病史采集(英文)

2011/09/06HistoryTaking2011/09/06Importance•Dataformakingdiagnosis•ClueforPE,Labandotherexamination•Patient-doctorrelationship•Bio-psycho-socialmedicalapproach•Always,thefirststeptotreatpatient2011/09/06A“goodphysician”•Agoodobserver•Agoodcommunicator•Agoodcritic•Agooddecisionmaker•Agoodstudent---nowandlater2011/09/06BasicPrinciples•Communication–Interviewer’sskill–Establishtrust–Questionsunderstandabletopatient–Interpreterifnecessary•Mainpurposeofinterview–Obtainbasicinformationrelatedtopatient’sillnessorreasonforvisit2011/09/06BasicPrinciples•Interviewer–Cheerful,friendly,butrespectfulandgenuinelyconcernedaboutthepatient•Noviceinterviewers–Havetogainexperienceaskingquestionsaboutsubjectsthataremorepainful,delicateorunpleasant•Permitpatienttoexpressthemselvesintheirownwords2011/09/06ObservebodylanguagefornonverbalcluesListeningwithoutinterruption:isimportantandrequiresskill.Ifyouinterruptthepatientyoucandisruptthepatient’strainofthoughtINGENERAL:ListenmoreTalklessandInterruptinfrequently2011/09/06BasicPrinciples•Ifpatientgivesavaguehistory–Askmoredirectquestions•Listenwithoutanysuggestionofprejudice•Treatallpatientswithrespect–Regardlessoftheirage,gender,beliefs,intelligence,educationalbackground,legalstatus,practices,culture,illness,bodyhabitus,emotionalcondition,oreconomicstate2011/09/06BasicPrinciplesFollowthe“ruleoffivevowels”•udition–Listencarefully•valuation–Sortoutrelevantfromirrelevantdata•nquiry–Probeintosignificantareasrequiringmoreclarification•bservation–Importanceofnonverbalcommunication–Regardlessofwhatissaid•nderstanding–Ofpatient’sconcernsandapprehensions–Playempatheticrole2011/09/06General:•Greetthepatient•Adequatelyidentifyyourselfandyourpurpose•Allowpatient’sprivacyandcomfortduringexam2011/09/06IdentifyYourself•UseMr./Mrs./Ms(Patient’sname)–formaladdressclarifiestheprofessionalnatureoftheinterview•Ex:–Iamamedicalstudentworkingfor(Preceptor’sName)whohasaskedmetodoaninterviewandgeneralexaminationforyou.Mynameis…..2011/09/06★Thecontentsofinquiry1generaldata﹡2chiefcomplaints﹡3presentillness4pastmedicalhistory5systemsreview6personalhistory7maritalhistory8menstrualhistory9childbearinghistory10familyhistory2011/09/06GeneralData•Name●Nativeplace•Sex●Address•Age●Dateofadmission•Race●Dateofrecord•Occupation●Narrator•Marriage●ReliabilityChiefComplaint2011/09/06ChiefcomplaintCC:asentencethatdescribepatient’smainun-comfortandits/theirdurationbypatient’swords•Mainsymptomorsigns.•Thetimingandduration.2011/09/06ChiefComplaint(s):•Notepatient’scomplaintintheirownwords.–Keepitbriefandconcise•Donotchangelaymentermsintomedicalvocabulary•Youmustcommunicatewiththeintentionofbeingunderstood.–Includelengthoftimecomplainthasbeengoingon(ifapplicable)TheHistoryofThePresentillness2011/09/06HistoryofPresentIllnessorHPI:•Itreferstorecentchangesinhealththatledthepatienttoseekmedicalattentionatthistime–Itdescribestheinformationrelevanttothechiefcomplaint–Usechronologicalordertoorganizehistory–Beverythorough2011/09/06HistoryofPresentIllness:Aclear,chronologicalnarrativeincludes:•Onsetofproblem•Settinginwhichitdeveloped•Manifestations•Associatedmanifestations•Anytreatments•Generalstate:appetite,sleeping,urine,bowelmovement,bodyweight,ect.•Principalsymptomsdescribedintermsof:–Location–Quality–Quantityorseverity–Timing(onset,duration,frequency)–Setting–Factorsthataggravatedorrelieved–Associatedmanifestations2011/09/06Freeofotherunrelatedinformation•“Thepatientnoted”,“Thepatientstatedthathewas…atthattime”•“HewaswelluntilApril1982,when,whilewalkingdownthestreetonasunnyday,withthebirdssingingoverhead,heexperiencedpaininhischest”•“ThemanwaswelluntilApril1982,whenwhilewalkingeasily,hehadchestpain”2011/09/06PastMedicalHistory•Generalstateofhealth.•Pastillness(includeChildhoodillnesses,Adultillnesses,Psychiatricillnesses,especiallyanyinfectiousdiseases).•PastsurgicalhistoryandAccidentsandinjurieshistory.•Vaccinations•Allergyhistory2011/09/06PastMedicalHistory:•GeneralHealthandVigor–Howpatientfeelstheirgeneralhealthhasbeentodate•Childhood–Illnessesanddevelopment:•Askaboutmeasles,rubella,mumps,varicella(chickenpox),rheumaticfever,scarletfever*andpneumonia.•Werethereanydevelopmentalissues?•Shortstature,cerebralpalsy,etc.*ScarletfeveriscausedbyStreptococcusgroupA,producingarash,sometimes,inpatientsthathavestrepthroat2011/09/06PastMedicalHistory:•Adult–SignificantIllnessesorconditions:•Examples:–recurrentsorethroats–urinarytractinfections–yeastinfections–hypertension–diabetes–coronaryarterialdisease–Note•timeofonsetordateofdiagnosis•controlofdiseaseorcondition•treatment,ifany2011/09/06PastMedicalHistory:•Accidentsorinjuries–includingfractures•Notedate&complicationsifany–Ifinjuryrequiredsurgicalintervention,candescribeitindetailhere.–Traumaduetomotorvehiclecollisions•Getdetailsaboutaccident:passenger/driver,restrained/unrestrained,fractures,etc.2011/09/06PastMedicalHistory:•Askaboutanysignificantcareorotherhospitalizationsnotcovered.•Askabouttoxicand/orIndustrialexposure.•Asktactfullyaboutanypsychiatrichistoryorhospitalization.•Ifp