2013级口八大三上学期课件-诊断学history taking询问者从与病人或家属、其他相关人员

病史HISTROY

TAKING左

川West

China

Hospital,

Sichuan

University1HISTORY

TAKING

The

procedure

of

taking

patient’s

story

of

illness

fromthe

patient

and/or

his

or

her

family

members

(or

otherrelated s

who

know

the

history

of

the

patient’sstory

of

illness)询问者从与 （或 的家属、其他相关

）的交谈中获得疾病资料的过程。2HISTORY

TAKING

A age

primary

care

physician

will

do140,000-160,000

interviews

during

aprofessional

life

of

40

years…3

Data

for

making

diagnosis

Clue

for

PE,

Lab

and

other

examination

Patient-doctor

relationship

Always,

the step

to

treat

patient4HISTORY

TAKING5

To

learn

Contents

内容What

to

do?

Method

方法How

to

do?STRUCTURE

OF

HISTORY

TAKING6INTRODUCTION

引言GENERAL

DATA

一般资料

Introduce

yourself介绍自己l

patient

your

role/position说明自己的

Call

patient

by

suitable

title恰当称呼

Ask

patient’s

name,

age,

nationality,

address,

etc.全名、

、民族、住址等

Greeting

or

so,

let

patient

relax

and

set

up

good

rapport简单交谈72.CHIEF

COMPLAINT

主诉8

CC:

a

sentence

that

describe

patient’s

mainfort

and

its/their

duration

by

patient’s

words

患者感受最痛苦的症状或体征，也是本次就诊最主要原因

主要症状or体征+持续时间CHIEFCOMPLAINT9

It

is

the

patient’s

brief

statement

explaining

why

he

orshe

sought

medical

attention

It

is

the

answer

to

the

question“What

is

the

problem

that

brought

you

to

the

hospital?”EXAMPLES

OF

CHIEFCOMPLAIN10

Chest

pain

for

the

5

hours

胸痛5小时

edema

for

10

days

水肿10天

Intermittent

right

abdominal

pain

for

3

years,

relapsed

for1

week

and

worsen panied

by

tar-like

stool

for

2days.反复上腹部疼痛3年，复发1周，加重伴黑便2天。EXAMPLES

OF

CHIEFCOMPLAIN

Leukemia

for

2

years.

×白血病2年。

Hepatocirrhosis

for

3

years.

×肝硬化3年。11HISTORY

OF

PRESENT

ILLNESS现病史The

main

problems

at

present目前的主要问题疾病的发生发展演变过程It

should

answer

the

questionswhat,

when,

how,

where,

which,

who,

and

why.1213HISTORY

OF

PRESENT

ILLNESS现病史Onset

of

the

problems:

acute

or

chronic起病情况：急缓、患病时间Any

reason

or

inducing

factors发病的原因和（或）诱因14HISTORY

OF

PRESENT

ILLNESS现病史(3)

Characteristics

of

main

symptoms主要症状特点

Locations

Natures

Frequency

of

episodes

Durations

Intensity

Radiation部位性质发作频率持续时间强度放射区

Factors

that

worsen

or

relieve

the

symptom加重和缓减的因素HISTORY

OF

PRESENT

ILLNESS现病史Progression

of

the

illness病情的发展和演变Other

symptoms

伴随症状Negative

symptoms

有临床意义的

症状History

of

diagnosis

and

treatment

和治疗的经过General

situation

since

the

illness患病以来的一般情况154.PAST

HISTORY

过去史16

Health

status

in

the

past

既往的健康情况

Illnesses

suffered

in

the

past

过去患过的疾病

Previous

Hospital

admissions

住院史

History

of

surgical

operations,trauma,

transfusion

andvaccines

手术外伤、意外事故、输血、预防接种史

History

of

allergic

disorders

过敏史REVIEW

OF

SYSTEMS系统回顾17

Respiratory

system

Cardiovascular

system

Digestive

system

Urinary

system

Blood

system

Endocrine

system

and

metabolism

Nervous

system

Muscle

skeleton

systemREVIEW

OF

SYSTEMS系统回顾18

Aims:

