自研调查问卷在眩晕头晕患者病史采集中的应用尝试

Effect of a self-createdquestionnaire to the history collection of patients with vertigo or dizziness

目的:自行设计眩晕头晕患者病史采集的调查问卷,并初步探讨其对临床工作的意义。方法:采取观察性研究,收集以"眩晕头晕"为主诉在我科接受了前庭功能检查的69例患者。从其自行填写的眩晕头晕病史问卷和医师撰写的住院病历中调取信息,对比调查问卷和住院病历对临床重要信息反映能力的差异。结果:调查问卷对患者病史信息的采集更全面、细致,涵盖了眩晕特点、持续时间、发作频率、病史时间、诱发及加重因素、与姿势位置的关系、伴随症状、耳部情况、视觉情况、头痛情况、其他系统情况、意识情况、用药情况、不稳程度的VAS评分、既往史、个人史、家族史、阳性辅助检查结果等,明显优于住院病历。在反映发作频率、每次持续时间、是否可疑耳石症、前庭代偿情况等方面,反映率亦明显优于住院病历(P<0.05)。结论:本调查问卷可以很好地帮助医师采集眩晕头晕患者的病史资料,作为住院或门诊病历的重要补充,值得临床推广。

Objective：To develop a self-designed questionnaire for history collection of patients with vertigo or dizziness,and to analyze its effect to clinical work.Method：An observational study was conducted to collect 69 patients who had undergone vestibular function tests in our department with main complaints of ＂dizziness and dizziness＂.Information was extracted from the questionnaires filled by patients themselves and the inpatient medical records wrote by doctors.The differences in ability to reflect clinically important information was investigated between the questionnaire and medical record.Result：Questionnaire is more comprehensive and meticulous for history collection.It is better than inpatient medical documents.It contains character of vertigo,duration,frequency of attack,time of onset,inducing and aggravating factors,relation with position and posture,concomitant symptoms,ear condition,vision,headache,conditions of other systems,consciousness,medication,VAS score of instability,previous history,personal history,family history,and positive results of examinations.It has a better detection rate in terms of vertigo frequency,duration,suspicious otolith or not,and vestibular compensation than that of inpatient medical record（P〈0.05）.Conclusion：This self-designed questionnaire can help doctors to collect medical history of patients with vertigo or dizziness.It is worthy of clinical promotion as an important supplement for inpatient and outpatient medical records.