down to my back and then to the left.It started in the middle of my stomach and moved down to the right. 89 BREAST LUMPS Breast lumpmammogram 乳房X線照片Doctor, I found this lump in my breast when I was having/taking/ a bath three days ago.Have you noticed any previous lumps in your breast or have you had any previous problems in your breast?Yes, I felt a small lump when I was in the bath several months ago, and that lump comes and goes with my period.Does that old lump hurt at all?No, not really.Ok this new lump. Has it been painful?Just a little tender.Have you noticed any change in size?Well, the lump gets larger and smaller every month with my periods.Have you noticed any discharge or any bleeding from the nipple?Yes, when I squeeze my breast, a small drop of yellowish bloody liquid comes out of the nipple. But it didn』t hurt and seemed so important. I really didn』t want to take up your time when I know you are so busy.No, no. that』s what we』re here for. It』s important to look at all these lumps and bumps wherever they are. Would you please take off your clothes down to the waist so that I can examine you… I』m going to examine under your armpit because sometimes there are glands there which maybe enlarged when you have a lump in the breast... and also I』m going to examine you neck because sometimes there are glands which become enlarged when you have a lump in the breast. The first thing we』ll do is send you for a mammogram to see if the lump is solid or cystic or if there are calcium deposit and then we』ll do a breast biopsy. I』ll insert a needle into the lump to obtain a tissue sample so that we can send it to a pathologist for examination to determine the nature of the cells. 90 GOOD AND BAD NEWS Good and bad newsI』m very pleased to say that you have a straightforward and simple fracture. As soon as the plaster was removed and the muscles have recovered, you』ll find absolutely no difference from your previous state and will able to function normally.Well, I』d like you to know that the fracture you have is closed to a blood vessel and a nerve, and because of this we may have to operate when we reduce the fracture because the artery may be damaged. We may have to replace a section of the artery and the nerve may have to be freed at the time of the reduction.I』m sorry, after your operation we found that we were unable to repair the fracture completely. Consequently, you』ll find that you』ll have a stiff knee, however, with time you』ll adapt to this condition and shouldn』t have too much disability and long run. 91 HERNIAHerniaThe day before yesterday, while lifting a wine barrel, I felt a crack /sharp pain/ in my left groin. Then a little lump came out which has grown. It hurts sometime, especially when I left something or cough.Is your bowel movement regular?Yes.Can you push the lump back?Yes. If I lie on my back it goes back by itself.Right. Get up on the couch and I』ll have/take/ a look at it. It will have to be operated on soon, otherwise if you can』t push it back it becomes hard and painful. 92 EMBOLISMEmbolismAbout half an hour ago I felt a sharp pain in my left calf. I could hardly stay on my feet, it was so painful.Can you move your toes?Yes, but they hurt terribly when I move them.Do you know if you have any heart problems?Yes, I was treated for arrhythmia. I was given anticoagulant tablet to thin my blood. I stopped taking them six months ago.It』s possible that a tiny blood clot has blocked one of the leg arteries. If that』s the case you』ll need an urgent operation, I』m afraid.93 AN(A) ESTHESIA AnesthesiaHave you had an operation before?Have you been given a general anesthetic?Have you ever had an injection into your spine? Have you ever had a spinal anesthetic?Did you have any problems or complication during or after anesthesia?Are you allergic to any drugs?Have you had any problems with your heart or lungs before?Do you get heartburn?Do you have too much gastric acid?Have you had any problems with your spine or any neurological disease?How do you bear stress?Do you experience shortness of breath?Do your legs well? Are any of your teeth loose?Do you have any caps or crowns?Do you have any removable dentures?Can you breathe easily through your nose?Do you have a cold or a cough?Do you have any disease that we should know about?Are you diabetic?Do you know if you have any kind of heart condition?Do you have high blood pressure? How high is it?Do you experience any irregular heartbeat?Do you drink alcohol regularly? how much?Have you had any problems with your liver?Do you take contraceptive pills regular?General anesthesiaWe are going to give you an injection, you』ll feel yourself going to sleep. I』ll give you some oxygen to breathe through a mask. We』ll give air anesthetic now. breathe evenly through nose. You may feel a little dizzy. Don』t be worried. Have a nice sleep.local anesthesiaI』m going to wash your back with some antiseptic, it may be a bit cold. You』ll felt a sharp sting. I』m going to give you an injection. Relax, don』t move. Curl up into a ball. tell me if your back goes numb or you feel a sharp shock in you leg. Try to move your leg if you can, I』m going to jab your leg. Tell me what you feel.Waking the patient upMrs brown, please cough. Take a deep breath, swallow and spit out what you have in you mouth. The operation is over. Wake up, do you feel sick? Or are you in any pain?94 SKIN APPENDAGES[生詞摘錄]Ringworm 癬/Fungi(pl.),fungus真菌/ paronychia 甲溝炎 / tinea barbae 須癬 /alopecia, 禿髮, alopecia areata 局限性脫髮,斑禿, / areata 簇狀的 / flare up 再發/hay fever枯草熱/ ooze 滲出/ burst 破裂/ Nail fold 甲褶[原文]DermatologySkin appendagesOne, ParonychiaTwo, alopeciaThree, tinea barbaeHow long have you had problems with your nail?It』s been swollen and sore for six months, and occasionally pus oozes out from it.Have you had any treatment for it?Yes, the doctor has given me some cream, but it hasn』t helped.I think what you have is paronychia, and I』ll recommend a treatment to your doctor when I write to him. This is an infection of the nail fold which tends to go on for quite a long time before it clears up. It requires treatment for at less six months and you need to keep using the treatment that I recommend during that time without a break. It』s due to fungus in the nail fold. If it flares up at any time and gets worse, you should go to see your doctor because you may need some antibiotics.I believe that you have problems with your beard area.Yes, I』ve had problems with painful spots which come to a head, and burst. It flares up from time to time.What treatment have you had for it?My doctor』s given me a short course of antibiotics which has not been effective.You have a condition called tinea barbae. I』ll suggest a treatment to your doctor which should be effective in clearing it up. It』s due to an infection which is spread by shaving. It would be better for you did not shave with water. I』ve taken a swab to determine what bacteria are causing the infection. The treatment will depend on the result from swab which be back in about one week』s time.How can I help you?I』ve been losing my hair.Are you losing it in small patches or all over?There』s one small patch which is falling out on the top of my scalp.How long has this been going on?It』s been going on for the last two months, and the patch is gradually getting bigger. I wonder if there』s something you can do about it.Have you ever had asthma, hay fever or eczema or has anybody in your family had these conditions?Yes I had eczema when I was younger.Has anybody in your family ever had diabetes, arthritis or any thyroid problems?No, I』m sure they haven』t.Have you had any treatment for the hair loss so for?No, the doctor just sent me up here for your opinion.The problem is called alopecia areata. That』s rather difficult to treat, but when there』s a small area affected, such as you have, we can treat it by injections. You need to have repeated injection every six weeks, and in your case it should be effective.95 PSORIASIS [生詞摘錄]Dithranol Acetate三乙醯1,8,9-蒽三酚,1,8,9-蒽三酚三醋酸酯[抗牛皮癬葯]Tar[=gum opium]阿片樹膠Dovenix 硝羥碘苄腈[抗寄生蟲葯]Methotrexate甲氨喋呤,米佐屈脫,威力氨甲喋呤,氨甲喋呤,氨克生,氨甲基葉酸,氨甲retinoid類維生素A,維生素A類,維甲酸類cyclosporine A環胞素A(免疫抑製劑)psoriasisI believe that you have problems with your scalp.Yes, I』ve had scaling of the scalp which started about two months ago, and has gradually been getting worse. It has also been itchy.Have you had any treatment for it?Yes, my doctor』s given me T-Gel shampoo, but it has not been effective.Your appear to have psoriasis involving the scalp, I would suggest you use a diprosalic scalp application which should be rubbed in at night and left overnight, washed out in the morning with a tar-based shampoo. You should use it every night until it has settled, and then gradually reduce the frequency with which it is applied.The letter from your doctor say you have psoriasis, when did this first start?I』ve had it for ten years, but I』ve never actually had to be sent to hospital.When did it flare up?It started flaring up about two months ago just about the time I was sitting for/taking / my exams.Which parts are affected now?I』ve got it all over my body. My arms and legs and my scalp are scaling.Can you please just go behind the screen and undress and lie on the couch under the sheet. Does anybody else in the family have psoriasis?Yes, my grandmother had it.Unfortunately, it』s now very widespread and it will be difficult for you to treat yourself at home. The best way to get it cleared will be to come into hospital where we』ll treat you with regular dressings with tar-paste and ultraviolet light treatment. You』ll probably be in hospital for about four weeks.Chronic plaque psoriasis is an inherited condition which normally occurs over the extensor aspects of the elbow and knees but can involve any part of body. Other sites that are affected are the nails, scalp, umbilicus, and occasionally there is flexural, or what is sometimes called inverse psoriasis. The plaques are well demarcated with silvery scale which leaves pin-point bleeding when the scale is removed. There is a hierarchy of treatment, starting with topical treatment consisting either of dithranol, tar or dovenix. Topic steroids are occasionally use to hands and feed for flexural psoriasis or for the scalp or the face.Ultraviolet treatment including UVB and PUVA are