病史采集(英文)课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,2011/09/06,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,2011/09/06,History Taking,2011/09/06History Taking,2011/09/06,Importance,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,2011/09/06ImportanceData for m,2011/09/06,A “good physician”,A good observer,A good communicator,A good critic,A good decision maker,A good student- now and later,2011/09/06A “good physician” A,2011/09/06,Basic Principles,Communication,Interviewer,s skill,Establish trust,Questions understandable to patient,Interpreter if necessary,Main purpose of interview,Obtain basic information related to patient,s illness or reason for visit,2011/09/06Basic PrinciplesComm,2011/09/06,Basic Principles,Interviewer,Cheerful, friendly, but respectful and genuinely concerned about the patient,Novice interviewers,Have to gain experience asking questions about subjects that are more painful, delicate or unpleasant,Permit patient,to express themselves in their own words,2011/09/06Basic PrinciplesInte,2011/09/06,Observe body language for nonverbal clues,Listening without interruption : is important and requires skill.,If you interrupt the patient you can disrupt the patients train of thought,IN GENERAL:,Listen more,Talk less and,Interrupt infrequently,2011/09/06 Observe body langua,2011/09/06,Basic Principles,If patient gives a vague history,Ask more direct questions,Listen without any suggestion of prejudice,Treat all patients with respect,Regardless of their age, gender, beliefs, intelligence, educational background, legal status, practices, culture, illness, body habitus, emotional condition, or economic state,2011/09/06Basic PrinciplesIf p,2011/09/06,Basic Principles,Follow the,“,rule of five vowels,”,udition,Listen carefully,valuation,Sort out relevant from irrelevant data,nquiry,Probe into significant areas requiring more clarification,bservation,Importance of nonverbal communication,Regardless of what is said,nderstanding,Of patient,s concerns and apprehensions,Play empathetic role,A,E,I,O,U,2011/09/06Basic PrinciplesFoll,2011/09/06,General:,Greet the patient,Adequately identify yourself and your purpose,Allow patient,s privacy and comfort during exam,2011/09/06General:Greet the p,2011/09/06,Identify Yourself,Use Mr./ Mrs./ Ms (Patient,s name),formal address clarifies the professional nature of the interview,Ex:,I am a medical student working for (Preceptor,s Name) who has asked me to do an interview and general examination for you. My name is,.,2011/09/06Identify YourselfUse,2011/09/06,The 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,2011/09/06The contents of inq,2011/09/06,General Data,Name,Native place,Sex,Address,Age,Date of admission,Race,Date of record,Occupation,Narrator,Marriage,Reliability,2011/09/06General Data Name,Chief,Complaint,Chief Complaint,2011/09/06,Chief complaint,CC: a sentence that describe patients main un-comfort and its/their duration by patients words,Main symptom or signs.,The timing and duration.,2011/09/06Chief complaintCC: a,2011/09/06,Chief Complaint(s):,Note patient,s complaint in their own words.,Keep it,brief and concise,Do not change laymen terms into medical vocabulary,You must communicate with the intention of being understood.,Include,length of time,complaint has been going on (if applicable),2011/09/06Chief Complaint(s):N,The History of The Present illness,The History of The Present ill,2011/09/06,History of Present Illness or HPI:,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 organize history,Be very thorough,2011/09/06History of Present I,2011/09/06,History of Present Illness:,A 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,Quantity or severity,Timing (onset, duration, frequency),Setting,Factors that aggravated or relieved,Associated manifestations,2011/09/06History of Present I,2011/09/06,Free 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”,2011/09/06Free of other unrela,2011/09/06,Past 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.,Vaccinations,Allergy history,2011/09/06Past Medical History,2011/09/06,Past Medical 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 stature, cerebral palsy, etc.,*Scarlet fever is caused by Streptococcus group A, producing a rash, sometimes, in patients