GP

CVS
GUS
severe chest RS
shaking house down GI
oug rusty CNS
extra night CVS
loss
loss GUS

CVS/RS
general MSS
sore 2
MSS
pneumonia GUS
ES
RS

died GIS
angina RS
brother GIS
asthma GUS
driver GIS
20 RS
beer wine ES
travel
GIS
CVS

GIS
CNS
GIS Your name
RS/CVS
GIS Sit down and what's

When did it start?

Where does it hurt exactly?

Did it hurt here before?

6
15 Was the pain consistent?
14
13 The pain stayed here, right?
11
How about your apettite?
12
3 Did you vomit yesterday?
20
10
Can you pass stool?
5
Have you measured your temperature?
8
4 Does it hurt when I press here?
19
1
Oh, I'm sorry. Are you fine now?
9
2
18
16
7
17
 abnormal male
ambulatory mental age
alert and oriented to person (..) medical history
alert and oriented no appreciable disease
auscultation and palpation no complains
asymptomatic not diagnosed
auscultation no disease found
alive and well no evidence of disease
blood pressure no known allergies
chronological age no known drug allergies
conscious and alert normal
chief complaint, complains of neurological vital signs
date of birth not yet diagnosed
diagnosis undetermined pulse
diagnosis percussion and auscultation
examination palpation
female physical examination
family history poor health
free of disease past history
follow-up present illness
fever of unknown origin past medical history
history of past medical illness
history and physical previous psychiatric history
height prognosis
history patient
ideal body weight respiration
inspection, palpation, percussion, auscultation rule out
intelligence quotient review of systems
living and well responds to verbal commands
living with disease subjective, objective, assessment, plan
 severity of illness vital signs

soft organs not palpable well developed, well nourished

signs and symptoms within normal limits
symptoms, signs weight
temperature
year
temperature, pulse & respiration
treatment years old
usual childhood diseases year of birth
under observation
Translation:

1. What is the reason of your hospital admission?

2. Can you describe your complaints?
3. Tell me please, where does it hurt?
4. Since when have you felt pain in the chest?
5. Does the pain radiate to the back? Left shoulder? Mandible?
6. Has this pain built up recently? Since when exactly?
7. Do you feel breathless?
8. When do you feel breathless? On exertion or while being relaxed aswell? At night?
9. Could you describe what do you mean by that?
10. Can you tell in which situations do you feel such symptoms?
11. Why did you say that you have to sleep on two pillows?
13. Do you have any other complaints?
14. Can you walk up the stairs without a rest?
15. Do you experience while walking a neet to stop for a moment?
16. Does anyone in your family or among relatives have similar symptoms?
17. Do you have difficulties with taking up the medication regularly?
19. Have you ever been admitted to the hospital?
20. Have you ever had any operations?
21. Have you been abroad recently?
22. Have you had contact with anyone with jaundice?
23. How many cigarettes per day do you smoke? Hom much alcohol do you dring? Per day? Per week?