2022年医学专题—病史采集(英文).ppt

HistoryTaking2011/09/06第一页，共三十七页。DataformakingdiagnosisImportance•ClueforPE,Labandotherexamination•Patient-doctorrelationship•Bio-psycho-socialmedicalapproach••Always,thefirststeptotreatpatient2011/09/06第二页，共三十七页。AgoodobserverA“goodphysician”•Agoodcommunicator•Agoodcritic•Agooddecisionmaker••Agoodstudent---nowandlater2011/09/06第三页，共三十七页。•CommunicationBasicPrinciplesInterviewer’sskillInterviewer’sskill第四页，共三十七页。•EstablishtrustEstablishtrust•QuestionsunderstandabletopatientQuestionsunderstandabletopatient•InterpreterifnecessaryInterpreterifnecessary••MainpurposeofinterviewObtainbasicinformationrelatedtopatient’sillnessorreasonforvisitObtainbasicinformationrelatedtopatient’sillnessorreasonforvisit•2011/09/06BasicPrinciples•Interviewer–Cheerful,friendly,butrespectfulandgenuinelyconcernedaboutthepatient•Noviceinterviewers–Havetogainexperienceaskingquestionsaboutsubjectsthataremorepainful,delicateorunpleasant•Permitpatienttoexpressthemselvesintheirownwords2011/09/06第五页，共三十七页。ObservebodylanguagefornonverbalcluesListeningwithoutinterruption:isimportantandrequiresskill.Ifyouinterruptthepatientyoucandisruptthepatient’strainofthoughtINGENERAL:ListenmoreTalklessandInterruptinfrequently2011/09/06第六页，共三十七页。•IfpatientgivesaBasicPrinciplesvaguehistory•Treatallpatientswith–Askmoredirectrespectquestions–Regardlessoftheirage,•Listenwithoutanygender,beliefs,suggestionofintelligence,educationalprejudicebackground,legalstatus,practices,culture,illness,bodyhabitus,emotionalcondition,oreconomicstate2011/09/06第七页，共三十七页。BasicPrinciplesFollowthe“ruleoffive•bservationvowels”–Importanceofnonverbalcommunication•udition–Regardlessofwhatissaid–Listencarefully•nderstanding•valuation–Ofpatient’sconcernsand–Sortoutrelevantfromirrelevantapprehensionsdata–Playempatheticrole•nquiry–Probeintosignificantareasrequiringmoreclarification2011/09/06第八页，共三十七页。•GreetthepatientGeneral:•Adequatelyidentifyyourselfandyourpurpose•Allowpatient’sprivacyandcomfortduringexam2011/09/06第九页，共三十七页。•UseMr./Mrs./Ms(Patient’sname)IdentifyYourself••Ex:•2011/09/06第十页，共三十七页。﹡3presentillness2011/09/06第十一页，共三十七页。•Name●Nativeplace•Sex●Address•●DateofadmissionAge•●DateofrecordRace•Occupation●Narrator•Marriage●Reliability2011/09/06第十二页，共三十七页。ChiefComplaint第十三页，共三十七页。CC:asentencethatdescribepatient’smainun-comfortandits/theirdurationbypatient’swordsMainsymptomorsigns.••Thetimingandduration.2011/09/06第十四页，共三十七页。•Notepatient’scomplaintintheirownwords.KKeeeeppititbbrieriefafannddccooncncisisee•DDoononotcthchanangegelalyaymmeenntetremrmssinintotommedediciacalvlvocoacabubulalraryy•YoYuoummusustctocommmmuunincicataetewwithiththteheinitnetnetnitoinonofofbebienigngunudndererstsotoodo.d.•ccoommpplalianintthhaassbbeeeennggooininggoonn(i(fifapappplilciacabblele))InInccluluddeelelnenggththofoftitmimee•2011/09/06第十五页，共三十七页。TheHistoryofThePresentillness第十六页，共三十七页。•ItreferstorecentchangesinhealththatledthepatienttoseekmedicalattentionatthistimeItdescribestheinformationrelevanttothechiefcomplaintItdescribestheinformationrelevanttothechiefcomplaint•UsechronologicalordertoorganizehistoryUsechronologicalord...