also useful, if these are ineffective, then severe psoriasis must be treated with second line therapy, the main drugs used for second line therapy include methotrexate, retinoid and cyclosporine-A. all the drugs have serious side effects and so they are only used when other forms of treatment have failed.96 HERPES SIMPLEX Herpes simplexZovirax阿昔洛韋,無環鳥苷,開糖環鳥苷製劑的商品名What has your problem been?I』ve had cold sores on my upper lip which have come on from time to time.When was the first time you got them?I』ve had them for years now but lately they』ve been coming up more frequently.Do they look like water blisters when they come up?Yes, they start as water blisters but then break down to form scabs.When do the cold sores break out?They tend to come on when I have a cough or cold.I think they would be best treated with a cream called Zovirax, which you should apply when you first feel tingling in your lip which suggests that the blisters are just starting. It』s due to a virus which is present in the nerves and can come to the surface whenever you are under any form of stress, such as another illness.97 ACNEacneHow long have you had problems with the spots and pimples?I』ve had acne on my face for the last four years. I』m now 17 and they started when I was 13.Have you had any treatment for it?The doctor gave me tetracycline for two weeks, but it just got worse when the tablets were stopped.Have you used any creams or ointments to rub in the skin?Yes, I got one from the chemist but it hasn』t really been helping.Unfortunately, when you use antibiotics for acne, they have to be continued for much longer. I would suggest in the first instance you take tetracycline two tablets twice a day for at least three months. These must not be taken with food, so I suggest you take two in the morning, half an hour before breakfast, and two in the evening, half an hour before your evening meal. You should take them with water rather than any milky substance. Please come back and see me in three months.98 WARTSWartsHow long have you had problems with warts?They started one year ago but have gradually been spreading over my hands.Do you have them on any other parts of your body?No, they』re just on my hands.What』s your job?Unfortunately, I serve school meals I can』t carry on with/continue /my job while I have warts.I see, we will treat them with a cold spray which is liquid nitrogen. They may have to be treated every three weeks. It will be more effective if you treat them in between times with a wart paint. You must soak you hands for four or five minutes in the evening and then rub the wart down with a pumice stone or emery board until it』s flat. you can then apply a wart paint and leave it on overnight and remove it in the morning. It may take some time to clear, but so long as you apply the treatment regularly it should be effective.99 MOLESMolesWhat seems to be the problem?I have some moles on my back and the doctor thought I ought to come along to get them checked out.Have any of them changed recently? Have they become darker in color? Have they changed shape or grown in size?My wife says they are growing and have become darker in color.Have you had any itching or bleeding from them?No, there』s been no itching and they have never bled.Have you had much sun exposure in the past?I go on holiday abroad every summer, but I usually tan easily and I』ve never burnt my skin.There』s one mole on your back which I think needs to be removed. This』ll require some local anesthetic. We』ll cut it out, put in some stitches which you』ll get out at your own doctor』s. I would advise you not to expose yourself to the sun. The best way of protecting yourself is to wear light clothing and to stay out of the sun between 11 in the morning and 3 in the afternoon. If necessary, wear a high-factor sun block.100 ECZEMABetnovate戊酸倍他米松[糖皮質激素]How long have you had problems with eczema?It started when I was a baby.Is this the worse it』s ever been?Yes, it flared up about two months ago and none of the treatments I』ve had from doctors has been effective.What treatments have you had?I"ve been using Betnovate on my body and hydrocortisone on my face.Do You know of anything which might have caused it to flare up recently?I"ve just changed jobs, and I』m working in a factory where I come into contact with oil. It started on my hands and this maybe what is causing it start up again.I think the best way of treating you will be to do daily dressing which will allow the skin to settle much more quickly. After it has settled, we』ll arrange for patch tests to be carried out to determine whether you are reacting to any of substance you are coming into contact with at work. This will require three visits to hospital. The patches will be put on your back at the first visit and removed on your second visit. They』ll be read at that time, and you』ll have to come back two days later in case there are any late reactions. If you』re positive to any of the patches, we』ll be able to give you advice about avoiding contact with this substance.101 FUNGAL INFECTIONSfungal infectionWhat』s the problem?I』ve had an itchy rash on my body and arms and legs for the last two months.Can you describe the rash?It』s pink with flat, oval spots.Where did it start?It started on my chest and has spread to my back, my abdomen and my arms.Have you had any problems with this before?Yes, two years ago I had a similar problem which was treated with Selsun shampoo.You have what is called pityriasis versicolor which is due to a fungus on the skin. I』ll give you some cream to treat this. Unfortunately, people who get this condition tend to have problems with it again after it has been treated.pityriasis versicolor 花斑癬，What』s the problem?I』ve had an itchy rash between my toes for years but, unfortunately, it has got quite a lot of worse recently.Will you please take off your shoes and socks so that I can have a look at your feet, and if you could spread your toes I』ll able to see it… Oh, you have what is called tinea pedis or athlete』s foot which is due to a fungus. I』ll give you a cream which should be put on four times a day. Unfortunately, it will tend to recur but it helps to wear light footwear as opposed to trainers/sneakers/tennis shoes/which tend to make the feet sweat and tend to make the fungal infection worse.tinea pedis 足癬How long have you had the problems with your nails?It started about a year ago.Which nails are infected?I』ve got two nails on my left foot and one on the right foot which have become abnormal.Will you take your shoes and socks off so that I can see them? Aha. you see, your nails have become white, opaque, thickened and brittle. It looks like a fungal infection of the nail called tinea unguium. To try to identify the fungus which is causing it, I』ll take a clipping from the nail, which we』ll send off to be looked at under a microscope and then we 』ll try to grow a fungus. It will take about four weeks for the results to come back so you must come back and see me in about five weeks』 times. If the result is positive, we』ll be able to treat it with three-months course of tablets.tinea unguium 甲癬 102 LEG ULCERLeg ulcerHow long have you had problems with this ulcer?It started with an infection about three months ago and has never healed.Have you had problems with varicose veins or thrombosis or pulmonary embolism?Yes, about fifteen years ago I had a thrombosis in my leg and was admitted to hospital with chest pain and coughing up blood. I was told it was because of the thrombosis in my leg.Because you』ve had thrombosis in the past, you』re more likely to develop these ulcers. They will heal up themselves but, unfortunately, it』ll take some time and requires regular dressings. As your leg is swollen, it will be necessary for your leg to be kept elevated when you』re sitting at rest. I』ll also give you an elastic stocking to help reduce the swelling which will allow the ulcer to heal up more quickly. I』ll arrange for the dressings to be done regularly by the district nurse.103 URTICARIA UrticariaNow, what』s the problem?For the last three months I』ve had problems with an itchy rash.Whereabouts does it occur?I get it all over my body, including my arms, legs, and hands and, occasionally, it affects my face and my upper lip is swollen.Have you had any swelling of the tongue or inside the mouth?No.Have you ever had any problems breathing?No.Are you quite well otherwise?Yes.Have you been taking any tablets or had any vaccinations recently?No. I』ve not taken any tablets for about three years and I haven』t been vaccinated for about two years.Are there any foods that you』ve noticed that can cause it, or does it come on during the exercise?No. I haven』t been able to identify any causes.How long does the last when it starts?It could be there in the morning and it will be gone by the evening.Does it ever last any longer than this?No. it doesn』t.Do you ever take aspirin as a headache remedy?No, I only take paracetamol sometimes.I』d like to do some blood tests to determine whether there is any underlying cause for your rash, due to what we call urticaria which, unfortunately, may go on for some time before it gets better. We may not find the cause for it, but it can be treated quite successfully with regular antihistamine. I』ll give you a note to take to your doctor, so that he can prescribe a daily dose of 10 mg of Zyrtec.urticaria 蕁麻疹Zyrtec仙特明(含cetirizine dihydrochloride)<抗過敏葯>paracetamol 撲熱息痛 104 ERYSIPELAS ErysipelasWhat』s the problem?I have a painful area on the side of my face and it』s gradually becoming more and more swollen.When did it start?It started yesterday.How are you feeling generally.I feel very shivery and generally under the weather./ I have shivers and I don』t feel well.I see that the whole right-hand side of your face is swollen and red and it is difficult for you to see out of your right eye, and your have a temperature. I think the problem is erysipelas. You have to be admitted to the hospital, to be treated with intravenous antibiotics. It should settle quite quickly and you should be able to go home in four or five days.Erysipelas [醫]丹毒 105 SCABIESScabiesI』ve got an itchy rash which is driving me absolute wild.How long has it been there?I』ve had it for three weeks and my wife and daughter』ve started to develop an itchy rash as