(1) Collection of admission history

When asking for medical history, you must be enthusiastic, caring, and serious about the patient, and gain the patient's trust and cooperation. When asking, you must be comprehensive and grasp the key points. Key points: seek truth from facts and avoid subjective assumptions and preconceptions. When the patient's narrative is unclear or in order to obtain necessary medical records, enlightenment can be provided, but subjective one-sidedness and hints must be avoided.

1. General items

Name, gender, age, marriage, ethnicity, occupation, place of birth, current address, work unit, ID number, postal code, telephone number, admission time, recording time, medical history narrator (note the degree of reliability).

Filling in requirements:

(1) Age must be written in "years", infants and young children should be written in "month" or "day", and "adult", "child", "Old" etc.

(2) The occupation should indicate the specific job category, such as lathe worker, unemployed, teacher, trade union cadre, etc. It cannot be written generally as worker or cadre.

(3) Address: For rural areas, write down the township or village, and for cities, write down the street house number; for factories, write down the department; for workshops, teams, and departments.

(4) The time of admission and recording time should be indicated.

(5) Medical history narrator: For adult patients, the narrator should narrate it himself; for children or those who are unconscious, the name of the complainant and his relationship with the patient should be written down.

2． Chief complaint

(1) Chief complaint refers to the main symptoms and signs of the patient's admission to the hospital and their occurrence time, nature or degree, location, etc. The first diagnosis can be made based on the chief complaint. The language of the main complaint should be concise and clear, generally no more than 20 words.

(2) Do not use diagnosis or test results as the main complaint (except for those who are truly asymptomatic). When there is more than one main complaint, they can be listed in order of priority or time of occurrence.

3. History of current illness

The history of current illness is the main part of the medical history. Focusing on the chief complaint, the occurrence, development and changes of the disease, as well as the diagnosis and treatment from the onset of illness to the time of treatment, are recorded in detail according to the order of symptoms. Its contents mainly include:

(1) Time of onset, urgency, possible causes and incentives (including some situations before the onset of illness if necessary).

(2) The time, location, nature, degree and evolution of the main symptoms (or signs).

(3) Along with the characteristics and changes of symptoms, important positive and negative symptoms (or signs) with differential diagnostic significance should also be explained.

(4) For those who suffer from chronic diseases related to this disease or those who have relapsed from old diseases, we should focus on understanding their initial conditions and major changes, as well as recent recurrences.

(5) Where and what kind of diagnosis and treatment has been done since the onset of the disease (including date of diagnosis and treatment, examination results, name of medication and its dosage, usage, surgical method, efficacy, etc.).

(6) Important injuries and illnesses in other departments that are not related to the main disease and still need to be diagnosed and treated should be described in a separate paragraph.

(7) General conditions since the onset of the disease, such as changes in spirit, appetite, food intake, sleep, defecation, physical strength and weight, etc.

4. Past history

Past history refers to the patient’s health and disease conditions before the onset of the disease, especially diseases closely related to the current disease, which are recorded in chronological order. Its contents mainly include:

(1) Past general health status.

(2) Whether you have suffered from infectious diseases, endemic diseases and other diseases, the date of onset and diagnosis and treatment. For diseases that the patient has suffered from before, if the diagnosis is certain, the disease name should be used, but it should be in quotation marks; if the diagnosis is not certain, the symptoms should be briefly described.

(3) Whether there is a history of vaccination, trauma, surgery, and allergies to drugs, food, and other contact objects.

5. System review

Connecting various systems of the body to inquire in detail about possible diseases, this is an indispensable part of standardizing medical records. It can help doctors briefly understand whether the patient's diseases and diseases have occurred in a certain system in a short period of time. Is there a causal relationship between the main complaints? Diseases of this system other than current history should also be recorded.

(1) Respiratory system: Whether there is a history of chronic cough, sputum, hemoptysis, chest pain, asthma, etc.

(2) Circulatory system: Whether there are palpitations, shortness of breath, cyanosis, edema, chest pain, fainting, hypertension, etc.

(3) Digestive system: Whether there is a history of changes in appetite, belching, acid reflux, abdominal distension, abdominal pain, diarrhea, constipation, hematemesis, melena, jaundice, etc.

