I. General information
(1) General project
General items include name, gender, age, native place, nationality, marriage, occupation, work unit, home address and communication.
Address, telephone number, admission date, recording date, medical history statement and reliability, etc. If the medical history presenter suffers from
Relatives or other people should indicate the relationship with the patient. The actual age should be filled in when recording the age.
(2) Chief complaint
Chief complaint is the most important and obvious symptom or sign that patients feel, and its nature and duration are also the second time.
The main cause of diagnosis. Through the chief complaint, we can get a preliminary understanding of the system and nature of the disease, which is helpful to the judgment of the chief physician.
The main complaint of the problem should be concise, summarized in one or two sentences, and indicate the time from the occurrence of the main complaint to the treatment.
Such as "chills, fever, right chest pain for 3 days", "palpitation, shortness of breath for 2 years, aggravated with edema of both lower limbs for 2 weeks". Avoid using diagnostics.
Words or names of diseases, such as "I suffered from diabetes for one year", should be recorded as "drinking, eating and urinating for one year".
(3) Current medical history
Current medical history is the main part of health history, including the whole process of disease occurrence, development, evolution, diagnosis and treatment.
I. Incidence
Different diseases have different ways of onset, some of which are sudden, such as cerebral embolism and acute gastrointestinal perforation. Some are slow to get sick.
Slow, such as tuberculosis, tumor, etc.
2. Time of illness
Refers to the time from onset to treatment or hospitalization. It can be calculated in years, months, days, hours and minutes according to the patient's condition.
3. Characteristics of main symptoms
Including the location, nature, duration and degree of the main symptoms, as well as the factors that reduce or aggravate the symptoms. Such as digestion
Sexual ulcer is epigastric pain, burning (or swelling or dull pain) in nature, which can last for several days or weeks and recur after several years.
Work or relaxation, aggravated in late autumn and early spring.
4. Etiology and inducement
When communicating, try to understand the causes (such as trauma, poisoning, infection) or incentives (such as
Climate change, environmental change, mood, eating disorders, etc. ), contribute to the diagnosis and treatment of diseases and prevention.
5. Development and evolution of diseases
Refers to the aggravation, alleviation or emergence of new symptoms in the course of the disease. For example, pulmonary tuberculosis with lung qi deficiency.
Patients with swelling often have shortness of breath, sudden chest pain and severe dyspnea after exercise, so spontaneous pneumothorax should be considered.
Maybe.
6。 Concurrent syndrome
On the basis of the main symptoms, a series of other symptoms appear at the same time, and these accompanying symptoms are often different.
Foundation. Because different diseases can have the same symptoms, such as acute epigastric pain, there are many reasons, if patients are accompanied at the same time.
If you have nausea, vomiting and fever, especially jaundice and shock, you should consider the possibility of acute biliary tract infection.
7. Diagnosis and treatment process
When patients have been treated by other medical units before this visit, they should ask when and where they have been treated and what they have done.
What kind of examination and nursing measures have you received, as well as the name, dosage, route and curative effect of the drugs you have used. Can you use them this time?
Nursing measures to provide reference.
4) Past history
Past medical history refers to the health status of patients from birth to onset. Including past health and the past.
Past diseases, such as trauma history, operation history, hospitalization experience, etc. Therefore, you should record the time of your illness in the past.
Time, cause, name of operation, diagnosis and treatment of trauma and its outcome, etc. ; Especially the diseases closely related to the present medical history,
For example, patients with rheumatic heart disease have a history of wind, dampness and heat. In addition, the vaccination history and the owner of the living area should be recorded.
Infectious diseases and local medical history. And whether there is a history of allergies to known substances in food, drugs or environmental factors. take for example
If you have allergic history, you should record the allergic time, allergens and allergic reactions.
(5) Personal history
Personal history includes social experience, occupation and working conditions, habits and hobbies, unclean sexual intercourse and sexual life history.
(6) Marriage history
Record unmarried or married, marriage age, spouse's health status, husband-wife relationship, etc.
(seven) menstrual history and birth history.
Including menarche age, menstrual cycle and menstrual days, the amount and color of menstrual blood, menstrual symptoms and whether it is painless.
Menstruation and leucorrhea, date of last menstruation, date of amenorrhea, menopausal age, etc. The number and age of pregnancy and childbirth; Man-made or natural
Number of abortions; Whether there are stillbirths, surgical deliveries, puerperal infections and family planning.
(8) Family history
Including asking parents, siblings and children about their health and illness, especially whether they have relatives.
Have the same disease as the patient, whether there are genetic related diseases, such as hemophilia, diabetes, psychosis, etc. Besides, don't rest until you die
The immediate family members of the deceased should also ask about the cause of death and age.
Second, the form of daily life and self-care ability
Health awareness and health maintenance
Healthy behavior refers to patients' ability to keep healthy and their behavior of seeking health. If you have the habit of smoking or drinking,
Whether there is drug dependence; Have you ever participated in harmful or dangerous activities; Lifestyle, whether there are risk factors for injury; Whether it is healthy or not.
Lack of health knowledge, lack of awareness of actively seeking health knowledge, and failure to follow doctor's advice.
(2) Nutrition and metabolism
Including the nutritional status, diet and intake of patients; Appetite, drinking water, swallowing; Are there any dietary restrictions?
System; Diet types (soft food, semi-liquid, liquid, etc.). ); Have you changed your weight recently?
(3) Rest and sleep
Including the patient's sleep status, whether sleeping pills and other auxiliary sleep measures are needed, and whether physical strength is easy to recover after rest.
Wait a minute. 10,
(4) Excretion
I. Shit
Habit and frequency of defecation, whether there is abnormal defecation, whether to use laxatives and other laxative measures.
2. So, Diao?
Urination frequency, urine volume, characteristics, whether there is abnormal urination, etc.
(5) Activities and sports
Including oral self-care ability (eating, washing, bathing, dressing, going to the toilet, etc. ) and functional level, activity ability,
Activity endurance, whether there are medical or disease restrictions, whether there are physical activity obstacles. Usually, the ability of self-care can be divided into three categories.
Grade: completely self-care, partially self-care, completely unable to take care of themselves.
Buxue net finishing
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