2022年醫(yī)學(xué)專題-病史采集(英文)

HistoryTaking2011/09/06第一頁，共三十七頁。ImportanceDataformakingdiagnosisClueforPE,LabandotherexaminationPatient-doctorrelationshipBio-psycho-socialmedicalapproachAlways,thefirststeptotreatpatient2011/09/06第二頁，共三十七頁。A“goodphysician”AgoodobserverAgoodcommunicatorAgoodcriticAgooddecisionmakerAgoodstudent---nowandlater2011/09/06第三頁，共三十七頁。BasicPrinciplesCommunicationInterviewer’sskillEstablishtrustQuestionsunderstandabletopatientInterpreterifnecessaryMainpurposeofinterviewObtainbasicinformationrelatedtopatient’sillnessorreasonforvisit2011/09/06第四頁，共三十七頁。BasicPrinciplesInterviewerCheerful,friendly,butrespectfulandgenuinelyconcernedaboutthepatientNoviceinterviewersHavetogainexperienceaskingquestionsaboutsubjectsthataremorepainful,delicateorunpleasantPermitpatienttoexpressthemselvesintheirownwords2011/09/06第五頁，共三十七頁。ObservebodylanguagefornonverbalcluesListeningwithoutinterruption:isimportantandrequiresskill.Ifyouinterruptthepatientyoucandisruptthepatient’strainofthoughtINGENERAL:

ListenmoreTalklessandInterruptinfrequently2011/09/06第六頁，共三十七頁。BasicPrinciplesIfpatientgivesavaguehistoryAskmoredirectquestionsListenwithoutanysuggestionofprejudiceTreatallpatientswithrespectRegardlessoftheirage,gender,beliefs,intelligence,educationalbackground,legalstatus,practices,culture,illness,bodyhabitus,emotionalcondition,oreconomicstate2011/09/06第七頁，共三十七頁。BasicPrinciplesFollowthe“ruleoffivevowels”uditionListencarefullyvaluationSortoutrelevantfromirrelevantdatanquiryProbeintosignificantareasrequiringmoreclarificationbservationImportanceofnonverbalcommunicationRegardlessofwhatissaidnderstandingOfpatient’sconcernsandapprehensionsPlayempatheticrole2011/09/06第八頁，共三十七頁。General: GreetthepatientAdequatelyidentifyyourselfandyourpurposeAllowpatient’sprivacyandcomfortduringexam2011/09/06第九頁，共三十七頁。IdentifyYourselfUseMr./Mrs./Ms(Patient’sname)formaladdressclarifiestheprofessionalnatureoftheinterviewEx:Iamamedicalstudentworkingfor(Preceptor’sName)whohasaskedmetodoaninterviewandgeneralexaminationforyou.Mynameis…..2011/09/06第十頁，共三十七頁?！颰hecontentsofinquiry

1generaldata

﹡2chiefcomplaints

﹡3presentillness

4pastmedicalhistory

5systemsreview

6personalhistory

7maritalhistory

8menstrualhistory

9childbearinghistory

10familyhistory

2011/09/06第十一頁，共三十七頁。GeneralData

Name●NativeplaceSex●AddressAge●DateofadmissionRace●DateofrecordOccupation●NarratorMarriage●Reliability2011/09/06第十二頁，共三十七頁。ChiefComplaint第十三頁，共三十七頁。ChiefcomplaintCC:asentencethatdescribepatient’smainun-comfortandits/theirdurationbypatient’swords

Mainsymptomorsigns.Thetimingandduration.2011/09/06第十四頁，共三十七頁。ChiefComplaint(s):Notepatient’scomplaintintheirownwords.KeepitbriefandconciseDonotchangelaymentermsintomedicalvocabularyYoumustcommunicatewiththeintentionofbeingunderstood.Includelengthoftimecomplainthasbeengoingon(ifapplicable)2011/09/06第十五頁，共三十七頁。TheHistoryofThePresentillness第十六頁，共三十七頁。HistoryofPresentIllnessorHPI:ItreferstorecentchangesinhealththatledthepatienttoseekmedicalattentionatthistimeItdescribestheinformationrelevanttothechiefcomplaintUsechronologicalordertoorganizehistoryBeverythorough2011/09/06第十七頁，共三十七頁。HistoryofPresentIllness:Aclear,chronologicalnarrativeincludes:OnsetofproblemSettinginwhichitdevelopedManifestationsAssociatedmanifestationsAnytreatmentsGeneralstate

