LEVEL III

Conditional
Tenses
1.The Present Conditional tense

Statements Questions

I go I go ?
We * should wait *Should wait?
(not) We

He play He play?
They would work Would They work?

*Note: Some people use would in place of should, particularly in speech and when the use of
should might suggest an obligation which the speaker does not intend.

The Present Conditional tense is used:

a. In place of the Simple Future tense when the main verb is in
a past tense, as in reported speech:
She said they would arrive at eight o'clock. I knew I would not find him in time.

b. To express an unlikely or improbable event, particularly with an 'if' clause which

contains a verb in the Simple Past tense. Notice the difference between these two
sentences:

possible: If it breaks, Mary will buy another one.

unlikely: If it broke, Mary would buy another one.
It is most important that you understand and remember the sequence of tenses in these two
sentences
Exercise I
The sentences in this exercise are based on the examples in ( b) above. Put the verb with if in
the Simple Present or Simple Past tense. Put the main verb in the Simple Future or Present
Conditional tense. The word in italics tells you which type of sentence to construct.
Rewrite the following sentences in the space given below.

1
 I. (possible) If we . . . (develop) the country's resources fully, we . . . (raise) our
standard of living considerably.
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-
2. (unlikely) If we . . . (fail) to develop the country's resources properly, we ....
(cause) a great deal of hardship.
-------------------------------------------------------------------------------------------------------.
3. (unlikely) If he . . . (drink) too much, he . . . probably (have) an accident.
-------------------------------------------------------------------------------------------------------
-
4. (possible) If he . . (drive) carefully, he . . . (not have) an accident.
-------------------------------------------------------------------------------------------------------
-
5. (possible) If that branch . . . (fall) down, it .' . . (hit) your bicycle.
-------------------------------------------------------------------------------------------------------
-
6. (unlikely) If that tree . . . (fall) down, it . . . (hit) the house.
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-
7. (unlikely) If you . . . (score) ten goals, Father . . . (be) astonished.
-------------------------------------------------------------------------------------------------------
8. (possible) If you . . . (score) a goal, we . . . (be) delighted.
-------------------------------------------------------------------------------------------------------
-
9. (possible) If a new university . . . (be) built, there . . (be) more places available for
students.
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10. (unlikely) If the university (be) closed, there . . . (be) a shortage of professional
men eventually.
-------------------------------------------------------------------------------------------------------.

Exercise 2
Put the verb in brackets into the Present Conditional tense.

2
Rewrite the following sentences in the space given below.
1. I knew he . . . (be) early.
-----------------------------------------------------------------------------------------------------.
2. He told us what . . . (happen).
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3. Did he tell you what he :. . (do) if he had a chance?
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4. They were certain that they . . . (win).
--------------------------------------------------------------------------------------------------
5. Mary promised that she . . . (phone) this evening.
-------------------------------------------------------------------------------------------------
6. If I had enough money, I . . . (buy) a new house for my parents.
------------------------------------------------------------------------------------------------
7. If you went to the dentist regularly, you . . . (not have) toothache so often.
-----------------------------------------------------------------------------------------------
8. He said that they . . . (not leave) until Thursday.
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Exercise 3
The following sentences express possible events. Change them to show unlikely events as in
the example below:
possible: If he comes, he will bring you a present.
unlikely: If he came, he would bring you a present.
1. If you fall off, you will hurt yourself.
--------------------------------------------------------------------------------------------------------
2. If the flood-water rises any higher, it will come in the house.
-------------------------------------------------------------------------------------------------------
3. If she writes more carefully, she will not make so many mistakes.
------------------------------------------------------------------------------------------------------
4. If an election is held now, Mr. Blank will be elected.
------------------------------------------------------------------------------------------------------
5. If income tax is raised, the Government will get more money.
------------------------------------------------------------------------------------------------------

3
 6. You will have a shock if he arrives tonight.
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7. That mat will be bleached if you leave it in the sun.
------------------------------------------------------------------------------------------------------
8. She will soon reduce her weight if she goes on a diet.
-----------------------------------------------------------------------------------------------------
9. Those plants will die if you don't water them.
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10. I'll help him if I can.
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2. The Perfect Conditional tense
i. If I had seen Mary, I would have told her about the game.
ii. Would you have stopped to help them if you had seen them?
This tense is formed with should/would have + a past participle. It is used to refer to
something which might have happened in the past but which did not happen. The other verb
in the sentence is often in the Past Perfect tense (e.g. had seen). Here are further examples;
notice the sequence of tenses involved:
iii. If you had played for us, we would have won. (but we lost)
iv. If I could have reached the shelf, I would have got the box down for you. (but I didn't)
v. I'm sure he would have phoned you if he could have reached a telephone in time.

Exercise 4
Complete each sentence by adding an expression which contains a verb in the Perfect
Conditional tense.

1.. If that knife had slipped, ................................................................................................

2. If you had told me that you hadn't enough money, ........................................................
3. If he had been driving any faster, ...................................................................................
4. If that fence hadn't been at the side of the road, .............................................................
5. If the burglar hadn't sneezed, . .......................................................................................
6. If the party had been on a Thursday instead of on a Friday,..........................................
7. If you had asked me to get the things for you, . ............................................................
8. If Susan had been listening carefully, . .........................................................................
9. If it hadn't been raining, . ...............................................................................................
4
 10. If you hadn't woken me up this morning, .....................................................................-

EXAMINING A PATIENT
SECTION 1 Giving instructions

Task 1

A neurologist carries out tests on Mr. Jameson for the sciatic and posterior tibial nerves and
the femoral nerve. Read the dialog carefully and create the situation in class.

