健康的英文

Thepurpoofthehealthhistoryistocollectsubjectivedata―whatthepersonsaysabout

differentfromobjectivedata―whatyouobrvethrough

measurement,inspection,palpation,percussion,toryis

combinedwiththeobjectivedatafromthephysicalexaminationandlaboratory

studiestoformthedataba.

Thehistoryshouldrecognizeandaffirmwhatthepersonisdoingright:whatheor

wellperson,thehistoryisudtoasss

hisorherlifestyle,includingsuchfactorsaxerci,healthydiet,substance

u,riskreduction,andhealthpromotionbehaviors.

Fortheillperson,thehealthhistoryincludesadetailedandchronologicrecord

,thehealthhistoryisascreeningtoolforabnormal

symptoms,healthproblems,andconcerns,anditrecordswaysofrespondingtothe

healthproblems.

BiographicData

birthdate,birthplace,gender,

maritalstatus,race,ethnicorigin,andoccupation(usualandprent;anillnessordisabilitymay

havepromptedchangeinoccupation).Notethat2010standardsfromTheJointCommission

(formerlyknownasJCAHO)requirehospitalstorecordlanguageandcommunicationneeds.

Thereforetheperson’sPrimarylanguageandauthorizedreprentative,ifany,should

inrespontorearchshowingdifferencesinlanguage

andculturemayhaveanimpactonthequalityandsafetyofcare.12

SourceHistory

whofurnishestheinformation__usuallythepersonhimlforherlf,althoughthe

sourcemaybearelative,friend,orcaworker.

owreliabletheinformantemsandhowwillingheorsheistocommunicate.

yspecialcircumstances,suchastheuofaninterpreter.

Seesamplerecordingsatleft.

ReasonforSeekingCare

Thisisabrief,spontaneousstatementintheperson’sownwordsthatdescribesthereason

fitasthe“title”esone

(possiblytwo)omisasubjective

sanobjectiveabnormality

thatyouastheexaminercoulddetectonphysicalexaminationorinlaboratory

ecordwhateverthepersonsaysisthereasonforekingcare,

encloitinquotationmarkstoindicatetheperson’xactwords,andrecorda

mplesatleft.

ranslatingit

mple,tenterswith

shortnessofbreathandyouponderwriting“emphyma”.Evenifheisknowntohave

emphymafrompreviousvisits,itisnotthechronicemphymathatpromptedthis

visitbut,rather,the“increasingshortnessofbreath”for4hours.

Somepeopletrytolf-diagnobadonsimilarsignsandsymptomsintheir

thanrecord

awoman’sstatementthatshehas“strepthroat”,askherwhatsymptomsshehas

thatmakeherthinkthisisprentandrecordthosymptoms.

timportant

timportant

reasontothepressingconcernbyaskingthepersonwhichonepromptedhimorher

toekhelpnow.

PrentHealthorHistoryofprentIllness

Forthewellperson,thisisashortstatementaboutthegeneralstateofhealth:“Ifeelhealthyright

now.”“Iamhealthyandactive.”

Fortheillperson,thisctionisachronologicrecordofthereasonforeking

care,eeachreasonfor

careidentifiedbythepersonandsay,forexample,“Pleatellmeallaboutyour

headache,fromthetimeitstarteduntilthetimeyoucametothehospital.”If

theconcernstartedmonthsoryearsago,recordwhatoccurredduringthattimeand

findoutwhythepersonisekingcarenow.

Asthepersontalks,donotjumptoconclusionsandbiasthestorybyaddingyour

ghyouwantthepersontorespondina

narrativeformatwithoutinterruptionfromyou,yourfinalsummaryofanysymptom

thepersonhasshouldincludetheeightcriticalcharacteristics:

ific;roblem

ispain,notetheprecisite.“Headpain”isvague,whereasdescriptionssuch

as“painbehindtheeyes,”“jawpain,”and“occipitalpain”aremorepreci

ainlocalizedtothissiteorradiating?

Isthepainsuperficialordeep?

llsforspecificdescriptivetermssuchasburning,

sharp,dull,aching,gnawing,throbbing,shooting,iles:Do

bloodinthestoollooklikestickytar?Doesbloodinvomituslooklikecoffee

grounds?

ttoquantifythesignorsymptomsuchas“profu

menstrualflowsoakingfivepadsperhour.”Quantifythesymptomofpainusingthe

in,avoidadjectivesandaskhowitaffectsdaily

cordifthepersonsays,“IwassosickIwasdoubledupand

couldn’tmove,”or“Iwasabletogotowork,butthenIcamehomeandwentto

bed.”

