Case history in Spanish Flashcards by Jaymi Jacob

What is the reason for your visit?

Por que nos visita hoy?

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Have you been referred by another professional?Why?

¿Fue referido por algun otro

profesional? Por que?

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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)

¿Dónde es la molestia ?

“¿En uno o ambos ojos?”

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Tell me how severe it is from 1 to 10?

¿Cuán severo es del 1 al 10?

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When was the first episode or first

time noticed?

¿Cuándo fue el primer episodio o que

lo notó por primera vez?

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How frequent is the complaint?

Timing/Frequency

¿Con qué frecuencia lo siente?

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

¿Con qué lo asocia? (cansancio, leer,

etc.)

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What reliefs the complaint?

¿Con qué lo alivia?

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What makes it worse?

¿Qué lo hace peor?

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Other complaints?

¿Alguna otra queja?

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Do you suffer any eye conditions such

as :

Padece de alguna condicion ocular

como

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cataracts

cataratas,

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flashes or floaters

ve “flashes” de luz o flotadores

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any injuries

golpes al ojo

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frequent infections,

infecciones frequentes

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itching

picor

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burning

ardor

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tearing

lagrimeo

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or any other?

o cualquier otra condicion?

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Date of diagnosis
 Treatment if any
 Outcome

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

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Your occupation?

 Any Leisure related/avocations?

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

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

CUANDO FUE SU ULTIMO EXAMEN

VISUAL COMPLETO?

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

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

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

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

What type do you wear? (single , | bifocal PAL

¿Qué usa?

Were prescribed for what?( D , N, | both)

¿Para qué fueron recetados?

When was the first time you were | prescribed correction?

¿Cuándo fue la primera vez que le | recetaron corrección?

This current Rx is how old?

Esta corrección, ¿cuánto tiempo tiene?

ENT (ears, nose throat problems such | as sinus or infections)

ENT (oídos, nariz, garganta, como | infecciones, rinitis);

Cardiovascular ( like heart problems, | HTN)

Cardiovascular ( como corazón, | hipertensión)

Allergies (you will ask again)

Alergias

Autoimmune (like HIV, lupus)

Autoinmune ( como HIV, Lupus);

GI ( gastrointestinal as colitis, chron, | constipation, colon cancer)

GI ( gastrointestinal como colitis, | chron, estreñimiento, colon cancer) ,

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

GU (genitourinario como cáncer | ovarios, cérvix, menopausia) ;

Musculoskeletal ( such as muscular | dystrophy, arthritis, osteroporosis)

Musculoesquelético ( como distrofia | muscular, artritis, osteoporosis)

Endocrine (such as diabetes, thyroid)

Endocrino ( como diabetes, tiroides)

Dermatologic (such as eczema, skin | cancer, skin ,hair/nail problems)

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

Neurologic (such as Alzheimer, | multiple sclerosis MS)

Neurológico ( como alzheimer, | esclerosis multiple)

Hematological/lymphatic (such as | anemia, hemophilia, leukemia)

Hematological/linfático ( como | anemia, hemofilia, leucemia)

Psychological (such as depression, | anxiety)

Psicológico ( como depresión, | ansiedad);

Respiratory (such as asthma, | bronquitis, lung cancer)

Respiratorio (como asma, | bronquitis,cáncer del pulmón),

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

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

Any surgeries?

¿Alguna cirugía?

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

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

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

``` ¿Alguna otra medicina para esta condicion?  ¿Sigue el tratamiento como indicado?  ¿Cuándo fue la última vez que el doctor le evaluó esta condición? ```

```  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? ```

```  ¿Le cambiaron el tratamiento? (ex. ¿Le aumentaron la dosis?)  ¿Ha estado controlado o no?  ¿Cuándo le toca ver otra vez al médico? ```

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

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

HIV (+) ask How much is the viral load? | and the CD4?

¿En cuánto está la carga | viral? Y el número de CD4?

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

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

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

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

``` Do you or have you have used alcohol, recreational drugs or tobacco? For each (+) document:  What type?  With what frequency?  Amount used? ```

``` ¿Usa o ha usado alcohol, drogas ilícitas o productos del tabaco? Que tipo?  Con que frecuencia?  Que cantidad? ```

Oral? Inhaled? IV?

Oral? Inhalado? Intavenoso?

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

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

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

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

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

¿ALGO MAS QUE YO DEBA SABER | ACERCA DE SU SALUD O SUS OJOS?

```  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?) ```

```  ¿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?) ```