DOCTOR: Would you slip off your top things, please. Now I Just want to
see you standing. Hands by your side. You’ re sticking that hip out a
little bit, aren't you?
PATIENT: Yes, well, I can't straighten up easily.
DOCTOR: Could you bend down as far as you can with your knees straight and stop when
you’ve had enough
PATIENT: Oh, that's the limit.
DOCTOR: Not very far, is it? Stand up again. Now I would like you to lean
backwards. That's not much either. Now stand up straight again. Now first
of all, I would like you to slide your right hand down the right side of
your thigh. See how far you can go. That's fine. Now do the same thing
on the opposite side. Fine. Now just come back to standing straight.
Now keep your feet together just as they are. Keep your knees firm.
Now try and turn both shoulders round to the right. Look right round.
Keep your knees and feet steady.
PATIENT: Oh that; sore.
DOCTOR: Go back to the centre again. Now try the same thing and go round to the
left side. Fine. Now back to the centre. That's fine. Now would you like to get
onto the couch and lie on your face. I'm just going to try and find out where
the sore spot is.
5
This dialog is based on a doctor testing a patient’s reflexes. Illustrate the order in which the
patient’s reflexes were tested by drawing them.
Tasks 2

DOCTOR: Would you like to lie down here on the couch, on your back?
PATIENT: OK.
DOCTOR: I'm going to test your reflexes by tapping you with this little hammer. It
won't hurt you. Let me hold your right arm. Let it go quite relaxed. Try
not to tighten up. There. Now the other one. Just let me have your wrist.
Let it go quite floppy. That's right. I'm going to tap your elbow. Fine.
Now the left one. OK?
PATIENT: Fine.
DOCTOR: I'll just give you a little tap here on the wrist. Now the other one. Now
let your legs go completely relaxed. I'll hold them up with my hand. There.
I'm just going to turn your leg out to the side for a moment. Just relax.
That's it. Now the other one. Fine.
Do drawing here.

6
Task 3

Using the drawings in task 2 to help you. Write down what you would say to a patient to test
these reflexes. When you finished, compare your instructions with the one in the dialog.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Task 4

First read the extract correctly as many times as you can before you attempt to instruct the
patient what to do.
1
Firstly I'd like you to kneel on that straight-backed chair so that your feet are just
slightly hanging over the edge. That's right. Now I'm going to tap them behind
your heel with this hammer. This is just a method of testing for your ankle jerk.
That's fine.
2
Now I'd like you to sit with your legs just dangling over the edge of the couch so
that I can test your knee jerks. Now nothing very much is happening here, so
what I'd like you to do is to clasp your hands together with the fingers and try to
7
 pull your fingers apart. Pull as hard as you can and concentrate on pulling. That's
fine. That makes it a lot easier to produce your knee jerk.
3
Now finally I want you to lie down on the bed with your legs stretched out in
front of you. Now I'm going to place my hand on your knee and with this key I'm
going to stroke the sole of your foot to see which way your big toe will turn. This
is called the plantar reflex. You shouldn't find it painful although it may tickle a
little. Fine. Now I'll check the other foot. Very good. That's your reflexes all
finished now. Thank you.

Task 4

CLASSWORK
Teacher’s help and guidance
Instruct a student to take up the correct position, prepare him or her for these tests, and
comment on each one. Use drawing to illustrate each one of these instructions.
1 Alternative method of
eliciting the ankle jerk

2 Reinforcement in
eliciting the knee jerk

3 Eliciting the
plantar reflex

When you have finished, compare your instructions and comments with the extract.

Task 5

The neurologist carries our stretch tests on Mr. Jameson for the sciatic and posterior tibial
nerves and femoral nerve. Complete the space in her instructions below.

8
DOCTOR: Would you like to get onto the couch and .......................................... on
your back, please? Now I'm going to take your left leg and see how
far we can.................................. it. Keep the knee straight. Does that
hurt at all?
PATIENT: Yes, just a little. Just slightly.
DOCTOR: Can I do the same with this leg? How far will this one go? Not very far.
Now let's see what happens if I....................................... your toes back.
PATIENT: Oh, that's worse.
DOCTOR: I'm going to ............................................ your knee. How does that feel?
PATIENT: A little better.
DOCTOR: Now let's see what happens when we................................... your leg again.
PATIENT: That's sore.
DOCTOR: I'm just going to ................................................. behind your knee.
PATIENT: Oh, that hurts a lot.
DOCTOR: Where does it......................................?
PATIENT: In my hack.
DOCTOR: Right. Now would you .............................. over onto your tummy?
Bend your right knee. How does that ..................................................?
PATIENT: It's a little bit sore.
DOCTOR: Now I'm going to ......................................... your thigh off the couch.
PATIENT: Oh, that really hurts.

Now read the dialog again to check your answers.

Task 6

A doctor has been called as an emergency to see a 55-year-old man at home with a
history of high blood pressure who has collapsed with a sudden crushing central chest pain
radiating to the back and legs. List what you would examine with such a patient.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

9
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Read the dialog and note down what the doctor examined.
Compare your list with the examinations the doctor carried out.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
LANGUAGE FOCUS 7.
Read the dialog again. Note how the doctor marks the end of each stage of examination.
Here are some of the ways he uses:
1. He pauses
2. He uses expressions such as OK, FINE, THAT’S IT.
3. He uses falling intonation on the expressions.

