Zbieranie wywiadu z zakresu Układu Powłokowego | Taking an Integumentary System history

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records”: “dokumentacja medyczna”, “dermatological issues”: “problemy dermatologiczne”, “rash”: “wysypka”, “pruritus”: “świąd”, “itching”: “swędzenie”, “localized”: “zlokalizowany (miejscowy)”, “generalized”: “uogólniony”, “eczema”: “egzema (wyprysk)”, “psoriasis”: “łuszczyca”, “contact dermatitis”: “kontaktowe zapalenie skóry”, “systemic issues”: “problemy ogólnoustrojowe”, “liver disease”: “choroba wątroby”, “kidney failure”: “niewydolność nerek”, “thyroid dysfunction”: “dysfunkcja tarczycy”, “persistent itching”: “utrzymujące się swędzenie”, “secondary skin lesions”: “wtórne zmiany skórne”, “scratching”: “drapanie”, “bacterial infections”: “zakażenia bakteryjne”, “viral infections”: “zakażenia wirusowe”, “fungal infections”: “zakażenia grzybicze”, “autoimmune diseases”: “choroby autoimmunologiczne”, “environmental irritants”: “czynniki drażniące środowiskowe”, “skin lesions”: “zmiany skórne”, “moles”: “pieprzyki (znamiona)”, “warts”: “brodawki”, “sores”: “rany”, “benign”: “łagodny”, “seborrheic keratosis”: “rogowacenie łojotokowe”, “lipomas”: “tłuszczaki”, “malignant”: “złośliwy”, “melanoma”: “czerniak”, “basal cell carcinoma”: “rak podstawnokomórkowy”, “lesion size”: “rozmiar zmiany”, “lesion shape”: “kształt zmiany”, “lesion color”: “kolor zmiany”, “lesion border characteristics”: “cechy granicy zmiany”, “erythema”: “rumień”, “skin redness”: “zaczerwienienie skóry”, “increased blood flow”: “zwiększony przepływ krwi”, “superficial capillaries”: “powierzchowne naczynia włosowate”, “inflammation”: “zapalenie”, “systemic lupus erythematosus”: “toczeń rumieniowaty układowy”, “ulcers”: “owrzodzenia”, “poor circulation”: “słabe krążenie”, “prolonged pressure”: “długotrwały ucisk”, “diabetes”: “cukrzyca”, “pressure ulcers”: “odleżyny”, “venous ulcers”: “owrzodzenia żylne”, “diabetic foot ulcers”: “owrzodzenia stopy cukrzycowej”, “secondary infections”: “wtórne zakażenia”, “delayed healing”: “opóźnione gojenie”, “xerosis”: “suchość skóry”, “dry skin”: “sucha skóra”, “flaky skin”: “łuszcząca się skóra”, “cracked skin”: “popękana skóra”, “low humidity”: “niska wilgotność”, “cold weather”: “zimna pogoda”, “aging”: “starzenie się”, “hypothyroidism”: “niedoczynność tarczycy”, “atopic dermatitis”: “atopowe zapalenie skóry”, “fissures”: “pęknięcia”, “alopecia”: “łysienie”, “focal”: “ogniskowe”, “alopecia areata”: “łysienie plackowate”, “telogen effluvium”: “telogenowe wypadanie włosów”, “androgenetic alopecia”: “łysienie androgenowe”, “tinea capitis”: “grzybica skóry głowy”, “genetic factors”: “czynniki genetyczne”, “iron deficiency”: “niedobór żelaza”, “onychomycosis”: “grzybica paznokci”, “lichen planus”: “liszaj płaski”, “vitamin B12 deficiency”: “niedobór witaminy B12”, “iron deficiency anemia”: “anemia z niedoboru żelaza”, “fluid retention”: “zatrzymywanie płynów”, “trauma”: “uraz”, “heart failure”: “niewydolność serca”, “nephrotic syndrome”: “zespół nerczycowy”, “hyperpigmentation”: “hiperpigmentacja”, “hypopigmentation”: “hipopigmentacja”, “melanin production”: “produkcja melaniny”, “melasma”: “ostuda”, “vitiligo”: “bielactwo”, “post-inflammatory changes”: “zmiany pozapalne”, “scars”: “blizny”, “burns”: “oparzenia”, “transient rashes”: “przejściowe wysypki”, “chronic conditions”: “przewlekłe choroby”, “systemic conditions”: “stany ogólnoustrojowe”, “adaptive immune responses”: “odpowiedzi immunologiczne adaptacyjne”, “associated symptoms”: “objawy towarzyszące”, “persistent symptoms”: “utrzymujące się objawy”, “Dryness”: “Suchość”, “Extensive rashes”: “Rozległe wysypki”, “Lesions”: “Zmiany skórne”, “Inflamed