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PCO3 > Case history in Spanish > Flashcards

Case history in Spanish Flashcards

1
Q

What is the reason for your visit?

A

Por que nos visita hoy?

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2
Q

Have you been referred by another professional?Why?

A

¿Fue referido por algun otro

profesional? Por que?

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3
Q 
Where is your complaint ? (Location)
(remember that if patient says I see
blurry, you are not going to ask where
if the blurriness, you know are the
eye(s)!! Ask if it is with both eyes or
one eye more than the other)
A

¿Dónde es la molestia ?

“¿En uno o ambos ojos?”

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4
Q

Tell me how severe it is from 1 to 10?

A

¿Cuán severo es del 1 al 10?

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5
Q

When was the first episode or first

time noticed?

A

¿Cuándo fue el primer episodio o que

lo notó por primera vez?

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6
Q

How frequent is the complaint?

Timing/Frequency

A

¿Con qué frecuencia lo siente?

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7
Q 
Any associated Factors (Fatigue,
reading) * remember that associated
factors are not necessarly the 2ry
complaint. You have to ask
specifically about another complaint
A

¿Con qué lo asocia? (cansancio, leer,

etc.)

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8
Q

What reliefs the complaint?

A

¿Con qué lo alivia?

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9
Q

What makes it worse?

A

¿Qué lo hace peor?

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10
Q

Other complaints?

A

¿Alguna otra queja?

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11
Q

Do you suffer any eye conditions such

as :

A

Padece de alguna condicion ocular

como

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12
Q

cataracts

A

cataratas,

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13
Q

flashes or floaters

A

ve “flashes” de luz o flotadores

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14
Q

any injuries

A

golpes al ojo

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15
Q

frequent infections,

A

infecciones frequentes

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16
Q

itching

A

picor

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17
Q

burning

A

ardor

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18
Q

tearing

A

lagrimeo

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19
Q

or any other?

A

o cualquier otra condicion?

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20
Q

Date of diagnosis
 Treatment if any
 Outcome

A

¿Cuándo se diagnosticó?
 ¿Tratamiento que usa o se le dio?
 ¿Cómo está ahora?

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21
Q

Your occupation?

 Any Leisure related/avocations?

A

¿Qué ocupacion/trabajo tiene?
¿Qué le gusta hacer en su tiempo libre? (or
¿Tiene hobbies? )

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22
Q

WHEN WAS YOUR LAST FULL EYE
EXAM? This is other than the hx of ocular
diseases

A

CUANDO FUE SU ULTIMO EXAMEN

VISUAL COMPLETO?

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23
Q

Any ocular or visual conditions found
 Any Treatment?
 For when a follow up was
recommended ?

A

¿Se le encontro alguna condicion
ocular o visual?
 ¿Se le dió tratamiento?
 ¿ Cuándo se le recomendó regresar?

24
Q

DO YOU HAVE TO WEAR A VISUAL
CORRECTION? (EYEGLASSES OR
CONTACT LENSES)

A

TIENE QUE USAR ALGUNA
CORRECION (ESPEJUELOS O LENTES
DE CONTACTO)

25
Q

What type do you wear? (single ,

bifocal PAL

A

¿Qué usa?

26
Q

Were prescribed for what?( D , N,

both)

A

¿Para qué fueron recetados?

27
Q

When was the first time you were

prescribed correction?

A

¿Cuándo fue la primera vez que le

recetaron corrección?

28
Q

This current Rx is how old?

A

Esta corrección, ¿cuánto tiempo tiene?

29
Q

ENT (ears, nose throat problems such

as sinus or infections)

A

ENT (oídos, nariz, garganta, como

infecciones, rinitis);

30
Q

Cardiovascular ( like heart problems,

HTN)

A

Cardiovascular ( como corazón,

hipertensión)

31
Q

Allergies (you will ask again)

A

Alergias

32
Q

Autoimmune (like HIV, lupus)

A

Autoinmune ( como HIV, Lupus);

33
Q

GI ( gastrointestinal as colitis, chron,

constipation, colon cancer)

A

GI ( gastrointestinal como colitis,

chron, estreñimiento, colon cancer) ,

34
Q

GU (genitourinary like urinary infections, ovary or cervix cancer,
menopause)

A

GU (genitourinario como cáncer

ovarios, cérvix, menopausia) ;

35
Q

Musculoskeletal ( such as muscular

dystrophy, arthritis, osteroporosis)

A

Musculoesquelético ( como distrofia

muscular, artritis, osteoporosis)

36
Q

Endocrine (such as diabetes, thyroid)

A

Endocrino ( como diabetes, tiroides)

37
Q

Dermatologic (such as eczema, skin

cancer, skin ,hair/nail problems)

A

Dermatológico (como eczema, cáncer
de la piel, problemas de piel o
pelo/uñas) ;

38
Q

Neurologic (such as Alzheimer,

multiple sclerosis MS)

A

Neurológico ( como alzheimer,

esclerosis multiple)

39
Q

Hematological/lymphatic (such as

anemia, hemophilia, leukemia)

A

Hematological/linfático ( como

anemia, hemofilia, leucemia)

40
Q

Psychological (such as depression,

anxiety)

A

Psicológico ( como depresión,

ansiedad);

41
Q

Respiratory (such as asthma,

bronquitis, lung cancer)

A

Respiratorio (como asma,

bronquitis,cáncer del pulmón),

42
Q

Constitutional (have you lost or gain
weight recently, night sweating, have
a fever)

A

Constitucional ( ha perdido o ganado
peso recientemente, sudor en la
noche,tiene fiebre)

43
Q

Any surgeries?