TASK 7

SECTION 2 Understanding forms

Study this checklist for the first examination of a patient on attendance at an antenatal
clinic. Some of these examinations are carried out as routine on subsequent visits. Mark
a tick ( ) on the checklist.
RST EXAMINATION
1 Height  9 Estimation of blood pressure 
2 Weight 10 Blood sample of blood group 
3 Auscultation of heart and lungs 11 Blood sample of haemoglobin 
4 Examination of breast and nipples  12 Blood sample of serological test
10
5 Examination of urine  for syphilis
6 Examination of pelvis  13 Blood sample for rubella antibodies 
7 Examination of legs  14 Examination of abdomen to assess
8 inspection of teeth  size of uterus [ ]
15 Examination of vagina and cervix 

Now study these extracts from an obstetrician’s examination of a patient attending for
her 32-week antenatal appointment. Match each extract to the numbered examinations
on the checklist. For example.
a) Have you brought your urine sample. 5
b) Now would you like to sit up and I’ll take your blood pressure. ...............
c) Now I’ll take a sample of blood to check your haemoglobin. ...................
d) Have you noticed any swelling of your ankles? ......... let’s have a quick look. .....
e) Now if you ‘d like to lie down on the couch, I’ll take a look at the baby. I’ll just measure
to see what height it is. ....... .
Task 8

Put the extracts on the previous page in order in which you would prefer to carry out these
examinations.
a) ........................................................................ b) ...............................................................
c) ........................................................................ d) ...............................................................
e) ........................................................................ f) ...............................................................
g) ........................................................................ h) ..............................................................

Task 9

Work in pairs. Student A should start.

A. Play the part of the obstetrician. The card below shows the findings on examination of a
patient attending for her 32-week appointment. Base your comments to the patient on these
findings.

11
B. Play the part of the patient. You are attending for a 32-week appointment. Ask about
anything the doctor says which you do not understand. Ask about anything on the card which
you do not understand.

N.B. If there is anything on this

ANTENATAL No
understand do not hesitate to ask
your Doctor or Midwife

SURNAME ............................... First name..............................................................

Address ........................................................................................................................

L.M.P ?22/3/96 Age 26 Pregnancy Test Ultrasound Scans

Date Result Date BPD weeks
E.D.D. 1. 3/2/97 Parity 0 + 0
2. 1. 4/5/96 + ve 1. 22/7/96 20 12~-4
Height 1.55

F.M.F.E 2. 2.
Blood Group .
O rh + ve 3.

Fundus
Date Wks Weight Urine BP (cm) Pres. Level FHH Hb Oed. Problems, Investigations. Treatment

Kg. P s / Grith (Please record all medicines)

10/6/96 6 76 126/76 Discussed screening test, diet , etc.

22/7/96 12 Neg 125/90 N.P 12.6

19/8/96 16 120/80 16 App 16 wks. (yes) No 16/8/96 Result

normal
7/10/96 22 Neg 110/80 22 FMF 3/52 ago

11/11/96 26 120/80 28 Capt. 

30/12/96 32 Neg 124/80 29 c NE  12.4 Small for dates, ref. for scan

12
 When you have completed your role-play, compare your version with the consultation.

Task 10

Section 3 Reading skills: Using a pharmacology reference

Using the prescribing information which follows, choose the most appropriate antibiotic
for these patients.

CEFUROXIME
Indications see under Cefaclor, surgical prophylaxis more active against
Haemophilus influenzea and Nesseria gonorrhoeae
Cautious Contra indications Side- effects: see under Cefaclor
Dose by mouth (OS cefuroxime axetil) 250 mg twice daily in most infections
including mild to moderate lower respiratory tract infections (e.g. bronchitis)
doubled for more severe lower respiratory tract infections or if pneumonia
suspected Urinary tract infection 125 mg twice daily. doubled in pyelonephritis
Gonorrhoea 1 g as a single dose
Children over 3 months, 125mg twice daily, if necessary doubled in child over 2
years with otitis media.
By intramuscular injection or intravenous injection or infusion 750 mg every 6
– 8 hours; 1.5 g every 6 – 8 hours in severe infections; single doses over 750 mg
intravenous route only.
Child usual dose 60 mg/kg daily (range 30 100 mg/kg daily) in 34 divided doses
(2-3 divided doses in neonates)
Gonorrhoea 1. 5 g as a single dose by intramuscular injection (divided between 2
sites)
Surgical prophylaxis 1..5 g by intravenous injection at induction may be
supplemented with 750 mg intramuscularly 8 and 16 hours later (abdominal
pelvic and orihopaedic operations) or followed by 750 mg intramuscularly every 8
hours for further 24--48 hours (cardiac pulmonary oesophageal and vascular
operations)
Meningitis 3 g intravenously every 8 hours:

13
 Child, 200 – 240 mg/kg daily (in 34 divided doses) reduced to 100 mg/kg daily
after 3 days or on clinical improvement- NEONATL, 100 mg/kg) daily reduced to
50 mg/kg daily

BENZYLPENICILLIN
(Penicillin G)
Indications throat infections, otitis media, streptococcal endocarditis, Meningococcal
meningitis, pneumonia (see table 1); prophylaxis in limb amputation
Cautions history of allergy; renal impairment; Appendix 1 (penicillins)
Contra indications: penicillin hypersensitivity
Side effects sensitivity reactions including urticaria fever Joint pains; angioedema; transient
leucopenia and thrombocytopenia; anaphylactic shock in hypersensitive patients; diarrhoea
after administration by mouth
Dose by intramuscular or by slow intravenous injection or by infusion, 1.2 g daily in 4
divided doses, increased if necessary to 2.4 g daily or more (see also below); PREMATURE
INFANT and NEONATE, 50 mg/kg daily in 2 divided doses; INFANT 14 weeks. 75 mg/kg
daily in 3 divided doses; CHILD 1 month-12 years, 1OO mg/kg daily in 4 divided doses
(higher doses may be required, see also below)
Bacterial endocarditis, by slow intravenous injection or by infusion, 7.2 g daily in 4--6
divided doses
Meningococcal meningitis, by slow intravenous injection or by infusion, 2.4 g every 4--6
hours; PREMATURE INFANT and NEONATE, 100 mg/kg daily in 2 divided doses;
INFANT 14 weeks, 150 mg/kg daily in 3 divided doses; CHILD 1 month-12 years, 180-
300 mg/kg daily in 4 divided doses
Important. If Meningococcal disease is suspected general practitioners are advised to give a
single injection of benzylpenicillin by intramuscular or by intravenous injection before
transporting the patient urgently to hospital. Suitable doses are: ADULT 1.2 g; INFANT
3OOmg; CHILD 1-9 years 6OOmg, 10 years and over as for adult
Prophylaxis in limb amputation, section 5.1, table 2

