(1) General project
Including: name, gender, age, native place, birthplace, nationality, marriage, address, work unit, occupation, date of admission, date of recording, medical history presenter and reliability, etc. If the person presenting the medical history is not himself, his relationship with the patient should be indicated. When recording age, you should fill in the actual age, and you can't use "son" or "success" instead, because age itself has diagnostic reference significance.
(2) Chief complaint
Patients feel the most important pain or the most obvious symptoms and signs, which is the most important reason for seeing a doctor. The chief complaint should be concise, summarized in one or two sentences, and indicate the time from onset to treatment. Such as "fever, cough, right chest pain for two days", "drinking more, eating more, urinating with emaciation for three years", "abdominal pain, vomiting with diarrhea for four hours" and so on.
(3) Current medical history
The main part of medical history, including the whole process of disease occurrence, development and evolution, is the key content in consultation. Mainly includes the following aspects:
1. onset time (priority) and onset time (how long have you been sick? )。
2. The characteristics of main symptoms, including location, radiation area, nature, attack frequency, duration, intensity, aggravating or mitigating factors.
3. Causes and incentives.
4. The development and evolution of the disease (recorded in chronological order, including the development of main symptoms and other related symptoms).
5. Accompanying symptoms. 6. Diagnosis and treatment (drugs, dosage, curative effect, etc. ).
7. General conditions since the onset (mental state, appetite, weight change, sleep and defecation, etc. ).
8. Induce, summarize and re-verify.
9. Ask questions about the past history in interlanguage.
(4) Past history
Also known as "past tense". Including:
1. The patient's past health status.
2. Past diseases (including various infectious diseases), especially the disease history closely related to the present medical history. For example, patients with coronary atherosclerotic heart disease should ask whether they had hypertension or diabetes in the past. Care should be taken not to confuse the description with the current medical history.
3. History of trauma, surgery, accidents and vaccination.
4. Allergy history (to drugs, food and environmental factors).
5. The main infectious diseases and endemic diseases in the living or living area should also be recorded in the past history.
6. The recording sequence is generally arranged in chronological order.
(5) Systematic review is the last time to collect medical history data after asking about the past history, so as to prevent patients or doctors from ignoring or omitting relevant contents during the consultation. The method is to ask about possible diseases in detail according to various systems of the body. It can help doctors to know whether the patient's system has diseases and whether there is a causal relationship between these diseases and this disease in a short time. Items mentioned in current or past medical history should be avoided. Positive and clinically significant negative items should be recorded.
Summary of system evaluation consultation:
1. The nature, occurrence and aggravation time of respiratory cough, and the relationship between cough degree and frequency and climate change and posture change. Characteristics, color, viscosity and smell of expectoration. Characteristics, color and quantity of hemoptysis. The nature, degree and time of dyspnea. The location and nature of chest pain and its relationship with breathing, cough and body position. Chills, fever, night sweats, loss of appetite, etc. Have a close contact history with pulmonary tuberculosis patients. And understand the nature of occupation, working environment and living conditions, whether smoking and the amount of smoking.
2. The time and inducement of circulatory palpitation, the nature and degree of precordial pain, the time and duration of occurrence, whether there is radiation, the location of radiation, the inducement of pain attack and the relief methods. The inducement and degree of dyspnea, the relationship between onset and physical activity and body position. Whether there is cough, hemoptysis, expectoration, etc. The location and time of edema; Whether there is ascites, liver pain, headache, dizziness, syncope, etc. Have you ever had similar symptoms before? Whether there is hypertension, arteriosclerosis, heart disease, etc.
3. Whether the digestive system has oral diseases, appetite changes, belching, acid regurgitation, abdominal distension, abdominal pain, diarrhea and their occurrence, degree, duration and progress. The relationship between the above symptoms and the types and properties of food and the influence of mental factors. Time, inducement and frequency of vomiting; The content, quantity, color and smell of vomit. The amount and color of hematemesis. Location, degree, nature, duration and regularity of abdominal pain, radiation to other parts, relationship with diet, climate and mental factors, and relief or aggravation of pain after pressing. Frequency of defecation, color, character, quantity and smell of feces. When defecating, do you have symptoms such as abdominal pain, urgency, heavy urine, fever, yellowing of skin and mucosa? Changes in physical strength and weight, food hygiene and habits, drinking habits and intake, etc.
