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History Taking

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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