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You are here: Home Lecture/Topic Medical Student 3 หัวข้อการถามประวัติผู้ป่วย



รศ.นพ.กำจัด สวัสดิโอ

แบบที่ 1 : ประวัติผู้ป่วยทางสูติกรรมและนรีเวชกรรม

I. Age and parity

II. Chief complaint

III. Present illness

A. Bleeding

1. Change in interval, duration, and amount of menstrual bleeding

2. Intermenstrual bleeding

3. Contact bleeding

4. Postmenopausal bleeding

5. Relation to exogenous steroids

B. Pain

1. Location

2. Relation to menses

3. Radiation

4. Character

C. Mass

1. Location

2. Time of onset

3. Rate of growth

4. Pain, discomfort, pruritus, discharge, or bleeding

5. Relation to menses

D. Vaginal discharge

1. Color, ordor, and consistency

2. Onset, duration, and quantity

3. Pain or pruritus

E. Urinary and gastrointestinal symptoms

1. Frequency, urgency, dysuria, urinary incontinence, and hematuria

2. Diarrhea, constipation, tenesmus, fecal incontinence, rectal bleeding

F. Protrusion through the vagina

1. Sensation of mass falling out

2. Difficulty in emptying bowel

3. Stress incontinence of urine

4. Relaxed vaginal outlet

G. Infertility

1. Female factors (endometrial biopsy; tubal patency test)

2. Male factors (sperm dount)

3. Reproductive incompatibility (refer to specialist)

IV. Menstrual history

A. Age of menarche

B. Character of early cycles

C. Interval between normal periods

D. Amount and duration of normal periods

E. Associated signs and symptoms

F. Last normal menstrual period and previous normal menstrual period

G. Premenstrual tension

H. Abnormalities of uterine bleeding

I. Hypomenorrhea or amenorrhea

J. Relation to oral contraceptives

K. Menopause

1. Date of last menses

2. Climacteric symptoms

V. Obstetric history

A. Dates of deliveries

B. Lengths of gestations

C. Complications during pregnancy (bleeding, headache, edema)

D. Durations of labors

E. Methods of deliveries (spontaneous, forceps, cesarean section)

F. Weight, sex, and condition of each infant at delivery

G. Number and health of children now alive

H. Postpartum complications

I. Abortions

1. Spontaneous

2. Medically indicated

3. Elective

VI. Contraceptive history

A. Type of contraceptive used

B. Duration of use

C. Reason for choice

D. Satisfaction with method

E. Effectiveness of method

F. Undesirable side effects

VII. Sexual history

A. Regularity of intercourse

B. Libido, satisfaction, and orgasm

C. Dyspareunia, frigidity, and other sexual problems such as premature ejaculation

VIII. Medical history

A. Diabetes

B. Hypertension

C. Cardiac disease

E. Syphilis

F. Tuberculosis

G. Epilepsy

H. Exposure to rubella

I. Allergies

J. Present medications

Ix. Surgical History

A. Dates of operations

B. Surgeons and hospitals where performed

C. Diagnoses

D. Results

X. Family history

A. Twinning

B. Hereditary disease

XI. Social History

A. Tobacco

B. Alcohol

C. Occupation

D. Hobbies and recreational activities

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file: TopicHxTaking.doc


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