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Das Anamnesegespräch // Teil 1 medizinische Fachsprachprüfung // Fall: akute Cholezystitis | ärztesprech | YouTubeToText
YouTube Transcript: Das Anamnesegespräch // Teil 1 medizinische Fachsprachprüfung // Fall: akute Cholezystitis
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This content presents a medical admission interview with a patient experiencing severe abdominal cramping pain, leading to a suspected diagnosis of gallbladder inflammation and outlining the initial diagnostic steps.
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Hello everyone, welcome to
our new video on the topic of
promises and examinations.
We are the last of Inmet Personal and
Nina from Ärzte Sprech, and we wanted to do another one
in a reading
conversation. Our patient
today has severe cramping abdominal pain.
abdominal pain.
Watch, pay close attention,
and write your differential diagnosis in the comments. Enjoy
watching! [Music]
[Music]
Good afternoon, my name is Nina
Collette. I am a resident physician
here on the ward and would like to
conduct the admission interview with you.
Are you okay with us
constantly... Wonderful... Briefly about the procedure: I
will now ask everyone a few personal
questions and then move directly to
your current complaints.
Okay, if you have any questions or do
n't understand something, I would ask you to give me
a quick signal. Then
we'll take a short break. Yes,
that was wonderful. What is your name? I... I'm Laura
Laura
Westenberger. Can you
please spell your last name slowly?
and then... Berger... BRG... two words or
written together... one word... a
board... written together... Best Okay,
Mrs. Westenberger, how old
are you and when is your birthday?
I'm 46 and my birthday is on January 31st.
Okay, that should be 74 then, right?
That's right. [Laughter]
Mrs. Westenberger, how tall are you?
I'm 1.65 meters tall. And how much do you weigh
72.7 kg. I just had sex yesterday.
Okay, wonderful, very good. Who is your family doctor? That's
family doctor? That's
Dr. Abdullah in the
city center. Please tell me that again.
really good now. The name is
also difficult and I did
n't really remember it, but I
think that's right.
We'll figure it out. No problem,
Mrs. Westenberger. What brings you here? Well,
I got very bad
stomach pains yesterday evening
very bad ever since. I
thought after
waking up today, okay, it's okay, which is why
I didn't come right away,
but then today I
also had pains around
noon and that's why I'm here now. I
came because it eventually became truly unbearable.
unbearable.
Okay, the stomach pains—what kind of pain is that? Is it a pressure
pain, or a stabbing pain? How
would you describe it?
It's more like cramps. When you
have a cramp, how long does it last?
I'd say 30, 30, 40 seconds,
That's okay. And how severe would
you rate the pain? Do
you have pain now, or do you
only have pain when you have a cramp?
I've had pain the whole time,
which only gets worse when I
have a cramp.
Okay, if you would rate the pain
on a
scale where one is very mild
and ten is very
severe, where would you rate it?
rate it?
I'd say 4 to 5 in a normal state,
and when I have a real cramp, it
goes up to 82.
Okay, good, I've noted that down. You said
you also vomited.
Schavan, was that the best, or more like bile, or
what did it look like to you? Was there blood
in the vomit? Was there blood?
Not the first two years,
the leftover food,
and the third time it was already much
improved. Okay, and then the diarrhea, did
you have the feeling that there was blood in it?
No, it was on the Westrick test, but there wasn't any. Okay,
very good. How often did you vomit?
Okay, has anything else
come up since then? Do you have a fever
or chills, headaches, or
other pain? I've had a
fever since yesterday, so
yesterday it was around 38.7 and today around
38.5, so always around that temperature the whole
time. And yes, I've also noticed
that the pain gets worse after eating.
This started yesterday evening
after dinner. At first,
I thought it was somehow due to the
food because I had a big meal, and
I thought maybe it was bad.
This morning when I woke up, it was
a little better, but after
lunch, which was also my first meal of the day,
the levels got
very high again.
Okay, where exactly is the pain? Can
you show me? Yes, it's in the
upper abdomen, on the
right side. Clearly, it's strongest there,
although sometimes I'm not so sure exactly
where. I can pinpoint it, but
the pain radiates most strongly in that area, to
other body regions,
into the back or downwards, or
somehow in another direction. The pain radiates
into the lower abdomen, and
Okay, has anything else come up
since you've had the pain, or has your
appetite changed recently? Have you unintentionally gained
or lost weight in the last few weeks?
No, not that. I don't
think I've gained or lost any weight, and my appetite
is completely normal.
What I've noticed is that I have a
burning sensation, which I didn't have before. Heartburn has increased.
I'd say this has been going on for about two months. It's good that you've observed this.
Mrs. Westenberger, are there any pre-existing
conditions I should know about?
Yes, I've had high blood pressure for
several years.
Since when have you been... Do you fit?
Yes, we are 67 years old. Okay, and
my last examinations showed that my
cholesterol levels were replenished. Okay,
cholesterol in... Do you take any medication for it?
