History Taking

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History Taking

• FuHaixiang

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• Accurate diagnosis rests firmly upon the
  foundation of a thoughtful and inclusive history
  and a compotently performed physical examination.

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Personal ID

• Name?address?phone?nearest of kin.Age?sex?rece?occ
  upation?marital status.
• Date of Entry and Hospital Numbor
• Source and Reliability of Iuformant

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• Previous Entries
• Dates?diagnoses?treatment?significant
  complications.
• Chief complaints(CC)
• Presenting complaints and duration.

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Present Illness(PI)

• AThe immediate history that brought the patient
  to the hospital
• BBackground history of disease leeding to the
  immediate history
• CSignificant positive and negative data that
  might give clues useful in differential
  diagnosis

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Family History

• AFather
• BMother
• CEach sibling
• DHistory of disease in which heredity or contact
  may play a role.
• ERecord a family tree

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Marital History

• AAge and health of spouse year married
• BAges and health of children
• CPrevious marriages

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Medical History

• AHospitalization
• BIllness
• CTrauma
• DOperations
• EChildhood diseases

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Social History

• ASerial residences
• BEducation
• CEmployment
• DMilitary service

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Habits

• AAppetite
• BUse alcohol,coffee,tea,tobacco
• CSexual habits
• Allergies
• Hay fever,asthma,hives,food,skin,drugs

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• Drug Use.
• AMedicines
• BDrug abuse
• Weight
• AHighest
• BAverage
• CPresent

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System History

• Physical Examination-general
• 1.Vital Sighs
• Blood pressure Pulse rate
• Temperature Respiratory rate
• Height Weight
• General appearance

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• 2.Mental status
• 3.Neck.shape,trachea,thyroid,blood vessels.
• 4.Breastssymmetry,nipples,masses,tenderness.

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• 5.Chestskin,thorax(shape,symmetry)
• ?Lungsfremitus,resonance,breath sounds
• ?Heart
• Inspectionjugular venous pulsations,point PMI
• Palpationlocate PMI,thrill
• Percussionheart size
• AuscultationRate,rhythm.Heart sounds.murmurs.

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• 6.Abdomencontour,skin,hair and scars.
• ?intestinal activity
• ?rigidity and tenderness.
• ?Percussion for dullness.
• ?organs and masses
• ?shifting dullness
• ?collateral circulation

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Back

• Curvatures,symmetry,mobility
• Tenderness over spine
• Pelvis
• Kidneys(costovertebral angle tenderness)

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• Rectum
• Genitals
• Pelvis
• Extremities
• Granial Nerves
• Gait? Cerebellum ?Sensory Associative?
  Functions?Motor

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• ReflexesRight left
• Biceps
• Triceps
• Patellar,
• Ankle,
• Cremaster,
• Abdominal,
• Plantar

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Basic Laboratory Data

• 1.HematologyWBC,RBC,Hematocrit,platelet
• 2.Indexes
• 3.Urinalysis
• 4.Stool Guaiac
• 5.Sputum Smear
• 6.Electrocardiogram
• 7.Purified Protein Derivative(PPD)
• 8.Chest X-ray

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Summary

• Brief but esseutial summary of
• ?history
• ?physical examination
• ?contribution ancillary data
• Formulation of Diagnoses.
• Problems and Plans
• Define and solve each diagnosis and problem
  individually.

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• 1.Diagnoses
• ? Analysis
• ?PlansDiagnostic tests
• Therapeutic measures
• 2.Problems
• ?Analysis
• ?PlansDiagnostic
• Therapeutic