well.Have you had any treatment for it yet?My doctor gave me Eurax, but it doesn』t seem to be helping.Which parts are mostly affected?I』ve got it between my fingers and all over my body but the itch is from head to toe.Can you please show me the parts that are affected? Just take things off behind the screen. You certainly seem to have evidence of scabies. There are burrows , and I』ll try to extract one of the mites from the burrow. I』ll arrange for your doctor to prescribe you some Quellada. This will have to be used by all the family. You must be treated from the neck down and it must be applied to all the skin creases. You have to change all your clothing, and bedding and change all the towels and repeat the treatment one week later. It should settle, though.Quellada 六六六,六氯化苯,六氯環己烷[殺蟲藥]Eurax 優樂散(抗疥癬葯)106 GOOD AND BAD NEWSGood and bad newsMrs Smith, two weeks ago you had black mole removed from your leg. We now have the result of histology available and I』m pleased to tell you that it was completely benign and should therefore cause you no further problem. There is not need for me to you again at the clinic.Mr Black, I』m now able to give you the result of the tests on the lump that we removed from you nose. It turned out to be a rodent ulcer. If it had been left, it would certainly have continued to grow, but would not have spread to involve other parts of the body. It appears to have been completely removed but we』ll need to follow you up at the clinic.Mr. Evans, We now have the result of the histology on the changing mole that we removed from you arm. Unfortunately, it is a type of mole that is now growing and is called a melanoma, this is a serious condition and there is a chance it would spread to involve other parts of the body. The best guide to the likelihood of it spreading is the thickness which in your case was one point five millimeter. This is very thin and there is therefore only a very small chance that it will spread. It will be necessary to perform another small operation just to ensure that it』s been completely removed. After that we』ll continue to see you regularly for at least five years. Although it』s serious condition it』s good that it was removed before it had grown any further. Do you have any questions that I can answer?107 REFERRALreferralHello John. How are you?Hello David. I』m fine, how about you?Fine thanks. I wanted to tell you about one of my patients I』d like you to see.Right, fire away.She has a mole on her right calf. She is thirty eight and says it』s been there for years.Doesn』t know how long?No, but she』s noticed that over the past few months it』s developed a crusty edge to it.Has it got any bigger?No, apparently not. When I had a good look at it I realized that it is just a speckled mole, which doesn』t look at all sinister. However, she is a bit worried it and really wants it removed or at least a biopsy. Is there any chance of you doing anything?Well, things are pretty busy at the moment but if you send her in I will have a look at it and try to reassure her. If she is the worrying kind I might be able to fit her in in a couple of months.That would be fine. Thanks a lot.Not at all. Keep in touch.Of course, thanks again. Goodbye.Bye. 108 GENITAL HERPES Genital and urine infectionGenital herpesI have a burning pain in my genital area, and it』s uncomfortable for me to pass water.How long have you had this?Two or three days.Have you noticed a genital discharge, Miss Johns?No.Do you mind if I examine you and take some swabs to see what infection you have. Could you please undress and sit up on the couch for me, I』m going to take a swab from the area which is painful. This may be a little uncomfortable. …I think that you may have a herpes infection, and you would benefit from getting some tablets to help this go away a little quicker. I think the best thing for you to take would be a tablet called acyclovir. Take one tablet that』s two hundred milligram five times daily for five days. You』ll find that you are still in some discomfort for the next two or three days but this will settle down, and there is nothing to worry about. I would also suggest that you take some painkiller such as paracetamol, two tablets every three hours for the pain, and you also find it helpful to take a salt water bath twice a day until this clears up completely. We』ll see you again at the clinic next week and by that time all your symptoms will have improved. Before you leave the clinic, I would be grateful if you would give me a specimen of urine as sometimes with a herpes infection you can have difficulty in passing urine. If in the next week you have any problem, you can, of course, contact the clinic and we』ll see you soon than arranged.109 VAGINAL INFECTIONS AND DISCHARGEVaginal infectionsDischargeTrichomonas vaginalis滴蟲性陰道炎,陰道毛滴蟲Flagyl 滅滴靈製劑的商品名slide載玻片,玻片,幻燈片I』ve noticed a green, smelly discharge from my vagina. It』s also painful when I pass water.How long have you had the discharge?Two weeks.Have you noticed an itching down below?No.Do you have a regular sexual partner?Yes, I have a partner who I have been with for six months.When was the last time you had sexual intercourse?The last time I had intercourse was a week ago.Does your partner have any of these symptoms?No, my partner』s been quite well with no problem. .I』d like to examine you and to do this I』ll need to ask you to undress and get up onto the couch. I』m going to take some routine swabs looking for infections such as gonorrhoea and Chlamydia. I』m going first to take some swabs from where you pass water and then I』ll insert a speculum and have a look at your cervix and the inside of you vagina. We』ll take some swabs both from your cervix and you vagina to look for signs of infection. I』ll then take a swab from the area around your back passage. .. I』ve had a look at one of your initial tests under the microscope and you』ve got an infection called Trichomonas vaginalis or TV which is the cause of your vaginal discharge. This is easily treated with a form of antibiotics called Flagyl metronidazole. You have to take one tablet 200 mg 3 times a day for one week. During that time it』s important that you avoid alcohol and sexual contact as this infection is sexually transmitted. It will be important for us to see and treat your regular sexual partner. You need to return to the clinic in about one to two weeks』 time so that we can check that this infection has cleared up, and also give you the results of your other tests.While you』re at the clinic you will be asked to speak to the departmental health advisor or contact tracer. He will give you some information about this infection, and I would recommend that you bring in your boyfriend for his check-up. Before you leave the clinic you』ll also be asked to provide a specimen of urine for testing and also take a routine blood test for syphilis. This is a routine blood test which is done and performed on everybody who attends the clinic.I leak from the penis. It』s hurting me to pass urine.How long has this been happening?A fortnight. /two weeks.Have you had a regular sexual partner?No.When did you last have sexual contact with a partner?Last week.Has your partner had any problems like this?They haven』t got/ don』t have / any symptoms.I need to take some swabs from the end of your penis. There may be a little uncomfortable. I』m going to send them off to be tested for infection such as gonorrhoea and Chlamydia which can be passed to you through sexual contact with somebody with the infection. Some of the slides that I』ll take from you today well be looked at in the clinic, and form these I』ll decide whether you require treatment or not… from the slide that I』ve just looked at, you seem to have an infection which you probably acquired through having sexual contact. I therefore think it』s necessary that we give you some antibiotic. I』m going to prescribe some oxytetracycline 250 mg taken four times a day for seven days. I would advise you not to take any alcohol while you are on these antibiotics, and to avoid taking the antibiotics with milk products as this can affect their absorption. We』ll see you again at the clinic in two weeks』 time by which time your symptoms should have settled. When you return to the clinic, we should have the results of the cultures that I have done today which should be back by then and they will hopefully indicate what infection you have.I』ll also get you to speak to one of the contact tracers who will give you some information about sexually transmitted infection and how you can prevent from them. Before you leave the clinic, could you please give me a specimen of urine so that I can test it for any signs of infection. I will also need to take a blood sample from you which will be tested for syphilis which is a routine blood teat we do no everybody that attends the clinic.Thank you.110 GENITAL WARTS Genital wartsI』ve noticed these lumps down below, a friend said they might be warts.How long have you had the warts?I first noticed them six months ago.Are they itchy?Yes, especially at night.Have you noticed any vaginal discharge?No, doctor, I haven』t.I』d like to examine you, and I would be grateful if you could possibly undress and sit up on the couch for me. I』m going to do some routine tests to make sure that you don』t have any other infection along with the warts. These will look for the infections such as gonorrhoea and Chlamydia and vaginal infections such as TV or candida etc. Once I』ve seen the warts I』ll decide how they are best treated. I also think it』s very important that your partner also attends to make sure that he doesn』t also have genital warts… Warts can be treated by freezing them with liquid nitrogen. but I think the best way to treat your warts would be to put some podophyllum paint on them. You will be required to wash the paint off after six hours because if you leave this on for longer this may cause some discomfort. I』ll ask you to go and speak to one of health advisers, who』ll give you some information on genital warts and how you』ve acquired them. You』ll need to return to the clinic in two weeks』 time for further treatment, and by that time the results of the tests that I have done will also be back. Would you like to ask me any questions before I ask you to see the health adviser?Doctor, I