2013級(jí)口八大三上學(xué)期課件-診斷學(xué)history taking詢(xún)問(wèn)者從與病人或家屬、其他相關(guān)人員

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)詢(xún)問(wèn)者從與 （或 的家屬、其他相關(guān)

）的交談中獲得疾病資料的過(guò)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

內(nèi)容What

to

do?

Method

方法How

to

do?STRUCTURE

OF

HISTORY

TAKING6INTRODUCTION

引言GENERAL

DATA

一般資料

Introduce

yourself介紹自己l

patient

your

role/position說(shuō)明自己的

Call

patient

by

suitable

title恰當(dāng)稱(chēng)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簡(jiǎn)單交談72.CHIEF

COMPLAINT

主訴8

CC:

a

sentence

that

describe

patient’s

mainfort

and

its/their

duration

by

patient’s

words

患者感受最痛苦的癥狀或體征，也是本次就診最主要原因

主要癥狀or體征+持續(xù)時(shí)間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小時(shí)

edema

for

10

days

水腫10天

Intermittent

right

abdominal

pain

for

3

years,

relapsed

for1

week

and

worsen panied

by

tar-like

stool

for

2days.反復(fù)上腹部疼痛3年，復(fù)發(fā)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現(xiàn)病史The

main

problems

at

present目前的主要問(wèn)題疾病的發(fā)生發(fā)展演變過(guò)程It

should

answer

the

questionswhat,

when,

how,

where,

which,

who,

and

why.1213HISTORY

OF

PRESENT

ILLNESS現(xiàn)病史Onset

of

the

problems:

acute

or

chronic起病情況：急緩、患病時(shí)間Any

reason

or

inducing

factors發(fā)病的原因和（或）誘因14HISTORY

OF

PRESENT

ILLNESS現(xiàn)病史(3)

Characteristics

of

main

symptoms主要癥狀特點(diǎn)

Locations

Natures

Frequency

of

episodes

Durations

Intensity

Radiation部位性質(zhì)發(fā)作頻率持續(xù)時(shí)間強(qiáng)度放射區(qū)

Factors

that

worsen

or

relieve

the

symptom加重和緩減的因素HISTORY

OF

PRESENT

ILLNESS現(xiàn)病史Progression

of

the

illness病情的發(fā)展和演變Other

symptoms

伴隨癥狀Negative

symptoms

有臨床意義的

癥狀History

of

diagnosis

and

treatment

和治療的經(jīng)過(guò)General

situation

since

the

illness患病以來(lái)的一般情況154.PAST

HISTORY

過(guò)去史16

Health

status

in

the

past

既往的健康情況

Illnesses

suffered

in

the

past

過(guò)去患過(guò)的疾病

Previous

Hospital

admissions

住院史

History

of

surgical

operations,trauma,

transfusion

andvaccines

手術(shù)外傷、意外事故、輸血、預(yù)防接種史

History

of

allergic

disorders

過(guò)敏史REVIEW

OF

SYSTEMS系統(tǒng)回顧17

Respiratory

system

Cardiovascular

system

Digestive

system

Urinary

system

Blood

system

Endocrine

system

and

metabolism

Nervous

system

Muscle

skeleton

systemREVIEW

OF

SYSTEMS系統(tǒng)回顧18

Aims:

avoid

missing

significant

symptoms,

suggestother

disorders

A

few

main

symptoms

for

each

system:screening

questions

Be

familiar

with

thesymptoms

in

each

system

避免醫(yī)學(xué)術(shù)語(yǔ)AL

HISTORY個(gè)人史

Social

experiences

社會(huì)經(jīng)歷

Occupation,

working

conditions

職業(yè)和工作條件

exposure

to

toxins

毒物接觸史

Habits:

food,

smoking,

drink

alcohol,

drug

abuse,

etc.(amount

and

duration)和嗜好，飲食、煙、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問(wèn)診的技巧24SKILLS

OF

HISTORY

TAKING問(wèn)診的技巧25The

methods

and

skills

of

history

taking

willseriously

influence

the

integrate,

reliability,

and

thepatient-physician

rapport.詢(xún)問(wèn)者獲得病史的資料所用的方式方法，它對(duì)獲取資料的完整性、可靠性，以及建立良好的醫(yī)患關(guān)系都有重要的影響。ORGANIZATION組織安排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過(guò)渡語(yǔ)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歸納小結(jié)

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問(wèn)診的進(jìn)度

Be

patient,

listen

with

concentration集中注意力，耐心

Do

not

interrupt

patient

lightly.Think

twice

before

interrupting

apatient不輕易打斷

Pause

when

necessary

,

but

not

too

long

sad

pause不要有尷尬的停頓30QUESTIONINGSKILLS-TYPE

OFQUESTIONS問(wèn)題類(lèi)型31

Begin

with

“open”

question

at

very

beginning

andbeginning

of

each

part

每部分開(kāi)始，最好以一般性的提問(wèn)開(kāi)始

Focused,

direct,

specific

of

forced

choice

questionsfor

collecting

specific

pertinent

information

問(wèn)診癥狀細(xì)節(jié)時(shí)，多采用特殊提問(wèn)或直接提問(wèn)TYPE

OF

QUESTIONS32

Avoidleading

questions避免 誘導(dǎo)性提問(wèn)

Avoid

why

questions避免 詰難性提問(wèn)

Avoidmultiple

q