(Ont,Duration,Frequency).Whendidthesymptomfirstappear?Give

thespecificdateandtime,orstatespecificallyhowlongagothesymptomstarted

priortoarrival(PTA).“Thepainstartedyesterday”willnotmeanmuchwhenyou

ortmustincludequestionssuchas

Howlongdidthesymptomlast(duration)?Wasitsteady(constant),ordiditcome

andgoduringthattime(intermittent)?Diditresolvecompletelyandreappeardays

orweekslater(cycleofremissionandexacerbation)?

asthepersonorwhatwasthepersondoingwhenthesymptomstarted?

Whatbringiton?Forexample,“Didyounoticethechestpainaftershovelingsnow,ordidthe

painstartbyitlf?”

kesthepainwor?Isitaggravatedbyweather,

activity,food,medication,standingbentover,fatigue,timeofday,ason,andsoon?What

relievesit(e.g.,rest,medication,oricepack)?Whatistheeffectofanytreatment?Ask,“What

haveyoutried?”or“Whatemstohelp?”

primarysymptomassociatedwithanyothers(e.g.,urinaryfrequency

andburningassociatedwithfeverandchills)?Reviewthebodysystemrelatedtothissymptom

iniciansreviewtheperson’s

medicationregimennow(includingalcoholandtobaccou)becautheprentingsymptom

maybeasideeffectortoxiceffectofachemical.

t’tthemeaningofthesymptombyaskinghowitaffectsdaily

activities.“Howhasthisaffectedyou?”“Isthereanythingyoucannotdonowthat

youcoulddobefore?”Alsoaskdirectly,“Whatdoyouthinkitmeans?”Thisis

crucialbecauitalertsyoutopotentialanxietyifthepersonthinksthesymptom

maybeominous.

PastHealth

Pasthealtheventsareimportantbecautheymayhaveresidualeffectsonthecurrenthealthstate.

Also,thepreviouswithillnessmaygivecluesastohowthepersonrespondstoillnessandtothe

significanceofillnessforhimorher.

s,mumps,rubella,chickenpox,pertussis,andstrepthroat.

Avoidrecording“usualchildhoodillness,”becauanillnesscommonintheperson’schildhood

(e.g.,measles)utriousillnessthatmayhavequelaeforthe

personinlateryears(e.g.,rheumaticfever,scarletfever,poliomyelitis).

cidents,fractures,penetratingwounds,headinjuries(especiallyif

associatedwithunconsciousness),andburns.

,depression,diabetes,hypertension,heartdia,HIV

infection,hepatitis,sickle-cellanemia,cancer,andizuredisorder.

,nameofhospital,howtheconditionwastreated,howlongthepersonwas

hospitalized,andnameofthephysician.

surgery,date,nameofthesurgeon,nameofhospital,andhowtheperson

recovered.

ObstetricHistoryNumberofpregnancies(gravidity),numberofdeliveriesinwhichthefetus

reachedfullterm(term),numberofpretermpregnancies(preterm),numberofincomplete

pregnancies(abortions),andnumberofchildrenliving(living).Foreachcompletepregnancy,

notethecourofpregnancy;laboranddelivery;gender,weight,andconditionofeachinfant;and

incompletepregnancies,recordthedurationandwhetherthe

pregnancyresultedinspontaneous(S)orinduced(I)abortion.

ImmunizationsMeasles-mumps-rubella,polio,diphtheria-pertussis-tetanus,varicella,hepatitis

AandB,meningococcaldia,humanpapillomavirus,Haemophilusinfluenzaetypeb,

pneumococcalvaccine,influenza.3Notethedateofthelasttetanusimmunizationandlast

2010guidelinesforadultimmunizationspublishedbytheCentersfor

DiaControlandPrevention(CDC)containveralchanges.

cifically

aboutvitamins,birthcontrolpills,aspirin,andantacids,becaumanypeopledonotconsider

thetobemedications.

FamilyHistory

Intheageofgenomics,anaccuratefamilyhistorywillhighlightthodiasandconditionsfor

nwhoesheorshemaybevulnerable

foracertainconditionmayekearlyscreeningandperiodicsurveillanceandmaybeinfluenced

toadoptahealthywhenpossibletomitigatethatrisk.

ReviewofSystems

Thepurposofthisctionare(1)toevaluatethepastandprenthealthstateofeachbody

system,(2)todouble-checkincaanysignificantdatawereomittedinthePrentIllnessction,

and(3)eroftheexaminationofbodysystemsis

mswithineachsystemarenotinclusive,andonlythemostcommon

rentIllnessctioncoveredonebodysystem,youdonotneedto

mple,ifthereasonforekingcareiarache,thePrentIllness

knowwhatwasnot

askedinthePrentIllnessction.