By intrathecal injection, not recommended

AMPICILLIN

14
Indications: urinary-tract infections, otitis media, sinusitis, chronic bronchitis, invasive
salmonellosis, gonorrhoea
Cautions: history of allergy; renal impairment; erythematous rashes common in
glandular fever, chronic lymphatic leukaemia, and possibly HIV infection; interactions:
(penicillins)
Contra-indications: penicillin hypersensitivity Side-effects: nausea, diarrhoea; rashes
(discontinue treatment); rarely, antibiotic-associated colitis; see also under Benzylpenicillin
Dose: by mouth, 0.25-1 g every 6 hours, at least 30 minutes before food
Gonorrhoea, 2-3.5 g as a single dose with pro-benecid 1 g
Urinary-tract infections, 500 mg every 8 hours By intramuscular injection or intravenous
injection or infusion, 500 mg every 46 hours; higher doses in meningitis
under 10 years, any route, half adult dose.

ERYTHROMYCIN
Indications alternative to penicillin in hypersensitive patients campylobacter enteritis,
pneumonia, legionnaires disease, syphilis, non-gonococcal urethritis chronic prostatitis,
acne vulgaris (see section 13 6); diphtheria and whooping cough prophylaxis
Cautions hepatic and renal impairment; prolongation of QT interval (ventricular
tachycardia reported) porphyria (see section 9.8.2); pregnancy (not known to be harmful)
and breastfeeding (only small amounts in milk); interactions Appendix 1 (erythromycin and
other macrolides)
Arrhythmias Avoid concomitant administration with astemizole or terfenadine, see pp. l39~0
also avoid with cisapride [other interactions]
Contra indications: estolate contra-indicated in liver disease
Side effects nausea, vomiting, abdominal discomfort diarrhoea (antibiotic-associated colitis
reported) urticaria, rashes and other allergic reactions; reversible hearing loss reported after
large doses; cholestatic jaundice and cardiac effects (including chest pain and arrhythmias)
also reported
Dose by mouth, ADULT and CHILD over 8 years, 25--500 mg every 6 hours or 0.5-1 g every
12 hours (see notes above); up to 4 g daily in severe 8 injections CHILD up to 2 years 125
mg every 6 hours 2-- 8 years 250 mg every 6 hours, doses doubled for severe infections
Acne see section 13.6
Early syphilis 500 mg 4 times daily for 14 days

15
By intravenous infusion, ADULT and CHILD severe infections, 50 mg/kg daily by
continuous infusion or in divided doses every 6 hours; mild infections hour (oral treatment
not possible), 25 mg/kg daily

TETRACYCLINE
Indications: exacerbations of chronic bronchitis ; brucellosis (see also notes above),
chlamydia, mycoplasma and rickettisa; pleural effusions due to malignancy or cirrhosis; acne
vulgaris
Cautions: hepatic impairment (avoid intravenous administration); renal impairment; rarely
causes photosensitivity; interactions:
Appendix 1 (tetracycline5)
Contra - indications : renal impairment (see Appendix 3), pregnancy and
breastfeeding, children under 12 years of age, systemic lupus erythematosus
Side - effects :nausea, vomiting, diarrhoea; crythema (discontinue treatment); headache and
visual disturbances may indicate benign intracranial hypertension; hepatoxicity antibiotic
associated pancreatitis and colitis reported
Dose: by mouth, 250 mg every 6 hours, increased in severe infections to 500 mg every 6-8
hours Acne.
Primary, secondary, or latent syphilis, 500 mg every 6 hours for 15 days
Non--gonococcal urethritis 500 mg every 6 hours for 7-14 days (21 days if failure or relapse
following the first course)
Counselling: Tablets or capsules should be swallowed whole with plenty of fluid while
sitting or standing

By intravenous infusion, 500 mg every 12 hours; max. 2 g daily

GENTAMICIN
Indications: septicaemia and neonatal sepsis; meningitis and other CNS infections; biliary-
tract infection acute pyelonephritis or prostatitis, endocarditis caused by Strep. viridans or
Strep. faecalis (with a penicillin); pneumonia in hospital patients, adjunct in listerial
meningitis.

16
Cautions: renal impairment, infants and elderly (adjust dose and monitor renal, auditory and
vestibular function together with plasma gentamicin concentrations) avoid prolonged use; see
also notes above interactions: Appendix 1 (aminoglycosides)
Contra-indications pregnancy, myasthenia gravis
Side-effects: vestibular and auditory damage, nephrotoxicity; rarely, hypomagnesaemia on
prolonged therapy, antibiotic-associated colitis; see also notes above
Dose: by intramuscular or by slow intravenous injection over at least 3 minutes or by
intravenous infusion, 25 mg/kg daily (in divided doses every 8 hours), see also notes above;
reduce dose and measure plasma concentrations in renal impairment.
CHILD up to 2 weeks, 3 mg/kg every 12 hours, 2 weeks-12 years, 2 mg/kg every 8 hours
By intrathecal injection, 1 mg daily (increased if necessary to 5 mg daily), with 2-4 mg/kg
daily by intramuscular injection (in divided doses every 8 hours)