(4) Genitourinary system: whether there is a history of frequent urination, urgency, dysuria, hematuria, dysuria, low back pain, edema, etc.

(5) Hematopoietic system: Whether there is fatigue, dizziness, bleeding spots on the skin or mucous membranes, ecchymosis, epistaxis, history of gum bleeding, etc.

(6) Endocrine system and metabolism: whether there is a history of chills, heat intolerance, excessive sweating, abnormal appetite, weight loss, dry mouth, polydipsia, and polyuria, and whether there is a history of personality, weight, hair and second Changes in sexual characteristics, etc.

(7) Nervous system: Whether there is a history of headache, dizziness, insomnia, drowsiness, disturbance of consciousness, convulsions, paralysis, convulsions, personality changes, visual impairment, abnormal sensation, etc.

(8) Musculoskeletal system: Whether there is a history of limb muscle numbness, disease, spasm, atrophy, paralysis, whether there is a history of joint swelling and pain, movement disorders, trauma, fractures, etc.

6. Personal history

(1) Place and time of birth, growth and residence (especially attention should be paid to epidemic foci and endemic areas), education level and hobbies, etc.

(2) Daily habits, hygiene habits, eating habits, tobacco and alcohol habits and their intake, whether there is a history of intake of other heterophilic substances and narcotic drugs, and whether there is a history of major mental trauma. Medicine all online www.drtest.cn

(3) Past and current occupation, labor protection situation and working environment, etc. Focus on understanding whether the patient has a history of frequent contact with toxic and harmful substances, and the time and extent of exposure should be noted.

(4) Do you have a history of travel, and have you ever suffered from chancre and gonorrhea?

(5) For child patients, in addition to understanding the mother’s pregnancy and birth process (natural delivery, dystocia) before birth, the feeding history, growth and development history must also be understood.

7. Marital, menstrual and reproductive history

(1) Whether you are married or not, your age at marriage, your spouse’s health, and whether you are married to a close relative. If the spouse dies, the cause and time of death should be stated.

(2) Menstrual status of female patients, such as age at menarche, menstrual cycle, number of menstrual days, date of last menstrual period, date of amenorrhea or age at menopause, etc. The recording format is as follows:

Age at menarche Menstrual period (days)/menstrual cycle (days) Last menstrual period time (or menopausal age)

Menstrual volume, color, presence or absence of dysmenorrhea, leucorrhea (amount and character), etc.

(3) Married women’s pregnancy parity, number of deliveries, history of miscarriage, premature birth, stillbirth, surgical delivery, puerperal fever, family planning status, etc. Male patients have reproductive system diseases.

8． Family history

(1) The health status of parents, brothers, sisters and children, whether they have the same diseases as the patient, and whether they have genetically related diseases. The deceased should indicate the cause and time of death.

(2) For familial hereditary diseases, it is necessary to inquire about the health and disease status of third-level relatives in both lines (see Appendix 1).

(2) Physical examination

The physical examination must be serious and careful, and carried out in order of parts and systems, focusing on certain areas and not missing any positive signs. You should have a kind and serious attitude toward the patient, concentrate your thoughts, use gentle techniques, pay attention to the patient's reaction, and keep warm in cold weather. Critical patients can be inspected first and rescued in a timely manner. Detailed inspection can be done after the condition is stable; do not move too much to avoid aggravating the condition. The specific contents are as follows:

1. Vital signs

Temperature (T) (C), pulse rate (P) (times/min), respiratory rate (R) (times/min), blood pressure (BP) (kPa).

2. General condition

Development (normal or abnormal), nutrition (good, moderate, poor), body position (autonomous, passive, forced or restless), gait, face Expression (acute or chronic illness, expression of pain, worry, fear, quiet), consciousness (clear, blurred, drowsy, coma), whether you can cooperate with the doctor. Medical.xue.online www.drtest.cn

3. Skin and mucous membranes

Color (flushing, cyanosis, paleness, jaundice, pigmentation), temperature, humidity , elasticity, whether there are edema, rash, petechiae, subcutaneous nodules or masses, spider nevi, ulcers and scars, hair distribution, etc.; if so, the location, range (size) and shape, etc. should be recorded.

