History Taking
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History Taking 王靖雯
Cathy
Wang The affilliated Hospital of Jining Medical College
Question What
is the medical history ？ How to take the patient’s history ？ What’s the method of inquisiton ？
Preface The
medical history is an account of the events in the patient's life that have relevance to the patient's mental and physical health.
It
is a specialized literary form in which the physician writes an account of the perceptions and events supplied by the patient or other informants.
In
taking the history ， clinician should record key statements in the patient's words. The history of the patient's history of their illness ， not the physician's interpretation
It
Component of Inquisiton
is the clinician's responsibility to see that the medical record is complete and accurate.
General Data
Identification Patient's
Name
recording name
the
complete
obtain the correct spellings
Race
or Nationality
minority race the Han nationality
Ethnic and genetic back grounds are of some importance in diagnosis ， for example ， of diseases such as hemoglobinopathies and Familial Mediterranean Fever.
Birth
Date and Age
The patient’s statement of the birth date should be recorded ， in addition to the stated age.
Birth place This information may be useful in assessing social or national incidence of disease.
Sex
This is obvious. In cases of intersex ， the problem of sex may be difficult to establish accurately ， but it is sufficient to give the sex the patient has assumed.
Marital Single Married
Status
Occupations
Precise knowledge of the patient's work history sheds light on education ， social status ， physical exertion ， psychologic trauma ， exposure to noxious agents ， and a variety of conditions that may cause disease. The Patient’s occupation is also important factor,especially if the patient’s job is exposes him to certain substances.
Residence The
address should be confirmed and recorded as completely as possible to facilitate efficient mailing of correspondence .
COMPLAINTS
The physician needs to know the exact circumstances of the appearance, exent,and duration of the symptoms. Further questioning develops details of the health of the patient’s family,his habits and lifestyle,and his previous medical experiences.
Finally, the physician asks a series of questions about each of the body systems such as the heart ,lungs , stomach,etc.
CHIEF COMPLAINTS
The history of symptoms begins with the chief complaints ， abbreviated CC. These should consist of a list of one or more symptoms that caused the patient to seek attention .
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS /HPIJ
Symptoms
The word symptom is derived from a Greek word meaning "something that has befallen one." A symptom is usually considered to be an abnormal sensation that is perceived by the patient ， in contrast to a physical sign that can be seen ， felt,or heard by the examiner.
Time and circumstances of onset Characters of symptoms Cause of diease Duration and development Concomitant symptoms Treament General data: consciousness ,weight loss ,urine, bowel Movement,etc
Question the patient until sufficient details are obtained to categorize the symptom. Do not accept vague complaints such as "I don't feel well. " If the patient complains of weakness ， ascertain if she is weak in one or more muscle groups or if she experiences lassitude ， malaise,or myalgia.
When a patient says she is dizzy inquire if she feels weak and unstable or if her surroundings seem to whirl about,as in vertigo. Determine whether dyspnea occurs at rest or with exertion.
Past History
Previous health status
Well Ordiary Bad Infectious disease Imunization Allergies:N Y ,Clinical manifestation Allergen Trauma Surgery
Personal
history Marital history Menorrhea and childbearing Family history
Review of Systems
Skin
Color ， pigmentation ， temperature ， moisture ， eruptions ， pruritus ， scaling ， bruising ， bleeding
Hair
Color ， texture ， abnormal loss or growth ， distribution
Nails
Color changes ， brittleness ， ridging ， pitting ， curvature.
Lymph Nodes
Enlargelnent ， pain ， suppuration ， draining sinuses ， location
Bones ， Joints ， and Muscles
Fractures ， dislocations ， sprains ， arthritis ， myositis ， pain ， swelling ， stiffness ， migratory distribution ， degree of disability ， muscular weakness ， wasting ， or atrophy ， night cramps
Hemopoietic System
Anemia (type ， therapy ， and response) ， Iymphade nopathy ， bleeding or clotting (spontaneous ， trauma familial)
Endocrine System
History of growth ， body configuration ， and weight. Size of hands ， feet ， and head ， especially changes during adulthood. Hair distribution. Skin pigmentation. Goiter ， exophthalmos ， dryness of skin and hair ， intolerance to heat or cold ， tremor. Polyphagia ，
Allergic and Immunologic History
Dermatitis ， urticaria ， angioedema ， eczema ， hay fever ， vasomotor rhinitis ， asthma ， migraine ， vernal conjunctivitis and seasonal occurrence of these.
