First, the method of consultation, chief complaint and medical history collection
(a) the inquiry method is that doctors know the occurrence, development, present situation, previous examination, treatment and curative effect of patients' diseases through inquiry. Therefore, consultation is the most basic and important means to collect medical history and diagnose diseases.
1. The contents of the consultation mainly include: ① general items (patient's name, gender, age, nationality, marriage, occupation, native place, address, etc. ); 2 chief complaint; ③ Past history; 4 past history; ⑤ Personal history; 6. History of menstruation, marriage and childbearing; ⑦ Family history.
2. Consultation methods and matters needing attention
(1) In the process of consultation, we should have a high sense of love and injury, have a warm attitude, be kind in language, show due medical humanistic care and respect to patients, and avoid damaging their language and expression.
(2) Be good at using easy-to-understand language, ask about illness concisely, and try not to use medical terms.
(3) Be good at grasping the key points, asking in-depth and meticulous questions, patiently inspiring patients to answer the medical history related to diagnosis, avoiding suggestion or induction, and ensuring the authenticity of the medical history.
(4) During the inquiry, attention should be paid to timely verifying the inaccurate or questionable information in the patient's statement.
(5) During consultation, doctors should listen patiently, and analyze, synthesize and summarize the relationship between patients' symptoms while listening.
(6) After the consultation, the patient's narrative should be summarized in order of priority, and a complete, systematic, simple and concise medical record should be written in standard format.
(2) chief complaint and medical history collection
1. Chief complaint is the most obvious and painful main symptom (or sign) and its duration. Records should include the most important symptoms, the place and time of onset. Words should be concise, generally no more than 20 words, and it is not appropriate to replace symptoms with diagnosis or examination results. If there is more than one chief complaint, they can be listed separately in chronological order. For cases with long course of disease and complicated condition, the chief complaint at clinical visit is not necessarily the main manifestation of the present disease, and a more suitable chief complaint should be selected based on the analysis of medical history.
2. The present medical history is the main part of the medical history, which describes the detailed process from onset to treatment, that is, the occurrence, development, evolution and diagnosis and treatment process. The current medical history mainly includes:
(1) Incidence includes onset time, etiology or inducement, location, nature and degree of main symptoms at present.
(2) Whether the evolution of the disease is initial or recurrent, whether the main symptoms are gradually aggravated or alleviated, and whether there are intermittent and concurrent symptoms; Whether you have received treatment, the way and effect of treatment (list the names and doses of drugs used and the names of various treatment methods as far as possible). Weighing, etc. ).
(3) Symptomatic manifestations with differential significance.
(4) There is no abnormality in spirit, appetite, food intake, weight, sleep and defecation after the onset.
3. Past history refers to the patient's past health status and what kind of diseases he suffered. The incidence of some oral diseases is related to patients' past health status and living habits, so it is necessary to understand the past situation related to the diagnosis and treatment of current diseases. When inquiring and recording, special attention should be paid to whether the patient has systemic diseases, injury history, operation history, acute and chronic infectious diseases, drug allergy history and important drug application history.
4. Personal history mainly includes social experience (birthplace, residence, moving history, economic situation, hobbies, etc. ), occupation, working environment, living habits, hobbies.
5. Menstruation and Marriage and Childbearing History Menstrual history includes menarche age, menstrual period (days)/cycle (days), last menstruation (or menopause age), menstrual regularity, menstrual volume, dysmenorrhea, etc. , as well as the number of pregnancies and deliveries, premature delivery and abortion history.
6. Family history Health and illness of parents, brothers, sisters and children. When asking, it is important to know whether there are the same or similar diseases in the family, and whether there are genetically related diseases (such as diabetes, hypertension, tumor, mental illness, etc.). It is also necessary to ask about the immediate family members who have passed away.
[Thinking]
1. Please describe the main contents and methods of consultation.
2. What is the chief complaint? What are the three elements of the chief complaint?
3. Please describe the main contents of the current medical history.