patches”: “Zapalone plamy”, “Bumps”: “Guzki”, “Blisters”: “Pęcherze”, “Bacterial”: “Bakteryjne”, “Viral”: “Wirusowe”, “Fungal”: “Grzybicze”, “Pattern”: “Wzór”, “Distribution”: “Rozkład”, “Underlying condition”: “Choroba podstawowa”, “Cellulitis”: “Zapalenie tkanki łącznej”, “Sunburn”: “Oparzenie słoneczne”, “Flaky”: “Łuszczący się”, “Focal”: “Ogniskowy”, “Diffuse”: “Rozproszony”, “Patterned”: “Wzorowy”, “Thyroid disorders”: “Zaburzenia tarczycy”, “Pitting”: “Dołkowanie”, “Nutritional deficiencies”: “Niedobory żywieniowe”, “Swelling”: “Obrzęk”, “Edema”: “Obrzęk”, “Venous insufficiency”: “Niewydolność żylna”, “Chief Complaint”: “Główny problem”, “History of Present Illness”: “Historia obecnej choroby”, “Onset”: “Początek”, “Location”: “Lokalizacja”, “Duration”: “Czas trwania”, “Character”: “Charakter”, “Associated Symptoms”: “Objawy towarzyszące”, “Radiation”: “Promieniowanie”, “Timing”: “Czas występowania”, “Severity”: “Nasilenie”, “Acute”: “Ostry”, “Chronic”: “Przewlekły”, “Rosacea”: “Trądzik różowaty”, “Syphilis”: “Kiła”, “Hand-foot-and-mouth disease”: “Choroba dłoni, stóp i jamy ustnej”, “Scaly plaques”: “Łuszczące się płytki”, “Itchy patches”: “Swędzące plamy”, “Blistered”: “Z pęcherzami”, “Fever”: “Gorączka”, “Malaise”: “Złe samopoczucie”, “Pruritic rashes”: “Świądowe wysypki”, “Herpes zoster”: “Półpasiec”, “Chills”: “Dreszcze”, “Fatigue”: “Zmęczenie”, “Widespread”: “Rozległe”, “Flare-ups”: “Zaostrzenia”, “Lupus”: “Toczeń”, “Dermatomyositis”: “Zapalenie skórno-mięśniowe”, “Squamous cell carcinoma”: “Rak płaskonabłonkowy”, “Skin checks”: “Kontrole skóry”, “Atopic conditions”: “Stany atopowe”, “Asthma”: “Astma”, “Current Medications”: “Obecne leki”, “Topical”: “Miejscowe”, “Systemic medications”: “Leki ogólnoustrojowe”, “Photosensitivity”: “Nadwrażliwość na światło”, “Over-the-Counter”: “Bez recepty”, “Herbal Supplements”: “Suplementy ziołowe”, “Prescribed”: “Przepisane”, “Exacerbating”: “Pogarszające”, “Sun Exposure”: “Ekspozycja na słońce”, “Sunburns”: “Poparzenia słoneczne”, “Tanning bed use”: “Korzystanie z solarium”, “Folliculitis”: “Zapalenie mieszków włosowych”, “Irritant dermatitis”: “Podrażnieniowe zapalenie skóry”, “Keloid formation”: “Tworzenie się bliznowców”, “Drug Allergies”: “Alergie na leki”, “Anti-inflammatory drugs”: “Leki przeciwzapalne”, “Pollen”: “Pyłki”, “Dust mites”: “Roztocza kurzu”, “Allergens”: “Alergeny”, “Irritants”: “Substancje drażniące”, “Hot, humid settings”: “Gorące, wilgotne otoczenie”, “Lyme disease”: “Borelioza”, “Scabies”: “Świerzb”, “Bedbugs”: “Pluskwy”, “Ticks”: “Kleszcze” }; // Normalize keys in the dictionary const normalizedWordsToTooltip = {}; for (const [key, value] of Object.entries(wordsToTooltip)) { const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value; } function processNode(node) { if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) { let content = node.nodeValue; // Regex to match only the main words (ignores parentheses) const regex = new RegExp( `b(${Object.keys(normalizedWordsToTooltip).join(‘|’)})b`, ‘gi’ ); if (regex.test(content)) { const wrapper = document.createElement(‘span’); wrapper.innerHTML = content.replace(regex, (match) => { const tooltip = normalizedWordsToTooltip[match.toLowerCase().trim()]; return `${match}`; }); node.replaceWith(wrapper); } } else if (node.nodeType === 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Szacowany czas lekcji: 14 minut
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Po omówieniu anatomii i funkcji układu Powłokowego możemy przejść do praktycznych aspektów jego oceny. Zaczniemy od tego, jak przeprowadzić wywiad po angielsku z pacjentem, który ma problemy skórne, i omówimy kluczowe elementy zbierania wywiadu.

