What are the steps of the consultation, and what are the contents of the consultation?

The general content of the consultation: 1. General information (name, age, occupation, etc.) 2. Chief complaint (the most important and obvious symptoms or signs for the patient) 3. History of present illness (time of onset and time of illness, main symptoms, development and evolution of the disease, accompanied by symptom diagnosis ** and nursing process) 4. Functional health forms of the human body (such as nutrition and metabolism, excretion activities and exercise, sleep and rest, etc.) 2. Special circumstances of the consultation, different cultural backgrounds, cognitive impairment, anxiety and anger, depression, children and the elderly, Dying patients will affect the steps and methods of consultation.

Consultation refers to the method of diagnosing diseases by using dialogue to inquire patients and their informants about the occurrence, development, current symptoms, and process of diseases. It is one of the four diagnoses.

The general contents of Western medicine include name, gender, age, place of origin, place of birth, ethnicity, marriage, mailing address, ** number, place of employment, occupation, date of admission, date of record, medical history statement and reliability, etc. If the person presenting the history is not the person, the relationship with the patient should be noted. The record age should be filled in with a specific age, and cannot be replaced by "child" or "cheng", because age itself also has the significance of diagnostic reference.

In order to avoid being too blunt at the beginning of the interview, you can intersperse the content of certain general items such as occupation and marital history with personal history.

Chief complaint 3: The history of present illness can be pressed 1Onset and duration of illness 2

** and Triggers 3Main symptom features 4Development and evolution of the disease 5

Concomitant symptom 6Diagnosis and treatment 7General Situation IV:

Anamnesis1Prior general health condition 2History of illness 3

History of vaccinations 4History of trauma, history of surgery 5History of blood transfusion 6

History of drug allergy 5: Personal history 6: Marital history 7:

Menstrual history 8: Fertility history 9: Family history.

Zhang Jingyue, a medical scientist in the Ming Dynasty, wrote the "Song of Ten Questions" on the basis of summarizing the key points of the predecessors' consultations, and Chen Xiuyuan of the Qing Dynasty slightly modified and added it as: "One asks about cold and heat, two asks about sweat, three asks about the head and body, four asks about the bowel and bowel, five asks about diet and six chest and abdomen, seven deafness and eight thirst are all distinguished, nine questions about old diseases and ten questions about the causes, and then take medicine to participate in the machine change, women must especially ask about menstruation, and slow aclusion can be seen. ”

The content of "Ten Questions Song" is concise and concise, which can be used as a reference for consultation. However, in the actual consultation, it is necessary to ask flexibly and emphatically according to the specific condition of the patient, and it is not possible to ask mechanically in the same way.

A new song of ten questions.

The first question of the consultation is general, and the general question is related to the question.

One asks about cold and heat, two asks about sweat, three asks about the head and body, and four asks about poop.

Five questions about diet, six chest and abdomen, seven deafness and eight thirst, nine questions about old diseases and ten questions about the causes, and then the diagnosis and treatment will be mixed.

The individual family should be asked, and the woman will have a birth with a woman.

History of pediatric infection vaccination, rash, pox, festive appetite.

In addition to listening to the patient's complaints, the following items can be asked: general information (name, gender, age, occupation, marriage, ethnicity, place of origin, address, date of consultation), occurrence and development of the disease, current symptoms, personal medical history, family medical history, etc., and for women, menstrual history and childbirth history should also be asked.

Among them, symptoms are the main content of the consultation and an important basis for syndrome differentiation, and the symptoms of the symptoms mainly include asking about cold and heat, sweating, head and body, chest and flank, stomach, waist and abdomen, diet, sleep, emotion, and stool, as well as asking about certain conditions of women and children.

The contents of the consultation mainly include: general situation, chief complaint, current medical history (onset, disease course, diagnosis and treatment, current symptoms), past history, personal life history, family history, etc.

Traditional Chinese medicine: cold and heat, deficiency and reality, sweating, head and body, stomach, chest and abdomen, under the menstrual belt, children, diet, sleep, stool, etc.

Western medicine: the patient's basic situation, chief complaint, current medical history (including many contents, which is also the focus of the consultation), past history, family history, genetic history, reproductive history, marital history, personal history, *****

Introduction, Subject, Present History, Past History, Systematic Review, Personal History, Family History, etc.

1. General information: including the patient's name, gender, age, occupation, marriage, ethnicity, place of origin, work unit, and current address.

2. The significance of the aspect is that it is responsible for the diagnosis and treatment of patients and is convenient for follow-up, and the second is that some disease-related information can be learned as a reference for diagnosing diseases. Chief complaint: the most distressing symptoms, signs, and duration of the patient's presentation.

The steps of the consultation are: one asks about cold and heat, two asks about sweat, three asks about pain, four asks about stool, five asks about vomiting and dizziness, six asks about palpitations, seven questions about bitterness and eight thirst, nine questions about old diseases and ten questions about the cause.

The contents of the interview include: the patient's age, name, gender, etc., chief complaint (the main reason or main symptom of the patient's visit), present medical history (the onset time, trigger, location, duration, etc. of the current symptoms), past history, systematic review, menstrual history, fertility history, family history, etc. Interviews can also make a preliminary distinction between disorders, such as appendicitis and ureteral stones, which can cause acute lower abdominal pain, in which case doctors can make a preliminary distinction by asking about the patient's menstrual history.