4. Whether the urinary system has dysuria, dysuria, frequent urination and urgency; Urine volume (nocturia), urine color (color of meat sample or soy sauce), etc. ), its turbidity, whether there is urinary retention and urinary incontinence. Whether there is abdominal pain, pain site, radiation pain. Have you ever had a history of pharyngitis, hypertension, edema and bleeding? History of lead-free and mercury poisoning. Whether the external genitals have ulcers, rashes and sexual desire is barrier-free.
5. Whether the hematopoietic system has fatigue, dizziness, dizziness, tinnitus, irritability, memory loss, palpitation, tongue pain, dysphagia, nausea and abnormal appetite (heterophilia). Whether the skin and mucosa are pale, yellow, bleeding, ecchymosis, hematoma, lymphadenopathy, liver and spleen, bone pain, etc. Nutrition, digestion and absorption. Have any contact history with drugs, poisons and radioactive substances.
6. Metabolic and endocrine systems are afraid of cold, heat, hyperhidrosis, fatigue, headache, visual impairment, palpitation, abnormal appetite, polydipsia, polyuria, edema, etc. Whether there are muscle tremors and spasms; Development of personality, intelligence, physique, sexual organs, changes of bones, thyroid, weight, skin and hair. No trauma, surgery, postpartum hemorrhage.
7. The location, nature and time of nervous system headache, insomnia, lethargy, hypomnesis, disturbance of consciousness, syncope, spasm, paralysis, visual disturbance, abnormal sensation and movement, personality disturbance and sensory and directional disturbance. If you suspect that your mental state has changed, you should also know your emotional state, thinking process, intelligence, ability and insight.
8. Whether there is numbness, pain, spasm, atrophy, paralysis, etc. In a moving system. Bone development, whether there is deformity, joint swelling and pain, dyskinesia, trauma, fracture, joint dislocation, congenital defects, etc.
(6) Personal medical history and personal experience related to health and disease. Including:
1. Social experience includes place of birth, place of residence and time of residence (especially epidemic areas and epidemic areas), education level, economic life and hobbies.
2. Occupation and working conditions include work type, working environment, exposure to industrial poisons and time.
3. Habits and hobbies Life and hygiene habits, the regularity and quality of diet, tobacco and alcohol hobbies and intake, etc.
4. Have you ever had unclean sexual intercourse, gonorrhea, condyloma acuminatum, chancre, etc.
(seven) the marriage history records unmarried or married, the age of marriage, the other party's health status, sexual life, husband and wife relationship, etc.
(8) menstrual history
Menstruation of female patients. It mainly describes menarche age, menstrual cycle, menstrual days, menstrual blood volume and color, menstrual symptoms, dysmenorrhea, leucorrhea, last menstrual date, amenorrhea date, menopausal age, etc.
(9) Birth history
The fertility status of the patient. Including the number and age of pregnancy and delivery, the number of induced or spontaneous abortions, whether there are premature births, stillbirths, surgical deliveries, puerperal fever and family planning. Male patients should record whether they have reproductive system diseases.
(10) family history
Refers to the health status of related members of the patient's family, including:
1. Parents' age and health status (including grandparents in pediatrics).
2. The age and health status of the spouse.
3. Age and health of brothers and sisters.
4. Children's age and health.
5. Is there any disease in the family that is the same as the patient, and is there any disease related to heredity, such as albinism, hemophilia, congenital spherocytosis, diabetes, familial hypothyroidism, psychosis, etc. For the immediate family members who have died, ask the cause of death and age. The family history of some hereditary diseases should also include some non-immediate relatives.
(1 1) End
1. Discuss health measures, such as reducing bad habits, dental care, food hygiene, etc.
2. Ask the patient to ask and discuss any incidental questions, the patient's views on the disease, the expectation of seeing a doctor, etc.
3. Explain what doctors and patients should do next, and arrange each project (further diagnosis and treatment plan).