First, the current medical history: including the following five parts.
1, according to the chief complaint an
First, the current medical history: including the following five parts.
1, according to the chief complaint and related identification.
1), etiology and inducement
2) Characteristics of main symptoms
3) Accompanied symptoms
4) general state: general state after onset (diet, sleep, defecation, weight change after onset)
2. After diagnosis and treatment
1), have you been to the hospital? What tests have you taken?
2) What treatments have you done and what are the effects?
Second, the past history (related medical history)
1, related medical history: smoking and drinking, similar seizures and family history, etc.
2. History of drug allergy and surgery (it must be mentioned that this is included in the annual scoring standard)
Third, the consultation must be organized, and you should think it over before writing, and don't add it later, so you will lose points.
Fourth, ask around the theme
It is impossible to make a diagnosis with only one chief complaint, but there is still a trend. For example, 24-year-old women are more likely to cough up blood and get tuberculosis, while 45-year-old men are considered to have lung cancer. The two have different collection tendencies, and they still rely on knowledge accumulation. In short, if you follow the above method when collecting, most of the scores have been obtained. It should be noted that whether the diagnosis result is correct or not is not the basis for scoring. As long as there is no shortage of items and contents collected.
First, a fever.
1. Etiology and inducement: Is there a cold or trauma?
2. Main symptoms: heat? Course of disease? Natural (continuous or intermittent)? The rule of fever (lingering fever or fever)? Duration? Aggravating or mitigating factors?
3. Accompanying symptoms: Are there chills, conjunctival congestion, lymphadenopathy and hepatosplenomegaly? Bleeding? Coma?
4. General state: changes in diet, sleep, defecation and weight since the onset.
5. Diagnosis and treatment process: Have you gone to the hospital for examination since the onset, and what examinations and treatments have you made? Is the treatment effective?
6. Related medical history:
7. Drug allergy and surgical history
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Second, headache.
1, etiology and inducement:
2, the main symptoms: the degree of acute attack? Course of disease? When does the pain appear? Location? Range? Natural? Degree? Duration? Aggravating or relieving factors (relationship with cough, sneezing and body position)?
3. Accompanying symptoms: whether there is fever, vomiting, dizziness, anxiety, insomnia or vision change.
4. General state: changes in diet, sleep, defecation and weight since the onset.
5. Diagnosis and treatment process: Have you gone to the hospital for examination since the onset, and what examinations and treatments have you made? Is the treatment effective?
6. Related medical history:
7. Drug allergy and surgical history
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Third, chest pain.
1, etiology and inducement:
2, the main symptoms: the degree of acute attack? Course of disease? Chest pain? Range? Natural? (Is there any radiation pain? ) degrees? Duration? Factors affecting pain (physical activity? Nervous? ) and breathing, coughing, posture, swallowing?
3. Accompanying symptoms: Are there any fever, cough, expectoration, hemoptysis, dysphagia, dyspnea and shock?
4. General state: changes in diet, sleep, defecation and weight since the onset.
5. Diagnosis and treatment process: Have you gone to the hospital for examination since the onset, and what examinations and treatments have you made? Is the treatment effective? Can oral nitroglycerin relieve it?
6. History of related diseases: Have you ever had a similar attack in the past? Do you have a history of hypertension, hyperlipidemia, diabetes, heart disease, tuberculosis, alcohol and tobacco hobbies?
7. Drug allergy and surgical history
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Fourth, abdominal pain.
1, etiology and inducement:
2, the main symptoms: the degree of acute attack? Course of disease? Location? Natural? Range? Time of occurrence (before meals? After dinner? ) and eating? Relationship with posture?
3. Accompanying symptoms: Do you have diarrhea, constipation, nausea and vomiting, acid reflux and hematuria? Is there yellow dye on the skin and sclera? Do you have menstrual cramps?
4. General state: diet, sleep, defecation, weight change and menstruation since onset.
5. Diagnosis and treatment process: Have you gone to the hospital for examination since the onset, and what examinations and treatments have you made? Is the treatment effective?
6. Related medical history: Have you ever had a similar attack history? Have a history of unclean food, overeating, abdomen, stones, surgery, gynecology, etc?
7. Drug allergy and surgical history
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Five, joint pain
1, etiology and inducement:
2. Main symptoms and characteristics: Acute onset? Course of disease (evolution? ) nature (is it wandering? Do you have redness, swelling, heat pain and joint deformity? ) degrees? Relationship with weather and activities?
3. Accompanying symptoms: Are there any fever, rash, muscle pain, muscle weakness, muscle atrophy, lymphadenopathy, hepatosplenomegaly?
4. General state: changes in diet, sleep, defecation and weight since the onset.
5. Diagnosis and treatment process: Have you gone to the hospital for examination since the onset, and what examinations and treatments have you made? What about the treatment of non-steroidal antipyretics, hormones and antibiotics? Is the treatment effective?
6. Related medical history: Have you ever had a similar attack history? Do you have a history of joints, joint injuries, tuberculosis, rheumatism and suspected infectious diseases?
7. History of drug allergy and joint surgery?
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Six, edema
1, etiology and inducement:
2, the main symptoms: edema? develop