Opening a Consultation

Taking a structured history is crucial for identifying symptoms related to the skin, hair, and nails. As a doctor, your role is to guide the patient with professionalism and empathy, ensuring you gather key information for accurate diagnosis and effective treatment.

If available, first review the patient’s medical records to familiarize yourself with any previous dermatological issues or relevant history that might guide the consultation.

Introduction

Politely ask the patient to confirm their full name and date of birth to ensure you are addressing the correct individual.

Teraz ty powiedz:

  • Mr. Smith? This way, please.
  • Ms. Smith? Please come in.
  • Could I please confirm your full name and date of birth?
  • Just to confirm, your name and date of birth?
  • Your full name and date of birth, please.

Upon entering the consultation room, greet the patient warmly and introduce yourself, stating your name and role.

Teraz ty powiedz:

  • Hello, I’m Dr. [Your Last Name]. How can I help you today?
  • Good morning/afternoon, I’m Dr. [Your Last Name]. What brings you in today?
  • Hi, I’m Dr. [Your Last Name]. What would you like to discuss today?

Common Skin Conditions and Symptoms

Patients may seek consultation for a wide range of skin concerns, from localized itching and dryness to extensive rashes and lesions. These symptoms can arise from various causes, including infections, allergic reactions, autoimmune processes, or systemic health issues. Frequent conditions seen in dermatology include:

