问题 问答题 案例分析题

【简要病史】唐某,女,30岁,腹痛1天。

【答题要求】

病史采集题要求根据简要病史口述应如何采集病史

答案

参考答案:

采集要点

(1)现病史:根据主诉及相关鉴别询问。

①发病诱因:是否有传染病接触史,是否有性生活史、停经史,腹痛有无诱因。

②病情演变过程:要按时间顺序询问从起病到就诊时病情发展变化的主要情况,腹痛的性质、部位、程度有无明显变化,其变化有无规律性,影响变化的原因或诱因是否存在,病情演变有无规律性,其总的趋势如何?

③诊察治疗过程:要询问起病之初到就诊前的整个过程中所做过的诊断与治疗情况。疾病初起曾到何处就医?做过何种检查?检查结果如何?诊为何病?做何治疗?服用何药物以及剂量、用法、时间、效果如何?有否出现其他不良反应等。

④现在症状:要询问这次就诊的全部自觉症状,这是问诊的主要内容。应问清疼痛产生的原因、性质、部位、时间、喜恶等。

⑤结合"十问歌"了解其他相关情况。

(2)相关病史:

①与该病有关的其他病史:肝炎患者接触史,胃肠疾病史、胆道疾病史、外伤手术史及家族史。

②药物过敏史。

选择题
完形填空

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小题1:Instruments      B. Installments          C. Indications            D. Instructions
小题2:
A.statesB.talksC.speaksD.says
小题3:
A.objectB.wordsC.pointD.purpose
小题4:
A.InsureB.Make sureC.See to it thatD.Assure
小题5:
A.settingB.contentC.peopleD.topic
小题6:
A.with B.forC.toD.of
小题7:
A.bestB.moreC.mostD.better
小题8:
A.studyB.serveC.doD.stay
小题9:
A.DescribeB.ImagineC.ReviewD.Report
小题10:
A.cleanB.easyC.betterD.neatly