病史和神经系统检查.ppt

Taking a history and Neurological examination
the neurology department,1st affiliated hospital of SUMS
Huang hai-wei
Being the essential skill
Necessary to learn the clinical method
history and neurological exam
symptoms signs

qualitative anatomic( topographic)
diagnosis diagnosis

other data lab test
pathologic(etiologic) diagnosis
patient’s trust and cooperation
reliable history and accurate exam
correct diagnosis
Taking the history
Purpose:
primary information of the disease
where,what,why…
guide to the exam and Lab test
Taking the history
Notice:
good attitude while patient saying
avoiding suggestion
prehension of what he/she say
taking care to negative or other systems’ symptoms
obtaining from a relative or friend
(coma,child,mental disorder)
Structure of the history
plaint
The presenting history
Past history
Personal history
Family history
plaint
What is the main problem?
What was it that caused you e here?
Use the patient’s language.
The presenting history
Information of onset
Nature of the main symptom
Process of the disease
Associated symptoms
Preceding treatment
Information of onset
When it was first noted by the patient?
Inducing factors of onset.
Was the onset sudden,subacute,insidious or gradual?
acute: vascular,poison,trauma,infection
chronic: tumor,metabolism,degeneration