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1、1,HISTORY RECORD,2,What is history record,The clinical record documents the patients history and physical findings. It shows how clinicians assess the patient, what plans they make on the patients behave, what actions they take, and how the patient responds to their efforts .,3,Importance of history
2、 record,1. Diagnosis and treatment purpose An accurate, clear, well organized record reflects and facilitates sound clinical thinking. It leads to good communication among the many professionals who participate in caring for the patient 2. Teaching and research purpose3. Medicolegal purposes,4,How t
3、o make a good history record,When creating a record, you do more than simply make a list of what the patient has told you and what you have found on examination. You must review your data, organize them, evaluate the importance and relevance of each item, and construct a clear, concise, yet comprehe
4、nsive report.,5,How to make a good history record,1. Order is imperative2. Keep items of history in the history 3. Describe specifically any pertinent negative information 4. Data not recorded are data lost 5. Use short words instead of long and probably fancier ones when they mean the same thing 6.
5、 Be objective7. You should write the record as soon as possible,6,Basic requirement for the history record,1. To be well organized and canonical2. No much erasion and gride could be done in the history record3. To be objective and accurate4. Using professional term to record instead of folksay5. Rem
6、ember to have your signature,7,A. Outline of case record,1. Biographical data Biographical information of patient should include his full name, age (date of birth), sex, race, occupation, nationality, marital status and permanent home address. Also, the date of admission, the time at which you took
7、the history, the source of history and estimate of reliability should be involved.2. chief complaint The chief complaint consists of main symptom(s) and duration. It should constitute in a few simple words the main reasons why the patient consulted doctor and should be state as nearly as possible in
8、 the patients own wards. In general, the chief complaint should include age, sex, complaint, and duration of the complaint. It should no included diagnostic terms or disease entities. For example:” This 70-year old man has had short breath for a week.”,8,3. History of present illness (HPI) The histo
9、ry of present ill ness should be a well-organized, sequentially developed elaboration of his chief complaint(s) on its various characteristics: date of onset, character of complaint, mode of onset, course and duration, location, relationship to other symptoms, bodily function and activities, exacerb
10、ation and remissions, and effect of treatment.4. Past history (PH) It should include a review of all past ill nesses, surgical procedures, and injuries, and allergy history (medicine, food), which are particularly related to the present illness.,9,5. Review of system (ROS) The purpose of sys tem rev
11、iew is twofold: a thorough evaluation and a double check prevent omission of significant data relative to the present illness. The review is a comprehensive account of all complaints referable to each body system progressing in a logical manner from the head toward the feet, including respiratory sy
12、stem, cardiovascular system, digestive system, Urinary system, hemopoietic system, endocrine system, nervous system and skeletal system.6. Personal history (social and occupational history) It includes personal habits (smoking, alcohol drinking), business life, sex life, occupation (exposure to cert
13、ain irritating agents), condition of work.,10,7. Marital history It includes data concerning the health of mate, sexual adjustment, the number of children and their Physical status, and the general social adjustment within the family.8. Menstrual history ( for female patients) Age of onset, interval
14、 between periods, duration, amount and character of flow, concomitant symptoms, date of last menstruation, age of menopause.9. Childbearing (reproductive) history Age and date of pregnancy(ies) and childbirth(s). Date of artificial or natural abortions, stillbirths, operative delivery, puerperal fev
15、er. Method of family planning, the possible factors of infertility (also for male patients).,11,10. Family history (FH) The health status of the patients family (mother, father, siblings and children) and if died, the age and cause of death should be recorded, such as diabetes, hypertension, cancer,
16、 obesity, allergic disorders, coronary artery disease and mental illness.11. Physical examination (PE) The recording of Physical examination should follow a logical sequence as follows: vital signs, general status, skin, nodes, head, neck, chest, lungs, heart and blood vessels, abdomen, genitalia, r
17、ectum, spine and extremities, nervous reflexes.12. Laboratory tests and instrumental examination The findings of them onkly serve to confirm what you have found on history and Physical examination. The routine laboratory studies include blood, urine and stool tests, electrolytes, X-rays and ECG.,12,