:appetite,sleeping,urine,bowelmovement,bodyweight,ect.Principalsymptomsdescribedintermsof:LocationQualityQuantityorseverityTiming(onset,duration,frequency)SettingFactorsthataggravatedorrelievedAssociatedmanifestations2011/09/06第十八頁，共三十七頁。Freeofotherunrelatedinformation“Thepatientnoted”,“Thepatientstatedthathewas…atthattime”“HewaswelluntilApril1982,when,whilewalkingdownthestreetonasunnyday,withthebirdssingingoverhead,heexperiencedpaininhischest”“ThemanwaswelluntilApril1982,whenwhilewalkingeasily,hehadchestpain”2011/09/06第十九頁，共三十七頁。PastMedicalHistoryGeneralstateofhealth.Pastillness(includeChildhoodillnesses,Adultillnesses,Psychiatricillnesses,especiallyanyinfectiousdiseases).PastsurgicalhistoryandAccidentsandinjurieshistory.VaccinationsAllergyhistory2011/09/06第二十頁，共三十七頁。PastMedicalHistory:GeneralHealthandVigorHowpatientfeelstheirgeneralhealthhasbeentodateChildhoodIllnessesanddevelopment:Askaboutmeasles,rubella,mumps,varicella(chickenpox),rheumaticfever,scarletfever*andpneumonia.Werethereanydevelopmentalissues?Shortstature,cerebralpalsy,etc.*ScarletfeveriscausedbyStreptococcusgroupA,producingarash,sometimes,inpatientsthathavestrepthroat2011/09/06第二十一頁，共三十七頁。PastMedicalHistory:AdultSignificantIllnessesorconditions:

Examples:recurrentsorethroatsurinarytractinfectionsyeastinfectionshypertensiondiabetescoronaryarterialdiseaseNotetimeofonsetordateofdiagnosiscontrolofdiseaseorconditiontreatment,ifany2011/09/06第二十二頁，共三十七頁。PastMedicalHistory:Accidentsorinjuries

includingfracturesNotedate&complicationsifanyIfinjuryrequiredsurgicalintervention,candescribeitindetailhere.TraumaduetomotorvehiclecollisionsGetdetailsaboutaccident:passenger/driver,restrained/unrestrained,fractures,etc. 2011/09/06第二十三頁，共三十七頁。PastMedicalHistory:Askaboutanysignificantcareorotherhospitalizationsnotcovered.Askabouttoxicand/orIndustrialexposure.Asktactfullyaboutanypsychiatrichistoryorhospitalization.Ifpatienthadmultiplesurgeries,thenaseparatecategorywouldbehelpful.2011/09/06第二十四頁，共三十七頁。PastSurgicalHistory:NotereasonforsurgeryifnotobviousEx:Totalabdominalhysterectomysecondarytoproblemswithdysfunctionaluterinebleedingvs.gynecologiccancerNoteanycomplicationsUsechronologicalorder&numberoruseaseparateparagraphifmorethanonesurgicalprocedure2011/09/06第二十五頁，共三十七頁。PastSurgicalHistory:exampleAppendectomyin1973;QueenshospitalinNewYorkbyDr.Carter,lengthofstayof3days.Generalanesthesiawithoutreaction.Nocomplications.Laparoscopiccholecystectomyin1988;inAlbuquerqueHospitalbyDr.Greenwithlengthofstayof3days.Spinalanesthesiawithoutreaction.Nocomplications.2011/09/06第二十六頁，共三十七頁。PastMedicalHistory:PreventiveHealth:Currentimmunizationstatus–willdependonageofpatient&associatedconditionsTetanus(notedate)andHepatitisBseriesBCG(bacilliCalmette-Guerin)vaccinationnotgiventothoseinUS,butaskresidentsfromothercountriesiftheyhavehadthevaccination2011/09/06第二十七頁，共三十七頁。AllergyhistoryAllergyDescribenotonlywhatthepatientisallergicto,butalsothemanifestationofthatallergySideeffectorallergy2011/09/06第二十八頁，共三十七頁。Reviewofsystems AprintedformthatcontainsthequestionsthatyouusuallyaskIfyourpatienthasachiefcomplaintinvolvingtheGIsystem,thereviewofsystemwillbeincludedintheHPIaspertinentpositivesandnegatives.“SeeHPI”2011/09/06第二十九頁，共三十七頁。AdmissionNotes-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,coldlimbs2011/09/06第三十頁，共三十七頁。AdmissionNotes-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,wasting2011/09/06第三十一頁，共三十七頁。Personalhistoryplaceofbirth

currentresidence

educationalbackground

economicstatus

livingconditions

professional

workingconditionsSmoking__Packsfor__years,quittingfor__yearDrinkingIllicitdrugsHeroin,Travel2011/09/06第三十二頁，共三十七頁。MenstrualandChildbearingHistoryageofonset

intervalbetweenperiods

duration

amountofflow

dateoflastmenstrualperiod(LMP)

ageofmenopause

ageofpregnancyand

childbirth

timesofartificialornatural

abortions

stillbirthoperativedeliverypuerperalfever

recordme