ComplaintDescription
PruritusPruritus, or itching, is a common symptom associated with various skin conditions. It may be localized or generalized, resulting from dermatological disorders like eczema, psoriasis, contact dermatitis, or systemic issues such as liver disease, kidney failure, or thyroid dysfunction. Persistent itching can lead to secondary skin lesions from scratching.
RashA rash involves changes in skin color, texture, or appearance and can present as red, inflamed patches, bumps, or blisters. Causes range from infections (bacterial, viral, fungal), allergic reactions, autoimmune diseases, to environmental irritants. The pattern, distribution, and characteristics of the rash help in diagnosing the underlying condition.
LesionsSkin lesions refer to any abnormal growth or appearance on the skin, such as moles, warts, or sores. Lesions may be benign (e.g., seborrheic keratosis, lipomas) or malignant (e.g., melanoma, basal cell carcinoma). Evaluating lesion size, shape, color, and border characteristics is essential for accurate diagnosis.
ErythemaErythema denotes skin redness due to increased blood flow in superficial capillaries, often linked with inflammation or infection. It may be seen in localized conditions like cellulitis, sunburn, or generalized conditions such as drug reactions or systemic lupus erythematosus.
UlcersSkin ulcers are open sores that develop due to poor circulation, prolonged pressure, infections, or systemic conditions like diabetes. Common types include pressure ulcers, venous ulcers, and diabetic foot ulcers. They can complicate with secondary infections and delayed healing.
Xerosis Xerosis refers to dry, flaky, or cracked skin, which may arise from environmental factors (e.g., low humidity, cold weather), aging, or underlying medical conditions like hypothyroidism or atopic dermatitis. Severe dryness increases the risk of fissures and infections.
Alopecia Alopecia describes hair loss, which can be focal (alopecia areata), diffuse (telogen effluvium), or patterned (androgenetic alopecia). It may be due to autoimmune conditions, infections (e.g., tinea capitis), genetic factors, or systemic diseases such as thyroid disorders or iron deficiency.
Nail ChangesChanges in nail appearance, such as discoloration, thickening, or pitting, may suggest local infections (onychomycosis), systemic conditions (psoriasis, lichen planus), or nutritional deficiencies (e.g., vitamin B12 or iron deficiency).
Swelling and EdemaSwelling in the skin or underlying tissues is often due to fluid retention, inflammation, or trauma. Edema may occur in localized conditions like cellulitis, venous insufficiency, or generalized conditions such as heart failure or nephrotic syndrome.
Hyperpigmentation or HypopigmentationChanges in skin color may be due to increased (hyperpigmentation) or decreased (hypopigmentation) melanin production. Conditions such as melasma, vitiligo, and post-inflammatory changes (e.g., scars, burns) result in visible pigmentation alterations.

Chief Complaint and History of Present Illness

The Chief Complaint (CC) is the primary symptom prompting a patient to seek care, often involving skin issues like rashes, itching, or other changes. Taking a detailed History of Present Illness (HPI) helps clarify when symptoms began, how they’ve progressed, and their overall impact.

Using the OLD CARTS mnemonic – Onset, Location, Duration, Character, Associated Symptoms, Radiation, Timing, and Severity – ensures a complete understanding of the patient’s symptoms, aiding in accurate diagnosis and effective management.

OLD CARTS assessment of Rash:

O – Onset: Determining when the rash started is important for diagnosis. Acute rashes often indicate infections or allergic reactions, while chronic rashes may suggest inflammatory or autoimmune conditions.

Teraz ty zapytaj – Onset:

  • When did the rash first appear?
  • Did it start suddenly, or did it develop gradually?
  • Was there any specific event or exposure that triggered it?
  • Have you experienced a rash like this before?
  • Did the rash appear after taking any new medications?

L – Location: The location can offer diagnostic clues. Facial and upper body rashes may suggest conditions like rosacea or lupus, while rashes on the palms and soles could indicate syphilis or hand-foot-and-mouth disease. Localized rashes often point to contact dermatitis or localized infections.

Teraz ty zapytaj – Location:

  • Where exactly is the rash located?
  • Has it spread to other parts of the body?
  • Is the rash confined to one area or generalized?
  • Does the rash appear on exposed skin or under clothing?
  • Is it affecting sensitive areas, such as the face or genitals?

D – Duration: Clarifying how long the rash has been present helps assess whether it is acute or chronic. Persistent rashes are more likely to indicate chronic conditions, while transient rashes may suggest acute issues.

Teraz ty zapytaj – Duration:

  • How long has the rash been present?
  • Is it constant, or does it come and go?
  • Has it changed in appearance over time?
  • Is the duration similar to previous episodes, if any?
  • Has there been any improvement or worsening recently?

C – Character: Describing the rash’s appearance, such as color, size, shape, and texture, aids in diagnosis. For example, psoriasis presents as red, scaly plaques, while eczema appears as dry, itchy patches.

Teraz ty zapytaj – Character:

  • Can you describe the appearance of the rash?
  • Is it raised, flat, scaly, or blistered?
  • Does it change color when you press on it?
  • Is the skin around the rash normal, or is it also affected?
  • Has the texture of the rash changed since it first appeared?

A – Associated Symptoms: Ask if there are additional symptoms like itching, pain, fever, or malaise. Pruritic rashes may suggest eczema or allergic reactions, while painful rashes can indicate herpes zoster or cellulitis.