PHENOXYMETHYLPENICILLIN (Penicillin V)
Indications: tonsillitis, otitis media, erysipelas; rheumatic fever and pneumococcal infection
prophylaxis
Cautions; Contra-indications; Side-effects: see under Benzylpenicillin; interactions:
Appendix 1 (penicillins)
Dose: 500 mg every 6 hours increased to 750 mg every 6 hours in severe infections; CHILD,
every 6 hours, up to 1 year 62.5 mg, 1-5 years 125 mg, 6-12 years 250 mg
Rheumatic fever and pneumococcal infection prophylaxis, section 5.1, table 2

Write the name of the most appropriate antibiotic for these patients.
1 A 4-year-old-boy with meningitis due to pneumococcus. He is allergic to penicillin.
......................................................................................................................................
2 A 67-year-old man with a history of chronic bronchitis now suffering from
pneumonia. The causative organism is resistant to tetracycline......................................

3 A 27-year-old woman with urinary tract infection in early pregnancy.

..........................................................................................................................................
4 A 4-year-old girl with septic arthritis due to haemophilus influenzae.
..........................................................................................................................................
5 An 18-year-old man with left leg amputation above the knee following a road traffic
accident. ..........................................................................................................................
17
 6 A 50-year-old woman with endocarditis caused by strep. viridans. ..............................
7 A 1 3-year-old girl with disfiguring acne.........................................................................
8 An 8-year-old boy with tonsillitis due to '3-haemolytic streptococcus. .........................
9 A 43-year-old dairyman with brucellosis. .....................................................................
10 A 4-year-old unimmunised sibling of a 2-year-old boy with whooping cough. .............
..........................

SECTION 4 Case history : William Hudson

TASK 11

Study these case notes from Mr Hudson’s consultation, part of which you studied in Unit 2,
section 4. Try to work out the meanings of the abbreviations in parentheses. Refer to key to
answers
For help.

SURNAME .............................................. FIRST NAME .......................................................

AGE ........................ SEX ...................... MARITAL STATUS .......................................
OCCUPATION ........................................................................................................................
PRESENT COMPLAINT
Headaches for 4mths. Wt loss. Headaches feel “ like a heavy weight”.
No nausea or visual symptoms.
No appetite.
Diff. Starting to (PU). Nocturia x3

O/E
General Condition
ENT
RS chest clear :
CVS P 110/min irreg. (? AF) BP 160/105 (HS) 1,11 ..................................... ,
18
GIS (abdo) ...................................... , NAD
GUS ( p.r.) prostrate moderately enlarged ..................................
CNS (NAD) .............................................................................

INNEMDIATE PAST HISTORY

......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
...............................................................................................................................................

POINTS OF NOTE:
Wife died 4/12 ago of (Ca.) ovary.
INVESTIGATIONS
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

Task 12

The case notes record the doctor's findings on examination. Write down what you would say
to Mr Hudson when carrying out this examination. Then read following dialog to compare
your answer.
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

19
......................................................................................................................................................
......................................................................................................................................................

Task 12

DOCTOR: I'll just check a few things to see if we can get to bottom of these problems.
First of all I'll check your pulse and then I'll do your blood pressure.
I'd like you to take off your jacket and roll up your sleeve
PATIENT: How is it doctor?
DOCTOR: It's just a little above normal, but that doesn't mean too much. If you'd like to
roll up your shirt, I'm going to check your heart and lungs. Now just breathe
normally. Good. Now I'd like you to take deep breaths in and out through your
mouth. That's fine. Now if you'd like to lie down on the couch, I’ll examine
your stomach.
PATIENT: Right.
DOCTOR: Take a deep breath in and out. And again. Aha. Now I'll just see if there's any
sign of a hernia. Could you slip your trousers down? That's fine. Give a cough,
please. Again, please. Now because you've been having trouble with your
waterworks, I'd like to examine your back passage. If you'd roll over on to
your left side and bend your knees up. You might find this a bit uncomfortable,
but it won't take long That's it. All finished. You can get your clothes on now.

Task 13

You decide to refer Mr Hudson for further treatment. The surgeon is Mr Fielding. Write a
letter to him outlining Mr Hudson's problems. Use the form below. When you have finished,
compare your version with the Key. The case of Mr Hudson continues in Unit 4.
Hospital
use Day Hospital
Only Clinic Date Time No GP112

20
 Ambulance Yes No REQUEST FOR OUT-PATIENT CONSULTATION
Required Urgent Yes
Sitting/Stretcher Appointment No
Required
Hospital ............................................................ Date ..........................................................
Please arrange for this patient to attend the ................................clinic of Dr/Mr ..................
Patient’s Surname ....................................... Maiden Surname ...............................................
First Names ....................................................... Single/Married/widowed/Other .............
Address ............................................................. Date of Birth ..........................................
Patient's Occupation ..........................................
Postal Code........................................................ Telephone Number ................................
Has the patient attended hospital before: YES/NO? If "YES" please state: ..........................
Name of Hospital ..................................................................................................................
Name, Address and Telephone Number of MEDICAL /DENTAL/PRACTITIONER :
................................................................................................................................................
Year of Attendance ......................................... Hospital No .................................................
If the patient's name and/or address has/have changed since then please give details:
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................

I would be grateful for your opinion and advice on the above named patient. A brief outline
of history, symptoms and signs is given below:
.......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
......................................................................................................................................................
.....................................................................................................................................................
.....................................................................................................................................................

21
Diagnosis/provisional diagnosis:.........................................................................................
Present drug treatment and potential special hazards: ........................................................
Relevant X-rays available from: .............................................. No. (it known) .................

