20xx年醫(yī)學(xué)專題—病史采集(英文)-預(yù)覽頁(yè)
【正文】 uration.,2011/09/06,第十四頁(yè)，共三十七頁(yè)。,History of Present Illness:,A clear, chronological narrative includes: Onset of problem Setting in which it developed Manifestations Associated manifestations Any treatments General state : appetite , sleeping, urine , bowel movement ,body weight, ect.,Principal symptoms described in terms of: Location Quality Quantity or severity Timing (onset, duration, frequency) Setting Factors that aggravated or relieved Associated manifestations,2011/09/06,第十八頁(yè)，共三十七頁(yè)。,Past Medical History:,Adult Significant Illnesses or conditions: Examples: recurrent sore throats urinary tract infections yeast infections hypertension diabetes coronary arterial disease,Note time of onset or date of diagnosis control of disease or condition treatment, if any,2011/09/06,第二十二頁(yè)，共三十七頁(yè)。,Past Surgical History:,Note reason for surgery if not obvious Ex: Total abdominal hysterectomy secondary to problems with dysfunctional uterine bleeding vs. gynecologic cancer,Note any complications Use chronological order amp。 in Albuquerque Hospital by Dr. Green with length of stay of 3 days. Spinal anesthesia without reaction. No complications.,2011/09/06,第二十六頁(yè)，共三十七頁(yè)。,Review of systems,A printed form that contains the questions that you usually ask If your patient has a chief complaint involving the GI system, the review of system will be included in the HPI as pertinent positives and negatives. “See HPI”,2011/09/06,第二十九頁(yè)，共三十七頁(yè)。,Menstrual and Childbearing History,age of onset interval between periods duration amount of flow date of last menstrual period(LMP) age of menopause age of pregnancy and childbirth times of artificial or natural abortions stillbirth operative delivery puerperal fever,record menstrual history as follows menstrual duration Age of LMP onset interval between periods,5 13 20080305 30,5 13 50 30,2011/09/06,第三十三頁(yè)，共三十七頁(yè)。,Summary,Inquiry ★The importance of inquiry ★The contents of inquiry ﹡chief complaints ﹡history of present illness ★The methods and skills of inquiry,2011/09/06,第三十六頁(yè)，共三十七頁(yè)。2011/09/06
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