病史采集(英文)课件.ppt

History Taking2011/09/062011/09/06ImportanceData for making diagnosis Clue for PE,Lab and other examinationPatient-doctor relationshipBio-psycho-social medical approachAlways,the first step to treat patient2011/09/062011/09/06A“good physician”A good observerA good communicator A good critic A good decision maker A good student-now and later 2011/09/062011/09/06Basic PrinciplesCommunicationInterviewers skillEstablish trustQuestions understandable to patientInterpreter if necessaryMain purpose of interviewObtain basic information related to patients illness or reason for visit2011/09/062011/09/06Basic PrinciplesInterviewer Cheerful,friendly,but respectful and genuinely concerned about the patientNovice interviewersHave to gain experience asking questions about subjects that are more painful,delicate or unpleasantPermit patient to express themselves in their own words2011/09/062011/09/06n n Observe body language for nonverbal clues Observe body language for nonverbal cluesn n Listening without interruption:is important Listening without interruption:is important and requires skill.and requires skill.n n If you interrupt the patient you can If you interrupt the patient you can disrupt the disrupt the patients train of thoughtpatients train of thoughtn nIN GENERAL:IN GENERAL:Listen moreListen more Talk less and Talk less and Interrupt infrequently Interrupt infrequently2011/09/062011/09/06Basic PrinciplesIf patient gives a vague historyAsk more direct questionsListen without any suggestion of prejudiceTreat all patients with respectRegardless of their age,gender,beliefs,intelligence,educational background,legal status,practices,culture,illness,body habitus,emotional condition,or economic state2011/09/062011/09/06Basic PrinciplesFollow the“rule of five vowels”uditionListen carefully valuationSort out relevant from irrelevant data nquiryProbe into significant areas requiring more clarification bservationImportance of nonverbal communicationRegardless of what is said nderstandingOf patients concerns and apprehensionsPlay empathetic role2011/09/062011/09/06General:Greet the patient Adequately identify yourself and your purposeAllow patients privacy and comfort during exam2011/09/062011/09/06Identify YourselfUse Mr./Mrs./Ms(Patients name)formal address clarifies the professional nature of the interviewEx: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.2011/09/062011/09/06The contents of inquiry 1 general data 2 chief complaints 3 present illness 4 past medical history 5 systems review 6 personal history 7 marital history 8 menstrual history 9 childbearing history 10 family history 2011/09/062011/09/06General Data Name Native placeSex AddressAge Date of admission Race Date of record Occupation NarratorMarriage Reliability 2011/09/062011/09/06Chief ComplaintChief complaintCC:a sentence that describe patients main un-comfort and its/their duration by patients words Main symptom or signs.The timing and duration.2011/09/062011/09/06Chief Complaint(s):Note patients complaint in their own words.Keep it brief and conciseDo not change laymen terms into medical vocabularyYou must communicate with the intention of being understood.Include length of time complaint has been going on(if applicable)2011/09/062011/09/06The History of The Present illnessHistory of Present Illness or HPI:It refers to recent changes in health that led the patient to seek medical attention at this timeIt describes the information relevant to the chief complaintUse chronological order to organize historyBe very thorough2011/09/062011/09/06History of Present Illness:A clear,chronological narrative includes:Onset of problemSetting in which it developedManifestationsAssociated manifestationsAny treatments General state:appetite,sleeping,urine,bowel movement,body weight,ect.Principal symptoms described in terms of:Location QualityQuantity or severityTiming(onset,duration,frequency)SettingFactors that aggravated or relievedAssociated manifestations 2011/09/062011/09/06Free of other unrelated information“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,he experienced pain in his chest”“The man was well until April 1982,when while walking easily,he had chest pain”2011/09/062011/09/06Past Medical History General state of health.Past illness(include Childhood illnesses,Adult illnesses,Psychiatric illnesses,especially any infectious diseases).Past surgical history and Accidents and injuries history.VaccinationsAllergy history2011/09/062011/09/06Past Medical History:General Health and VigorHow patient feels their general health has been to dateChildhood Illnesses and development:Ask about measles,rubella,mumps,varicella(chicken pox),rheumatic fever,scarlet fever*and pneumonia.Were there any developmental issues?Short stature,cerebral palsy,etc.*Scarlet fever is caused by Streptococcus group A,producing a rash,sometimes,in patients that have strep throat2011/09/062011/09/06Past Medical History:Adult Significant Illnesses or conditions:Examples:recurrent sore throatsurinary tract infectionsyeast infectionshypertensiondiabetes coronary arterial disease Note time of onset or date of diagnosiscontrol of disease or conditiontreatment,if any2011/09/062011/09/06Past Medical History:Accidents or injuries including fracturesNote date&complications if anyIf injury required surgical intervention,can describe it in detail here.Trauma due to motor vehicle collisionsGet details about accident:passenger/driver,restrained/unrestrained,fractures,etc.2011/09/062011/09/06Past Medical History: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 helpful.2011/09/062011/09/06Past Surgical History:Note reason for surgery if not obvious Ex:Total abdominal hysterectomy secondary to problems with dysfunctional uterine bleeding vs.gynecologic cancer Note any complicationsUse chronological order&number or use a separate paragraph if more than one surgical procedure2011/09/062011/09/06Past Surgical History:example1.Appendectomy in 1973;Queens 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.2011/09/062011/09/06Past Medical History:Preventive Health:Current immunization status will depend on age of patient&associated conditionsTetanus(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 vaccination2011/09/062011/09/06Allergy history Allergy Describe not only what the patient is allergic to,but also the manifestation of that allergy Side effect or allergy 2011/09/062011/09/06Review of systems A printed form that contains the questions that you usually askIf 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”2011/09/062011/09/06Admission Notes-Systems ReviewGeneral:weakness,fatigue,anorexia,fever,insomniaIntegument(skin,hair,nails):changes in color(pigmentation,jaundice,cyanosis),pruritus,rash,hair lossHEENT:Head:headache,dizziness,vertigoEyes:visual acuity,color vision,corrective lenses,photophobia,diplopia,painEars:pain,discharge,hearing loss,tinnitusNose:epistaxis,discharge,stuffiness,sense of smellThroat: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 limbs2011/09/062011/09/06Admission Notes-Systems ReviewGI: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,impotenceFemale-menarche,menstrual history(including 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,speech disturbance,loss of sensation,paresthesis,ataxia,weakness or paralysis,tremor,anxiety,depression,irritabilityMusculoskeletal:joint pain,stiffness,limitation of motion,muscular weakness,wasting2011/09/062011/09/06Personal historyplace of birth current residence educational background economic status living conditions professional working conditionsSmoking _ Packs for_ years,quitting for_ yearDrinking Illicit drugs Heroin,Travel2011/09/062011/09/06Menstrual and Childbearing History age 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 operative delivery puerperal fever record menstrual history as follows menstrual duration Age of LMP onset interval between periods 513 2008-03-05 30 513 50 302011/09/062011/09/06Marrital History married or unmarried marriage age relations of couple2011/09/062011/09/06Family History:wAsk about&summarize nagesnstate of healthnAge and cause of death(if applicable)wof 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 2011/09/062011/09/06Summary Inquiry The importance of inquiry The contents of inquiry chief complaints history of present illness The methods and skills of inquiry2011/09/062011/09/06