Signature ............................................................................

Most of the materials for this section were taken and modified from English in medicine

SECTION 5

I The Compartments of the Body

I READING AND COMPREHENSION

The body has three compartments. The first of these consists of active tissue, which is also
known as cell mass. This does most of the chemical work of the body.
22
The second compartment consists of supporting tissue. This is composed of bone minerals,
extracellular proteins, and the internal environment, or the extracellular fluid in the blood and
lymph.
The third compartment is the energy reserve. 'This consists of fat, which lies round the
principal internal organs and in adipose tissue.

Study the following statements carefully and decide whether they are true or not true
according to the information in the reading passage above. Then check your answers by
referring to the solutions at the end of the unit.*
(a) The first compartment of the body consists of cell mass.
(b) The second compartment of the body is composed of bone minerals.
(c) The internal environment is composed of the extracellular fluid in the blood and lymph
(d) The energy reserve is composed of adipose tissue and fat which lies round the
principal internal organs.

These compartments cannot be separated by physical dissection, but it is possible to measure

them indirectly. This may be done using methods such as the dilution technique.
The size each compartments varies according to the age, sex and health the individual . In a
healthy young man the total body weight is divided approximately: 55% cell mass, 30%
supporting tissue, and 15% energy reserve. A healthy young woman has normally twice as
much fat.
(e) The compartments of the body are measurable.
(f) The dilution technique is the only method of measuring the compartments of
the body.
g) The sum of the sizes of the compartments = the total body weight.
h) The energy reserve of a healthy young woman is approximately 300 % of her
total body weight.

*The following symbols are used in the solutions:

:. therefore
i.e. that is to say
= equals, means the same as
# does not equal, does not mean the same as

23
EXERCISE A Contextual reference
Write the following sentences in your notebook, and complete them after studying the
reading passage.
EXAMPLE
'This' in sentence 5 refers to the second compartment (OR supporting tissue).

1. 'these' in sentence 2 refers to ................................................................

2. 'this' in sentence 3 refers to ...............................................................
3. 'this' in sentence 7 refers to ..............................................................

EXERCISE B Rephrasing
Rewrite the following sentences, replacing the words printed in italics with expressions
from the reading passage which have the same meaning.

EXAMPLE
Fat is located round the principal internal organs.
= Fat lies around the principal internal organs. (lies: from sentence~7)
1. In a healthy young man, approximately 55 of the total body weight consists of cell mass.
2. The energy reserve consists of fat.
3. The supporting tissue consists partly of the extracellular fluid in the blood and lymph
4. The compartments are not separable by physical dissection.
5. Supporting tissue makes up about 30% of the total body weight.
6.A young woman has usually twice as much fat as a young man.
EXERCISE C Relationships between statements
Place the following expressions in the sentences indicated. Where necessary, replace and re-
order the words in the sentences, and change the punctuation.

EXAMPLE
however (8)
These compartments cannot be separated by physical dissection. It is, however, possible to
measure them indirectly.
(a) i.e. (5) (d) for example (11)

24
(b) of course (8) (e) as follows (11)
(c) for example (9) (f) however (12)

FOCUS ON LANGUAGE
EXERCISE A The description of structure

1. Copy the following diagram into your notebook. Refer to the reading passage and
complete the diagram by filling in the blanks.

the compartments of the body

..............
active tissue the............
or ...............

Fat, which lies

................... .................. the........................
In ............and

round the ..........

the............... ............
in the blood
and .............

2. Write the following sentences in your notebook, using the completed diagram to finish
them use the verb consist of
EXAMPLE
The compartments of the body consist of active tissue, or cell mass, supporting tissue, and the
energy reserve.
(a) Supporting tissue ...................................................................................................................
(b)The energy reserve .................................................................................................................
(c) The internal environment .......................................................................................................
Write the sentences again, this time using the verb be composed of

25
EXAMPLE
The compartments of the body are composed of active tissue; or cell mass, supporting tissue,
and the energy reserve.
3. Write the following sentences in your notebook, using the completed diagram to finish
them. Use the verb form.
EXAMPLE
Fat, which lies in adipose tissue and round the principal internal organs; forms the energy
reserve.
(a) The extracellular fluid in the blood and lymph ...................................................................
(b) Active tissue, supporting tissue, and the energy reserve .......................................................
(c) Bone minerals, extracellular proteins, and the internal environment.....................................

Write the sentences again, this time using the verb make up.
EXAMPLE
The fat which lies in adipose tissue and round the principal internal organs makes up the
energy reserve.
4. Write the following sentences in your notebook, using the diagram and the verbs consist of
be composed of, form and make up.
(a) ............................ consists of bone minerals .........................................................................
(b) The extracellular fluid in ........................................................... the internal environment.
(c) The energy reserve is ........................................................................................................
(d) Active' tissue, .............................,and the energy reserve .................................................
(e) The internal environment consists of ................................................................................
(f) Bone minerals ...................................................................................................................

5. Use the following diagrams to write brief descriptions of

(a) the structure of the coraco - acromial arch (1 sentence), and
b) the structure of skin (3 sentences).
a) ..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
b) ..................................................................................................................................................

26
.................................................................................................................................................
.................................................................................................................................................
................................................................................................................................................

The structure of the coraco - acromial arch

The coraco-acromial arch

the horizontal part the coraco-acromial the acromion

of the coracoid process ligament

The structure of skin

skin

The dermis The epidermis

stratified squamous
Fibrous and elastic connective epithelium
Tissue
27
EXERCISE B Defining and non-defining relative clauses
Look at the following sentences:
(a) The large intestine extends from the ileum to the anal capal.
(b) The large intestine is about five feet long.
These two sentences can be combined as follows:
(c) The large intestine, which is about five feet long, extends from the ileum to the
anal canal.