wonder how I got the warts.You』ve been exposed to the genital warts virus through sexual contact with somebody who either has genital warts or the virus in his skin and the genital area. Unfortunately, I cannot tell you how long you』ve had the virus in your skin or who you could caught it from. As it does not have to be your present partner but could』ve been from a partner several years ago. Don』t be disheartened. The warts will disappeared with treatment, but unfortunately, I can』t give you any guarantee that they will not return. Warts are a very common problem and I don』t think there is any thing to worry about. While you have the warts, I would suggest that you use a barrier method of contraception during intercourse, such as a condom and don』t have genital contact without this. 111 HIVHIVI』ve just told you that you have got a Chlamydia infection, Chlamydia is a common sexually transmitted disease. We also know that sexually transmitted diseases tend to go together. For these reason I think you should consider either before you leave the clinic or at a future date having a blood test to check whether or not you』ve got antibodies to the IV virus. This does not tell us whether you have got AIDS, but it does tell us whether or not you are infected with the virus and as well as being a danger to your health, obviously, you』re also sexually infectious to other people, so you may think about having this blood test in order to protect future sexual partners. However, this test is not compulsory and it is only done with your cooperation after you』ve thought through the various arguments for and against having the test. If you do have the test it is a simple blood test and the result will be available for you if you come back to the clinic in one week』s time. This result is not given over the phone and you must attend in person. If you are unlucky enough to be HIV positive, we』ll give you all the support and information which is necessary to come to terms with this infection. 112 ADVICE TO A HOMOSEXUAL MANAdvice to a homosexual manI』ve just told you that you have gonorrhea which is an ST infection. Unfortunately, we also know that gay men are prone to other infection particularly viral hepatitis, hepatitis B and C and also HIV. I would advise you to have these tests. However, we』ll only perform them with your agreement and after we』ve discussed the implication fully. If you also turn out to be negative for hepatitis B, then for your future protection we can offer you a course of hepatitis B vaccination which will protect you from future infection form the virus. Particularly if you have booster injections every few years. Before you leave the clinic, you』ll also be interviewed by a health adviser who will instruct you in the techniques of safe sex, such as the use of condoms, so that you are less likely in the future to contract one of theses infections. 113 MOST COMMON COMPLAINTSOphthalmologyMost common complaintsI feel my vision』s deteriorated. I don』t see clearly any more.I』m not seeing as well as I used to. Everything is blurred. Things aren』t sharp any more.I』ve noticed my eye gradually becoming a bit red and painful recently.My vision has become blurred. Things seem cloudy and misty.I have real difficulty driving because of the glare from headlights or even from the sun reflected on the road.Sometimes I get black specks floating in front of my eyes.My eyes are watery and my eyelids stick together in the morning.I』m worried about my eyes. I sometimes see flashing lights.I seem to have a problem with my eyesight. It』s as if a gray curtain is being pulled across my face.I』m having severe pain in one eye and when I look at a light there seems to be a strange rainbow halo round it.Doctor, I see two of everything.I keep getting a sharp pain in my eye.My eye feels dry and gritty.I』ve noticed that my eyeball is more prominent.114 REFRACTIVE ERRORS Refractive errorsThe reason your vision is blurred is because you are long-sighted / far-sighted/ - this is called hyperopia in medical terms. This is not a pathological condition but a variant of normal. You have been born with a shorter than average length eyeball and we can overcome this problem by prescribing glasses for distance-outside specs (= spectacles ) – and for reading.Will my vision become worse with time?In the absence of any other problems the glasses should correct the blurred vision completely and the vision should not deteriorate over time.How do the glasses work?Normally a person with long-sightedness can compensate for the small eye by increasing the refractive power of their own lens inside the eye which has the effect of focusing the light rays on the retina, the seeing layer of the eye and obtaining a sharp focus of the object they are looking at.This means that you are short-sighted / near-sighted/. You have a problem focusing on distant objects. You have to be closer to an object to see it well. This is because the average length of your eyeball is longer than normal. This means the image is formed before your retina. To form the image on the retina you need to wear corrective glasses. There may be retinal complication with ageing.In your condition you may see blurred objects become of a problem in your cornea. This means that the curve on your corneal surface is not the same everywhere. This can distort images that you see. That』s why you need to wear glasses.As you get older, usually after about forty, the ability of the lens to change its shape, which we call the power of accommodation decreases, and the person first of all has difficulty reading. Later the distance vision is also affected. 115 EYE TESTS Eye tests1,I will cover your left eye now. look at the chart on the wall. Just start reading the chart from the top down to the bottom. That』s fine. Would you cover your right eye now and just read the letters with your left eye.I』d just like you to take this pinhole in your right hand, cover over your left eye, hold the pinhole up to your right eye. Do you see the light through the pinhole.No.Just move the pinhole slightly over your head until you first see the light.Yes.Do you see a letter in the middle of the light?I can』t make a letter out.2,Put your chin on the rest here and your forehead up against the bar. Now that you are sitting comfortably, can you see my left ear? Always keep your eye fixed on my ear. Don』t take your eye off my ear. Look straight ahead. Now look up. Now look down.3,I just want to pop/put /some drops into your eyes that will open up the pupils so we can see into the back of the eye more sharply. The drops will just smart for a second or two and it takes ten minutes for the drops to work so if you just take a seat outside. I』ll call you back in ten minutes. The drops usually last about 4 or 5 hours or so, so don』t be worried. Your vision will be blurred for a while, and you won』t be able to read until the drops wear off. The pupil of the eye will be much bigger but it will be normal by the time you wake up tomorrow morning.4,We just have to check the pressure in the eye. We have a small device that touches the front of the eye. Don』t be worried. You won』t feel anything because I』ll put some anaesthetic drops in first. It』s important not to squeezes the eyes or to blink.5,I』m checking the right visual field. Cover over the left eye with your fingers. Sit facing me and look straight at my nose. I』m going to hold out my hand to the side and wiggle my fingers. Keep looking straight at my nose. Don』t take your eyes off my nose. Tell me when you can see my wiggling fingers.6,Can you see the number in the plate? If you can, tell me what number it is? (if so, can you tell me what it is?) 116 CHALAZION, HORDEOLUM / STY(E)chalazion, hordeolum/styEnvelopeI』ve notice a small lump on my eyelid which has become sore and red. I think it』s a sty (e ).Aha. Let me have a look … no, that isn』t a stye. A stye is always on the edge of the eyelid and it』s an infection at the root of an eyelash due to a chronically inflamed gland. This is further up the eyelid and it』s what is called a chalazion. It』s caused by the oil secretions which have been trapped. We』ll put on a patch to bring the chalazion to a head and then we』ll put on some local anaesthetic to freeze it and then make a small cut in the inside of the eyelid and scrape the contents out. We』ll also give you an eye patch to put on the affected eye. You』ll have to use some ointment before you put the patch on. 117 CORNEAL ABRASION Corneal abrasionYou have a scratch in the front of your eye. What has happened is that the epithelium of the cornea, which is 「the skin in front of the eye 」 has been injured so it just feels as though there is something in your eye. When the local anaesthetic wears off, there will still be a feeling that there is something in your eye. But don』t worried there is nothing in there now, it is only the scratch you can feel. It』ll take about 24 hours till the feeling disappears. I want you to wear this patch on your eye and I want you to keep it on for 24 hours. Then you can take the patch off….. I want you to put more ointment on and put the bandage back for another 24 hours. Once you have taken the patch off, then use the ointment. It is chloromycin. Use it three times a day for about three days and if your eye doesn』t go completely back to normal, come back and see us. 118 IRITIS IritisWe are not sure what exactly causes iritis? It could be cause by one of the several things, so we need to send you for a few tests to see if we can get to the root of the problem. There are two types of drops I want to give you. One of these is a steroid drop, steroids just tend to suppress inflammation and make the eye less red and irritable. This doesn』t cure the underlying problem. The other drop is the dilate drop, these are just going to make your eyes feel more comfortable and it will dilate pupil and help to heal the eye. You must keep up with the drops since it will take several weeks to heal the condition. Don』t be worried if you see that your pupil is big, particularly if your version is blurred for reading; that is known side effect of the drops so don』t be worried if you get that …. Although we』ve cured your iritis, it still can recur and may even come back in the other eye. 119 CATARACT CataractI am having