General History and Physical (other than Chief Complaint and History of Present Illness)

MD: Do you have any allergies to any medications?
Meron po ba kayong anumang alerdyi sa anumang gamot?

MD: What medications are you taking?
Ano pong mga gamot ang iniinom ninyo? What dose? Ano ang dosis? How often do you take it? Gaano kadalas po ninyo ito iniinom?

Some medications can be used to treat many different diseases.
May mga gamot na maaaring gamitin sa paggamot ng maraming iba't-ibang sakit.

What disease is this medication __<name>______ supposed to treat for you?
Ano po ang sakit na dapat lunasan ng gamot na ____________________?

MD: What illnesses do you have?
 Ano po ang mga sakit ninyo?

Not looking for past illnesses, but only ones that continue currently or are chronic diseases. For example, not pneumonia, yes diabetes.
Hindi po mga nakalipas na karamdaman, kundi mga sakit ninyo ngayon o mga palagiang sakit.  Halimbawa, hindi pulmonya, oo ang dayabetis

MD: What surgeries have you had in the past?
Ano pong mga operasyon  ang ginawa sa inyo noong nakaraan?

MD: Do your parents/ brothers/ sisters, have heart disease, stroke, or cancer? Mayroon po ba ang inyong mga magulang/ mga kapatid na lalake/ mga kapatid na babae, ng sakit sa puso, istrok o kanser?

What age were they when they were diagnosed?
Ano po ang edad nila nang sila ay ma-diagnosed?

MD: With whom do you live?
Sino po ang kasama n’yo sa bahay?

MD: What is the phone number of someone we can contact in case of emergency?
Ano po ang numero ng telepono ng isang tao na maaari naming makontak kung may emergency?

MD: Do you have a primary care doctor or a doctor you see regularly?
Mayroon ba kayong pangunahing tagapag-alaga na doktor o isang doktor na regular n’yong pinupuntahan?

MD: Do you smoke or have you ever smoked?
 Naninigarilyo po ba kayo o nanigarilyo po ba kayo kahit minsan?

How many packs a day?
Gaano karaming pakete sa isang araw?

How many years?
Ilang taon?

When did you quit?
Kailan kayo tumigil?

MD: Do you drink alcohol?
Umiinom ka ba ng alak?

How many drinks in a week on average?
Gaano karami humigit-kumulang sa isang linggo?

Have you ever been a fairly heavy drinker in the past?
Naging malakas ba kayong uminom noong nakalipas?

MD: Have you ever done recreational drugs?
Nakagamit na ba kayo ng panlibangang droga o recreational na droga?

Which drugs?
Aling mga droga?

 Have you ever used IV drugs?
Gumamit na ba kayo ng  IV na droga?

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Review of Systems

MD: How long have you had this problem? (for all of the below questions, this question applies)
Gaano katagal na kayong may problemang ganito?

MD: Do you have a fever?
Mayroon ba kayong lagnat?

How high has it gotten?
Gaano ito kataas?

When was the last time you had a fever?
Kailan kayo huling beses na nagkaroon ng lagnat?

Are you taking any medications for it?
Uminom ba kayo ng anumang gamot para dito?

MD: Have you lost or gained weight in the past week?
Bumaba ba o tumaas ang timbang ninyo nitong nakaraang linggo?

In the past month?
Sa nakaraang buwan?

MD: Do you have any pain in your chest?
Mayroon ba kayong nararamdamang sakit sa inyong dibdib?/  Mayroon bang kumikirot sa inyong dibdib?

MD: Do you have a cough?
Mayroon ba kayong ubo?

Do you have any blood with your cough?
Mayroon bang anumang dugo sa inyong pag-ubo?

MD: Do you have any problems breathing?
Mayroon ba kayong anumang problema sa paghinga?

MD: Do you have any pain in your abdomen?
Mayroon ba kayong anumang masakit sa inyong tiyan o abdomen?

MD: Do you have nausea or vomiting?
Nahihilo ba kayo o nagsusuka?