The use of commas with relative clauses

Look at the following sentences:
(d) The inguinal canal, which is an intermuscular slit, lies above the inguinal ligament.
(e) Endocrine glands, which secrete into the blood, are found in various parts of the body.
(f) Glands which secrete into the blood are known as endocrine glands.
(g) The amount of oxygen which is consumed by the body can be calculated using
laboratory techniques.
(h) The pleura has a squamous lining which allows the organs inside to slide over each other.
(i) The pleura has a squamous lining which allows the organs inside to slide over each other.

In sentence (d) and in sentence (e), the relative clause is separated from the rest of the
sentence by commas. These relative clauses are called non-defining relative clauses. The
information in a non-defining relative clause is not essential to the understanding of the rest
of the sentence. The non-defining relative clause only adds extra information to the sentence.
In sentence (f) and sentence (g), the relative clause is not separated from the rest of the
sentence by commas. The information in the relative clauses is essential to the correct
understanding of the rest of the sentence. (Read the sentences again, omitting the relative
clauses, and you will see how necessary the relative clauses are.) These are called defining
relative clauses.
Sometimes a relative clause can be treated either as defining or as non-defining. This depends
largely on whether the writer wishes to present the information as essential or additional.
Sentence (h) might occur in any paragraph describing the contents of the thorax. Sentence (i)
might occur when there is particular emphasis on the function of the pleura: i.e. it might
follow a description of the mobility of the organs in the thorax.

28
As a general rule, when a choice can be made between defining and non-defining, the non-
defining relative clause, with commas, is the more usual choice in medical writing.
Remember, however, that in sentences like sentences (d), (e), (f), and (g), no choice is
possible. The relative clauses in sentences (d) and (e) must be non-defining and must have
commas; the relative clauses in sentences (f) and (g) must be defining and must not have
commas.
Combine each of the following pairs of sentences into a single sentence. Make the second
sentence into a relative clause and insert it .into the first sentence in the appropriate place.
Use commas when necessary (i.e. when the relative clause is non-defining).

EXAMPLE
The posterior tibial artery divides into two branches in the foot. The posterior tibial artery
runs through the muscle down behind the tibia:
The posterior tibial artery, which runs through the muscle down behind the tibia, divides
into two branches in the foot.

1. The pinna is composed of elastic cartilage covered with skin. The pinna is the part
of the ear lying outside the head.
..........................................................................................................................................
..........................................................................................................................................
2. Glucose is stored in the body as glycogen. Glycogen is reconverted into glucose
when it is needed for energy.
..........................................................................................................................................
..........................................................................................................................................
3. The energy reserve is composed of fat. Fat lies round the principal internal organs
and in adipose tissue.
.........................................................................................................................................
.........................................................................................................................................
4. Valves are round in most veins. Valves direct the blood flow proximally.
..........................................................................................................................................

.........................................................................................................................................

5. The bone is called the femur. The bone extends from the hi-bone to the knee.
.........................................................................................................................................
29
 .........................................................................................................................................
6. The centre of a tooth consists of pulp. The pulp is surrounded by dentine.
........................................................................................................................................
........................................................................................................................................
7. The veins or the legs can be divided into two groups, superficial and deep.
The two groups, superficial and deep, are joined at intervals by communicating veins.
..........................................................................................................................................
..........................................................................................................................................
8. The renal arteries supply the kidneys. The renal arteries arise immediately below the
superior mesenteric artery.
......................................................................................................................................
.....................................................................................................................................
9. Ducts and secretory units are surrounded by connective tissue. The connective tissue
acts as a supporting framework.
........................................................................................................................................
........................................................................................................................................
10. Osteoclasts send out processes. The processes erode bone.
........................................................................................................................................
........................................................................................................................................
11. Synovial membrane secretes a lubricating fluid. Synovial membrane lines joints.
........................................................................................................................................
.........................................................................................................................................
12. Short bones consist of cancellous bone covered with a thin layer of compact bone;
Short bones are cuboid in shape.
......................................................................................................................................
.......................................................................................................................................
13. Round the .branches of the splenic artery there may be found aggregates of
lymphocytes. These aggregates of lymphocytes are known as Malpighian corpuscles.
........................................................................................................................................
........................................................................................................................................
14. Bile is stored in the gall-bladder. Bile is excreted by the liver.
........................................................................................................................................
15. The surface of the body is covered by a layer of skin. A layer of skin protects the

30
 body tissues.
..........................................................................................................................................
..........................................................................................................................................
16. The fluid makes up the internal environment. The fluid is contained in the blood and
lymph.
.........................................................................................................................................
.........................................................................................................................................
17. One compartment of the body is active tissue. Active tissue is also known as cell
mass.
.........................................................................................................................................
18. The lacrimal gland is continually secreting fluid. The fluid keeps the eye moist and
free from dust particles.
..........................................................................................................................................
..........................................................................................................................................

EXERCISE C Relative clauses with a prepositions

In medical writing there are many relative clauses with a preposition before which. Such
clauses are formed in the following way:
(a)Connective tissue is a matrix.
(b) More highly organized tissues are embedded in this is matrix
= Connective tissue is a matrix in which more highly organized tissues are embedded.

Combine each of the following pairs of sentences into a single sentence containing a
relative clause beginning with a preposition + which Use commas when the clause is a
non-defining one.

1. The cerebellum is the centre for reflexes. Muscles are co-ordinated and balance
is maintained by these reflexes.
......................................................................................................................................
........................................................................................................................................
2. .The ear has a central part, the vestibule. From the vestibule three canals and cochlea
are given off.

31
 ........................................................................................................................................
........................................................................................................................................
..

