(1) General project
Including: name, gender, age, native place, birthplace, nationality, marriage, address, work unit, occupation, date of admission, date of recording, medical history presenter and reliability, etc. If the person presenting the medical history is not himself, his relationship with the patient should be indicated. When recording age, you should fill in the actual age, and you can't use "son" or "success" instead, because age itself has diagnostic reference significance.
(2) Chief complaint
Patients feel the most important pain or the most obvious symptoms and signs, and the main reason for seeing a doctor is to collect and sort out. The chief complaint should be concise, summarized in one or two sentences, and indicate the time from onset to treatment. Such as "fever, cough, right chest pain for two days", "drinking more, eating more, urinating with emaciation for three years", "abdominal pain, vomiting with diarrhea for four hours" and so on.
(3) Current medical history
The main part of medical history, including the whole process of disease occurrence, development and evolution, is the key content in consultation. Mainly includes the following aspects:
1. onset time (priority) and onset time (how long have you been sick? )。
2. The characteristics of main symptoms, including location, radiation area, nature, attack frequency, duration, intensity, aggravating or mitigating factors.
3. Causes and incentives.
4. The development and evolution of the disease (recorded in chronological order, including the development of main symptoms and other related symptoms).
5. Accompanying symptoms.
6. Diagnosis and treatment (drugs, dosage, curative effect, etc. ).
7. General conditions since the onset (mental state, appetite, weight change, sleep and defecation, etc. ).
8. Induce, summarize and re-verify.
9. Ask questions about the past history in interlanguage.
(4) Past history
Also known as "past tense". Including:
1. The patient's past health status.
2. Past diseases (including various infectious diseases), especially the disease history closely related to the present medical history. For example, patients with coronary atherosclerotic heart disease should ask whether they had hypertension or diabetes in the past. Care should be taken not to confuse the description with the current medical history.
3. History of trauma, surgery, accidents and vaccination.
4. Allergy history (to drugs, food and environmental factors).
5. The main infectious diseases and endemic diseases in the living or living area should also be recorded in the past history.
6. The recording sequence is generally arranged in chronological order.
(5) Systematic review
It is the last time to collect medical history data after asking about past history, so as to avoid patients or doctors ignoring or omitting relevant contents when asking. The method is to ask about possible diseases in detail according to various systems of the body. It can help doctors to know whether the patient's system has diseases and whether there is a causal relationship between these diseases and this disease in a short time. Items mentioned in current or past medical history should be avoided. Positive and clinically significant negative items should be recorded.