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简要病史:女性,42岁 。反复发作上腹痛3年,加重伴呕吐1周门诊就诊 。既往有"十二指肠球部溃疡"病史 。要求:你作为住院医师,请围绕以上简要病史,写出应该询问的患者现病史及相关病史的内容 。

发布日期:2022-07-14

简要病史:女性,42岁 。反复发作上腹痛3年,加重伴呕吐1周门诊就诊 。既往有十二指肠球部溃疡病史 ...

试题解析

病史

病史,亦称“病案”、“病历”。医务人员对病人患病经过和治疗情况所做的文字记录。内容包括病人的姓名、年龄、性别等一般登记事项,本次和以往患病和治疗经过,个人和家庭及其他有关疾病,体格检查、化验和其他有关检查的结果,诊断,护理和治疗,病情发展经过和结果等记录。是医学科学研究的重要资料,也是病人健康情况的档案。病史我国古称“诊籍”,后称“医案”。

中文名
病史
别名
病案

发作

发作,指起作用或开始动作;动怒、发脾气。见《山海经·西山经》:“瑾瑜之玉为良,坚粟精密,浊泽而有光。五色发作,以和柔刚。”

中文名
发作
外文名
break out
拼音
fā zuò
词性
动词

腹痛

腹痛(abdominal pain)是临床常见的症状,也是促使患者就诊的原因。腹痛多由腹内组织或器官受到某种强烈刺激或损伤所致,也可由胸部疾病及全身性疾病所致。此外,腹痛又是一种主观感觉,腹痛的性质和强度,不仅受病变情况和刺激程度影响,而且受神经和心理等因素的影响。即患者对疼痛刺激的敏感性存在差异,相同病变的刺激在不同的患者或同一患者的不同时期引起的腹痛在性质、强度及持续时间上有所不同。

就诊科室
普通外科
常见病因
腹腔脏器急性炎症、腹腔脏器扭转等
常见发病部位
腹部
常见症状
疼痛

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