Translations:Medicine/9/ja: Difference between revisions

Latest revision as of 13:41, 25 June 2023

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Message definition (Medicine)

The components of the medical interview and encounter are:
* Chief complaint (CC): the reason for the current medical visit. These are the '[[symptom]]s.' They are in the patient's own words and are recorded along with the duration of each one. Also called 'chief concern' or 'presenting complaint'.
* History of present [[illness]] (HPI): the chronological order of events of symptoms and further clarification of each symptom. Distinguishable from history of previous illness, often called past medical history (PMH). [[Medical history]] comprises HPI and PMH.
* Current activity: occupation, hobbies, what the patient actually does.
* [[Medication]]s (Rx): what drugs the patient takes including [[Medical prescription|prescribed]], [[over-the-counter drug|over-the-counter]], and [[Home remedy|home remedies]], as well as alternative and [[Herbalism|herbal medicines or remedies]]. [[Allergy|Allergies]] are also recorded.
* Past medical history (PMH/PMHx): concurrent medical problems, past hospitalizations and operations, injuries, past [[infectious disease]]s or [[vaccination]]s, history of known allergies.
* Social history (SH): birthplace, residences, marital history, social and economic status, habits (including [[diet (nutrition)|diet]], medications, [[:en:tobacco smoking|tobacco]], alcohol).
* [[Family history (medicine)|Family history]] (FH): listing of diseases in the family that may impact the patient. A [[Wikipedia:family tree|family tree]] is sometimes used.
* Review of systems (ROS) or ''systems inquiry'': a set of additional questions to ask, which may be missed on HPI: a general enquiry (have you noticed any [[Wikipedia:weight loss|weight loss]], change in sleep quality, fevers, lumps and bumps? etc.), followed by questions on the body's main organ systems ([[human heart|heart]], [[human lung|lungs]], [[digestive tract]], [[Urinary system|urinary tract]], etc.).

問診とカウンセリングは以下の通り:

主訴(CC): 現在の受診の理由。これは症状である。患者自身の言葉で書かれ、それぞれの期間とともに記録される。'主訴(chief concern)'または1'主訴提示(presenting complaint)'とも呼ばれる。
現病歴（History of present illness：HPI）：症状の時系列的な順序と、各症状の詳細な説明である。過去病歴（PMH）と呼ばれることもある。病歴はHPIとPMHからなる。
現在の活動：職業、趣味、患者が実際に行っていること。
医薬品(Rx)：処方薬、市販薬、家庭薬、代替薬や漢方薬など、患者が服用している薬物。アレルギーも記録する。
過去の病歴（PMH/PMHx）：同時発生した医学的問題、過去の入院や手術、怪我、過去の感染症や予防接種、既知のアレルギー歴など。
生活履歴（SH）：出生地、居住地、婚姻歴、社会的・経済的地位、習慣（食事、医薬品、タバコ、アルコールを含む）。
家族歴（FH）：患者に影響を及ぼす可能性のある家族の疾患のリスト。家系図が用いられることもある。
システム・レビュー（ROS）またはシステム探求：質問すべき一連の追加質問、一般的な問診（体重減少、睡眠の質の変化、発熱、しこりやこぶに気づいたか、など）に続いて、身体の主な臓器系（心臓、肺、消化管、尿路など）に関する問診を行う。

Translations:Medicine/9/ja: Difference between revisions

Latest revision as of 13:41, 25 June 2023

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