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技能病史采集(Skill history acquisition)
技能病史采集(Skill history acquisition)
Fever:
In 1. cases
History: female, 25 years old, 2 days of high fever and dysuria in emergency departments.
Initial diagnosis: acute urinary tract infection. The interrogation content is as follows:
(I) present medical history;
1. according to the chief complaint and related differential examination
(1) the possible causes of the disease are the poor sanitary condition of womens genitals.
(2) temperature rise and change, whether or not shivering.
(3) odynuria properties (burning pain, pain) and voiding time, whether with frequent micturition, urgency and dysuria.
(4) the urine color changes (such as hematuria or haze like pyuria).
(5) whether there is lumbago or not.
(6) the changes of diet, sleep, stool and weight since onset.
2. diagnosis and treatment
(1) whether to go to a hospital or not? What tests have you made? If you go to the hospital to do urine routine, blood routine, urine bacteriological examination and kidney B ultrasonic examination, etc..
(2) treatment and medication, how is the curative effect? If antibiotic therapy has been used, what kind of antibiotic is used? What is the effect?
(two) related medical history;
1. do you have any history of drug allergy?.
2. other diseases associated with the disease: there have been no similar attacks, there is no diabetes, tuberculosis, or immunosuppression of gynecological disease history, menstrual and obstetrical history and feculent sexual intercourse etc..
In 2. cases
History: male, 52 years old, 2 days with fever, accompanied by red and sore skin of right lower limb, came to the clinic.
Preliminary diagnosis: right lower limb erysipelas. The interrogation content is as follows:
(I) present medical history;
1. according to the chief complaint and related differential examination
(1): if there is no incentive for pathogenesis of tinea pedis, local skin damage etc..
(2) temperature rise and change, whether or not shivering.
(3) the characteristics of red and painful skin of
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