病史采集(英文)课件.ppt

1、History Taking Data for making diagnosis Clue for PE,Lab and other examination Patient-doctor relationship Bio-psycho-social medical approach Always,the first step to treat patient A good observer A good communicator A good critic A good decision maker A good student-now and later Communication Inte

2、rviewers skill Establish trust Questions understandable to patient Interpreter if necessary Main purpose of interview Obtain basic information related to patients illness or reason for visit Interviewer Cheerful,friendly,but respectful and genuinely concerned about the patient Novice interviewers Ha

3、ve to gain experience asking questions about subjects that are more painful,delicate or unpleasant Permit patient to express themselves in their own words If patient gives a vague history Ask more direct questions Listen without any suggestion of prejudice Treat all patients with respect Regardless

4、of their age,gender,beliefs,intelligence,educational background,legal status,practices,culture,illness,body habitus,emotional condition,or economic stateFollow the“rule of five vowels”udition Listen carefully valuation Sort out relevant from irrelevant data nquiry Probe into significant areas requir

5、ing more clarification bservation Importance of nonverbal communication Regardless of what is said nderstanding Of patients concerns and apprehensions Play empathetic role Greet the patient Adequately identify yourself and your purpose Allow patients privacy and comfort during exam Use Mr./Mrs./Ms(P

6、atients name)formal address clarifies the professional nature of the interview Ex:I am a medical student working for(Preceptors Name)who has asked me to do an interview and general examination for you.My name is.Name Native place Sex Address Age Date of admission Race Date of record Occupation Narra

7、tor Marriage Reliability CC:a sentence that describe patients main un-comfort and its/their duration by patients words Main symptom or signs.The timing and duration.Note patients complaint in their own words.Keep it brief and concise Do not change laymen terms into medical vocabulary You must commun

8、icate with the intention of being understood.Include length of time complaint has been going on(if applicable)It refers to recent changes in health that led the patient to seek medical attention at this time It describes the information relevant to the chief complaint Use chronological order to orga

9、nize history Be very thoroughA clear,chronological narrative includes:Onset of problem Setting in which it developed Manifestations Associated manifestations Any treatments General state:appetite,sleeping,urine,bowel movement,body weight,ect.Principal symptoms described in terms of:Location Quality

10、Quantity or severity Timing(onset,duration,frequency)Setting Factors that aggravated or relieved Associated manifestations “The patient noted”,“The patient stated that he was at that time”“He was well until April 1982,when,while walking down the street on a sunny day,with the birds singing overhead,

11、he experienced pain in his chest”“The man was well until April 1982,when while walking easily,he had chest pain”General state of health.Past illness(include Childhood illnesses,Adult illnesses,Psychiatric illnesses,especially any infectious diseases).Past surgical history and Accidents and injuries

12、history.Vaccinations Allergy history General Health and Vigor How patient feels their general health has been to date Childhood Illnesses and development:Ask about measles,rubella,mumps,varicella(chicken pox),rheumatic fever,scarlet fever*and pneumonia.Were there any developmental issues?Short statu

13、re,cerebral palsy,etc.*Scarlet fever is caused by Streptococcus group A,producing a rash,sometimes,in patients that have strep throat Adult Significant Illnesses or conditions:Examples:recurrent sore throats urinary tract infections yeast infections hypertension diabetes coronary arterial disease No

14、te time of onset or date of diagnosis control of disease or condition treatment,if any Accidents or injuries including fractures Note date&complications if any If injury required surgical intervention,can describe it in detail here.Trauma due to motor vehicle collisions Get details about accident:pa

15、ssenger/driver,restrained/unrestrained,fractures,etc.Ask about any significant care or other hospitalizations not covered.Ask about toxic and/or Industrial exposure.Ask tactfully about any psychiatric history or hospitalization.If patient had multiple surgeries,then a separate category would be help

16、ful.Note reason for surgery if not obvious Ex:Total abdominal hysterectomy secondary to problems with dysfunctional uterine bleeding vs.gynecologic cancer Note any complications Use chronological order&number or use a separate paragraph if more than one surgical procedure1.Appendectomy in 1973;Queen

17、s hospital in New York by Dr.Carter,length of stay of 3 days.General anesthesia without reaction.No complications.2.Laparoscopic cholecystectomy in 1988;in Albuquerque Hospital by Dr.Green with length of stay of 3 days.Spinal anesthesia without reaction.No complications.Preventive Health:Current imm

18、unization status will depend on age of patient&associated conditions Tetanus(note date)and Hepatitis B series BCG(bacilli Calmette-Guerin)vaccination not given to those in US,but ask residents from other countries if they have had the vaccination Allergy Describe not only what the patient is allergi

19、c to,but also the manifestation of that allergy Side effect or allergy A printed form that contains the questions that you usually ask If your patient has a chief complaint involving the GI system,the review of system will be included in the HPI as pertinent positives and negatives.“See HPI”General:

20、weakness,fatigue,anorexia,fever,insomniaIntegument(skin,hair,nails):changes in color(pigmentation,jaundice,cyanosis),pruritus,rash,hair lossHEENT:Head:headache,dizziness,vertigo Eyes:visual acuity,color vision,corrective lenses,photophobia,diplopia,pain Ears:pain,discharge,hearing loss,tinnitus Nose

21、:epistaxis,discharge,stuffiness,sense of smell Throat:status of teeth,gums,dentures,taste,soreness,hoarseness,lumpRespiratory:cough,sputum,hemoptysis,wheezingCV:dyspnea(on exertion,at rest,paroxysmal nocturnal dyspnea,orthopnea),edema,chest distress/pain,palpitation,intermittent claudication,cold li

22、mbsGI:dysphagia,nausea,vomiting,abdominal distress pain,change in bowel habit(diarrhea,constipation,character of stool),hematemesis,melena,bloody stoolGU:urinary frequency,hesitancy,urgency,dribbling,incontinence,dysuria,hematuria,nocturia,polyuria,impotence Female-menarche,menstrual history(includi

23、ng the date of last period),vaginal bleeding or discharge,pregnancy Metabolic and endocrine:growth and development,weight change,heat/cold intolerance,nervousness,sweating,polydipsiaHematologic:anemia,easy brusity or bleeding,lymphoadenopathy,transfusionNeuropsychiatry:dizziness,syncope,seizures,spe

24、ech disturbance,loss of sensation,paresthesis,ataxia,weakness or paralysis,tremor,anxiety,depression,irritabilityMusculoskeletal:joint pain,stiffness,limitation of motion,muscular weakness,wasting place of birth current residence educational background economic status living conditions professional

25、working conditions Smoking _ Packs for_ years,quitting for_ year Drinking Illicit drugs Heroin,Travelage of onset interval between periods duration amount of flow date of last menstrual period(LMP)age of menopause age of pregnancy and childbirth times of artificial or natural abortions stillbirth op

26、erative delivery puerperal fever record menstrual history as follows menstrual duration Age of LMP onset interval between periods 513 2008-03-05 30 513 50 30 married or unmarried marriage age relations of coupleFamily History:w Ask about&summarize nagesnstate of healthnAge and cause of death(if appl

27、icable)w of family members parents,siblings,spouse,and childrenlInquire about any similar symptoms or signs in family members if patient presents with inheritable symptoms or signslExample:thyroid disorders,cancers,diabetes Inquiry The importance of inquiry The contents of inquiry chief complaints history of present illness The methods and skills of inquiry