ANAMNESIS

1. INTRODUCTION/ DATE:

Bun ziua, numele meu este --------, sunt student la UMF, Medicina generala, secia englez.

Imi pare raudar, vorbesc puin romn, nc nv. Colegul mea mvaajuta.

Pot sv pun ontrebare? Mulumesc.

Vrugmsvorbiirar / Please speak slowly!

2. PERSONAL DATA

Name:

Age:

Gender:

Occupation:

Marital:

1. Cumvnumii? /Cum techeam?

2. Ce vrsta avei / Cai ani ai?
3. Careesteoccupaia ta? Careesteslujba ta? / What is your job?
4. Sunteticasatorit?/Are you married?
5. Care estenumeledumnealui/ dumneaiei(lui/ei)? /What is his/her name?

3. CHIEF COMPLAINT

6. Care esteproblema?/Cevderanjeaz?(taPrincipala) /What is your problem? (main)

7.a)Cev-a fcutsvenii la doctor /What made you come to the doctor?

8. b) A fost o urgen? / Was it an emergency?

4. FAMILY HISTORY

8. Care estevrstasoiei/souluidumneavoastr?/ What is the age of your wife/ husband?

9. AveiCopii? Cti? Cevrst au? /Do you have children? How many? Age?

10. Copiiidomnevoastrasuntsntoi? / Are your children healthy?

11.a) Priniidomnevoastrtriesc? / Are your parents still alive?

11. b) Dac nu, la cevrst au decedat? / If not, at what age did they die?

12. Din cecauz au decedat? / What was the cause for the death?

13. Aveifraisausurori? Suntsntoi? / Do you have siblings? Are they healthy?

14.a) Existbolinfamiliadumneavoastrpe care le stii? / Is there any disease in the family?

15. b) de exemplu, diabet zaharat, hipertensiune i aa mai departe? /for example

5. PERSONAL HISTORY

If woman:

16. Cndaiavut prima/ultimamenstruaie?? / When did you have your first/last menstruation?

17. a) Aiavutprobleme cu ciclurilemenstruale? /Problems with menstruation cycle?

17. b) Este mailung de 28 de zilesaumaipuin? / Is it longer than 28 days or shorter?

Mult= more lung=long

18. Cumestemenstruaia? Groas? subire? Normal? /How is the menstruation? Thick? Thin?

19. AveiDureri in timpulmenstruaiei? / Do you have pain during menstruation?

20. Aveisngerriiregulare? / Do you have irregular bleedings?

21. Cndaiavutmenopauza?/ When did you have menoapause?

22. Medicamentehormonaleluai? / Do you take hormonal medications?

 23. Ct de multe sarcini ai avut? / De cte ori ai fost insarcinata? /How many pregnancies did
you have?

24. Aiavutvreodatavort, avortspontan? / Have you ever had an abortion /misscarriage?

25. Aiavutbolilecopilariei? Cumar fi: Pojar (Measles), Rubeol, Tuseconvulsiv (Whooping

cough) Varicel (Chicken pox), Scarlatin (Scarlet fever) iaamaideparte

26. Ai suferit de Tbc, Diabet Zaharat, Hipertensiune, Astm, Boli cu transmitere sexual, HIV,
hepatit, Atac de Cord, Epilepsie?

27. Aisuferitvreointerveniechirurgical? Cnd? De ce? / Have you had any surgeries? When?
Why?

28. Aisuferiivreunaccindent? / Have you suffered any accidents?

29. Cnd /Cum a fostdiagnosticat? / When /who was it diagnosed?

30. Cetratamentaiprimit? / What treatment did you get?

6. ALLERGIES

31. Avei alergii? mpotriva cror medicamente? Polen, animale?/ Do you have allergies? Against
any particular medications?

7. SOCIAL HISTORY

32. Undelocuii? Cu cine locuii?Este unapartamentesau o cs?

33. Existascriacolo? La ceetaj? / Is there any stairs? What floor?

34. Are cine svajuteacas/ Is there anyone who can help you at home?

35. Imiparerau, dartrebuiesintrebasta, Avei o relaiebun cu familiaacas? / I am sorry but I

must ask this, Is the relation to your family good at home?

36.Aveiproblemeacas? / Do you have problems at home?

37. Aveianimale de companie? / Do you have pets?

 38. Cine se ocupa de splat, gtit, Curenieiaamaideparte? /Who does the dishes, laundry,
cooking and so on?

39.Cu cevocupai?/Care esteocupaiadumneavoastr? / What is your occupation?

40. Ceailucratnainte? / What did you work with before?

41. V place slujba/ muncadumneavoastr? / Do you like your work?

42. Vaplacutslujbaanterioar? / Did you like your previous job?

43. Aifostomer? Faralucru? / Have you been unemployed? Without job?

44. Care suntsarciniledomnevoastra? / What are your tasks at job?

45. Este stresant? / Is it stressful?

 46. Sunteifericitcu slujba? De ce nu? / Are you happy with your job? Why not?

47. Slujbadumneavoastrestedificil? / Is the job though?

48. Cumestedietadumneavoastr? / How is your diet?

49. Cemancai de obicei? Multagrasime? / What do you usually eat? Much fat?

50. Mncai legume ifructe? / Do you eat vegetables and fruits?

51.Ctapabeipezi? / How much water do you drink per day?

52.Faceiexerciii? Cefel? / Do you exercise? What kind?

53. Care sunt hobby-urile tale? Pasiunile? / What are your hobbies/ passion?
 54. Cefacipentru a tedistra? / What do you do for fun?
Polite form: Cefaceipentru a vdistra?

