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History Taking

History Taking. The Endocrinal Department, The First Affliated Hospital, Liao Ning Medical Univercity Liu xin yu. Premise. 1. An account of the events which have relevance to the patient's mental and physical health 2. A specialized literary form

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History Taking

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  1. History Taking The Endocrinal Department, The First Affliated Hospital, Liao Ning Medical Univercity Liu xin yu

  2. Premise 1. An account of the events which have relevance to the patient's mental and physical health 2. A specialized literary form 3. Supplied by the patient or other informant 4. The history is the patient's history of their illness, not the physician's interpretation of the patient's history 5. The doctor's task at this time is to try to understand the patient's experience and interpretation of her illness

  3. Component of inquisition Attention: Once entered and signed, the information in the medical record can not be altered. 1. Indentification 1) Patient's name 2) Sex 3) Residence 4) Birth date and age 5) Ethnic group, Marital status, Ocupation and so on.

  4. 2. The informant 1) The source of the history 2) Interpreters

  5. 3. Chief complaints Difinition: These should consist of a list of one or more symptoms that caused the patient to seek attention and be followed by the approximate duration in time units. Attention: Must be words or phrases, not as complete sentences. Complaints are not diagnoses by the doctor or the patient. Purposes: Making a differential diagnosis; Remind doctors

  6. 4. History of present illnessDescribe the whole process after illness：Occurrence, development , evolution and treatment through. Symptoms Difinition: A symptom is usually considered to be an abnormal sensation that is perceived by the patient. Physical signs: Can be seen, felt, heard by the examiner.

  7. History of present illness 1.Onset and disease duration; 2.Characters of the main symptoms; 3.Cause of diaseases； 4. Development and Evolution of the disease； 5. Accompanying symptoms； 6. The treatment process； 7. The general situation in the course.

  8. 5. Past medical and surgical history 1) General Health 2) Chronic and Episodic Illnesses a. Chronic Medical illnesses b. Infectious Diseases 3) Operations and Injuries 4) Previous Hospitalizations 5) Allergic history 6) History of preventive inoculation

  9. 6. Family History

  10. 7. Social History 1) Place of Birth 2) Nationality and Ethnicity 3) Marital Status 4) Occupation 5) Military History 6) Gender Preference 7) Social and Economic Status 8) Habits 9) Violence and Safety 10) Prostheses and In-home Assistance

  11. 8. Review of History Attention: You should ask the questions while examing the part of the body to which the questions pertain. 1) Respiratory System 2)Cardiovascular System 3)Gastrointestinal System 4)Genitourinary System 5) Hematopoietic System 6)Endocrine System 7)Nervous System 8) Musculoskeletal System

  12. Method and Techniques of Inquisition Attention: Listen actively; Do not interrupt the patient; Ask open-ended questions; Be patient, give the patiet time to think and speak.

  13. Four objectives of taking a diagnostic history • Discovering symptoms • Obtaining accurate quantitative descriptions • Securing a precise chronology of events • Determining how the illness has changed the patient's life

  14. Arrangement 1) Address patients formally 2) Limit the interview to the patient and one other informant 3) Physician's manner: Respect the patient. 4) Note Taking: 5) Language: 6) Patient's Motivation:

  15. thank you

  16. NECK

  17. Anterior cervical triangle: posterior margin of sternocleidomastoideus; inferior margin of mandible; anterior median line Posterior cervical triangle: hinder margin of sternocleidomastoideus; superior margin of clavicle; costal margin of trapezius Normal shape: symmetry of two sides; erect Attention: swellings; sternocleidomastoideus; cervical spine; shoulder; clavicles Normal movement: flexion; extention; lateral bending; rotation of the head

  18. 1.Torticollis: 1) Congenital type hematoma or partial rupture of the muscle at birth unilateral muscle shortening 2) Dystonic reaction phenothiazine drugs the dystonic sternocleidomastoideus is the most prominent 2.Stiff Neck: Pain in the neck and limitation of its motion muscles; bones; joints of the neck. Meningeal inflammation should be evaluated at first. *Brudzinski sign

  19. 3. Skin and Mass Skin: spider angioma; infection; scar; psoriasis（银屑病） Mass: location; quantity; size; texture; activity; relation to neighbour organs; tenderness 4.Hematoma of the sternocleidomastoideus

  20. 5.Blood Vessels 1) external jugular vein: normal: collapse in the erect or seat position; light turgor in the prostration abnormal: distention in the prostration or the thorax reclining at 45 degrees; collapse in the prostration---hypovolemia common diseases: right congestive heart failure; constrictive pericarditis; hydropericardium; superior vena cava obstruction syndrome

  21. 2) Jugular vein pulsation common cause: tricuspid incompetence 3) Carotid artey pulsation Normal: weak after strong rexercises Abnormal: manifest in quiet common diseases: aortic incompetence; hypertension; hyperthyroidism; critical aneamia Distinguish pulsation between jugular vein and carotid artery: Jugular vein pulsation: extent dispersion; impalpable

  22. THYROID Constructions: isthmus; lateral lobes Normal: not palpable and not visible

  23. Thyromegaly scale division Ⅰdegree: not visible but can be palpated Ⅱ degree: can be visited and can be palpated but not surpass sternocleidomastoideus Ⅲ degree: surpass sternocleidomastoideus

  24. THYROID PALPATION 1. Palpation from behind 2. Frontal palpation

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