病史采集(英文)課件

HistoryTaking2011/09/06ImportanceDataformakingdiagnosisClueforPE,LabandotherexaminationPatient-doctorrelationshipBio-psycho-socialmedicalapproachAlways,thefirststeptotreatpatient2011/09/06A“goodphysician”AgoodobserverAgoodcommunicatorAgoodcriticAgooddecisionmakerAgoodstudent---nowandlater2011/09/06BasicPrinciplesInterviewerCheerful,friendly,butrespectfulandgenuinelyconcernedaboutthepatientNoviceinterviewersHavetogainexperienceaskingquestionsaboutsubjectsthataremorepainful,delicateorunpleasantPermitpatienttoexpressthemselvesintheirownwords2011/09/06ObservebodylanguagefornonverbalcluesListeningwithoutinterruption:isimportantandrequiresskill.Ifyouinterruptthepatientyoucandisruptthepatient’strainofthoughtINGENERAL:

ListenmoreTalklessandInterruptinfrequently2011/09/06BasicPrinciplesIfpatientgivesavaguehistoryAskmoredirectquestionsListenwithoutanysuggestionofprejudiceTreatallpatientswithrespectRegardlessoftheirage,gender,beliefs,intelligence,educationalbackground,legalstatus,practices,culture,illness,bodyhabitus,emotionalcondition,oreconomicstate2011/09/06BasicPrinciplesFollowthe“ruleoffivevowels”uditionListencarefullyvaluationSortoutrelevantfromirrelevantdatanquiryProbeintosignificantareasrequiringmoreclarificationbservationImportanceofnonverbalcommunicationRegardlessofwhatissaidnderstandingOfpatient’sconcernsandapprehensionsPlayempatheticroleAEIOU2011/09/06IdentifyYourselfUseMr./Mrs./Ms(Patient’sname)formaladdressclarifiestheprofessionalnatureoftheinterviewEx:Iamamedicalstudentworkingfor(Preceptor’sName)whohasaskedmetodoaninterviewandgeneralexaminationforyou.Mynameis…..2011/09/06GeneralData

Name●NativeplaceSex●AddressAge●DateofadmissionRace●DateofrecordOccupation●NarratorMarriage●Reliability2011/09/06ChiefcomplaintCC:asentencethatdescribepatient’smainun-comfortandits/theirdurationbypatient’swords

Mainsymptomorsigns.Thetimingandduration.2011/09/06ChiefComplaint(s):Notepatient’scomplaintintheirownwords.KeepitbriefandconciseDonotchangelaymentermsintomedicalvocabularyYoumustcommunicatewiththeintentionofbeingunderstood.Includelengthoftimecomplainthasbeengoingon(ifapplicable)2011/09/06TheHistoryofThePresentillnessHistoryofPresentIllnessorHPI:ItreferstorecentchangesinhealththatledthepatienttoseekmedicalattentionatthistimeItdescribestheinformationrelevanttothechiefcomplaintUsechronologicalordertoorganizehistoryBeverythorough2011/09/06HistoryofPresentIllness:Aclear,chronologicalnarrativeincludes:OnsetofproblemSettinginwhichitdevelopedManifestationsAssociatedmanifestationsAnytreatmentsGeneralstate

:appetite,sleeping,urine,bowelmovement,bodyweight,ect.Principalsymptomsdescribedintermsof:LocationQualityQuantityorseverityTiming(onset,duration,frequency)SettingFactorsthataggravatedorrelievedAssociatedmanifestations2011/09/06PastMedicalHistoryGeneralstateofhealth.Pastillness(includeChildhoodillnesses,Adultillnesses,Psychiatricillnesses,especiallyanyinfectiousdiseases).PastsurgicalhistoryandAccidentsandinjurieshistory.VaccinationsAllergyhistory2011/09/06PastMedicalHistory:GeneralHealthandVigorHowpatientfeelstheirgeneralhealthhasbeentodateChildhoodIllnessesanddevelopment:Askaboutmeasles,rubella,mumps,varicella(chickenpox),rheumaticfever,scarletfever*andpneumonia.Werethereanydevelopmentalissues?Shortstature,cerebralpalsy,etc.*ScarletfeveriscausedbyStreptococcusgroupA,producingarash,sometimes,inpatientsthathavestrepthroat2011/09/06PastMedicalHistory:Accidentsorinjuries

