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History Taking

History Taking. FuHaixiang. Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a compotently performed physical examination. Personal ID. Name、address、phone、nearest of kin.Age、sex、rece、occupation、marital status. Date of Entry and Hospital Numbor

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History Taking

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  1. History Taking FuHaixiang

  2. Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a compotently performed physical examination.

  3. Personal ID • Name、address、phone、nearest of kin.Age、sex、rece、occupation、marital status. • Date of Entry and Hospital Numbor • Source and Reliability of Iuformant

  4. Previous Entries： • Dates、diagnoses、treatment、significant complications. • Chief complaints（CC）： • Presenting complaints and duration.

  5. Present Illness（PI）： A：The immediate history that brought the patient to the hospital B：Background history of disease leeding to the immediate history C：Significant positive and negative data that might give clues useful in differential diagnosis

  6. Family History： A：Father B：Mother C：Each sibling D：History of disease in which heredity or contact may play a role. E：Record a family tree

  7. Marital History： A：Age and health of spouse； year married B：Ages and health of children C：Previous marriages

  8. Medical History： • A：Hospitalization • B：Illness • C：Trauma • D：Operations • E：Childhood diseases

  9. Social History： • A：Serial residences • B：Education • C：Employment • D：Military service

  10. Habits： • A：Appetite • B：Use alcohol，coffee，tea，tobacco • C：Sexual habits • Allergies： • Hay fever，asthma，hives，food，skin，drugs

  11. Drug Use. • A：Medicines • B：Drug abuse • Weight： • A：Highest • B：Average • C：Present

  12. System History Physical Examination-general • 1.Vital Sighs • Blood pressure： Pulse rate： • Temperature： Respiratory rate： • Height： Weight： • General appearance：

  13. 2.Mental status 3.Neck.shape，trachea，thyroid，blood vessels. 4.Breasts：symmetry，nipples，masses，tenderness.

  14. 5.Chest：skin，thorax（shape，symmetry） • ⑴Lungs：fremitus，resonance，breath sounds • ⑵Heart： • Inspection：jugular venous pulsations，point PMI • Palpation：locate PMI，thrill • Percussion：heart size • Auscultation：Rate，rhythm.Heart sounds.murmurs.

  15. 6.Abdomen：contour，skin，hair and scars. • ⑴intestinal activity • ⑵rigidity and tenderness. • ⑶Percussion for dullness. • ⑷organs and masses • ⑸shifting dullness • ⑹collateral circulation

  16. Back • Curvatures，symmetry，mobility • Tenderness over spine • Pelvis • Kidneys（costovertebral angle tenderness）

  17. Rectum： • Genitals： • Pelvis： • Extremities： • Granial Nerves • Gait、 Cerebellum 、Sensory Associative、 Functions、Motor

  18. Reflexes：Right left • Biceps • Triceps • Patellar， • Ankle， • Cremaster， • Abdominal， • Plantar

  19. Basic Laboratory Data • 1.Hematology：WBC，RBC，Hematocrit，platelet • 2.Indexes • 3.Urinalysis • 4.Stool Guaiac • 5.Sputum Smear • 6.Electrocardiogram • 7.Purified Protein Derivative（PPD） • 8.Chest X-ray

  20. Summary • Brief but esseutial summary of • ⑴history • ⑵physical examination • ⑶contribution ancillary data • Formulation of Diagnoses. • Problems and Plans • Define and solve each diagnosis and problem individually.

  21. 1.Diagnoses • ⑴ Analysis • ⑵Plans：Diagnostic tests • Therapeutic measures • 2.Problems • ⑴Analysis • ⑵Plans：Diagnostic • Therapeutic

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