病案分析公式（Case analysis formula）.doc

病案分析公式（Case analysis formula） A history of present history: including the following 5 parts 1. Inquire according to the main complaint and related discrimination 1) cause and cause 2) characteristics of main symptoms 3) with symptoms 4) general state: the general state after onset (since the onset, diet sleep, urine and weight changes) 2. Diagnosis and treatment Have you visited the hospital? What tests have been done? 2) what treatments have been done, and how effective are they? Second, previous history (related history) 1. Related medical history: previous smoking and drinking, similar attacks and family history, etc 2. History of drug allergy, history of surgery (be sure to mention, the annual evaluation criteria are included) 3. Must be a reasonable person in the consultation, think well and write again, dont later add, so lose points 4. Ask around the main statement A chief complaint is alone cannot make a diagnosis, but still have a tendency, such as: 24 years old female fever hemoptysis tuberculosis probability, and 45 years old male fever, coughing up blood Consider for lung cancer, the tendency of the collection is different, these still depends on knowledge accumulation. In a word, most of the values are already in hand when collected, as in the above way. It should be noted that the diagnosis is correct or not based on the score. As long as the project and content is not short. A, fever 1. Causes of the cause: cold and trauma? 2. Main symptom characteristics: heat? Course of the disease? Nature (continuity or discontinuity)? Heating rule (stay hot or chi zhang hot)? Duration? Aggravating or mitigating factors? 3. Accompanying symptoms: cold war, conjunctival congestion, lymphatic enlargement, liver splenomegaly? Bleeding? Coma? 4. General state: diet, sleep, urine and weight changes since the onset of illness 5. Diagnosis and treatment: have you ever been to a hospital since the onset of the disease? What have you done to check and treat? Is treatment ef