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History Taking

A 28-year-old woman presents with suprapubic pain and frequent urination that has worsened over the past two days. She reports her urine has a fishy smell. The doctor examines her urine which shows signs of an infection. He prescribes antibiotics and advises her to drink more water to help flush out her bladder. He assures her the infection is treatable and she should follow up if her symptoms do not

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102 views

History Taking

A 28-year-old woman presents with suprapubic pain and frequent urination that has worsened over the past two days. She reports her urine has a fishy smell. The doctor examines her urine which shows signs of an infection. He prescribes antibiotics and advises her to drink more water to help flush out her bladder. He assures her the infection is treatable and she should follow up if her symptoms do not

Uploaded by

olwethu.mpepanduku
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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“Ngichama njalo, umchamo uyashisha” A YOUNG WOMAN PRESENTS WITH URINARY

SYMPTOMS
Initiating the session
Doctor: Sawubona mama, sisi.
(Hello, sir)
Patient: Yebo, sawubona, dokotela.
(Hello doctor.)
Doctor: Igama lami ngingudokotela …….
(My name is Doctor ……)
Doctor: Ngubani igama lakho?
(What is your name?)
Patient: Igama lami ngingu………….
(My name is…………..)
Doctor: Ngubani isibongo sakho?
What is your surname?
Patient: Isibongo sami ngingu…………..
My surname is…………….
Doctor: Uneminyaka emingaki? (How old are you?)
How old are you?
Patient: Ngineminyaka engu – 28 dokotela.
I am 28 years old.
Doctor: Uhlalaphi? (Where do you live?)
Where do you live?
Patient: Ngihlala eMorningside. (I live in Morningside)

Establishing the presenting complaints


Doctor: Uphethwe yini sisi?
(What is wrong, sisi?)
Patient: Ngiphethwe yisinye.
(I have suprapubic pain.)

Gathering information
Biomedical perspective
Doctor: Uphethwe isinye? Qhubeka.
(You have suprapubic pain? Continue.)
Patient: Dokotela, isinye sami sibuhlungu kakhulu. Ngichama njalo.
(Doctor, my lower abdomen is very painful. I pass urine quite often.)
Doctor: Kuqale nini?
(When did it start?)
Patient: Kuqale ngaphambili kwayizolo, kodwa kuyaqhubeka.
(It started the day before yesterday, but it is getting worse)
Doctor: Umchamo ungcolile?
(Is your urine dirty?)
Patient: Yebo dokotela kubukeka kanjalo, kodwa angazi kahle.
(Yes doctor, it looks like that but I am not sure)
Doctor: Umchamo wakho unuka kabi?
(Is your urine smelling bad?)
Patient: Yebo unuka njengenhlanzi.
(Yes, it’s a fishy smell)
Doctor: Umchamo wakho unegazi?
(Are you passing urine with blood?)
Patient: Cha (No)
Doctor: Ngiyezwa, sisi. Umensa kahle?
(I understand, sisi. Are you getting your periods nicely?)
Patient: Yebo, dokotela, kahle kakhulu, kanye ngenyanga.
(Yes, doctor, very nicely, once a month.
Doctor: Kuhle. Sisi, umchamo wakho unjani? Uma uchama, kuyashisa yini?
(That’s good. Sisi, how is your urine? When you pass urine, does it burn?)
Patient: Eish, dokotela – kakhulu! Futhi, ngichama njalo, ngisho nasebusuku futhi
ngikhathele!
(Eish, doctor – so much! Also, I am passing urine often, even at night and I am tired!)
Doctor: Kulungile, sisi. Unesi uhlole umchamo wakho. Umchamo wakho ungcolile.
(Alright, sisi. The nurse tested your urine. You have an infection.)
Patient: Hawu, dokotela!.
(Oh no, doctor!)

Background information
Past medical history

Doctor: Kukhona izifo ezake zakuphatha ngaphambili?


(any previous illnesses?)
Patient: Chabo dokotela, ngiphile kahle ngiye ngiphathwe umkhuhlane nje kuphela.
(No doctor, I am a healthy person. I only get cold and flu sometimes).
Doctor: Wake walaliswa noma wahlinzwa esibhedlela?
(Have you ever been admitted to hospital or have you ever had surgery?)
Patient: Yebo dokotela ngake ngalaliswa ngesikhathi ngiyohlinzwa i appendix.
(Yes, doctor I was once admitted for appendicectomy).

Medication

Doctor: Uphuza maphi amaphilisi?