4． Lymph nodes

Whether systemic or local superficial lymph nodes are swollen (location, size, number, tenderness, hardness, mobility, fistulas, scars, etc.).

5. Head and its organs

(1) Skull: size, shape, presence or absence of tenderness, masses, hair (amount, color, distribution, baldness and alopecia areata). Infants need to record the size of the anterior fontanel, whether it is full or sunken.

(2) Eyes: vision (check if necessary), eyebrows (falling off, sparse), eyelashes (trichiasis), eyelids (edema, movement, drooping), eyeballs (bulging, sunken, movement, Strabismus, tremor), conjunctiva (hyperemia, hemorrhage, paleness, edema), sclera (yellowing), cornea (transparency, turbidity, reflection), pupil (size, shape, symmetry, response to light and accommodation).

(3) Ears: hearing, whether there are deformities, secretions, and mastoid tenderness.

(4) Nose: Whether there is deformity, nasal flaring, secretions, bleeding, obstruction, and tenderness in the paranasal sinus area.

(5) Mouth: oral odor, saliva secretion, lips (deformity, color, herpes, cracks, ulcers, deviation of the corners of the mouth), teeth (caries, missing teeth, dentures, residual roots, in the following forms Mark the location, such as: caries 3+4), gums (color, swelling, pus, bleeding, lead lines), mucosa (rash, ulcers, bleeding), tongue (shape, tongue texture, tongue coating, ulcers, movement, tremor) , deviation), tonsils (size, congestion, secretions, pseudomembranes), pharynx (color, secretions, reflexes), larynx (clear pronunciation or hoarseness, stridor, aphonia).

6. Whether the neck is symmetrical, whether there is ankylosis, jugular venous distension, hepatojugular reflux sign, abnormal carotid artery pulsation, masses, tracheal position, thyroid (size, hardness, tenderness, nodules, tremor, Noise, up and down movement with swallowing).

7. Chest

(1) Thoracic cage (symmetry, deformity, local bulge or collapse, tenderness), breathing (frequency, rhythm, depth), whether there are abnormal pulses and varicose veins. Breast disease is described in terms of breast examination requirements.

(2) Lungs:

Visual examination: respiratory movement (comparison of both sides), breathing type, and whether the intercostal space is widened or narrowed.

Palpation: tremor, pleural friction, subcutaneous twisting sensation.

Percussion: Percussion sounds (voiceless, voiced, solid, supervoiceless or tympanic sounds), lower lung boundary, and mobility of the lower lung edge.

Auscultation: breath sounds (nature, intensity, abnormal breath sounds), presence or absence of dry and wet rales and pleural friction, voice conduction (pay attention to symmetrical parts), etc.

(3) Heart:

Visual examination: apical pulse (position, range, intensity), whether there is precordial bulge.

Palpation: apical pulse (nature, location, range, intensity), presence or absence of tremor (location, duration) and pericardial friction.

Percussion: The left and right dullness boundaries of the heart (relative dullness boundaries) are expressed by the distance between the midline of each intercostal space, and the distance from the midclavicular line to the anterior midline is noted under the table (Table 1).

Auscultation: heart rate, heart rhythm, heart sounds (intensity, splitting, comparison of P2 and A2, extra heart sounds, gallop rhythm) with or without murmurs (location, nature, period, intensity, conduction direction) and pericardial rub .

Right side (cm) Left side of intercostal space (cm)

Ⅱ

Ⅲ

Ⅳ

Ⅴ

The midclavicular line is cm from the anterior midline

8. Vascular examination

(1) Radial artery: pulse rate, rhythm (regular or irregular, pulse Shortness of breath), presence or absence of paradoxical and alternating pulses, comparison of left and right radial artery pulses, and the nature and tension of the arterial wall.

(2) Peripheral vascular signs: presence or absence of capillary pulsation, shooting sound, and water pulse.

