History Taking.ppt

文档介绍：History Taking
Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and potently performed physical examination.
Personal ID
Name、address、phone、nearest of 、sex、rece、occupation、marital status.
Date of Entry and Hospital Numbor
Source and Reliability of Iuformant
Previous Entries:
Dates、diagnoses、treatment、plications.
):
plaints 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
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
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
Habits:
A:Appetite
B:Use alcohol,coffee,tea,o
C:Sexual habits
Allergies:
Hay fever,asthma,hives,food,skin,drugs