病史采集
HISTROYTAKING1
HistoryTakingTheprocedureoftakingpatient’sstoryofillnessfromthepatientand/orhisorherfamilymembers(orotherrelatedpersonswhoknowthehistoryofthepatient’sstoryofillness) 询问者从与病人（或病人的家属、其他相关人员）的交谈中获得疾病资料的过程。2
HistoryTakingAnaverageprimarycarephysicianwilldo140,000-160,000interviewsduringaprofessionallifeof40years…3
DataformakingdiagnosisClueforPE,LabandotherexaminationPatient-doctorrelationshipAlways,thefirststeptotreatpatient4
HistoryTakingTolearnContents内容Whattodo?Method方法Howtodo?5
StructureofHistoryTaking6
Introduction引言
GeneralData一般资料Introduceyourself 介绍自己Tellpatientyourrole/position说明自己的身份Callpatientbysuitabletitle恰当称呼病人Askpatient’sname,age,nationality,address,etc.全名、年龄、民族、住址等Greetingorso,letpatientrelaxandsetupgoodrapport 简单交谈7
2.Chiefcomplaint主诉CC:asentencethatdescribepatient’smainuncomfortandits/theirdurationbypatient’swords患者感受最痛苦的症状或体征，也是本次就诊最主要原因主要症状or体征+持续时间8
ChiefcomplaintItisthepatient’sbriefstatementexplainingwhyheorshesoughtmedicalattentionItistheanswertothequestion“Whatistheproblemthatbroughtyoutothehospital?”9
ExamplesofChiefcomplainChestpainforthe5hours胸痛5小时edemafor10days水肿10天Intermittentrightabdominalpainfor3years,relapsedfor1weekandworsenaccompaniedbytar-likestoolfor2days. 反复上腹部疼痛3年，复发1周，加重伴黑便2天。10
ExamplesofChiefcomplainLeukemiafor2years.× 白血病2年。Hepatocirrhosisfor3years.× 肝硬化3年。11
Historyofpresentillness
现病史Themainproblemsatpresent病人目前的主要问题疾病的发生发展演变过程Itshouldanswerthequestionswhat,when,how,where,which,who,andwhy.12
Historyofpresentillness
现病史(1)Onsetoftheproblems: acuteorchronic起病情况：急缓、患病时间(2)Anyreasonorinducingfactors发病的原因和（或）诱因13
Historyofpresentillness
现病史(3)Characteristicsofmainsymptoms主要症状特点Locations 部位Natures 性质Frequencyofepisodes