a problem with my eyes. My vision』s been very poor lately. It』s very blurred, and I』ve got to have a bright light to read anything these days.With the vision that you』ve got, are you able to do very things, or is it holding you back? Is your vision interfering with your lifestyle?I』m not sure, doctor.I see. Are you still having trouble with your diabetes?Yes, but we』re gradually getting it under control.I see. Then let』s do an examination on your eyes…. The problem is that you have a cataract. It』s an opacity of the lens of the eye. It』s often associated with diabetes or with getting older. You have nothing to lose in waiting for the operation. But I wouldn』t put off the decision if I were you because the sooner you have your operation done, the sooner you』ll be able to get back your normal sight. You do have an early degree of cataract. Cataract is very common. Almost every one over the age of 50 or 60 has it and it』s almost normal to have some degree of cataract then. It』s just the amount of cataract. If the cataract interferes with your ability to enjoy your life, then we would consider operating.This is the procedure of cataract surgery.We will need to do an artificial intraocular lens implantation. Before the operation, we will measure your eye to decide on the lens that you need. This is the very latest technique and we have had some excellent results for it. What we』ll do is to give you a local anesthetic and something to help you relax, so you』ll be awake during the operation. But you won』t be able to see or feel anything. Then we make a small cut on the surface of your eye and remove the grey lens. If all goes well, we put in the lens implant. After the operation you can carry on with life as usual except for strenuous activities. You』ll have to use eye drops as well and come back to let us check on how the eye is healing. 6 weeks after the operation, we』ll prescribe some glasses for you. I can』t guarantee putting a lens implant in, but nine times out of ten we have no problems getting a lens implant in. And if we didn』t put the lens implant in, there』s still something else we can do. We can either put a contact lens on or we can give you a plus 10 (+ 10) dioptre lens to correct your vision or consider putting a lens of plant in the eye at a later date. 120 GLAUCOMAGlaucomaGlaucoma is a dangerous condition because it doesn』t give you any symptoms in time. There』s no pain, no redness. But if the pressure in the eye is uncontrolled it well continue to damage the nerve at the back of the eye and reduce the width of your version. That is why you must carry on with/keep using/ these drops. You must come back to the hospital on a regular basis just to have the pressure checked. Even if the pressure is high, you』ll have no symptoms. One of the ways of the monitoring the condition is to come to out-patient regularly. Here we』ll check the eye pressure, visual acuity, optic nerve head and do a perimetry examination. It』s important to use the drops. With glaucoma there』s no way we can get back the vision that』s been lost. It』s a matter of retaining what vision is left.I can see that your eyes are sore and red and your vision is blurred. This is because you are having a glaucoma attack at the moment. The pressure is very high inside your eye. We really have to admit you to hospital to get the pressure down. Hopefully we』ll be able to do this with drops and some tablets. You are almost certain to require a laser operation to get the pressure under control afterwards. It』s not beyond the bounds of possibility that you』ll need an operation rather than a laser treatment on the other eye as well just to prevent the same thing from happening again. It』s because of an underlying tendency for the other eye to be at risk and because both eyes tend to be the same. That is the reason it needs treatment.121 RETINAL DETACHMENTRetinal detachmentI describe it like an old football, you see. The eyeball is like an old leather football. The leather is the back of the eye and the retina is the bladder of the football. Normally the bladder is hard up/directly/ against the football, the retina is held closely to the back of the eye together. There is normally fluid inside the bladder and what happens in a retinal detachment is that you have a small tear in the bladder and the fluid comes out from the middle of the football through the tear and then floats the bladder, the retina tears away from the back of the eye, the football. And what we have to do in the operation is to find the tear, seal it with a freezing technique to create a scar around it and then as the fluid is absorbed, the retina will become flat up against the eye again. There are two aspects of vision, central vision and the width of your /peripheral/ vision. Central vision is the vision you use 99 percent of the time, but it only accounts for 1 percent of the eye. And when this area becomes detached or damaged, then even though it』s replaced right way it sometimes doesn』t work as well. So the chances are your reading and writing vision won』t be as good as it』s been, even if the operation is totally successful. 122 MACULAR DEGENERATIONMacular degenerationI』m having problems with my eyes. My vision seems to be getting blurred. This is causing problems with my reading. It』s strange because I can see quite well at the sides but not when I look straight at something, there seems to be a blurred patch in the middle.You』ve got some changes at the back of the eye due to aging and we』ll need to decide whether it』s treatable or not. There is no chance of going blind with this. The aging change of the macula affects central vision, that』s your reading and writing vision, but you still have peripheral vision, this is your navigating vision. You』ll never ever loss this with macular degeneration, so you』ll never ever go blind. You』ll be able to live a reasonably normal life.macular degeneration 黃斑變性never ever 從不, 永不123 RETROBULBAR NEURITIS Retrobulbar neuritisThe nerve at the back of the eye relays information back to the brain and that is why you see things. What』s happened is you』ve had an inflammation of the never at the back of the eye. This normally gets better on its own so there is no really active treatment we can give you to improve it. The retina recovers and in the great majority of people the vision comes back to normal or almost completely to normal. There is a chance of the problem recurring and I』d be happy to see you any time if this should happen. Are there any other questions you want to ask me?Not really, doctor.Do you have any dizziness or tingling or weakness or unsteadiness?Why are you asking me these types of questions?Because this types inflammation can affect nerves all over the body not just in the eye.Do you think I』ve got multiple sclerosis, doctor?Well, there is an association with multiple sclerosis so there is a possibility that this may happen again and may turn out to be multiple sclerosis. However there are other causes and it may well be a simple post-viral type of thing. Other causes for this problem are nicotine and alcohol. But you are right, we couldn』t say for sure that this wouldn』t happen again. 124 EYE INJURIES Eye injuriesI』ve got something in my eye, doctor.I』ve been poked in the eye.My son scratched my eye.I splashed some acid in my eye.I had something sprayed in my eye.I』ve got a flash burn.I was hammering some sheet metal, I think a small piece of metal shot into my eye.I was grinding an engine block and a sliver of metal flew into my eye.I was frying some eggs and some hot fat spattered into my eye.125 DIPLOPIA, STRABISMUSDiplopia, strabismusI see two of everything, doctor.Now I』d like you to look in a number of the direction. Follow my finger with your eyes, look up, look down, look left, look right. Do you see one blurred image, or do you see two separate images?Two.Are you sure about that?Yes, I still see two images when I look to the left.Cover one eye, do you still see two, or do you see one?Just one.Cover the other. Do you see two images now?Yes.Doctor, I』m worried about Susans』 eye. She』s got a bad squint.Right, let me have a look at it…. Yes, she』s got a definite squint in the left eye. There are two things here__ the cosmetic appearance and the risk of amblyopia. The difficult with a squint is that for the vision to develop normally both eyes must see a sharp image and they must both be pointing in the right direction. If one eye isn』t seeing sharply, or if it is not pointing in the right direction and then the brain tends to ignore the image from that eye. If that is case then the connections never develop in the brain and that eye then becomes what we call a lazy eye. This is the reason why we have to keep the patch on the good eye. Little Susan will want to keep taking it off, but we must make sure she keeps it on to make the lazy eye work and build up those connection to the brain, If your vision is as good as you』re going to get, it』s purely a matter of cosmetic appearance, How is Susan getting on/along/ at the school? Does she get teased or bullied?Yes, she』s sometimes very unhappy when she comes home.That』s a pity. However, it』s only a small angle of a squint and the risk of surgery really outweigh and potential benefits. Squint surgery is much more of an art than a science and we can』t guarantee getting the eyes absolutely straight although we always try our best. So if the angles are very small, I would advise you not to have the operation because we couldn』t guarantee that we』re going to make the appearance that much better.126 TUMOUR OF THE EYE, BLIND REGISTRATION tumour of the eye, blind registrationYou have a tumour of orbit and we need to check upon exactly what it is so we will perform a biopsy. I suspect it to be a cancer. The only way of making sure of this to actually send it to the histology department. There they will look at it under a microscope to determine the diagnosis…There』s a small tumour on the eyelid which is actually a basaloma, but that』s not all bad news because we』ll be able to remoe that for you and there』s a 95% chance that it won』t grow back again. We will remove the whole tumour so don』t worry.Although you』ve got a melanoma in you eye, it』s still in an early stage so we』ll treat it with laser therapy. It』s not affecting the eye at the moment and hopefully we』ll be able to treat it without affecting the eyesight. Laser therapy is very effective and it is highly unlikely that there will ve any recurrence of the cancer.I』m sorry to have to tell you that you do have an eye tumour and we』ll have to do something about it. I』m afraid that It』s melanoma of the eye. It』s in an advanced stage so it is very likely that we will have to remove the eye itself. I know that sounds very drastic but eye tumours behave differently from other tumours in the body so there』s a high chance that once we take the eye out that will be the end of the rumour and the cancer will be removed totally. So although you』ll have lost your eye you』ll have a normal life span and it won』t affect your general health.After the operation you will receive information regarding blind registration.Although you are technically qualified for blind registration, this does not actually mean that you are totally blind, it』s just a measurement of your poor vision and your vision is poor enough to actually qualify for blind registration. 