history taking fuhaixiang. accurate diagnosis rests firmly upon the foundation of a thoughtful and...
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History Taking
FuHaixiang
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Accurate diagnosis rests firmly
upon the foundation of a thoughtful
and inclusive history and a
compotently performed physical
examination.
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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
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• Previous Entries :– Dates 、 diagnoses 、 treatment 、 signif
icant complications.
• Chief complaints ( CC ):– Presenting complaints and duration.
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Present Illness ( PI ):A : The immediate history that brought the
patient to the hospitalB : Background history of disease leeding
to the immediate historyC : Significant positive and negative data
that might give clues useful in differential diagnosis
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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
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Marital History :
A : Age and health of spouse ; year married
B : Ages and health of children
C : Previous marriages
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Medical History :
• A : Hospitalization
• B : Illness
• C : Trauma
• D : Operations
• E : Childhood diseases
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Social History :
• A : Serial residences
• B : Education
• C : Employment
• D : Military service
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Habits :
• A : Appetite
• B : Use alcohol , coffee , tea , tobacco
• C : Sexual habits
• Allergies :• Hay
fever , asthma , hives , food , skin , drugs
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• Drug Use.– A : Medicines– B : Drug abuse
• Weight :– A : Highest– B : Average– C : Present
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System History
Physical Examination-general
• 1.Vital Sighs– Blood pressure : Pulse rate :– Temperature : Respiratory rate :– Height : Weight :– General appearance :
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2.Mental status
3.Neck.shape , trachea , thyroid , blood vessels.
4.Breasts :symmetry , nipples , masses , tenderness.
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• 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.
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• 6.Abdomen : contour , skin , hair and scars.– ⑴intestinal activity– ⑵rigidity and tenderness.– ⑶Percussion for dullness.– ⑷organs and masses– ⑸shifting dullness– ⑹collateral circulation
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Back
• Curvatures , symmetry , mobility
• Tenderness over spine
• Pelvis
• Kidneys ( costovertebral angle tenderness )
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• Rectum :• Genitals :• Pelvis :• Extremities :• Granial Nerves• Gait 、 Cerebellum 、 Sensory Associative 、
Functions 、 Motor
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• Reflexes : Right left– Biceps– Triceps– Patellar ,– Ankle ,– Cremaster ,– Abdominal ,– Plantar
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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
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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.
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• 1.Diagnoses– ⑴ Analysis– ⑵Plans : Diagnostic tests– Therapeutic measures
• 2.Problems– ⑴Analysis– ⑵Plans : Diagnostic– Therapeutic