Head
Headaches ， migraine ， trauma ， vertigo ， syncope ， convulsive seizures.
Eyes
loss of vision or color blindness ， diplopia ， hemianopsia ， trauma ， inflammation ， glasses (date of refraction) ， discharge ， excessive tearing
Ears
Deafness ， tinnitus ， vertigo ， discharge from the ears ， pain ， mastoiditis ， operations.
Nose
Coryza ， rhinitis ， sinusitis ， discharge ， obstruction ， operations
Mouth
Soreness of mouth or tongue ， symptoms referable to teeth.
Throat
Hoarseness ， sore throats ， tonsillitis ， voice changes
Neck
Swelling ， suppurative lesions ， enlargement of lymph nodes ， goiter ， stiffness and limitation
Breasts
Development ， lactation ， trauma ， lumps ， pains ， discharge from nipples ， gynecomastia ， changes in nipples.
Respiratory System Cardiovascular System
Gastrointestinal system Genitourinary System
Gynecologic History Male History Veneral Disease History
Nervous System Cranial Nerves Motor System Sensory System Autonomic System
Psychiatric History
Medications Allergies and Medication intolerance Preventive Care Service
Method and Techniques of inquisiton
listen actively don't interrupt the patient listen actively to be patient,give the patient time to think and speak listen actively
Arrangements Physician’s Manner Note taking Language Patient’s Motivation Procedure
Key Pionts
静听（ Audition ） 评价（ Evaluation ） 询问（ Inquiry ） 观察（ Observation ） 理解（ Understanding ）
Summary
Definition Component Techniques
You are welcome
TANKS A LOT !
临床表 现及诊 断 ： 30 岁以上的经产妇， 出现经量增多、经期延长以及逐年加剧的 进行性痛经，子宫呈均匀性增大或有局限 性结节隆起，质硬而有压痛，经期压痛尤 为显著。 保守治 疗 ：已近绝经期 全子宫 切除术
SEE YOU NEXT TIME !
Cathy
Wang The affilliated Hospital of Jining Medical College
Question What
is the medical history ？ How to take the patient’s history ？ What’s the method of inquisiton ？
Preface The
medical history is an account of the events in the patient's life that have relevance to the patient's mental and physical health.
It
is a specialized literary form in which the physician writes an account of the perceptions and events supplied by the patient or other informants.
In
taking the history ， clinician should record key statements in the patient's words. The history of the patient's history of their illness ， not the physician's interpretation
It
Component of Inquisiton
is the clinician's responsibility to see that the medical record is complete and accurate.
General Data
Identification Patient's
Name
recording name
the
complete
obtain the correct spellings
Race
or Nationality
minority race the Han nationality
Ethnic and genetic back grounds are of some importance in diagnosis ， for example ， of diseases such as hemoglobinopathies and Familial Mediterranean Fever.
Birth
Date and Age
The patient’s statement of the birth date should be recorded ， in addition to the stated age.
Birth place This information may be useful in assessing social or national incidence of disease.
Sex
This is obvious. In cases of intersex ， the problem of sex may be difficult to establish accurately ， but it is sufficient to give the sex the patient has assumed.
Marital Single Married
Status
Occupations
Precise knowledge of the patient's work history sheds light on education ， social status ， physical exertion ， psychologic trauma ， exposure to noxious agents ， and a variety of conditions that may cause disease. The Patient’s occupation is also important factor,especially if the patient’s job is exposes him to certain substances.
Residence The
address should be confirmed and recorded as completely as possible to facilitate efficient mailing of correspondence .
COMPLAINTS
The physician needs to know the exact circumstances of the appearance, exent,and duration of the symptoms. Further questioning develops details of the health of the patient’s family,his habits and lifestyle,and his previous medical experiences.
Finally, the physician asks a series of questions about each of the body systems such as the heart ,lungs , stomach,etc.
CHIEF COMPLAINTS
The history of symptoms begins with the chief complaints ， abbreviated CC. These should consist of a list of one or more symptoms that caused the patient to seek attention .
