History Taking

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History Taking

• The Endocrinal Department, The First Affliated
  Hospital, Liao Ning Medical Univercity
• Liu xin yu

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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

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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.

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2. The informant

• 1) The source of the history
• 2) Interpreters

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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

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4. History of present illnessDescribe the whole
process after illnessOccurrence, 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.

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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.

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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

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• 6. Family History

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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

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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

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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.

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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

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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

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• thank you

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• NECK

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• 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

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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
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3. Skin and Mass

• Skin spider angioma infection scar
  psoriasis(???)
• Mass location quantity size texture
  activity relation to neighbour organs
  tenderness

4.Hematoma of the sternocleidomastoideus
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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

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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

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THYROID

• Constructions isthmus lateral lobes
• Normal not palpable and not visible

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Thyromegaly scale division

• ?degree not visible but can be palpated
• ? degree can be visited and can be palpated but
  not surpass sternocleidomastoideus
• ? degree surpass sternocleidomastoideus

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THYROID PALPATION

• 1. Palpation from behind
• 2. Frontal palpation