病史采集(英文)课件

1、History 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,2011/09/06,A “good physician”,A good observer A good communicator A good critic A good decision maker A good student- now and later,2011/09/06,Basic Principles,Communication Interviewers skill Establish trust Questions understandable to patient Interpreter if necessary Main purpose of interview

2、 Obtain basic information related to patients illness or reason for visit,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,2011/09/06,Observe body language for nonverbal clues Listening without interruption : is important and requires skill. If you inter

3、rupt the patient you can disrupt the patients train of thought IN GENERAL: Listen more Talk less and Interrupt infrequently,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,2011/09/06,Basic Principles,Follow the

4、 “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 patients concerns and apprehensions Play empathetic role,A,E,I,O,U,2011/09/06,General:,Greet the patient Adequately identify yourself and your purpose Allow patients privacy and comfort during exam,2011/09/06,Identify Yourself,Use Mr./ Mrs./ Ms (

5、Patients name) formal address clarifies the professional nature of the interview Ex: 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 ,2011/09/06,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,2011/09/06,General Data,Name Native place Sex Address Ag

6、e Date of admission Race Date of record Occupation Narrator Marriage Reliability,2011/09/06,Chief Complaint,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.,2011/09/06,Chief Complaint(s):,Note patients 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 ti

7、me complaint has been going on (if applicable),2011/09/06,The History of The Present illness,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,2011/09/06,History of Present Illness:,A clear, chronological narrative includes: Onset of problem Setting in which it developed Manifestations Associat

8、ed 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,2011/09/06,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

9、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”,2011/09/06,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,2011/09/06,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,2011/09/06,Past Medical History:,A

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