Do you have any blood in your vomit?
Mayroon bang anumang dugo sa inyong suka?

MD: Do you have diarrhea?
Nagtatae ba kayo?

Constipation?
Tinitibi?

MD: Do you have any blood in your stool?
Mayroon bang anumang dugo sa inyong dumi?

MD: Do you have any pain when you urinate?
Mayroon ba kayong anumang nararamdamang sakit kapag kayo’y umiihi?

MD: Do you have any blood in your urine?
Mayroon ba kayong anumang dugo sa inyong ihi?

MD: Do you have any numbness or tingling in any part of your body?
Mayroon ba kayong anumang pamamanhid o “tingling” o pangingilabot sa bahagi ng inyong katawan?

MD: Do you feel particularly weak or paralyzed in part of your body?
Nararamdaman ba ninyo na mahina o paralisado sa isang bahagi ng katawan ninyo?

As in a stroke
Tulad sa istrok

MD: Do you have any pain anywhere else in your body?
 Mayroon ba kayong anumang masakit pa sa kahit saan sa inyong katawan?

 

Physical Exam

MD: I am going to do a physical exam.
Eeksaminin ko kayo./  Gagawin ko ang isang pisikal na eksamen.

MD: I am going to listen to your heart and lungs.
Pakikinggan ko ang inyong puso at baga.

MD: Please breathe deeply.
Mangyaring huminga nang malalim.

Please breathe normally.
Mangyaring huminga nang normal.

Please hold your breath.
Pakipigil ang inyong paghinga.

MD: Please lie down.
Mangyaring humiga./ Humiga po kayo. 

Please sit up.
Mangyaring umupo./ Maupo ho kayo.

MD: Do you have any pain when I press here?
Mayroon ba kayong anumang nararamdamang sakit kapag dinidiinan ko rito?

MD: Is the pain worse when I press in, or when I let go?
Mas masakit ba kapag dinidiinan ko, o kapag inaalis ko.

MD: (When patient is lying down.) Please relax your legs.
Paki-relaks ang iyong mga binti.

I will pick your leg up for you. <testing reflexes>
Itataas ko ang iyong binti para sa iyo.

MD: Please lift up your (right/ left) leg and don’t let me push it down.
Paki-angat ang iyong kanang/kaliwang binti at huwag mong hayaang itulak ko itong pababa.

MD: Please squeeze my hands very hard.
Pakipisil nang mahigpit na mahigpit ang mga kamay ko.

Don’t let me move your arms.
 Huwag mong hayaang maigalaw ko ang mga braso mo.

MD: Follow my finger with your eyes only.
Sundan mo ng tingin ang aking daliri.

MD: Does this feel equal on both sides when I touch your face?
Pareho ba ang pakiramdam sa magkabilang pisngi kapag hinawakan ko ang iyong mukha.

MD: Raise your eyebrows.
Itaas mo ang iyong mga kilay.

MD: Stick out your tongue.
 Ilabas mo ang iyong dila.

MD: Smile really big.
Ngumiti ka nang abot tainga.

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Chest Pain Scenario

Patient is admitted to the hospital, no longer in the ER, but in a patient room on the floor and has had pain overnight, unaddressed. Then, the morning nurse, notes that the patient has pain and calls the doctor, who comes to see the patient

MD: Hello, Mrs. _____________, am I pronouncing your name correctly?
MD: Kumusta ho, Misis ____________, tama po ba ang pagkakasabi ko sa pangalan ninyo?

Pt: Yes.
PT: Opo.

No. You say it ____________.
Hindi po.  (says name correctly) po ang pangalan ko.

MD: Is there a phone number of someone we can contact for translation?
MD: Meron po ba kayong numero ng telepono ng isang kakilala na puwedeng tumulong magsalin ng pag-uusap natin? 

Pt:  Yes, there is.
Pt:  Opo, meron po.

MD:  What is the number?

MD:  Ano pong numero?