3 3. There are little branching tubes in dentine. Nutritive material is conveyed from
the bloodstream through the little branching tubes in dentine.
..........................................................................................................................................
..........................................................................................................................................
4. The cranium is a large, bony case. The brain is protected by this large, bony case.
.........................................................................................................................................
5. In the epidermis there are different strata. In the different strata, the cells
have distinctive anatomical features.
..........................................................................................................................................
..........................................................................................................................................
6.Strands of Schwann cells provide surfaces. The growing axons cling to these surfaces.
..........................................................................................................................................
4 7. The muscle is known as the mylo -hyoid. The hyoid bone is connected to
5 the mandible by the muscle.
6 ....................................................................................................................................
......
7 ....................................................................................................................................
......
8.The stomach is attached to the abdominal wall by its mesentery. Through its
mesentery run blood vessels, lymphatics and nerves.
..........................................................................................................................................
..........................................................................................................................................

9. Some motor fibres enter the medulla oblongata. They form two pyramidal tracts
in the medulla oblongata.
......................................................................................................................................
......................................................................................................................................
10. Endocrine glands have lost their connection with the alimentary cavity. They
were derived from the alimentary cavity.
32
 ........................................................................................................................................
........................................................................................................................................
11. The pre-vertebral fascia provides a foundation. The pharynx and the oesophagus
can slide upon this foundation.
..........................................................................................................................................
..........................................................................................................................................
12. The bone is pierced by many openings, or foramina. The vessels and nerves
pass through the openings, or foramina.
............................................................................................................................................
..........................................................................................................................................
13.There are small veins in the palms and fingers. The superficial and deep palmar
arches are formed from the small veins in the palms and fingers.
..........................................................................................................................................
..........................................................................................................................................
14.The capsule of a lymph node is made up of fibrous tissue. There is a certain amount
of plain muscle in the fibrous tissue.
.............................................................................................................................................
.............................................................................................................................................

15.The walls of the capillary and the alveolus fuse to make a very thin wall.
The interchange of gases takes place through this very thin wall.
............................................................................................................................................
............................................................................................................................................

KEY ANSWERS
Task 5
1 lie
2 raise/lift
3 bend
4 bend
33
5 straighten
6 press
7 hurt
8 roll
9 feel
10 lift/raise
Task 6
1 radial pulses
2 BP
3 heart sounds
4 lungs
5 abdomen
6 femoral pulses
Task 8
THE FIRST EXAMINATION

1 Height [ ] 9 Estimation of blood pressure [ ]

2 Weight* [ ]
3 Auscultation of heart and lungs [ ]
4 Examination of breasts and nipples [ ]
5 Examination of urine [ ]
6 Examination of pelvis [ ]
7 Examination of legs [ ]
8 Inspection of teeth[ ]
10 Blood sample for blood group[ ]
11 Blood sample for haemoglobin
12 Blood sample for serological test for
syphilis [ ]
13 Blood sample for rubella antibodies [ ]
14 Examination of abdomen to assess
size of uterus [ ]
15 Examination of vagina and cervix [ ]

In the UK, weight is no longer measured as routine on subsequent visits.

a5 b9 e 11 d7 e 14

Task 9
Suggested order:
1a 2e 3d 4b 5c
34
Task 11
1 gentamicin
2 benzylpenicillin, erythromycin
3 ampicillin
4 cefuroxime
5 benzylpenicillin
6 gentamicin, benzylpenicillin
7 eryrthromycin, tetracycline
8 phenoxymethylpenicillin, benzylpenicillin
9 tetracycline
10 erythromycin

Task 12
PU pass urine
?AF possible atria] fibrillation
HS heart sounds
abdo. abdomen
p.r. per rectum
NAD no abnormality detected, nothing abnormal detected
4/12 four months
Ca. carcinoma, cancer

SECTION 5 Solutions
(a) active tissue, which is also known as cell mass
i.e. active tissue cell mass
The first compartment of the body consists of active tissue.
.: The first compartment of the body consists of cell moss.

(b) This is composed of bone minerals, extracellular fluid, and the internal environment
this = the second compartment
The second compartment of the body is composed of bone minerals AND
OTHER THINGS.
It is NOT TRUE that the second compartment of the body is composed of
35
 bone mineral (only).

(c) the internal environment, OR the extracellular fluid in the blood and lymph
i.e. the internal environment the extracellular fluid in the blood and lymph
The internal environment is composed of the extracellular fluid in the blood and lymph.

(d) fat, which lies round the principal internal organs and in adipose tissue
(e) = fat; Which lies round the principal internal organs AND fat which lies in
adipose tissue
(adipose tissue is composed of fat and other things)
The energy reserve is composed of fat, which lies in adipose tissue and round
the principal internal organs.
:. The energy reserve is NOT composed of adipose tissue and fat which lies round
the principal internal organs.

(e) it is possible to measure them

it is possible to measure the compartments of the body.
:. The compartments of the body are measurable.

(f) methods SUCH AS the dilution technique (9)

= methods LIKE, FOR EXAMPLE, the dilution technique
i.e. .The dilution technique is ONE EXAMPLE of the methods of measuring
the compartments of the body.
:. The dilution technique is NOT the only method of measuring the compartments of
the body.
(f) the total body weight is divided approximately: 55% cell mass, 30% supporting
tissue, and 15% energy reserve (11)
55%+30%+l5% =100%
:. The sum of the sizes of the compartments form the total body weight.

h) A healthy young woman has normally twice as much fat

twice as much fat = twice as much energy reserve
twice as much energy reserve (as a healthy young man)
= 2 x approximately 15%. of the total body weight (see 11)
36
:. The energy reserve of a healthy young woman is approximately 30% of her
total body weight.

37