Teraz ty zapytaj – Associated Symptoms:

  • Do you have any other symptoms, like itching or pain?
  • Have you experienced fever, chills, or fatigue?
  • Is there any swelling or warmth around the rash?
  • Do you feel unwell or have any other skin changes?
  • Are there any other areas of your body affected?

R – Radiation: Determine if the rash has spread. Localized rashes often suggest a contact or irritant source, while symmetrical or widespread rashes may indicate systemic conditions.

Teraz ty zapytaj – Radiation:

  • Has the rash spread from its original location?
  • Did it start in one area and then appear elsewhere?
  • Are there new areas affected that were not involved before?
  • Does the rash appear in a symmetrical pattern?
  • Is it spreading despite treatment or care measures?

T – Timing: Understanding how the rash has evolved provides insights into its nature. Acute rashes might be due to infections or allergic reactions, while chronic or recurrent rashes suggest conditions like psoriasis or eczema.

Teraz ty zapytaj – Timing:

  • How has the rash changed over time?
  • Is it more severe at certain times of the day?
  • Does it flare up or calm down under specific conditions?
  • Have there been any periods of complete resolution?
  • Does the rash follow a pattern or cycle?

S – Severity: Assessing the severity of the rash helps determine its impact on the patient’s quality of life. Asking patients to rate their symptoms on a scale can provide valuable information.

Teraz ty zapytaj – Severity:

  • On a scale of 0 to 10, how bothersome is the rash?
  • Does the rash interfere with your daily activities?
  • Is it severe enough to disturb your sleep?
  • Have you noticed any changes in severity since it began?
  • Is there anything that makes the rash feel better or worse?

Po zebraniu informacji na temat przebiegu obecnej choroby przećwiczymy zadawanie pytań pacjentowi dotyczących jego przeszłości zdrowotnej oraz innych aspektów życia.

Dla każdego układu ciała pytania będą nieco inne, dlatego każdy system należy dokładnie przerobić z osobna. Pozwoli to na skuteczne utrwalenie umiejętności zbierania wywiadu po angielsku oraz zapewni lepsze zrozumienie stanu zdrowia pacjenta w przyszłości.

Past Medical History

Review the patient’s medical history to identify any conditions that may predispose them to dermatological issues:

  • Eczema, Psoriasis, or Acne: A history of these conditions is essential, especially if the patient is experiencing flare-ups. Understanding the severity and frequency of previous episodes can help guide management.
  • Autoimmune Diseases: Conditions like lupus or dermatomyositis can manifest with skin rashes, requiring a thorough examination of any associated symptoms or systemic involvement.
  • Skin Cancer: A personal history of basal cell carcinoma, squamous cell carcinoma, or melanoma increases the risk for new lesions. Regular skin checks are vital for early detection.

Teraz ty zapytaj – Past Medical History:

  • Have you had any skin conditions in the past, such as eczema, psoriasis, or acne?
  • Are you currently experiencing flare-ups of any previous skin conditions?
  • Do you have any history of autoimmune diseases, like lupus or dermatomyositis?
  • Have you been diagnosed with any form of skin cancer, such as basal cell carcinoma, squamous cell carcinoma, or melanoma?

Family History

Certain dermatological conditions have a genetic component, so family history is crucial:

  • Psoriasis: A family history of psoriasis increases the likelihood of the patient developing the condition, highlighting the need for early intervention.
  • Atopic Dermatitis (Eczema): Eczema is often familial and may co-exist with other atopic conditions like asthma, which can complicate management.
  • Skin Cancer: A family history of melanoma increases the patient’s risk of developing skin cancer.

Teraz ty zapytaj – Family History:

  • Does anyone in your family have a history of psoriasis?
  • Is there a family history of eczema or other atopic conditions, like asthma?
  • Has anyone in your family been diagnosed with skin cancer, particularly melanoma?