127 TYPICAL SYMPTOMSTypical symptomsAI have a bad headache.I have a throbbing headache.I feel dead tired.I have poor balance.My memory is going.I have a terrible memory.I have a difficulty concentrating.I have a double vision.I have a difficulty focusing.My vision seems blurred.I have zig-zag lines in front of my eyes.My eyes hurt in bright light.I have difficulty speaking.I cannot get the words out clearly.I have difficulty swallowing.Food seems to stick in my throat.BMy neck feels stiff.My neck clicks.My back』s gone (in spasm).My hands are shaky.I have no strength in my fingers.I can』t pick up a cup any more.My co-ordination is poor, especially is my arms.My arms feel weak.I feel pins and needles in my hands.My leg drags.I tend to catch my foot when I walk.My foot is numb.My foot has dropped.My leg feels stiff.Both my legs feel stiff.I can』t feel my feet.My toes feel numb.CI have difficulty passing water.I find it difficult going to the toilet.I find I go to the toilet very frequently.I have sudden blackouts.I loss consciousness without warning.Someone said that I had a convulsion.Someone said that I had a fit.Someone said that I had a seizure.My arm twitches for no reason.My hand jerks without warning.I seem to go vacant /blank/ for a short period of time.My muscles feel stiff.My muscles are sore.My muscles are painful.I』m losing weight.My muscles are getting thin.I』m aching all over.My face has gone lop-sided. / I can』t move one side of my face.My face has twisted to one side. /half of my face is paralyzed.My face seems to have got weak on one side.My mouth is drooping.DI was sitting watching TV when my arms suddenly became numb and heavy. My wife said that my face twisted to one side. It came very suddenly just out of the blue. I thought I was having a stroke. It seemed to get better by itself after about half an hour.EI』ve got a problem with my back., I was lifting a heavy box and I felt something give in my back. It was suddenly sharp pain, like lightening going down the back of my leg. The pain went down all the way to my heal. It was like a flash just for a moment. Since then, I』ve had a lot of pain low down in the back.blackout 一過性視覺喪失 drag （雙下肢）行動緩慢費力128 NAMES OF INSTRUMENTS USED IN NEUROLOGICAL EXAMINATIONName of instrumentVisual acuity chart --- used in testing visual acuityOphthalmoscope -- to look into the back of the eye.Auriscope – to look into ears.Tongue depressor--- to examine the tongue and the back of the mouth.Orange stick --- (don』t know what it is)Wisp of cotton wool --- to examine with a light toughSterile neurological pin --- to test skin sensationTuning fork.---- to test vibration senseTendon hammer --- to elicit deep tendon reflexes.Patellar hammer --- to test palatal sensation129 ASSESSMENT OF HIGHER MENTAL FUNCTIONSAssessment of higher mental functionCan you tell me your name and address? I』m going to ask you some simple questions to assess how good your concentration is. Can you tell me what day of the week it is today? What month are we in? What year is it? Approximately what time of day is it at that moment? Can you tell me anything that is going on in the news at present? What is name the Prime Minister? I』m going to give you an imaginary name and address. I want you to remember the name of address, and after 5 minutes I』ll ask you to repeat the name of address to me. Now I』d like to assess how clear you speech is. Say some words for me. Start by saying the days of the work starting with Monday. Now I』m going to ask you to say some more difficult things. Say after me 「baby hippopotamus」, 「British constitution」. Now, I』m going to examine your understanding of the words that I say to you. Lift your right hand in the air. Touch your right ear with the little finger of your left hand. Now I』d like to see how you walk. I want you to stand up and walk to the other side of the room, then turn around and come back to me. 130 EXAMINATION OF THE CRANIAL NERVES Examination of the cranial nerves1, Cover one nostril and smell this substance, tell me what it smells like.2, I』d like to check your version, read the chart in front of you, please. Starting from about here.3, I』m going to assess what you can see out of the corner of your eye, look at the middle of my face and point at my finger when I wiggle it.4, Now I』m going to shine a light in your eye to look at the reaction of the pupil. Keep looking straight ahead. Keep looking straight ahead while I shine a light in the back of your eye to examine the retina. Try and keep looking forward at the wall behind me. try and ignore the light.5, Now I』m going to assess the movements of your eyes. Hold your head still and follow my finger just by move your eyes.1. Now I』m going to assess the feeling on your face. I』m going touch the skin on your face very lightly with some cotton wool. Say 「yes」 when I touch your face and keep your eyes closed.2. Now I want to examine the strength in the muscles of your face. Screw /close/ your eyes up very tightly, don』t let me open them. Now purse/close/ your lips together very tightly, stop me from opening them. blow your cheeks out like this.3. Now I』m going to test your hearing. Tell me if you can hear what I』m whispering into each ear in turn. Twenty nine, forty five.4. Now I want to examine the muscles of the back of your mouth. Open your mouth wide and say oh.5. I』m going to test the feeling at the back of your mouth, tell me if you feel a gentle touch of a wooden stick.6. Now, open your mouth wide again and stick your tongue out, wiggle your tongue quickly from side to side.7. Finally, shrug your shoulders against me and turn your head to one side and then turn it to the other side so that I can see the strength of the muscle in you neck. 131 EXAMINATION OF THE ARMS Examination of the armsNow we』re moving on to examine your arms and legs neurologically.Start by putting both arms out in the air in front of you and shut your eyes. Hold the arms still while I look at them. Now wiggle your fingers as though you were playing the piano. Now let me assess the co-ordination in your arms. Open your eyes, make a pointer by stretching out your index finger. Now touch my finger and then touch your nose. Go between my finger and your nose with your finger very quickly. Now try this on the other side.Now I』m going to assess the strength in the muscles of your arms.1. Stick your arms out on both sides and show me the strength of your shoulder muscles.2. Now pull the elbows down towards your sides.3. Now testing each arm in turn, make a fist and pull the fist up towards your shoulder while I try to stop you.4. Now straighten your arms out at the elbow while I try to stop you. Do that again on the other side.5. Now holding both arms in front of you, make two fists and cock the wrists backwards. stop me from moving the wrists. Now cock the wrists downwards while I try to stop you. Now do the same fingers.6. Stretch all your fingers out straight and stop me from bending your fingers.7. Now curl your fingers up tightly into my fingers and make a strong grip. Keep the fingers tightly curled up.8. Now squeeze my fingers as tightly as you can in both hands.9. Now spread your fingers wide apart while I test the small muscles in the hand, stop me from pushing the fingers together….. Ok, very good.Now I』m going to examine the sensation on your skin, keep your eyes closed throughout the examination.1. I』m going to touch the skin of your arms in various different places just using a light touch with cotton wool. Say 「yes」 every time I touch the skin.2. Now I』m going to test the same feeling, but using a prick of a pin instead of cotton wool. Say 『yes」 every time you feel the touch of the pin. Can you feel the pinprick? Does it feel the same on both sides?3. Now I』m going to assess whether you can feel vibration, I』ll start with your hand. Tell me if you can feel the vibration of the tuning fork.4. Finally, I』m going to assess whether you can feel your fingers being moved up and down. I』m going to hold your little finger and move it up and down slowly. Shut your eyes, and when you feel the fingers move up say 「up」 and when it』s down say 「down」.Now I』m going to test the reflexes in your arms. Relax you arms and I』ll tap the reflexes of the biceps and the triceps muscles, and also the supinator reflex.I』m going to test the reflexes in your legs, relax your legs while I tap the reflexes in the knees and at the ankles.I』m going to scratch the bottom of your foot with a wooden stick. 