HISTORY OF PRESENT ILLNESS
HISTORY OF PRESENT ILLNESS /HPIJ
Symptoms
The word symptom is derived from a Greek word meaning "something that has befallen one." A symptom is usually considered to be an abnormal sensation that is perceived by the patient ， in contrast to a physical sign that can be seen ， felt,or heard by the examiner.
Time and circumstances of onset Characters of symptoms Cause of diease Duration and development Concomitant symptoms Treament General data: consciousness ,weight loss ,urine, bowel Movement,etc
Question the patient until sufficient details are obtained to categorize the symptom. Do not accept vague complaints such as "I don't feel well. " If the patient complains of weakness ， ascertain if she is weak in one or more muscle groups or if she experiences lassitude ， malaise,or myalgia.
When a patient says she is dizzy inquire if she feels weak and unstable or if her surroundings seem to whirl about,as in vertigo. Determine whether dyspnea occurs at rest or with exertion.
Past History
Previous health status
Well Ordiary Bad Infectious disease Imunization Allergies:N Y ,Clinical manifestation Allergen Trauma Surgery
Personal
history Marital history Menorrhea and childbearing Family history
Review of Systems
Skin
Color ， pigmentation ， temperature ， moisture ， eruptions ， pruritus ， scaling ， bruising ， bleeding
Hair
Color ， texture ， abnormal loss or growth ， distribution
Nails
Color changes ， brittleness ， ridging ， pitting ， curvature.
Lymph Nodes
Enlargelnent ， pain ， suppuration ， draining sinuses ， location
Bones ， Joints ， and Muscles
Fractures ， dislocations ， sprains ， arthritis ， myositis ， pain ， swelling ， stiffness ， migratory distribution ， degree of disability ， muscular weakness ， wasting ， or atrophy ， night cramps
Hemopoietic System
Anemia (type ， therapy ， and response) ， Iymphade nopathy ， bleeding or clotting (spontaneous ， trauma familial)
Endocrine System
History of growth ， body configuration ， and weight. Size of hands ， feet ， and head ， especially changes during adulthood. Hair distribution. Skin pigmentation. Goiter ， exophthalmos ， dryness of skin and hair ， intolerance to heat or cold ， tremor. Polyphagia ，
Allergic and Immunologic History
Dermatitis ， urticaria ， angioedema ， eczema ， hay fever ， vasomotor rhinitis ， asthma ， migraine ， vernal conjunctivitis and seasonal occurrence of these.
Head
Headaches ， migraine ， trauma ， vertigo ， syncope ， convulsive seizures.
Eyes
loss of vision or color blindness ， diplopia ， hemianopsia ， trauma ， inflammation ， glasses (date of refraction) ， discharge ， excessive tearing
Ears
Deafness ， tinnitus ， vertigo ， discharge from the ears ， pain ， mastoiditis ， operations.
Nose
Coryza ， rhinitis ， sinusitis ， discharge ， obstruction ， operations
Mouth
Soreness of mouth or tongue ， symptoms referable to teeth.
Throat
Hoarseness ， sore throats ， tonsillitis ， voice changes
Neck
Swelling ， suppurative lesions ， enlargement of lymph nodes ， goiter ， stiffness and limitation
Breasts
Development ， lactation ， trauma ， lumps ， pains ， discharge from nipples ， gynecomastia ， changes in nipples.
Respiratory System Cardiovascular System
Gastrointestinal system Genitourinary System
Gynecologic History Male History Veneral Disease History
Nervous System Cranial Nerves Motor System Sensory System Autonomic System
Psychiatric History
Medications Allergies and Medication intolerance Preventive Care Service
Method and Techniques of inquisiton
listen actively don't interrupt the patient listen actively to be patient,give the patient time to think and speak listen actively
Arrangements Physician’s Manner Note taking Language Patient’s Motivation Procedure
Key Pionts
静听（ Audition ） 评价（ Evaluation ） 询问（ Inquiry ） 观察（ Observation ） 理解（ Understanding ）
Summary
Definition Component Techniques
You are welcome
TANKS A LOT !
临床表 现及诊 断 ： 30 岁以上的经产妇， 出现经量增多、经期延长以及逐年加剧的 进行性痛经，子宫呈均匀性增大或有局限 性结节隆起，质硬而有压痛，经期压痛尤 为显著。 保守治 疗 ：已近绝经期 全子宫 切除术
SEE YOU NEXT TIME !
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