(Are you taking any pills?)
Patient: Ngiphuza ipanado engithenge ekhemisi namaphilisi okuhlela.
(I am taking contraceptive pills.)
Doctor: Ukhona umuthi noma umjovo ongezwani nawe?
(Are you allergic to any medication?)
Patient: Yebo. Ngesikhathi ngiyohlinzwa ngavele ngaqubuka umzimba wonke odokotela
bathi angizwani nepenicillini.
(I had a very bad skin rash at the time of operation. The doctors wrote in my charts
thereafter that I was allergic to penicillin.)
Family history
Doctor: Basaphila abazali bakho?
(Are your parents still alive?)
Patient: Ubaba washona ngineminyaka engu 10 engozini yemoto. Umama uphila kahle.
Nginobhuti omncane oyedwa. Uphila kahle.
(My father died when was 10 years old. He was involved in a car accident. My mum is alive
and healthy. I have 1 sibling, my younger brother, who is well.)
Social and personal history
Doctor: Ushadile? unazo nezingane?
(Are you married? Do you have children?)
Patient: Ngisanda kushada. Umyeni wami usebenza ka Unilever uhamba kakhulu
nomsebenzi. Sinobudlelwano obuhle. Anginabo abantwana kodwa ngifisa ukuba naye.
(I am recently married. My husband works for Unilever and travels a lot on work. I have a
good relationship with my husband. I have no children yet but would like to have a child
soon.)
Doctor: Uyasebenza? (Are you working?)
Patient: Yebo ngisebenza e ABSA bank ngiwuthanda kakhulu umsebenzi wami. Ngisebenza
amahora amade njalo.
(You work at Absa bank as a teller and enjoy your job very much. You work long hours on
most days.)
Doctor: Uhlala kuphi? (Where do you live?)
Patient: Ngihlala eMorningside. (I live in Morningside.)
Doctor: Injani indlu enihlala kuyo? (Type of housing)
Patient: Indlu enamakamelo amabili nogesi namanzi. Nginenja elala ekameleni lami.
(Small 2 bedroom flat with all facilities. You have a pet dog that sleeps in your bedroom.
Doctor: Uyabhema? (Are you moking?)
Patient: Cha dokotela angibhemi. (No doctor I am not smoking.)
Doctor: Uyaphuza utshwala? (Are you drinking alcohol?)
Patient: Cha dokotela angiphuzi. (No doctor I am not drinking alcohol)
Doctor: Udla kahle? (Are you eating well?)
Pateint: Ngidla kathathu ngosuku. Ngiyazama ukudla okunempilo namafruits and
vegetables. (I prepare 3 meals a day. I try to eat healthy food with lots of
fruits and vegetables.)
Doctor: Uyazivocavoca?(Do you exercise?)
Patient: Yebo ngihamba nomakhelwane ntambama kungisiza ngiphumule kahle.
(Yes. I walk with my neighbour every evening and find it a good way to relax and unwind.)

Patients perspectives

Doctor: Ucabanga ukuthi yini imbangela yalokhu kugula kwakho?


(what did you think might have caused your problem?:)
Patient: Angazi ukuthi kungani ngoba angikaze ngigule kanje ngaphambilini.
(I don’t know why I am ill because I have not had this problem before.)
Doctor: Ukhathazekile?
(what are you concerned about?)
Patient: Angazi kungani lokhu kwenzeka. Izinto azihambi kahle kulezizinsuku. Ngifuna
ukuphila kahle ngikwazi ukunakekela ikhaya nomndeni wami.
(I don’t know why this is happening. Things just seem to be going wrong these days. I just
want to keep fit and take care of my home and family.)
Doctor: Uthanda ukuba ngikwenzeleni?
( What are you hoping for?)
Patient: Ngiyathemba akukubi kakhulu futhi uzongipha amaphilisi azoqeda lenkinga.
(I hope nothing is seriously wrong with me and my symptoms can be resolved with some
antibiotics.)
Doctor: Uzizwa kanjani ngalokugula kwakho?
(How are you feeling about it all?)
Patient: Ngizizwa ngithukile futhi ngikhathazekile ngoba ngifuna umyeni wami angithole
ngiphilile ngasosonke isikhathi.
(I am feeling anxious and worried because I want to stay fit and healthy for my husband.)
Doctor: Lokhukugula kunamiphi imiphumela empilweni yakho?
(What effect is this having on your life?)
Patient: Ngizizwa ngicasukile ukuthi ngiyagula futhi nginamahloni emsebenzini ngiya endlini
encane njalo. Angikwazi ngisho nokulala kahle ebusuku.
(I feel upset at being ill and its embarrassing at work to keep walking to the bathroom so
often. Also not been able to sleep well at night.)
Preliminary explanation
Doctor: Ungakhathazeki, sisi ngizokusiza. Kufanele uthathe amaphilisi zonke izinsuku uzoba
ngcono.
(Don’t worry, sisi. I will help you. You must take pills every day. You will get better.)
Patient: Ngiyabonga, dokotela.
(Thank you, doctor)
Doctor: Futhi, ngicela uphuze amanzi amaningi azokusiza ukuthi ube ngcono. Ahlanza isinye.
(Also, please drink a lot of water. It helps you to get better - “to wash the bladder”)
Patient: Kulungile, dokotela.
(Alright, doctor.)

Closing the session


Doctor: Ngicela ulande amaphilisi ekhemisi. Abahlengikazi bazokutshengisa. Unawo
umbuzo?
(Go and collect your treatment from pharmacy. The nurses will show you. Do you have any
question?)

Patient: Cha dokotela ngizwe kahle.


(No doctor I heard you clearly)

Doctor: Ngicela ubuye uma unenkinga


(Please come back if there are any problems or if it doesn’t get better.)

Patient: Ngiyabonga dokotela, usale kahle


(Thank you doctor, goodbye)

Doctor: Ngiyabonga. Uhambe kahle


(Thank you. Goodbye)

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