A

¿Alguna cirugía?

44
Q

This was diagnosed when?
 What treatment do you have for it?
(med’s or surgeries)
 Dosage of the medication?

A

 ¿Cuándo se le diagnostico?
 ¿Qué tratamiento tiene o tuvo?
 ¿Dosis del medicamento?

45
Q

 Any other medication for this
 Are you compliant with the treatment?
 When was the last time you were seen for this?

A 
¿Alguna otra medicina para esta
condicion?
 ¿Sigue el tratamiento como indicado?
 ¿Cuándo fue la última vez que el
doctor le evaluó esta condición?
46
Q 
 The Doctor changed anything in your
treatment (example : increased the
dosage)
 What is the current status (controlled,
uncontrolled)
 When is the next follow up visit?
A 
 ¿Le cambiaron el tratamiento? (ex.
¿Le aumentaron la dosis?)
 ¿Ha estado controlado o no?
 ¿Cuándo le toca ver otra vez al
médico?
47
Q

Diabetic: ask How much was the last
blood sugar level (FBS), Glycosilated
hemoglobin test (HbA1C)? What type?

A

If Diabetic: ¿Cuánto fue su última lectura
de azúcar (FBS)? Hemoglobina glicosilada
(HbA1C) ? Que typo?

48
Q

HIV (+) ask How much is the viral load?

and the CD4?

A

¿En cuánto está la carga

viral? Y el número de CD4?

49
Q

What medications do you use,
including over the counter,
homeopathics, supplements?

A

¿Qué medicamentos usa, incluyendo
los sin receta, homeopáticos y
suplementos?

50
Q

Are you allergic to anything including
medications, food, enviromental
agents? To what?
 What reaction do you have?

A

¿Es alérgico a medicinas, comidas o
cosas en el ambiente? A qué?
 ¿Qué reacción tiene?

51
Q 
Do you or have you have used
alcohol, recreational drugs or tobacco?
For each (+) document:
 What type?
 With what frequency?
 Amount used?
A 
¿Usa o ha usado alcohol, drogas
ilícitas o productos del tabaco?
Que tipo?
 Con que frecuencia?
 Que cantidad?
52
Q

Oral? Inhaled? IV?

A

Oral? Inhalado? Intavenoso?

53
Q

Does anyone in your immediate
family suffer any eye conditions?
 What eye conditions?

A

 Alguien en su familia inmediata sufre
de condiciones oculars(de los ojos)?
 Que padecen?

54
Q

Does anyone in your immediate family suffer
any HEALTH conditions?
What conditions?

A

Alguien en su familia inmediata sufre de
condiciones DE SALUD?
Que padecen?

55
Q

ANYTHING ELSE I SHOULD KNOW
ABOUT YOUR MEDICAL AND EYE
CONDITION?

A

¿ALGO MAS QUE YO DEBA SABER

ACERCA DE SU SALUD O SUS OJOS?

56
Q 
 Premature or full term?
 How many gestation weeks?
( normal from 38-40 weeks)
 Any complications during the
pregnancy?
 Has C-section or natural birth?
 Weight?
 Was she/him in an incubator with
oxygen?
 Milestones were reached as
expected? ( crawling, then walking,
talking as expected: remember that
jumping crawling can bring BV
deficiencies. Speech delays can be
associated with learning
deficiencies)
 Any therapies that she/he is receiving and why?( speech,
occupational, psychological)
 Updated vaccines?
 How is she/him doing at school?
(notice: does age correspond to
grade?)
A 
 ¿Prematuro o término completo?
 ¿Cuántas semanas de gestación
tuvo? (normal 38-40)
 ¿Alguna complicación en el
embarazo?
 ¿Fue cesárea o parto natural?;
 ¿Cuanto pesó al nacer?
 ¿Estuvo en incubadora con
oxigeno?
 ¿Las etapas del desarrollo fueron
normales (gateó, caminó y habló
al tiempo esperado?) remember that
jumping crawling can bring BV
deficiencies. Speech delays can be
associated with learning
deficiencies)
 ¿Recibe alguna terapia ( habla, ocupacional, psicológica y por qué)
 ¿Tiene sus vacunas al día?
 Cómo está en la escuela?
(notice: does age correspond to grade?)

PCO3 (3 decks)

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