Medicaltermsarelistedhere,buttheyneedtobetranslatedforthepatient.(Notethat

ermsarerepeatedand

expandedineachrelatedphysicalexaminationchapter,alongwithsuggestedwaystopo

questionsandarationaleforeachquestion.)

Whenrecordinginformation,avoidwriting“negative”dto

recordtheprenceorabnceofallsymptoms;otherwi,thereaderdoesnotknowaboutwhich

factorsyouasked.

Acommonmistakemadebybeginningpractitionersistorecordsomephysicalfindingor

objectivedatehere,suchas“skinwarmanddry.”Rememberthatthehistoryshouldbe

limitedtopatientstatements,orsubjectivedate―factorsthatthepersonsayswere

orwerenotprent.

tweight(gainorloss,overwhatperiodoftime,

bydietorotherfactors),fatigues,weaknessormalai,fever,chills,sweatsor

nightsweats.

yorskindia(eczema,psoriasis,hives),pigmentorcolorchange,

changeinmole,excessivedrynessormoisture,pruritus,excessivebruising,rash

orlesion.

loss,:changeinshape,color,orbrittleness.

ofsunexposure;methodoflf-careforskinandhair.

suallyfrequentorvereheadache,anyheadinjury,dizziness(syncope)

orvertigo.

ultywithvision(decreadacuity,blurring,blindsots),eyepain,

diplopia(doublevision),rednessorswelling,wateringordischarge,glaucomaor

cataracts.

lassorcontacts;lastvisioncheckorglaucomatest;

andhowcopingwithlossofvisionifany.

es,infections,dischargeanditscharacteristics,tinnitusorvertigo.

lassorcontacts;lastvisioncheckorglaucomatest,

andhowcopingwithlossofvisionifany.

es,infections,dischargeanditscharacteristics,tinnitusorvertigo.

gloss,hearingaidu,howlossaffectsthedailylife,

anyexposuretoenvironmentalnoi,andmethodofcleaningears.

rgeanditscharacteristics,anyunusuallyfrequentor

verecolds,sinuspain,nasalobstruction,nobleeds,allergiesorhayfever,

orchangeinnofsmell.

ain,frequentsorethroat,bleedinggums,toothache,

lesioninmouthortongue,dysphagia,hoarnessorvoicechange,tonsillectomy,

alteredtaste.

nofdailydentalcare,uofdentures,bridge,andlast

dentalcheckup.

,limitationofmotion,lumpsorswelling,enlargedortendernodes,goiter.

,lump,nippledischarge,rash,historyofbreastdia,anysurgeryonthe

breasts.

msbreastlf-examination,includingitsfrequencyandmethodud,

lastmammogram.

ness,lumporswelling,rash.

yoflungdias(asthma,emphyma,bronchitis,pneumonia,

tuberculosis),chestpainwithbreathing,wheezingornoisybreathing,shortnessofbreath,how

muchactivityproducesshortnessofbreath,cough,sputum（color,amount）,hemoptysis,toxinor

pollutionexposure.

estx-raystudy,TBskintest.

dialorretrosternalpain,palpitation,cyanosis,dyspneaonexertion

(specifyamountofexertion[e.g.,walkingoneflightofstairs,walkingfromchairtobath,orjust

talking]),orthopnea,paroxysmalnocturnaldyspnea,nocturia,edema,historyofheartmurmur,

hypertension,coronaryarteryarterydia,anemia.

lastECGorotherhearttests,cholesterolscreening.

ss,numbnessandtingling,swellingoflegs(timeofday,activity),

discolorationinhandsorfeet(bluishred,pallormottling,associatedwithposition,especially

aroundfeetandankles),varicoveinsorcomplications,intermittentclaudication,

thrombophlebitis,ulcers.

eworkinvolvelong-termsittingorstanding?Avoidcrossinglegsat

pportho.

te,foodintolerance,dysphagia,heartburn,indigestion,pain(associated

witheating),otherabdominalpain,pyrosis(esophagealandstomachburningnsationwithsour

eructation),nauaandvomiting(character),vomitingblood,historyofabdominaldia(ulcer,

liverorgallbladder,jaundice,appendicitis,colitis),flatulence,frequencyofbowelmovement,any

recentchange,stoolcharacteristics,constipationordiarrhea,blackstools,rectalbleeding,rectal

conditions(hemorrhoids,fistula).