18、13 Summary14. Primary diagnosis As the results of differential analysis of a number of significant data, a primary diagnosis could be established. It consists of etiologic diagnosis, pathological diagnosis, pathophysioloical diagnosis (stage or period and classification or subtype), cardiac or/and p
19、ulmonary function and complication(s).15.signature,13,BOutline of Summary,Name, gender, age and occupationAdmission dateAhief complainsPresent history(70%-80% percent of the original present history )Simplified document of the original past history(only positive data recruited)Very simplified docume
20、nt of the original personal and family historyPhysical examination: vital signs, important positive and negative signs, especially valuable information for differentiation, but you can not omit such important items as heart/lung/abdominal examination. Positive laboratory and instrumental results,14,
21、Example of case record,Biographical data:NameLUO LEN SHENG Age: 30 Sex: M Marital status: Married Native place: China Race: HanOccupation : Mechanic Date of Admission date: 2003/11/16Statement: patient herself,15,Chief complaint: recurrent abdominal pain and melena for more than one yearHistory of p
22、resent illness: Mr. luo has been suffered from abdominal pain and recurrent melena since 2002, began on May 2,2002 he had upper abdominal pain and melena first time, with no any inducement factors, obscure upper abdominal pain happened with no radiation, no belching ,no vomiting, no fever and tremor
23、. Pain was hungry pain and can be relieved by antacid agent or by meal. Melena occurred three times a day, about 250g each time, continuing for 5 days with little fatigue, no hematomeses. He went to the local county,16,hospital on the third day of melena, where he received gastroscopy that showed du
24、odenal bulb ulcers with bleeding. Then he was administered Omeprazole (PPI) intravenously for 6 days, 40mg each time, twice a day (Bid). On the second day of treatment, the melena disappeared . On Nov. 15, 2003, without any inducement he had melena again 3 times a day and 250-500gm. Every time accom
25、panied with fatigue and timed but no dizziness and syncope. This time he went to the second Peoples hospital. He took PPI but didnt receive gastroscopy. After receiving PPI., melena disappear. But the OB(occult blood) test was still positive. The next day he was shifted to 1st affiliated hospital of
26、 Guangxi Medical University and received further examination and treatment. The general condition is good and work is not affected in any way since he had such a disease.,17,Past history: Previous health status: Well ordinary bad infectious disease Immunizations allergies: N Y clinical manifestation
27、: allergen Trauma history: surgery history:Review of systems: (Tick if positive, cross out if negative. If positive, you should write down your disease history and brief course of diagnose and therapy),18,Review of systems: (Tick if positive, cross out if negative. If positive, you should write down
28、 your disease history and brief course of diagnose and therapy)Respiratory system:sore throat chronic cough sputum hemoptysis wheezing dyspnea chest pain,19,Cardiovascular system:palpitation dyspnea on exertion hemoptysis syncope edema of lower limbs precordial pain hypertentionDigestive system:anor
29、exia sour regurgitation belching nausea vomit abdominal distention abdominal pain constipation diarrhea hematemesis melenahematochezia jaundiceUrinary system:lumbago frequent micturition urgent micturition urodynia dysuria hematuria nocturia polyuria oliguria facial edema,20,Hemopoietic system:fatig
30、ue dizziness blurred vision gingival bleeding subcutaneous hemorrhage ostealgia epistaxisMetabolic and endocrine system:excessive appetite anorexia sweets cold intolerance olydipsia polyuria tremor hands change of character obvious obesity emaciation hairiness hair losing pigmentation change of sexu
31、al function amenorrheaMusculoskeleton system:floating arthralgia arthralgia swelling of joints deformities myalgia atrophy of muscle,21,Nervous system:dizziness headache vertigo syncope degeneration of memory visual disturbance insomnia disturbance of consciousness tremor spasm paralysis paresthesia
32、Personal history:birthplace occupation sexual history: N Y smoking: N Y about yrs average pieces/d ceased for yrs alcohol intake: N occasional frequentabout yrs average ml/d others:Maritial history:marrying age companions state of health,22,Menstruation and Childbering history:menarche age - date of
33、 last period (age of menopause) amount of flow: little normal large menstrual pain: N Y cycle: regular irregular pregnancy: times natural labor times abortions times premature delivery timesstillbiriths times difficult labor and its condition:Family history: (pay attention to the congenital diseases
