病史和神经系统检查PPT教案.pptx

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会计学
病史和神经系统检查
patient’s trust and cooperation
reliable history and accurate exam
correct diagnosis
Taking the history
Purpose:
primary information of the disease
where,what,why…
guide to the exam and Lab test
Taking the history
Notice:
good attitude while patient saying
avoiding suggestion
accurate comprehension of what he/she say
taking care to negative or other systems’ symptoms
obtaining from a relative or friend
(coma,child,mental disorder)
Structure of the history
The complaint
The presenting history
Past history
Personal history
Family history
The complaint
What is the main problem?
What was it that caused you to come here?
Use the patient’s language.
The presenting history
Information of onset
Nature of the main symptom
Process of the disease
Associated symptoms
Preceding treatment
Information of onset
When it was first noted by the patient?
Inducing factors of onset.
Was the onset sudden,subacute,insidious or gradual?
acute: vascular,poison,trauma,infection
chronic: tumor,metabolism,degeneration
Nature of the main symptom
What is its distribution?
unilateral,bilateral,frontal,occipital etc.
What is its nature and severity?
:throbbing,stabbing,tensing…
Is there anything that makes it better or worse?
. movement,posture,sleep,coughing …
How long does it take for every attack?
…
has it
Process of the disease
Is the symptom episodic or constant?
Has it worsened,improved,or stayed the same since?