病史和神经系统检查.pptxVIP

病史和神经系统检查第1页/共61页 history and neurological exam symptoms signs qualitative anatomic( topographic) diagnosis diagnosis other data lab test pathologic(etiologic) diagnosis 第2页/共61页 patient’s trust and cooperation reliable history and accurate exam correct diagnosis第3页/共61页 Taking the history Purpose:primary information of the disease where,what,why…guide to the exam and Lab test 第4页/共61页 Taking the history Notice: good attitude while patient saying avoiding suggestionaccurate comprehension of what he/she saytaking care to negative or other systems’ symptomsobtaining from a relative or friend (coma,child,mental disorder) 第5页/共61页 Structure of the historyThe complaintThe presenting historyPast historyPersonal historyFamily history第6页/共61页 The complaint What is the main problem?What was it that caused you to come here?Use the patient’s language.第7页/共61页 The presenting historyInformation of onsetNature of the main symptomProcess of the diseaseAssociated symptomsPreceding treatment 第8页/共61页 Information of onsetWhen it was first noted by the patient?Inducing factors of onset.Was the onset sudden,subacute,insidious or gradual? acute: vascular,poison,trauma,infectionchronic: tumor,metabolism,degeneration 第9页/共61页 Nature of the main symptomWhat is its distribution? unilateral,bilateral,frontal,occipital etc.What is its nature and severity? e.g.headache:throbbing,stabbing,tensing…Is there anything that makes it better or worse?