Transcript health history

Health History
Inquiry
history taking by questioning to
take a history
★The contents of inquiry
1 general data
﹡2 chief complaints
﹡3 present illness
4 past medical history
5 systems review
6 personal history
7 marital history
8 menstrual history
9 childbearing history
10 family history
1 General Data
Name
Sex
Age
Race
Occupation
Marriage
Address
Native place
Working unit
Date of admission
Date of record
2 Chief Complaints
The chief complaints should
constitute in a few simple
words: symptom(s) plus
time. The main reasons why
the patient consults a doctor.
The chief complaints should be
stated as nearly as possible in
the patient’s own words.
For example:
▲sore throat, high fever for
two days
▲chill, fever, right chest pain,
cough for three days
▲recurrent epigastric pain for
eight years, it has been getting
worse over the past two weeks.
The chief complaint should not
include diagnostic terms
or disease entities
such as:
diabetes
heart disease
hypertension
Diabetes: polydipsia
polyphagia
polyuria
weight loss
Heart disease: palpitation
short of breath
Hypertension: dizziness
headache
3 History of Present Illness
(1) Onset and Duration
(2) Features of chief symptoms
(3) Causes of illness and
Precipitating factors
(4) Progression of the illness
(5) Accompanied symptoms
(6) Previous treatment
(7) General condition
(1)Onset and Duration
sudden: acute myocardial
infarction
acute pancreatitis
insidious: cancer of the
colon
Duration minutes
hours
days
months
years
for example:
Severe precardiac pain for
twenty minutes
--acute myocardial infarction
(2) Features of Chief Symptoms
for example: pain
location
frequency
duration
intensity
quality (blunt colic distention
burning )
radiation
alleviating and aggravating
factors.
(3) Causes of Illness and
Precipitating Factors
causes: infection trauma
precipitating factors:
climate change
environmental change
emotive change
irregular meals
(4) Progression of the Illness
the development of main symptom
and appearance of new symptoms.
pulmonary emphysema(short of
breath)
severe dyspnea
pneumothorax
angina pectoris (severe chest pain)
myocardial infarction
(5) Accompanied Symptoms
for example:
diarrhea accompanied by
vomiting
food poisoning
diarrhea accompanied by
tenesmus
dysentery
(6) Previous Treatment
medication dosage effects
(7) General Conditions
mental state after illness
appetite
body weight
sleeping
urine
bowel movement
4 Past Medical History
past health status
past illness
mainly indicate
infections
contagious diseases
such as Tuberculosis(TB)
Hepatitis
any illness relevant to
present illness,
such as
operations
injuries
vaccinations
allergies
5 Systems Review
(1) respiratory system
(2) cardiovascular system
(3) gastrointestinal system
(4) urinary systems
(5) hematopoietic system
(6) endocrine system
(7) neurological system
(8) musculoskeletal system
(1) Respiratory System
cough
character of the cough
dry cough pleurisy
bronchial TB
productive cough
chronic bronchitis
bronchiectasis
time of cough
morning and going to bed at
night: chronic bronchitis
at night:
pulmonary congestion
due to left heart failure or
mitral stenosis
Sputum: amount
consistency color
hemoptysis: amount color
dyspnea: nature intensity
onset of time
chest pain location nature
intensity
duration …
(2) Cardiovascullar System
palpitation: time
the pain of precordial region
feature extent radiation
precipitating factors
edema: location lower extremities
congestive heart failure
breath lessness: on exertion
heart failure
(3) Gastrointestinal System
vomiting: time
precipitating factors
the contents of vomiting
hematemesis: amount color
hematochezia: diarrhea
constipation
(4) Urinary Systems
amount of urine
increased polyuria
diminished oliguria anuria
bladder involvement
urinary frequency
urgency
burning on urination
(5) Hematopoietic System
fatigue
lassitude
palpitation
dizziness
anorexia
(6) Endocrine System
diabetes mellitus
typical symptoms
polyguria
polydipsia
polyphagia
weight loss
(7) Neurological System
common symptoms
convulsion
vertigo
headache
paresthesia
paralysis
(8) Musculoskeletal System
muscular pain
swelling
deformity
disability of joints
6 Personal History
place of birth
current residence
educational background
economic status
living conditions
professional
working conditions
habits and hobbies:
such as
sleeping
eating
drinking
smoking
alcohol consumption
amount
duration
drugs (including sedative
or narcotics)
7 Marital History
married or unmarried
marriage age
relations of couple
8 Menstrual History
age of onset
interval between periods
duration
amount of flow
date of last menstrual period(LMP)
age of menopause
record menstrual history as
follows
menstrual
duration
Age of
onset
LMP
interval
between periods
9 Childbearing History
age of pregnancy and
childbirth
times of artificial or natural
abortions
stillbirth operative delivery
puerperal fever
method of family planning
10 Family History
ages and health status of parents
family history of illness
similar to patients
family incidence of
infectious diseases
TB hepatitis
genetic illness such as hemophilia
★The methods and skills of
inquiry
1 The organization of inquiry
introduction
introduce yourself and explain
your role
the body of interview
chief complaints
present illness
past medical history
the end of interview
2 The sequence of inquiry
to begin with complaints
for example:
a patient complains he has a headache
you can ask
When did you begin to have headache?
Have you ever had this kind of
headache before?
Where is the pain?
How long dose the pain last?
3 The types of question
to begin with general questions
for example:
what brings you here today?
What’s the matter with you?
Tell me about your general
health.
4 To avoid leading questions
for example:
Your chest pains have
radiated to left arm? Right?
5 To avoid medical terms and
jargon
for example:
palpitation epistaxis
tenesmus
6 Documentation
you must document the
information given to you
by the patient
If the patient tell you I
have hypertension,
you should ask patient
How did you know that you
had hypertension?
Summary
Inquiry
★The importance of inquiry
★The contents of inquiry
﹡chief complaints
﹡history of present illness
★The methods and skills of
inquiry