avoid

missing

significant

symptoms,

suggestother

disorders

A

few

main

symptoms

for

each

system:screening

questions

Be

familiar

with

thesymptoms

in

each

system

避免医学术语AL

HISTORY个人史

Social

experiences

社会经历

Occupation,

working

conditions

职业和工作条件

exposure

to

toxins

毒物接触史

Habits:

food,

smoking,

drink

alcohol,

drug

abuse,

etc.(amount

and

duration)和嗜好，饮食、烟、酒、19MARITAL

HISTORY史

Marital

history:single

or

marriedage

of

marriageheath

condition

of

partner20MENSTRUAL

PERIOD

AND

CHILDBEARING和

史HISTORY

Menstrual

historyage

of

menarche

(cycles

and

flow

lastingmenstrual

cycle)amount

of

vaginal

bleeding/dischargesmenopause

and

age

of

menopause

Formatflow

lasting(day)menarche

------------

-------

last

menopausecycle(day)pregnancy,

delivery,

abortion,

family

plan,

etc.21

It

provides

information

about

the

health

of

the

entirefamily,living

and

dead.22

Pay

attention

to

possible

genetic

and

environmental

aspects

ofdisease

that

might

have

implications

for

the

patient.

Discuss

health

promotion

Discuss

with

patients

(allow

the

patient

to

discuss

anyadditional

questions

concerns,

requirements,

or

expectations,etc)

Explain

what

to

do

next

step

for

both

physician

and

patient23SKILLS

OF

HISTORY

TAKING问诊的技巧24SKILLS

OF

HISTORY

TAKING问诊的技巧25The

methods

and

skills

of

history

taking

willseriously

influence

the

integrate,

reliability,

and

thepatient-physician

rapport.询问者获得病史的资料所用的方式方法，它对获取资料的完整性、可靠性，以及建立良好的医患关系都有重要的影响。ORGANIZATION组织安排26

Introduction,

main

body

and

closure

Good

organization

in

each

part,e.g.

History

of

Present

Illness

When

was

last

free

of

the

earliest

symptom

Chronological

progression

of

the

the

symptomsand

signs

To

avoid

missing

important

information:

newsymptoms

“---thenwhat

happened?”,

“---and

then

what---”27TRANSITIONAL

STATEMENT过渡语言

“We

have

been

talking

why

you

came

to

see

me

today.

Now

I’dlike

to

get

some

information

about

your

own

past

medicalhistory

to

see

if

it

has

any

bearing

on

your

present

problem”

Before

past

medical

history,

review

of

systems,history,

family

history,

etc.al28SUMMARIZATION归纳小结

Allo tient

to

hear

how

the

doctor

understand(interpretation)

his

information

Let

doctor

not

to

forget

important

part

Provide

an

opportunity

to

verify

what

the

patient

has

told

thedoctor

Detailed

summary

be

done

after

Present

Illness

A

brief

general

statement

may

be

sufficient

in

other

subsections.29PACING

OF

HISTORY

TAKING问诊的进度

Be

patient,

listen

with

concentration集中注意力，耐心

Do

not

interrupt

patient

lightly.Think

twice

before

interrupting

apatient不轻易打断

Pause

when

necessary

,

but

not

too

long

sad

pause不要有尴尬的停顿30QUESTIONINGSKILLS-TYPE

OFQUESTIONS问题类型31

Begin

with

“open”

question

at

very

beginning

andbeginning

of

each

part

每部分开始，最好以一般性的提问开始

Focused,

direct,

specific

of

forced

choice

questionsfor

collecting

specific

pertinent

information

问诊症状细节时，多采用特殊提问或直接提问TYPE

OF

QUESTIONS32

Avoidleading

questions避免 诱导性提问

Avoid

why

questions避免 诘难性提问

Avoidmultiple

q