Step OneAsk Basic Information
Hello, I am Dr. Wang from a certain department of a certain hospital. May I ask your surname, your name, how old you are this year, are you married, where is your hometown, what is your ethnicity, what do you do, and where do you work?
Step TwoAsk About Current Medical History
What brings you here today, what seems to be the problem?
1Cardiac Diseases (chief complaint: chest tightness, shortness of breath)
Where exactly does it hurt, how long has it been, can you describe the pain? For example, is it a sharp pain or a dull ache? Is it a stabbing pain or a cutting pain, or a twisting pain? Is it a constant pain or does it come and go? Can you tolerate it? When does it hurt the most, does the pain radiate anywhere? Can you recall what might have caused the chest pain? Can you describe any factors that worsen the pain? Have you visited a hospital when the pain occurred? (If so, ask what tests were done, what the diagnosis was, and what medications were prescribed.) Have you taken any medications, did the symptoms improve? Besides medication, are there any other factors that help alleviate your chest pain? Is there any relationship between your chest pain and eating? Is there any other discomfort besides chest pain? Fatigue, cough? Any symptoms like heartburn, nausea, vomiting? If you vomited, what did you vomit, was there any blood? Is your bowel movement normal, how many times a day, what color? Do you have a fever? How is your appetite recently? Have you lost weight? How is your sleep? Have you continued to work since becoming ill? Do you have hypertension or diabetes?
2Digestive System Diseases (chief complaint: chest pain, abdominal pain)
If the complaint is chest pain, follow the cardiac inquiry. Ask about eating habits, whether it is related to greasy food, whether there has been overeating, and the relationship between eating and pain. If there is vomiting blood or blood in the stool, ask about the color and amount.
If the complaint is abdominal pain, do not forget to ask about referred pain. Pay attention to female patients and inquire about any changes in menstrual flow, whether there are any masses in the abdomen, and if there is a possibility of pregnancy (internal medicine patients likely do not have these symptoms, but it is important to ask for differential diagnosis).
3Respiratory Diseases (chief complaint: fever, fatigue, cough, or difficulty breathing)
What was the highest temperature? Has it been constant or fluctuating? How long has the fever lasted? Is there any cough, is there phlegm, what color is it, is there blood? What triggers the fever? Have you experienced shortness of breath recently? If so, how long has it been, can you lie flat? Do you feel chest tightness or palpitations? Have you woken up suddenly at night feeling breathless? Have you visited a hospital? (If so, ask what tests were done, what the diagnosis was, and what medications were prescribed.) Have you taken any medications, did the symptoms improve? Have there been any changes in the last couple of days? Have you experienced night sweats? Any symptoms like heartburn, nausea, vomiting? If you vomited, what did you vomit, was there any blood? Is your bowel movement normal, how many times a day, what color? How is your appetite recently? Have you lost weight? How is your sleep? Have you continued to work since becoming ill? Do you have hypertension or diabetes?
4Diabetes (chief complaint: thirst, increased appetite, frequent urination, weight loss)
How much water can you drink in a day, how many meals do you eat, how is your appetite, how big is your bowl of rice, how many bowls? How many times do you go to the bathroom each day, is the amount of urine large? If you were to fill a large drink bottle, how many bottles would it fill? What color is your urine? Is your bowel movement normal? How much weight have you lost recently? How is your sleep? How is your heart usually? How is your vision? Is there any swelling in your body? Are there any sores or darkening of the skin on your legs and feet? Is there any other discomfort, such as cough, nausea, vomiting, fever? Do you usually have high blood pressure? Have you visited a hospital? (If so, ask what tests were done, what the diagnosis was, and what medications were prescribed.) Have you taken any medications, did the symptoms improve?
5Appendicitis (chief complaint: pain around the navel that later shifts to the lower right abdomen)
How long has it been, can you describe the pain? For example, is it a sharp pain or a dull ache? Is it a twisting pain? Is it a constant pain or does it come and go? Can you tolerate it? When does it hurt the most, does the pain radiate anywhere? If you press on the painful area and suddenly lift your hand, does the pain increase? Can you recall what might have caused the abdominal pain? Can you describe any factors that worsen the pain? Have you visited a hospital when the pain occurred? (If so, ask what tests were done, what the diagnosis was, and what medications were prescribed.) Have you taken any medications, did the symptoms improve? Besides medication, are there any other factors that help alleviate your pain? Is there any other discomfort besides this area? Fatigue, cough? Any symptoms like heartburn, nausea, vomiting? If you vomited, what did you vomit, was there any blood? Is your bowel movement normal, how many times a day, what color? Do you have a fever? How is your appetite recently? Have you lost weight? How is your sleep? Have you continued to work since becoming ill? Do you have hypertension or diabetes? Pay attention to female patients and inquire about any changes in menstrual flow, whether there are any masses in the abdomen, and if there is a possibility of pregnancy.
6Cholecystitis (chief complaint: pain in the upper right abdomen)
How long has it been, can you describe the pain? For example, is it a sharp pain or a dull ache? Is it a twisting pain? (Usually presents as paroxysmal colicky pain.) Is it a constant pain or does it come and go? Can you tolerate it? When does it hurt the most, does the pain radiate anywhere? (Right shoulder, back) If you press on the painful area and suddenly lift your hand, does the pain increase? Can you recall what might have caused the abdominal pain? (Overeating, greasy food) Can you describe any factors that worsen the pain? Have you visited a hospital when the pain occurred? (If so, ask what tests were done, what the diagnosis was, and what medications were prescribed.) Have you taken any medications, did the symptoms improve? Besides medication, are there any other factors that help alleviate your abdominal pain? Is there any other discomfort besides this area? Fatigue, cough? Any symptoms like heartburn, nausea, vomiting? If you vomited, what did you vomit, was there any blood? Is your bowel movement normal, how many times a day, what color? Do you have a fever? (Usually there is a fever.) When you have a fever, do you feel chills? (If there are chills, it indicates possible perforation or other complications.) Has anyone mentioned that your eyes look yellow? How is your appetite recently? Have you lost weight? How is your sleep? Have you continued to work since becoming ill? Do you have hypertension or diabetes? Pay attention to female patients and inquire about any changes in menstrual flow, whether there are any masses in the abdomen, and if there is a possibility of pregnancy.
7Other Cases, if other cases arise, follow the order of inquiry for the above diseases, and you will not miss any items.
Step ThreeAsk About Past Medical History
Now that I understand your current illness, I would like to know about your past medical history. Overall, how has your health been? Have you had any major illnesses? Have you had infectious diseases such as hepatitis, tuberculosis, or typhoid? Have you had any surgeries in the past?When was the last time you received any vaccinations or medications? Do you have any allergies to food or medications, such as penicillin?
