中国医科大学：《诊断学》课程教学课件（PPT讲稿）History Taking

History Taking FuHaixiang

History Taking FuHaixiang

Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a compotently performed physical examination

Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a compotently performed physical examination

Personal ID ·Name、address、phone、nearest of kin.Age、sex、rece、occupation、marital status. Date of Entry and Hospital Numbor Source and Reliability of luformant

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

·Previous Entries: -Dates、diagnoses、treatment、 significant complications. Chief complaints (CC): -Presenting complaints and duration

• Previous Entries： – Dates、diagnoses、treatment、 significant complications. • Chief complaints（CC）： – Presenting complaints and duration

Present Illness (PI): A:The immediate history that brought the patient to the hospital B:Background history of disease leeding to the immediate history C:Significant positive and negative data that might give clues useful in differential diagnosis

Present Illness（PI）： A：The immediate history that brought the patient to the hospital B：Background history of disease leeding to the immediate history C：Significant positive and negative data that might give clues useful in differential diagnosis

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

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

Marital History: A:Age and health of spouse;year married B:Ages and health of children C:Previous marriages

Marital History： A：Age and health of spouse； year married B：Ages and health of children C：Previous marriages

Medical History: ·A:Hospitalization ·B:Illness ·C:Trauma ·D:Operations E:Childhood diseases

Medical History： • A：Hospitalization • B：Illness • C：Trauma • D：Operations • E：Childhood diseases

Social History: ·A:Serial residences ·B:Education ·C:Employment ·D:Military service

Social History： • A：Serial residences • B：Education • C：Employment • D：Military service

Habits: ·A:Appetite B:Use alcohol,coffee,tea,tobacco ·C:Sexual habits ·Allergies: Hay fever,asthma,hives,food,skin, drugs

Habits： • A：Appetite • B：Use alcohol，coffee，tea，tobacco • C：Sexual habits • Allergies： • Hay fever，asthma，hives，food，skin， drugs