132 EXAMINATION OF THE LEGS Examination of the legsI』d like to assess your walking. Let me see you walk round. Just slowly, walk 20 or 30 feet away from me, and turn around and walk back towards me.Relax your legs while I move them around slowly, now, let me see the strength in the muscles. Lift your legs up in the air and hold it straight, now, let me look at the other side. Now put the leg down flat onto the examination table, now the other side.Bend the knee and keep it bent, stop me from straightening it, now, kick the leg straight against me.Flex you foot up towards your face and stop me from pulling it down. Now push the foot away from you to push me away.Turn the foot so the sole of the foot is facing the other foot and keep it there.Now turn the sole of the foot outwards and keep it there. Stop me from strengthening the ankle.I』m going to touch you with a small piece of cotton wool on the leg, shut your eyes and say 「yes」 when you feel the touch of the cotton wool. I want to compare the two sides. Tell me if the touch feels the same on the left leg as it does on the right.Now, I』m going to test the sensation using a pinprick, tell me whether there』s a clear difference between the touch of the pin and the cotton wool.Can you feel the vibration of the tuning fork when I press it onto the bones in your ankle.I』m going to wiggle your big toe up and down, shut your eyes and say 「up」 when I move the toe up, 「down」 when I move the toe down. 133 HEADACHE HeadacheTell me about your headache.I get a headache that comes and goes.Tell me whereabouts the headache is.It seems to be on the right side of my head.How long does the headache last when you get it?It varies. it can be between half an hour and four or five hours.When you get the headache, does anything else happen at the same time?Yes, I get flashing lights that seem to be in the right eye.Anything else?Yes I feel sick, sometimes I actually vomit.What do you do when you get the headache?Well, I』m not able to carry on with what I』m doing, I have to go to a dark room and lie down.Have you found any medication that helps the headache?Sometimes if I take an aspirin early in the course of the headache the aspirin seems to help. At other times nothing seems to help.Does any body else in your family have this sort of a headache?Yes, my mother used to suffer from migraines, but that was when she was younger.Tell me about the pain, does it seem to be sharp or dull? Is it just constant ache or does it seem to be throbbing?It throbs.Tell me, how old are you?I』m 29.How long have you been having this headache?I have had them for several months, they seems to have been there for most of the past year.Can you describe the headache?They』re like a band all around my head, sometime they like a weight pressing down on the top of my head.Does the pain come and go?It never seems to go away completely, sometimes it is worse than at other time, but it』s there most of the time.When you get a headache, does anything else happen?Sometimes I feel slightly sick.Do you ever actually vomit?No, I just felt sick, I』ve never actually been sick.Do the headaches upset your eye?Sometimes I feel that my vision is a little blurry, but never anything more than that.What do you do about a headache when you get it?Well, I』ve tried to take pills and tablets, but nothing really seems to help.Is there any particular time of the day when you have a headache?Yes, it seems to be most troublesome towards the end of the day, but often it』s there throughout the whole day and builds up during the evening. 134 HEAD INJURYHead injuryI injured my head two weeks ago, I was in a car which was hit from behind and I banged my head on the windscreen. I was knocked out for a few seconds, and I was taken to hospital in an ambulance. They examined me and said everything was all right, but since then I』ve had headaches which are there all the time. I have difficulty concentrating. I find I can』t remember people』s names and the headache stop me from sleeping at night.I think we』ll do some tests and take an x-ray to check out what』s happened. … the tests have shown that your headache was due to a burst blood vessel inside the head. The scans show that there is a weak area on the wall of one of the blood vessels in your head called an aneurysm, and this weak area in the wall has burst. So to stop this happening again we need to do an operation. What we』ll do is identify the blood vessel with the weak area, and then we』ll place a very small metal clip around the aneurysm to stop it from bursting and bleeding again.135 EXPLAINING NEUROLOGICAL PROCEDURES explaining neurological procedures12.9.AI am going to arrange for you to have a special test of the electrical activity of the brain, which is called an EEG or electroencephalogram. We"ll ask you to lie down on the couch and then the technical staff will connect to you up to about 20 small electrodes which we stick to the surface of the head using special glue. We"ll then just ask you to relax and lie still while a special machine records the electrical activity of the brain. Sometimes during this test we"ll ask you to breathe very fast to see if that changes the electrical pattern that we record. We"ll also flash a bright light very quickly because this also can change the pattern of electrical activity that we see on the tracing that we get.12.9.BWe are going to do some small electrical tests to look at the efficiency with which the nerve are working.The first stage of this test is to measure the speed of conduction of impulses in the nerves. To do this we"ll connect you up to some electrodes and give you a very small electrical impulse. We can then measure the length of time it takes for the impulse to travel through the nerves, and the machine will record it on the screen. This feels like a tickle and is not unpleasant. As we increase the stimulus, you may feel a small electrical shock .It will make your thumb of your fingers jump. The second stage of the test is to measure the electric activity in the muscles themselves. This is called an EMG. We need to put a small needle under the skin into the muscles, and then I will ask you to move some of your muscles. This will then allow me to record the progress of the electrical activity in the muscles on the screen.12.9.CWe want to examine the fluid which circulates around the brain and spinal cord ,called cerebrospinal fluid, CSF. To do this we are going to do a lumbar puncture. I want you to lie on your left-hand side on the couch. Then I am going to clean the skin on the back with some antiseptic solution. You"ll then feel me giving you some anesthetic into the skin to make the surface of the skin go numb. Once the skin is numb, you will feel a little bit of pressure and pushing and pulling While I put a very fine needle through the skin between the bones of the back to let me take off some of the spinal fluid. I will measure the pressure in the fluid and then collect several samples of the fluid to send away for analysis in the lab. Once the needle is taken out I"ll put a small plaster over the site where I did the lumbar puncture. And then I"ll ask you to lie flat for about an hour after the lumbar puncture to reduce the risk of getting a headache.12.9.DWe are going to do a scan of the brain cord, CT scan or CAT scan. This is an easy test. You just need to lie on the special stretcher which moves and runs into the head scanner. It is a little bit like putting your head in a large washing machine. You lie still and you will hear the machine making noises while it takes some special cross- sectional X-rays to give us a picture of your brain.12.9.eWe are going to do a special scan of the brain called magnetic resonance imaging scan or MRI scan. You lie on a stretcher that slides into a long tunnel which is the scanner itself. You need to lie still for about 10 or 15 minutes while the machine builds up cross sectional pictures of the brain. This test is quite noisy and you will hear a lot of thumbing and banging noises while the machine works. You may feel claustrophobic. So we"ll give you a little rubber pump to hold. If you really need to come out, just press the pump. 136 ROUTINE CHECK-UP Routine check upHave you been having any problems?I have been getting toothache.Can you describe the pain for me, is it a sharp pain or is it a dull pain?It』s quite a dull pain and my face is swollen.Is the tooth sensitive to hot and cold?Yes, it hurts when I drink anything hot.Is the tooth tender when you bite on it?Yes, it』s.Does it hurt just during the day or at night as well?It hurts all the time.Your tooth is infected, and there might be an abscess under it. I』ll give you antibiotics to reduce the infection. If the swelling doesn』t go down, I』m afraid I』ll have to lance it or perhaps drain the root canal. I want you to return in a week, and I』ll put a gold post in the tooth before I crown it for you. Assuming the root canal treatment is successful. We usually leave the tooth to settle for three / six months before crowning.Can you describe the pain, does it hurt just during the day or at night as well?Is it sensitive to hot and cold?Has your face been swollen?Is the tooth tender when you bite on it?137 ROUTINE FILLING Routine fillingGood morning. Come in, sit yourself down. Now, I』m going to give you a small routine filling. First, I need to give you an injection. Before the injection I』m going to put some cream on your gum to make the injection less painful. I could use a spray but this time I』ll use cream. I』m going to put this scream on a small cotton wool roll/swab/, and put it next to your tooth. Now, just leave it for a few minutes and then when it starts to take effect, because it』s an upper tooth, I』m going to put the injection next to your tooth. If it were a lower tooth then I would put the injection in the black of your mouth and that would make the whole of your jaw numb. Now, I』ll put the injection next to your tooth here, and that will take about two minutes before it takes effect on the tooth. In the meantime, what I』ll do is I』ll scale and polish your tooth, and that means I』m going to take off the plaque that grows around the salivary glands. And polish them up.Ok now, The injection has worked. I』ve scaled and polished your teeth and I』m going to start doing the drilling now, I』m going to take out the old filling because it』s leaking on one side. For this, we you excuse me if we wear my protective glasses because this drill works very very quickly and debris can fly out of your mouth, and hit me in the eye. I』m also going to put on my protective face mask. Now, I』ll take out the old filling. First of all, I have to put the salivary suction/sucker/ ejector in your mouth to remove the saliva. When I』ve done that, I』ll be using a slower drill. This will vibrate quite a lot, but I need to do that to take out the decay which will be under the old filling. If the decay has gone quick deep into your tooth then I』ll use something we call an excavator. It』s a small spoon- like tool which will scrape