includingfracturesNotedate&complicationsifanyIfinjuryrequiredsurgicalintervention,candescribeitindetailhere.TraumaduetomotorvehiclecollisionsGetdetailsaboutaccident:passenger/driver,restrained/unrestrained,fractures,etc. 2011/09/06PastMedicalHistory:Askaboutanysignificantcareorotherhospitalizationsnotcovered.Askabouttoxicand/orIndustrialexposure.Asktactfullyaboutanypsychiatrichistoryorhospitalization.Ifpatienthadmultiplesurgeries,thenaseparatecategorywouldbehelpful.2011/09/06PastSurgicalHistory:exampleAppendectomyin1973;QueenshospitalinNewYorkbyDr.Carter,lengthofstayof3days.Generalanesthesiawithoutreaction.Nocomplications.Laparoscopiccholecystectomyin1988;inAlbuquerqueHospitalbyDr.Greenwithlengthofstayof3days.Spinalanesthesiawithoutreaction.Nocomplications.2011/09/06PastMedicalHistory:PreventiveHealth:Currentimmunizationstatus–willdependonageofpatient&associatedconditionsTetanus(notedate)andHepatitisBseriesBCG(bacilliCalmette-Guerin)vaccinationnotgiventothoseinUS,butaskresidentsfromothercountriesiftheyhavehadthevaccination2011/09/06AllergyhistoryAllergyDescribenotonlywhatthepatientisallergicto,butalsothemanifestationofthatallergySideeffectorallergy2011/09/06AdmissionNotes-SystemsReviewGeneral:weakness,fatigue,anorexia,fever,insomniaIntegument(skin,hair,nails):changesincolor(pigmentation,jaundice,cyanosis),pruritus,rash,hairlossHEENT:Head:headache,dizziness,vertigoEyes:visualacuity,colorvision,correctivelenses,photophobia,diplopia,painEars:pain,discharge,hearingloss,tinnitusNose:epistaxis,discharge,stuffiness,senseofsmellThroat:statusofteeth,gums,dentures,taste,soreness,hoarseness,lumpRespiratory:cough,sputum,hemoptysis,wheezingCV:dyspnea(onexertion,atrest,paroxysmalnocturnaldyspnea,orthopnea),edema,chestdistress/pain,palpitation,intermittentclaudication,coldlimbs2011/09/06AdmissionNotes-SystemsReviewGI:dysphagia,nausea,vomiting,abdominaldistresspain,changeinbowelhabit(diarrhea,constipation,characterofstool),hematemesis,melena,bloodystoolGU:urinaryfrequency,hesitancy,urgency,dribbling,incontinence,dysuria,hematuria,nocturia,polyuria,impotenceFemale-menarche,menstrualhistory(includingthedateoflastperiod),vaginalbleedingordischarge,pregnancyMetabolicandendocrine:growthanddevelopment,weightchange,heat/coldintolerance,nervousness,sweating,polydipsiaHematologic:anemia,easybrusityorbleeding,lymphoadenopathy,transfusionNeuropsychiatry:dizziness,syncope,seizures,speechdisturbance,lossofsensation,paresthesis,ataxia,weaknessorparalysis,tremor,anxiety,depression,irritabilityMusculoskeletal:jointpain,stiffness,limitationofmotion,muscularweakness,wasting2011/09/06Personalhistoryplaceofbirth

currentresidence

educationalbackground

economicstatus

livingconditions

professional

workingconditionsSmoking__Packsfor__years,quittingfor__yearDrinkingIllicitdrugsHeroin,Travel2011/09/06MenstrualandChildbearingHistoryageofonset

intervalbetweenperiods

duration

amountofflow

dateoflastmenstrualperiod(LMP)

ageofmenopause

ageofpregnancyand

childbirth

timesofartificialornatural

abortions

stillbirthoperativedeliverypuerperalfever

recordmenstrualhistoryasfollows

menstrual

du