one
Overall situation:
Including the patient's name, gender, age, occupation, marriage, nationality, native place, work unit and current address.
Two aspects of meaning
One is responsible for the diagnosis and treatment of patients, which is convenient for follow-up.
Second, you can learn some information related to the disease.
As a reference for disease diagnosis. two
Main complaints:
The most painful symptoms, signs and duration of the patient's visit.
For the chief complaint
: First, it must be accurate (patients' statements often have no priority)
Grasp the main crux of the disease and describe it roughly.
Secondly, the location and nature of the symptoms or signs mentioned in the complaint should be
Ask clearly the form, degree and time, and be unambiguous and not general.
Describe the chief complaint: concise and focused: (diagnostic terms cannot be used)
Such as: fever, cough, asthma for two days, aggravated for half a day.
Palpitation, chest tightness, shortness of breath for one month, aggravated by two days. three
Current medical history:
Refers to the whole process of complaining about the disease from onset to treatment.
(Occurrence, development, change and treatment of diseases)
Ask questions in the following order:
1. Incidence:
Including the new onset time, the cause or inducement, the characteristics, location, duration and treatment of the main symptoms and signs.
2. Pathological process:
Inquiry process: Ask about the changes of the disease from onset to treatment, which symptoms are aggravated or alleviated, which new symptoms or signs appear, and whether the development of the disease is regular.
3. Diagnosis and treatment:
What kind of diagnosis and treatment have you had before seeing a doctor, what kind of examination have you had, what is the basis of diagnosis, drugs used for treatment, etc. (The effect and reaction of treatment, etc. Asking about the current symptoms also belongs to asking about the current medical history, and another section is devoted to it.
four
anamnesis
Past health status
disease
In order to know whether the patient's current disease is related to the previous disease, and the problems that should be paid attention to in the treatment of the current disease (some drug allergies, etc.). ).
five
personal record
Life experience: birthplace, residence, experience, etc.
Occupation and working conditions: type of work, working environment, daily working hours and working hours.
Working years.
Living habits and hobbies: hobbies such as alcohol and tobacco.
Personality, spirit and emotion
six
Marriage and childbearing history:
Married, unmarried, age of marriage, health status of the other party.
Whether to have children, etc. (Induced abortion and spontaneous abortion, with or without stillbirth)
seven
Family calendar
Health and illness of parents, brothers, sisters and children, etc. Pay special attention to whether relatives have hereditary or infectious diseases.
(For the immediate family members who have died, the cause of death and age should be asked. )
eight
Menstrual history:
Age of menarche, menstrual cycle, menstrual days, color and quality of menstrual blood and accompanying symptoms, date of last menstruation or age of menopause.
The recording format is as follows:
Menstruation (days)
Age of menarche, time of last menstruation (or menopause age)
Menstrual cycle (days)