that have strep throat,2011/09/06Past Medical History,2011/09/06,Past Medical History:,Adult,Significant Illnesses or conditions:,Examples,:,recurrent,sore throats,urinary tract infections,yeast infections,hypertension,diabetes,coronary arterial disease,Note,time of onset or date of diagnosis,control of disease or condition,treatment, if any,2011/09/06Past Medical History,2011/09/06,Past Medical History:,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: passenger/driver, restrained/unrestrained, fractures, etc.,2011/09/06Past Medical History,2011/09/06,Past 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.,2011/09/06Past Medical History,2011/09/06,Past 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 complications,Use chronological order & number or use a separate paragraph if more than one surgical procedure,2011/09/06Past Surgical Histor,2011/09/06,Past Surgical History: example,Appendectomy in 1973; Queens hospital in New York by Dr. Carter, length of stay of 3 days. General anesthesia without reaction. No complications.,Laparoscopic cholecystectomy in 1988; in Albuquerque Hospital by Dr. Green with length of stay of 3 days. Spinal anesthesia without reaction. No complications.,2011/09/06Past Surgical Histor,2011/09/06,Past Medical History:,Preventive Health:,Current immunization 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,2011/09/06Past Medical History,2011/09/06,Allergy history,Allergy,Describe not only what the patient is allergic to, but also the manifestation of that allergy,Side effect or allergy,2011/09/06Allergy history Alle,2011/09/06,Review of system,s,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”,2011/09/06Review of systems A,2011/09/06,Admission Notes- Systems Review,General : weakness, fatigue, anorexia, fever, insomnia,Integument (skin, hair, nails): changes in color (pigmentation, jaundice, cyanosis), pruritus, rash, hair loss,HEENT:,Head: headache, dizziness, vertigo,Eyes: visual acuity, color vision, corrective lenses, photophobia, diplopia, pain,Ears: pain, discharge, hearing loss, tinnitus,Nose: epistaxis, discharge, stuffiness, sense of smell,Throat: status of teeth, gums, dentures, taste, soreness, hoarseness, lump,Respiratory: cough, sputum, hemoptysis, wheezing,CV: dyspnea(on exertion, at rest, paroxysmal nocturnal dyspnea, orthopnea), edema, chest distress/pain, palpitation, intermittent claudication, cold limbs,2011/09/06Admission Notes- Sys,2011/09/06,Admission Notes- Systems Review,GI: dysphagia, nausea, vomiting, abdominal distress pain, change in bowel habit (diarrhea, constipation, character of stool), hematemesis, melena, bloody stool,GU: urinary frequency, hesitancy, urgency, dribbling, incontinence, dysuria, hematuria, nocturia, polyuria, impotence,Female-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, polydipsia,Hematologic: anemia, easy brusity or bleeding, lymphoadenopathy, transfusion,Neuropsychiatry: dizziness, syncope, seizures, speech disturbance, loss of sensation, paresthesis, ataxia, weakness or paralysis, tremor, anxiety, depression, irritability,Musculoskeletal: joint pain, stiffness, limitation of motion, muscular weakness, wasting,2011/09/06Admission Notes- Sys,2011/09/06,Personal history,place of birth current residence educational background economic status living conditions professional working conditions,Smoking,_ Packs for_ years, quitting for_ year,Drinking,Illicit drugs,Heroin,Travel,2011/09/06Personal historyplac,2011/09/06,Menstrual 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,5,13 2008-03-05,30,5,13 50,30,2011/09/06Menstrual and Childb,2011/09/06,Marrital History,married or unmarried marriage age relations of couple,2011/09/06Marrital History mar,2011/09/06,Family History:,Ask about & summarize,ages,state,of,health,Age and cause of death (if applicable),of family members parents, siblings, spouse, and children,Inquire about any similar symptoms or signs in family members if patient presents with inheritable symptoms or signs,Example: thyroid disorders, cancers, diabetes,2011/09/06Family History:Ask a,2011/09/06,Summary,Inquiry,The importance of inquiry The contents of inquiry chief complaints history of present illness The methods and skills of inquiry,2011/09/06Summary Inquiry T,作品欣赏,谢谢观看！,作品欣赏,