34、 and communicable diseases related to the patient)father: still alive illness died cause of death mother: still alive illnessdied cause of death siblings: others:,23,Physical examinationVital signs: T 36 P 70 /min R 20 /min Bp 110 /70 mmHgGeneral Appearance:development: ortho-sthenic type asthenic t
35、ype sthenic type nutrition: well fairly poor cachexia facial features: normal acute chronic others expressions: natural painful anxious dreadful indifferent position: active semi-recumbent others gait: normal abnormalconsciousness:aware somnolence confusion stupor coma delirium cooperation:well badl
36、y,24,Skin, mucous membrane: color: normal red pale cyanosis yellow pigmentationrash: N Y (type and distribution) subcutaneous hemorrhage: N Y (type and distribution)hair: normal scattering losing (position) moisture and temperature: normal cold dry wetelasticity: normal reduced edema: N Y (position
37、and degree) hepatic palm: N Yspider angioma: N Y (position numbers) others:,25,Lymph nodes:superficial lymph nodes: non-swellingswelling (position and characteristics)Head:cranium:size:normal large small deformity:N Y(oxycephaly squared skull deforming skull)others: tenderness mass sunk (position )e
38、yes: eyelid: normal edema ptosis trichiasis conjunctive: normal hyperemia edema hemorrhage eyeball: normal exophthalmos depression tremormotion dysfunction (left right),26,sclera: normal yellow cornea: normal abnormal (left right )pupils: equal roundness same size unequal left cm, right cmreaction t
39、o light: normal delay (left right ) disappear (left right ) others:ears: auricle: normal deformity fistula others (left right )excretions of external canal: N Y (left right feature )tenderness of mastoid: N Y (left right ) audition dysfunction: N (left right )nose: shape: normal abnormal( ) other ab
40、normalities: N Y nasal flapobstruction excretions nasal sinus tenderness: N Y (position ),27,mouth: lips: red cyanosis pale herpes fissure mucous: normal abnormal (pale bleeding)opening of parotid gland duct: normal abnormal (swelling pyogenic excretions)tongue: normal abnormal (coverings tremor lea
41、ning to left or right )gums: normal swelling pus overflow hemorrhage pigmentsteeth: regular edentulous carious teeth false toothtonsils: pharynx: voice: normal hoarse,28,Neck: resistance: N Y carotid artery pulsation: normal increased decreased (left right)jugular vein: normal distention high disten
42、tion trachea: middle deviation to (left right)hepatojugular reflux: (-) (+) thyroid: normal swelling degree symmetrydominance in one side:spreading nodular: soft hard others: N Y (tenderness tremor bruits ),29,Chest: topography: normal barrel chest flat chest pigeon chest funnel chestbulging or retr
43、action (left right) bulging in the precordial region tenderness of sternumbreast: normal symmetrical abnormal: left right (gynecomastia mass tenderness)excretions of nipples ),30,Lung:inspection: movement of respiration: normal abnormal: left right (increased decreased)intercostals space: normal wid
44、e narrow (position )palpation: vocal fremitus: normal abnormal: left right (increased decreased)pleural friction rubs: N Y (position )percussion: resonance abnormal: dullness flatness hyperresonance tympanylower borders: scapular line: right intercostals space left intercostals spacerange of mobilit
45、y: right cm, left cm,31,auscultation: breath: regular irregularbreath sound: normal abnormal (feature, position )rales: N Y: rhonchi: sonorous sibilant moist rales: coarse medium fine rales crepitusvocal conduction: normal abnormal: reduced increasedPleural friction rubs: N Y (position ),32,Heart:in
46、spection: bulging in precordial region: N Y apex impulse: normal unseen increased diffusingpoisition: normal deviation (the distance from midclavicular line cm)other precordial pulsations: N Y (position )palpation:apex impulse: normal increased thrust unclearthrills: N Y (position period ) pericardi
47、al friction rubs N Ypercussion: relative cardiac outline: normal shrink extant (right left),33,Normal boundary of the heart right(cm) intercostals space left(cm) 2-3 2-3 2-3 3.5-4.5 3-4 5-6 distance from anterior midline to the left midclavicular line(cm):,34,auscultation: heart rate bpm/min rhythm
48、(regular irregular absolutely irregular)heart sound: S1 normal increased decreased split S2 normal increased decreasedS2 split: normal fixed paradoxical S3 N Y S4 N Y A2 P2extra heart sound: N gallop (diastolic presystolic summation gallop) opening snap othersmurmurs: N Y,35,Location: apical region
49、aortic area pulmonary area tricuspid arealeft sternal border in 3nd intercostals space OthersTiming: systolic diastolic bothQuality: blowing rumbling sighing musical Austin Flint Graham Steell GibsonIntensity: Grade Transmission: N Y direction to left axilla over the apex over the carotid arteriesPe
50、ricardial friction rubs: N Y,36,Peripheral vessels: normal pistol shot: N Y Duroziez sign: N Ywater hammer pulse: N Y capillary pulsation: N Ypulse deficit: N Y paradoxical pulse: N Y pulse alternations: N Y othersAbdomen:inspection: shape: normal distention frog belly cm scaphoid abdomen apical bel