9． Abdomen

(1) Visual rash: appearance (symmetrical, flat, bulging, concave), respiratory movement, umbilicus, whether there are rashes, stripes, scars, masses, varicose veins (if any, record blood flow direction), gastrointestinal peristaltic waves, and upper abdominal pulsations.

(2) Palpation:

Abdominal wall: Abdominal wall tension, whether there is tenderness, rebound tenderness, fluid wave tremor and masses (location, size, shape, hardness, tenderness, pulsation, mobility). Abdominal circumference should be measured when there is ascites or abdominal mass.

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Liver: size (how many centimeters from the right lobe from the costal margin to the lower edge of the liver from the right midclavicular line, the left lobe from the xiphoid process to the lower edge of the left liver lobe) Expressed), texture, surface, edges, presence or absence of tenderness and pulsation.

Gallbladder: size, shape, and whether there is tenderness.

Spleen: size, hardness, surface, edge status, and whether there is tenderness. The giant spleen is represented by the three-line method (Fig. 1).

Kidney: size, shape, hardness, mobility, whether there is tenderness in the renal area and ureteral tender points, and whether there is bladder distension.

(3) Percussion: In the area of ??liver dullness, whether there is percussion pain in the liver area, moving dullness, high tympanic sound and percussion pain in the kidney area.

(4) Auscultation: Bowel sounds (normal, enhanced, weakened or disappeared), presence or absence of vibrating water sounds and vascular murmurs.

10． Anus and rectum

Whether there are hemorrhoids, anal fissures, anal prolapse, or anal fistulas. During digital anal examination, attention should be paid to anal sphincter tension, stenosis, internal hemorrhoids, tenderness, prostate size and hardness; special attention should be paid to the presence of palpable masses (size, location, hardness, mobility, etc.). When exiting the finger examination, you should pay attention to the color of the finger cot.

11． External genitalia

According to the needs of the disease, conduct corresponding examinations.

(1) Males: distribution of pubic hair, presence of developmental malformations, penile scars, urethral secretions, foreskin, testicles, epididymis, spermatic cord, varicocele, and hydrocele.

(2) Women: Please have a gynecological examination if necessary. Male doctors must be accompanied by female medical staff during examinations.

12． Spine and limbs

(1) Spine: Whether there is deformity, tenderness, percussion pain, and mobility.

(2) Limbs: Whether there are deformities, clubbing of fingers (toes), varicose veins, fractures, edema, muscle atrophy, limb paralysis or increased muscle tone, joints (redness, swelling, pain, tenderness, effusion) , dislocation, limited range of motion, ankylosis).

13． Nervous system

(1) Physiological reflexes: corneal reflex, abdominal wall reflex, cremasteric reflex, biceps reflex, triceps reflex, knee tendon reflex, and Achilles tendon reflex.

(2) Pathological reflexes: Babinski’s sign, etc.

(3) Meningeal irritation signs: cervical stiffness, Brudzinski sign, Kernig sign.

(4) Carry out motor, sensory and other neurological examinations if necessary.

14. Specialty conditions

Record the special conditions of specialist diseases, such as surgical conditions, ophthalmology conditions, gynecological conditions, etc. (see the key points for writing medical records of each specialty).

(3) Laboratory and equipment inspection

Record laboratory and equipment inspection results related to diagnosis. If it is an examination done before admission, the location and date of the examination should be indicated.

(4) Abstract

Summarize the main information such as medical history, physical examination, laboratory examination and equipment examination, and highlight the positive findings to provide the basis for diagnosis.

(5) Preliminary diagnosis

Write on the last right half of the medical record. List the diseases in order of priority, with diseases related to the main complaint or life-threatening being listed first. In addition to the full name of the disease, the diagnosis should also include a diagnosis of the cause, anatomical location and function of the disease as much as possible.

(6) Admission diagnosis

The admission diagnosis shall be made by the attending physician within 72 hours after the patient is admitted to the hospital. Write in red ink on the last left half of the medical record (at the same height as the initial diagnosis), mark the date when the diagnosis was confirmed, and sign.

(7) Record the reviewer’s signature

The signature should be written on the bottom right corner of the medical record. Draw a slash above the signature to facilitate the superior physician's review and revision before signing.