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