病史采集)（Collection of medical history）.docVIP

病史采集)（Collection of medical history） 1, according to the chief complaint and related identification inquiries 1) cause of disease and cause 2) the characteristics of the main symptoms 3) accompanied by symptoms 4) body condition: the general state after onset (after onset, diet, sleep, stool and urine weight changes) 2. Diagnosis and treatment 1) did you visit the hospital? What tests have you made? 2) what kind of treatment has been done and how effective is the treatment? Two, the past history (related medical history) 1, related history: past smoking, drinking, similar episodes and family history 2, the history of drug allergy, surgery (must be mentioned, the annual scoring criteria have this) Three, interrogation must be organized, ready to write again, dont mess with later, so points Four. Ask around the subject On a single complaint is not to make a diagnosis, but still have a tendency, such as: the possibility of a 24 year old female fever hemoptysis tuberculosis is large, and 45 year old male fever hemoptysis were considered to have lung cancer, the tendencies are different, they still rely on the accumulation of knowledge. In short, the acquisition, as in the way above, most of the scores have been achieved. It needs to be explained whether the diagnosis is correct or not. As long as the collection of items and content is not missing. I. fever 1, causes: no cold, trauma? 2, the main symptoms characteristics: heat? Course of disease? Nature (continuity or discontinuity)? The regulation of fever (or continued fever remittent fever)? Duration? Aggravating or mitigating factors? 3, there is no accompanying symptoms: chills, conjunctival congestion, lymphadenopathy and hepatosplenomegaly? Bleeding? Coma? 4, the body condition: since the onset of diet, sleep, feces and weight changes 5, diagnosis and treatment process: since the onset of the hospital has been checked, what examinations and treatment have been done? Is the treatment effective? 6, related medical h