Medications

Understanding the patient’s current and past medications provides insight into their treatment history and potential drug-related causes for dermatological symptoms:

  • Current Medications: Inquire about any topical or systemic medications currently being used, particularly corticosteroids, retinoids, or antibiotics, and evaluate their effectiveness.
  • Recent Changes in Medications: Ask about any recent changes in medication regimens, as adjustments may lead to new or worsening skin conditions.
  • Medications with Dermatological Side Effects: Some medications can cause skin reactions, such as rashes or photosensitivity. It’s essential to evaluate the patient’s medication list for potential culprits.
  • Over-the-Counter and Herbal Supplements: These can interact with prescribed medications or have dermatological effects, including exacerbating skin conditions or providing benefits.

Teraz ty zapytaj – Medications:

  • Are you currently taking any medications for your skin conditions?
  • Have there been any recent changes in your medication regimen?
  • Are you using any over-the-counter products or herbal supplements for your skin?
  • Have you noticed any side effects from your current medications, particularly skin reactions?

Social History

Social and environmental factors are significant contributors to dermatological diseases:

  • Sun Exposure: Prolonged UV exposure increases the risk of skin cancers. Ask about sunburns, tanning bed use, and sun protection measures.
  • Occupational Exposures: Jobs involving chemicals, dyes, or irritants can increase the risk of contact dermatitis or occupational skin diseases.
  • Hygiene Practices: Bathing habits, shaving frequency, and personal care products may contribute to conditions like folliculitis or irritant dermatitis.
  • Tattoos or Piercings: These practices increase the risk of infections, allergic reactions, or keloid formation.

Teraz ty powiedz:

  • How often are you exposed to the sun, and do you use any sun protection?
  • Have you ever experienced frequent sunburns, or do you use tanning beds?
  • Does your job involve exposure to chemicals, dyes, or other potential skin irritants?
  • Could you describe your bathing habits and personal care products? For example, how often do you shave or use specific skincare products?
  • Do you have any tattoos or piercings? If so, have you had any issues, like infections or allergic reactions?

Allergies

Assessing allergies helps identify potential triggers and guides management in dermatological conditions:

  • Drug Allergies: Identify any medications that cause allergic reactions, especially those related to dermatological treatment, such as antibiotics or anti-inflammatory drugs.
  • Environmental Allergies: Environmental allergies can directly exacerbate dermatological conditions like eczema and contact dermatitis. Identifying specific allergens is crucial for effective management.

Teraz ty zapytaj – Allergies:

  • Do you have any known drug allergies, especially to medications used for treating skin conditions?
  • Have you experienced any allergic reactions to medications recently?
  • Are you allergic to environmental triggers such as pollen, dust mites, or certain foods that may affect your skin?

Environmental and Occupational Exposures

Environmental factors can significantly impact the skin:

  • Allergens or Irritants: Frequent exposure to substances like nickel, latex, or specific soaps can lead to contact dermatitis.
  • Living or Working Conditions: Exposure to dry, cold indoor environments can worsen eczema, while hot, humid settings may increase the risk of fungal infections.
  • Insect Bites: Bites from mosquitoes, ticks, or bedbugs can lead to localized skin reactions or even transmit diseases like Lyme disease or scabies.

Teraz ty powiedz:

  • Are you regularly in contact with substances like nickel, latex, or specific soaps that might irritate your skin?
  • Do you live or work in conditions that are very dry or cold, or perhaps warm and humid?
  • Have you noticed any unusual skin reactions from insect bites, like those from mosquitoes or ticks?

Closing the Consultation

Summarize the main points discussed during the history-taking to confirm understanding and ensure no details were missed.

Teraz ty powiedz:

  • Let me summarize what we’ve discussed so far to make sure I have everything correct.
  • To confirm, you’ve mentioned [key symptoms or points]. Does that sound accurate?
  • Is there anything important that we haven’t covered?
  • Before we proceed, is there anything else you’d like to add or clarify?
  • Thank you for sharing all these details; it will help us plan the next steps effectively.

Ask the patient if they have any remaining questions or concerns before moving forward with the examination.

Teraz ty powiedz:

  • Do you have any other questions or concerns before we start the examination?
  • Is there anything else you’d like to discuss before we begin the physical exam?