out all the decay.Ok, I』ll start that right now. ok, now then we』ve moved the old filling, I』ve taken out the decay under the filling, now I』m going to putting in a lining, in this case it』s calcium hydroxide. The fact is this is an insulating layer which insulate the tooth from the filling so that the heat passing through the filling doesn』t reach the never. I』ve put that in, now I』m going to put a strip of steel, the matrix retainer, around the tooth, and then I』m going to put in the amalgam to fill in the tooth. amalgam is the normal sort of filling which we use. Ok. Off we go, ok, now the filling is all in place. I』d like you to very, very gently bite on the filling, then I can see if there』s any part that』s a little bit high. Ok, bite very gently please. Now, move your jaw from side to side. Right, open, thank you. Ok, the filling is a little bit high, so I』ll shave it off a little bit. Ok, bite together again, very gently…., ok, side to side, open, ok, yes, I think that is good, fine, how does it feel? Now, I』d like you to come back in a week time.There is another filling to do and I』d also like to polish the amalgam surface so that it does not attract food,---so the food doesn』t stick to it. Thank you very much. See the receptionist on the way out. I』m sorry, there is one more thing, try not to eat on the side where the filling is for the next two or three hours. By tomorrow morning, it』ll definitely be set solid, so you can eat. Just for two or three hours, eat on the other side preferably avoid eating together. Ok, thanks a lot, see you next week, bye- bye!138 BRIDGEWORK bridge workI think you need some bridgework. This is a replacement of a tooth by a fixed metal framework. It usually involves crowning your teeth on either side of the space with the false tooth being welded on to the metal substructure. The whole of the bridge is usually covered by a facing of porcelain. There are two kinds of bridgework you can have. First, fixed-fixed bridges. These have to be treated with great care. They must never be abused. They must never be used for biting anything too hard or too sticky. And you must make sure that you have cleaned them extremely well. Then there is adhesive bridge. These are basically held in place by boned wings. The wings of the bridge which fit round the adjacent teeth are etched and we use a bonding technique to bond the bridge. They are not as robust as the fixed-fixed bridge, but the great advantage of them is that they don』t require too much tooth destruction and in the right conditionsnthey can be extremely effective….. I』m going to take an impression. I』m going to fill this tray up with a pink paste, which I』ll pop/put/ into the tray and then I』ll put the tray over your teeth for a minute or two. Breathe through your nose normally; relax your cheeks, lips and tongue. 139 BLEEDING GUMS Bleeding gumsOk, now you tell me that you have bleeding gums. When you brush your teeth, your gums bleed. Now, surprisingly, this is caused by not enough brushing rather than too much. What』s happening is that there』s a natural build-up plaque and calculus on your teeth. Both of which are quite natural and normal but they have to be removed. That』s why we brush our teeth.Now, what』s happening is that you are not effectively moving plaque and calculus. The calculus, I will remove. I』m going to scale your teeth to get off the hard deposit the flossing and toothbrushing can』t remove. You have to get rid of the plaque yourself by brushing. And now I』m going to give you a demonstration of how to do this… ok, you are lucky because the infection is not severe. Some people have a very severe infection which we call Vincent』s angina and for that I have to give a drug which is called Flagyl, which is taken for a few days and it clears it up very quickly. Your condition is not as severe as that, and with good brushing, once I』ve removed the calculus, we can restore the gums to health. If you had a slightly more severe infection, I』d have to prescribe Corsodyl which is a very effective mouthwash. The only problem is that it tends to discolor that rest of the teeth. 140 ORTHODONTICS OrthodonticsOk do come in. so, you』re not very happy with the appearance of your teeth. You seem to think they』re sticking out a bit. Ok this is what we do when we have a problem like this. First of all, we』ll take some impressions of your teeth, that means make some plaster models of them. We』ll also take some x-rays and a couple of photographs and then we can study these carefully and eventually decide if you need any treatment. But we have to go through these initial planning stages. If we decide, or I should say, if you decide that you』d like to go ahead with some orthodontic treatment, straightening your teeth, then there are two types of braces or appliances that we can use. One is a fixed appliance, that』s an appliance which stays in all the time. Nowadays we actually stick this, almost glue it, to your teeth, and that locks onto your teeth. Then we put wires between the teeth which can move or rotate the teeth in the way that we want.The other type of appliance that we use is called the removable appliance, and this is one that you can take in and out for cleaning. One very important point you have to remember with any appliance is you』ve got to keep your teeth clean. If It』s a fixed appliance this is even more important, because you can』t take it out to clean it, so you have to very, very careful about brushing. Also the fixed appliance can rub against your cheeks or against your gums. In that case if that were to happen, I』ll give you some soft red wax which you can pack around the appliance, which sort of pads it and stops it from rubbing. Ok well, I think that』s all you need to know for now. let』s go ahead and take the impression….Now that you have had the brace fitted, you』re going to have to be extra careful about cleaning your teeth. Your oral hygiene will have to be very good. Maybe your teeth will feel rather tender for a few days. This means that the brace is doing its job, and the teeth are beginning to move. The soreness will go away after a couple of days. I』m going to give your some of this red wax. If your gums or cheeks get sore just put some wax on the appliance where it is rubbing and it will act like a plaster to protect your mouth. 141 Following extractionFollowing extractionOk, well, that』s the tooth out. (that tooth is out). Now what I』d like you to do is to bite on this cotton wool roll/swab/ for about ten to twenty minutes until the bleeding stops. I want you to bite as hard as you can and just wait in the waiting room, and I』ll see you in twenty minutes. Ok now let me check and see if the bleeding』s stopped. Yes. That looks nice and dry. If the bleeding starts again, and it might, it』s not unusual, I』d like you to take a clean handkerchief and bite hard on it until the bleeding stops. Don』t worry, that』s quite nature. Try to keep food away from the extraction area, eat on the other side and rinse your mouth out after eating. Now this was quite a big extraction, and we』ve had to put a stitch in as you know. I』m going to give you some mouth wash which will help to relieve pain, and it will help to reduce the inflammation and help the healing. It』s a bottom tooth, bottom teeth take much longer to heal up than a top tooth so be patient. If there』re any problems at all, any pain, any whiteness around the extraction site, please come back and see us, and we can do something about it.142 NEW DENTURES, ANGULAR CHEILITIS New dentures, angular cheilitisIt always takes time and practices to get used to new dentures, and in the early days you may get a sore mouth, if you do have any ulceration you』re advised to return to the practice / dentist』s office/.Clean your dentures using soap, warm water and a nail brush. Leave the dentures out at night because if you don』t, you』re likely to get denture sores, which are caused by Candida albicans.I』m not surprised you』re complaining about soreness at the corners of you mouth. I can see that they』re looking red and cracked. Now this is a condition which we call angular cheilitis, which is a technical term referring to a fungal infection which grows at the corners of the mouth. It is caused by ill-fitting dentures, so we have to consider re-making your dentures. Would you open your mouth a little bit to stop those little creases and folds appearing at the corners of the mouth. In the meantime, I』ll give you two things, I』m going to give you some lozenges which I want you to suck. They』ll release into your mouth some antifungal agent which will, hopefully, kill the fungal infection at the corners of your mouth. Also, I』m going to give some paint which I want you to paint on you dentures. This will slowly release the antifungal agent into your mouth which will eventually clear up the infection. I want you especially to take your dentures out at night. This will give a chance for the lips and the corners of your mouth to heal more quickly. When you take them out at night, make sure to put them in water. 143 MOST COMMONLY SEEN DISEASESMost commonly seen diseasesAlso known as tooth decay, it is the common cause of losing teeth, up to about the age of 55.This is a disease affecting the gums which is caused by a build-up of plaque and bacteria around the neck of the tooth which, if not removed by the patient, forms tartar or calculus.This is concentration of the mineral salts which irritates the gum causing an inflammatory response which results initially in gingivitis.This is a reddening and swelling of the gums with bleeding. If it is not treated then it will cause further irritation which results in the bone surrounding the tooth being lost, which eventually will cause mobility and the tooth will be shed.These usually require antibiotic therapy followed by scaling and root-planing if the tooth is to be saved.The cause is not known/ autoimmune disease/. The treatment is usually by prescription of the either mouth wash, benzydamine hydrochloride /Difflam/, or Triancinolone paste, which is an extremely strong steroid, extremely good for the treatment of this ulceration.Gingivitis dental caries abscess/ ulceration periodontal disease calculus acute bacterial infections
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