How much? Once a day. [Music]
[Music]
How much? milligrams 20 40 and 80 20
milligrams 20 milligrams all right do
you take any other medications
I occasionally take Klo Verlag
very good Have you ever had
surgery Mrs. Westenberger very good good
Are you vaccinated
I am the one who is perfect at heart here how are things with you
otherwise your
physical sensations are you feeling well do you feel well do you feel well do you
feel that something has changed
recently can you sleep well
or do you sweat more or anything
like that well I don't feel
bad at all
I was able to lose a few kilos but well
I've been meaning to do that for a few
years now otherwise
yes I sleep well what I
very strong headaches at night do you even have to change your t-
shirt or is it sometimes not possible not
every time but
sometimes it is very strong okay Mrs.
Westenberger do you have any
allergies to medications or foods food
foods food
intolerances yes I
have a gluten intolerance yes and
a pollen allergy too and that now
for spring in spring yes I am because of it
Again, Mrs. Westenberger, how is
your cycle? Do
you still get your period? Do you get it
regularly? Do you have any problems with it? I
get it regularly, haven't had any
problems with it so far. Wonderful. Do you
take the pill? No, no, Mrs.
Westenberger. Do you smoke?
I hope so. How much? May I ask?
Not that much? I'd estimate five
to ten cigarettes a day.
Okay, and for how long? For 15 years.
years. [Music] Do
[Music] Do
you also drink alcohol
occasionally? That means once a week
or once a month. So, once a
week, not new. I would say once
every two weeks. When I
meet up with friends, we have a twig, but...
or a wine spritzer at the party.
Okay, great, Mrs. Westenberger.
Please don't take this personally. It's just a
routine question I'm going to ask you now.
I had to ask it, though, which is why I'm asking it. Do you
take any other drugs? For
example, do you also use marijuana or take a
course? No, for God's sake, no.
Very good. That's very good. What about
your family? Are there any pre-existing
illnesses in your family that might concern
me? Relevant things could include, for example,
a heart attack, diabetes, or
kidney disease, or English...
so yes, my father had a heart attack,
heart attack,
luckily he recovered very well,
that makes me happy. And my mother has
diabetes and high blood pressure,
both are alive, but yes, both are doing well, thank God. Do you have siblings?
No, I'm a target. Do you know Mrs.
Westenberger? Are you married?
My husband unfortunately passed away
a few years ago.
No, I'm sorry. Yes, thank you very much, I'm very sorry. Was
he ill
or was it an accident?
He was ill. May I ask what your
husband had?
He had colon cancer. Unfortunately, we
found out too late. And what? I'm very sorry.
Thank you, it's always very sad, Mrs. Westenberger.
Yes, do you have children?
I have two children, a son and his
daughter. Are they both healthy? Luckily,
they are. That's not very nice,
that makes me happy. Did you stay
with your children or have
they already left home?
My daughter still lives with me, my son has
already moved out.
Okay, what do you actually do for a
living, Mrs. Westenberger? I
you also perform weddings, yes, oh how wonderful!
So, if you'd like to get married,
you're welcome to come to me.
Now, back to that. Thank you very much
for the offer. I have one more question, Ms.
Westenberger. Have you been abroad recently?
No. Okay, wonderful, good. From my side,
that will be fine. Do you have any more questions for me?
me?
What did you mean then? Could that be it? It's
now my legal right to
measure it easily, or I ca
n't tell you for sure yet. However, I
suspect inflammation of
your gallbladder. To confirm this, I naturally need to conduct a few more tests. I would like to take a blood sample for that. I would also like to palpate your abdomen. Furthermore, I would like to perform an ultrasound of your abdomen in January, just to be on the
safe side.
And as soon as I have all the results and
findings, I can
tell you exactly what it is. Yes, great. Okay, good.
I would like to briefly go over
the information
I've noted down with you again so that I
know everything is correct and
complete, and then we can
begin the examinations.
Okay. So, Ms. Westenberger, you've had
severe abdominal pain since yesterday evening.
These are cramps that occur briefly each time.
occur briefly each time.
You've also had constant abdominal pain
since yesterday evening, and the intensity of the pain varies considerably.
considerably.
That is, when you don't have a cramp,
the pain intensity is four to
five on a pain scale; when you do have
a cramp, the
pain intensity is an 8. The
pain is intensified when you
eat and radiates to your lower abdomen
and back.
You reported that you vomited
three times since yesterday evening
and again since noon today.
Yes, that's correct. You also
noticed that you've had a fever since yesterday evening—
38.7°C yesterday,
only 38.5°C today—
and that you've been experiencing increased heartburn for the past two months. Well, okay,
wonderful. That's the most
important thing for me right now.
I would ask you to
go to the next room
so we
can carry out the examinations. Please also ask you to
undress your upper body, specifically your abdomen,
so I can examine you. I can examine you right away
and also perform the ultrasound there,
and then as soon as I've
discussed the findings with the senior physician,
I'll get back to you with a more
precise diagnosis. Yes, okay,
you're welcome, Ms.
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