7. CHRONIC INTOXICATIONS

55. Fumai? Aifumatvreodat? Cttimp? / Do you smoke? Did you ever smoke? How long?

56. Cianiaveaicandainceputsauterminat? / When did you start and end smoking?

57. Cteigaripezi? / How many cigarettes per day? ( Obs! Dont forget pack years!)

58. Cndairenunat? / When did you quit?

59. Fumeazcineva din familiadumneavoastr? / Does anyone in your family smoke?

60. Crezicaesti un fumtorpasiv?/Do you think you are a passive smoker?

 61.Aibutvreodatalcoolsaubeialcool? Ct de mult? / Did you / Do you ever drink alcohol? How
much?

62. Ctepaharepezi (de vin) / How many glassed per day (of wine) 21 units = male; 14 units =
female

63. Numai in week-end? Sauzilnic/ Only on weekends or daily?

64. Cefel de butur? / What kind of drink?

65. Singur? Sau cu prietenii? / Alone? Or with friends?

8. DRUG HISTORY

66. Cemedicamenteluai? / What medications are you on?

67. De cteoripezi? / How many times per day?

 68. Luaipicturipentruochii, inhalatoare, pastile de dormit, anticonceptionale, vitamine?

9. PRESENT ILLNESS (HISTORY OF PRESENTING COMPLAINT)

69 .Cnd au nceputdurerile cu .. / When did the pain start concerning ..

70. La ceor? Iiaminteti? Pecedat? / What time did it start? Do you remember?
Polite form: Vamintii?

71. Durereaanceputprogresivsaubrusc? / Did the pain start slowly or rapid?

72. Unde au nceputdurerile? / Where did the pain start?

73. Undesuntlocalizate? Artai-mi cu mna / Where is localized? Show me with your hand

74. Cumestedurerea? De launu la zece? Discomfort moderat, durereascuit, pulsatil, constrictiv

/ How is the pain? From 1-10?

75. De ceaicutatajutoracum? / Why did you come for help now?

76. A fost /este o durereconstantsaudoarperioade? / Was /Is the pain constant or in periods?
 77. Cat timpdureaz? / How long does it last?

78. Etimai bine acumdectnainte? / Is it better now than before?

Polite form: Suntei

79. Ce o face mairau? Bine?Aezat? / What makes it worse? Better?Ex. Sitting

80. Cecrezica a fost? / What did you think it was?

Polite form: Cecredeica

10 . SYSTEM INQUIRY

81. Cemaifacei? / How are you doing?

82. Avei un apetit bun?/ Do you have a good apetite?

83. Aipierdutsaucastigatngreutate? / Did you lose or gain weight?

84. Vsimtiienergic? / Do you feel energetic?

 85. Cumdormii? Bun saurau/ How is your sleep? Good or bad?

86.Aveisauaiavuttemperatur (febr)? / Did you have or do you have fever?

11. PHYSICAL EXAMINATION

Stand at patients right side!

Inspection, Palpation, Percussion, Auscultation (Sometimes combining)
1. Diagnosis at first sight:

2. General survey (Wash hands!):

General state of health:

Bed side clues:

Level of consciousness (state and content)(Glasgow Coma Scale):

Height, Weight and Build (Normosthenic/ Hyposthenic or Asthenic / Hypersthenic/

Athletic (Look at fat distribution):
Ceinaltimeaveti, domnule? (nmetri) / How tall are you, sir? (in meters)

Care estegreutateadomnevoastra? (in kilograme)

BMI (18,5- 24,9; 25-29,9; 30- 39,9; 40):

 Waist circumference (>97 cm / >80 cm):

Clothing, grooming and personal hygiene:

Signs of distress/ Facial expressions (anxiety, fear, anger or gried):

Odors of the body and breath (Halitosis) (fetor hepaticus - mousy/ DKA- acetone/
Necrotic suppuration Rotten/Fetid/ Fishy in case of bacterial vaginosis/ Urine-
Ammonia (worst one is gastrocolic fistula!)

Posture, Gait and Motor activity:

Stance (Rombergs sign): Ne-amdorisvexaminm, este bine?Stai in picioare,
cu picioareleapropiate. Si inchideiochiii/We would like to examine you, is it ok?
Stand up with your feet close together! And close your eyes.

Facetica mine/ Do as I do

Vrugm, mergeide aiciacoloiapoinapoi/Can you please walk, from here to

there and back, thank you

Vrugm, mergeipevrfuldegetelor/ Please walk on your toes

Vrugam, mergetipeclcie / Please walk on your heels

3. Examination of skin, hair nails

- 1. SKIN
AveiBoli de piele? Erupie? / Do you have skin diseases? Etc.
Cndsantmplatasta? / When did this happen?
- Color:

- Lesions (Colour, shape, size, surface, edge and nature of surrounding skin)
- Moisture-hydradtion (Skin turgor)

- Temperature:

- Texture:

Lumps or swelling:

- 2. HAIR
Cand v-aipierdutprul? / When did you lose hair?

- Inspection and Palpation of Hair diffuse, patchy or total (Male escutcheon)

- 3. NAILS
12. SUMMARY OF PATIENT

1. Personal Data

Name:
Age:
Gender:
Occupation:
Marital status:

2. Chief complaint

3.Family History

4. Personal History / Past medical history

5. Allergies
6. Social history

7. Chronic intoxication

Smoking:

Alcohol:

8. Drug history
9. Present illness
10. Physical examination