PT:  No. I don’t know anyone.
PT:  Wala po akong kakilala

MD: Are you having any pain?
MD: May nararamdaman po ba kayong sakit??

Pt: Yes.
PT:  Opo.

MD: Put your hand on where your pain is located. Point to where your pain is located.
MD: Ilagay po ninyo ang kamay n’yo sa lugar na masakit.  Ituro po ninyo kung saan masakit.

Pt: Here.
PT. Dito po.

Diagnoses: heart attack, pulmonary emboli, aortic dissection
<Suppose it is chest pain.>
MD: How long have you had that pain? How many years? Months? Days? Minutes?
MD: Gaano katagal na kayong may nararamdamang masakit/kumukurot? Ilang taon? Buwan? Araw? Minuto?
Pt:  ________________ 30 minuto po. (30 minutes)

MD: What is the longest time that the pain has been there without going away?
MD: Ano po ang pinakamatagal na panahong nandiyan ang sakit na hindi nawawala? 
Pt:  _________________

MD: Did the pain start out bad, in the first 5 seconds, and then get even worse? 
Or, did it start out bad, in the first 5 seconds, and then stay the same or get better?
MD: Matindi ba ang sakit sa unang limang segundo, tapos lalong sumakit?
O, nag-umpisa ang sakit na matindi sa unang limang segundo tapos hindi nawala o nabawasan ang sakit?
Pt:  _____________________

MD: Are you currently in pain?
MD: May nararamdaman ho ba kayong sakit ngayon, o mayroon bang kumukurot ngayon?
Pt:  _____________________

MD: On a scale of 1 to 10, with 1 being not that bad and 10 being the worst pain of your life (for example, the pain of giving birth for women), how bad is your pain
MD: Kung sa eskala po na isa (1) hanggang sampu (10), ang isa po ay hindi gaanong masakit, at ang sampu (10) ang pinakamasakit na naranasan ninyo sa tanang buhay n’yo (halimbawa, iyong sakit ng panganganak para sa mga babae), gaano katindi ang inyong nararamdamang sakit?
Pt:_______________________

MD: What makes the pain better? Worse?
MD: Anong nagpapawala ng sakit? Nagpapalala?
Pt: _______________________

MD: If you walk around is the pain better, worse, or do you think it has no relation? walking upstairs?
MD: Kung naglalakad kayo, nawawala ba o lumalala ang sakit o walang kaugnayan ang paglalakd sa sakit?  pag-akyat sa hagdanan?
Pt:  _______________________

MD: Does the pain move to another part of the body?
MD:  Lumilipat ba ang sakit sa ibang parte ng katawan?
Pt:  Yes.
Pt:  Opo.

MD: Where?
MD:  Saan?

 

MD: Do you have any problems breathing?
MD: Mayroon ba kayong problema sa paghinga?
Pt:  Yes._______________________
Pt:  Opo.

 

MD: Do you feel like you want to throw up?
MD: Pakiramdam n’yo ba parang gusto niyong masuka?
Pt: No.
Pt:  Hindi naman po.

MD: Do you feel like you are going to pass out?
MD: Pakiramdam n’yo ba ay mawawalan kayo ng malay-tao?
Pt:

MD: Do you feel your heart is not beating normally?
MD: Pakiramdam po ba ninyo hindi normal ang tibok ng puso n’yo?
Pt:  ________________________

MD: Do you have any pain in your legs? If so, which leg?
MD: May kirot ba o masakit sa binti niyo? Kung mayroon, aling binti po?
Pt:  ________________________

MD: Do you notice that your leg or legs are more swollen than previously? When did that start?
MD: Napapansin po ba ninyo na namamaga ang binti n’yo kaysa sa dati? Kailan po ito nagsimula?
Pt:  ________________________

MD: Do you have any cough? Is there anything coming up with the cough? What about blood?
MD: Inuubo po ba kayo? May sumasama po ba sa ubo n’yo?  E dugo po?
Pt:  ________________________

MD: Do you have any questions?
MD: May tanong po ba kayo?

 

 

 

 

 

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