History_TakingPPT课件

Physical Examination-general
• 1.Vital Sighs
Hale Waihona Puke – Blood pressure： Pulse rate：
– Temperature： Respiratory rate：
– Height：
Weight：
– General appearance：
2.Mental status
Social History：
• A：Serial residences • B：Education • C：Employment • D：Military service
Habits：
• A：Appetite • B：Use alcohol，coffee，tea，tobacco • C：Sexual habits
• Allergies： • Hay fever，asthma，hives，food，skin，
drugs
• Drug Use.
– A：Medicines – B：Drug abuse
• Weight：
– A：Highest – B：Average – C：Present
System History
• 6.Abdomen：contour，skin，hair and scars.
– ⑴intestinal activity – ⑵rigidity and tenderness. – ⑶Percussion for dullness. – ⑷organs and masses – ⑸shifting dullness – ⑹collateral circulation
• Granial Nerves • Gait、 Cerebellum 、Sensory Associative、
Functions、Motor
• Reflexes：Right left
– Biceps – Triceps – Patellar， – Ankle， – Cremaster， – Abdominal， – Plantar
Back
• Curvatures，symmetry，mobility • Tenderness over spine • Pelvis • Kidneys（costovertebral angle tenderness）
• Rectum： • Genitals： • Pelvis： • Extremities：
• Inspection：jugular venous pulsations，point PMI • Palpation：locate PMI，thrill • Percussion：heart size • Auscultation：Rate，rhythm.Heart
sounds.murmurs.
3.Neck.shape，trachea，thyroid，blood vessels.
4.Breasts：symmetry，nipples，masses， tenderness.
• 5.Chest：skin，thorax（shape，symmetry）
– ⑴Lungs：fremitus，resonance，breath sounds – ⑵Heart：
History Taking
Accurate diagnosis rests firmly upon the foundation of a thoughtful and inclusive history and a compotently performed physical examination.
A：The immediate history that brought the patient to the hospital
B：Background history of disease leeding to the immediate history
C：Significant positive and negative data that might give clues useful in differential diagnosis
• Previous Entries：
– Dates、diagnoses、treatment、 significant complications.
• Chief complaints（CC）：
– Presenting complaints and duration.
Present Illness（PI）：
Personal ID
• Name、address、phone、nearest of kin.Age、sex、rece、occupation、marital status.
• Date of Entry and Hospital Numbor • Source and Reliability of Iuformant
Family History：
A：Father B：Mother C：Each sibling D：History of disease in which heredity or
contact may play a role. E：Record a family tree
Marital History：
A：Age and health of spouse； year married B：Ages and health of children C：Previous marriages
Medical History：
• A：Hospitalization • B：Illness • C：Trauma • D：Operations • E：Childhood diseases
Basic Laboratory Data
• 1.Hematology：WBC，RBC，Hematocrit， platelet
• 2.Indexes • 3.Urinalysis • 4.Stool Guaiac • 5.Sputum Smear • 6.Electrocardiogram • 7.Purified Protein Derivative（PPD） • 8.Chest X-ray