History Taking

The Endocrinal Department, The First Affliated Hospital,

Liao Ning Medical Univercity

Liu xin yu

Premise1. 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 physi

cian's interpretation of the patient's history

5. The doctor's task at this time is to try to understand the patien

t's experience and interpretation of her illness

Component of inquisition

Attention: Once entered and signed, the information i

n 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.

2. The informant

1) The source of the history

2) Interpreters

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 du

ration in time units.

Attention: Must be words or phrases, not as compl

ete sentences. Complaints are not diagnoses by

the doctor or the patient.

Purposes: Making a differential diagnosis; Remind

doctors

4. History of present illnessDescribe the whole process after illness ：Occurrence, development , evolution and treatment through.

Symptoms

Difinition: A symptom is usually considered

to be an abnormal sensation that is perceiv

ed by the patient.

Physical signs: Can be seen, felt, heard by t

he examiner.

History of present illness1.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.

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

6. Family History

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

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

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.

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

Arrangement

1) Address patients formally

2) Limit the interview to the patient and on

e other informant

3) Physician's manner: Respect the patien

t.

4) Note Taking:

5) Language:

6) Patient's Motivation:

thank you

NECK

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

1.Torticollis: 1) Congenital type hematoma or partial rupture of t

he muscle at birth unilateral muscle shortening

2) Dystonic reaction phenothiazine drugs the dy

stonic sternocleidomastoideus is the most prominen

t

2.Stiff Neck:

Pain in the neck and limitation of its motion

muscles; bones; joints of the neck. Meningeal i

nflammation should be evaluated at first.

*Brudzinski sign

3. Skin and Mass

Skin: spider angioma; infection; scar; psor

iasis（银屑病）Mass: location; quantity; size; texture; acti

vity; relation to neighbour organs; tend

erness

4.Hematoma of the sternocleidomastoideus

5.Blood Vessels1) external jugular vein:

normal: collapse in the erect or seat position; light tur

gor in the prostration

abnormal: distention in the prostration or the thorax re

clining at 45 degrees; collapse in the prostration---h

ypovolemia

common diseases: right congestive heart failure; cons

trictive pericarditis; hydropericardium; superior ven

a cava obstruction syndrome

2) Jugular vein pulsation

common cause: tricuspid incompetence

3) Carotid artey pulsationNormal: 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

THYROID

Constructions: isthmus; lateral lobes

Normal: not palpable and not visible

Thyromegaly scale division

Ⅰdegree: not visible but can be palpated

Ⅱ degree: can be visited and can be palpated but not sur

pass sternocleidomastoideus

Ⅲ degree: surpass sternocleidomastoideus

THYROID PALPATION

1. Palpation from behind

2. Frontal palpation