Rosenzweig Margaret Quinn, Gardner Diane, Griffith Brenda
University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania; University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; Allen Interactive Media Consultants, Minneapolis, Minnesota.
J Adv Pract Oncol. 2014 Jul-Aug;5(4):262-8. doi: 10.6004/jadpro.2014.5.4.3.
Advanced practitioners (APs) specializing in cancer care will most likely need to perform or participate in obtaining the history and physical (H & P) of a new patient. The core infrastructure of the history-taking and physical examination process remains the same across all patients regardless of diagnosis. There are, however, important distinctions in the H & P of the patient with cancer. These distinctions can be challenging for the student or novice oncology AP, leading to frustration and potentially poor patient satisfaction and outcomes. In each component of the patient history, certain considerations related to the cancer and its diagnosis and/or treatment to date must be included; these elements are different from those in the general medical H & P. This article focuses mainly on the structure and elements of the history of the present illness phase of the H & P. The similarities and differences between taking a cancer-focused H & P vs. a traditional medical one are discussed as well.
专门从事癌症护理的高级从业者很可能需要进行或参与获取新患者的病史和体格检查(H&P)。无论诊断如何,所有患者病史采集和体格检查过程的核心基础设施都是相同的。然而,癌症患者的H&P存在重要差异。这些差异对于肿瘤学专业的学生或新手高级从业者来说可能具有挑战性,可能导致挫败感,并可能使患者满意度和治疗效果不佳。在患者病史的每个组成部分中,都必须包括与癌症及其迄今为止的诊断和/或治疗相关的某些考虑因素;这些要素与普通医学H&P中的要素不同。本文主要关注H&P中现病史阶段的结构和要素。还讨论了以癌症为重点的H&P与传统医学H&P之间的异同。