余静问诊英文1双语.ppt

DIAGNOSTICS,Part 2: INQUIRY ( HISTORY TAKING),Lanzhou University Second Hospital Yu Jing,Review,The main contents of diagnostics,history taking symptoms and signs physical examinations laboratory examinations assistant examinations Write-up Principles and methods to make diagnosis,Symptom,Abnormal (uncomfortable) feeling because of any disease Subjective: pain, palpitation, dizziness. Subjective and objective: fever, abdominal mass, constipation.,Sign,Abnormal findings detected by physical examination Differentiate normal and abnormal Clinical significance of signs Signs in what disease (Disease: what signs) Probability: how common ?,The four cardinal principles of physical examination,Inspection Palpation Percussion Auscultation,Basic method!,The basic principles of clinical thinking,The principle of realistic The principle of “monism” Taking diagnosis according the morbidity and spectrum of a disease Organic disease first and functional disease second The principle of “ simplify “,Order of general clinical diagnosis,1、Etiological diagnosis 2、Pathological diagnosis 3、Pathophysiological diagnosis 4、Typing and staging of disease 5、The diagnosis of complication 6、The diagnosis of accompany disease,Todays Class History taking,To patient,respect,be patient,careful,Importance of Inquiry,Gaining clinical information and collecting case history based on the systemic inquiry Foundation of clinical practice 6080% diagnosis could be confirmed from the interview to a patient by physician,Traditional and major: face to face New pattern： consultation by telephone, consultation through internet,Style,OBJECTIVE OF INQUIRY,The medical interview serves three functions: To collect information, Realize patients emotional state, To educate patient and influence patients behavior.,1. METHODS &SKILLS,Skill of communication Suitable environment Greeting patient Active listener Avoided force or hint patient Language & term Non-language communication Ending talk,Introduce yourself 介绍自己 Tell patient your role/position 说明自己的身份 Call patient by suitable title 恰当称呼病人,Prologue 开场白 Introduction,1.METHODS &SKILL,Skill of collection Emphasis chief complain Opening & closing questioning Simple to complicate Avoiding complicated medical term Avoiding irritable term Skillful induce sensitive topic,1.METHODS &SKILL,Avoid leading questions 避免 诱导性提问 Avoid why questions 避免 诘难性提问 Avoid multiple questions 避免 连续多个提问,Is the color of your stool black？ Does the pain radiate to your right shoulder? Did you feel headache with nausea and vomiting?,What color of your stool？ Did you feel pain in other parts of your body when you have stomachache? Did you have other sick when you feel headache ?,Correct,Focused history taking 重点问诊的方法,Purpose: emergency and outpatient clinic Selected contents Focus 1-2 main points and develop them Form the hypothesis of diagnosis Arrange the proper chemical examination and assistant examination Observe the development of a disease Reconfirm the diagnosis,Which part did you feel upset？ Whats wrong with you?,e.g： stomachache fever cough,e.g： puffiness (edema) skin stained yellow （jaundice） mass (tumor) of neck,2.CONTENTS OF INQUIRY,General items（data) Chief complains (C.C) Present history (P. H) Past history include systemic review Personal history Marital history Menstrual history（MH） and childbearing history Family medical history（FMH）,2.1 General Data 一般资料,Ask patients name, age, nationality, address, etc. 全名、年龄、民族、住址等,Formats and contents of case record,Name Gender Age Marital status Native place Nationality Profession,Working place Current address Date of admission Date of case record Status of admission Source Reliability,Case record,2.2 Chief complaint, CC 主诉,CC: a sentence that describe patients main uncomfortable and their duration by patients words 用病人自己的语言概括 主要症状和/或体征及其时间。,Two key points of chief complaint,main un-comfort duration,Examples of Chief complain,Activated palpitation 4 years, worsen and accompanied by puffiness of lower extremities for 2 weeks. 活动后心悸4年，加重伴下肢水肿2周。,Examples of Chief complain,进食后上腹痛半年，加重三天。 Upper abdominal pain after eating for 6 months and aggravating 3 days,Examples of Chief complain,Persistent chest pain for 2 hours,2.3 Present History 现病史,The main problems at present 病人目前的主要问题 (1) Onset of the problems: acute or chronic 起病情况：急缓、患病时间 (2) Any reason or inducing factors 发病的原因和（或）诱因,(3) main symptoms,Characteristics Characteristics 特点 Location 部位 Properties 性质 Frequency of episodes 发作频率 Durations 持续时间 Intensity 强度 Radiation 放射区 Factors that worsen or relieve the symptom 加重和缓减的因素,Progress of the illness 病情的发生和演变 (5) Other symptoms 伴随症状 Negative symptoms 有临床意义的阴性症状 History of diagnosis and treatment 诊断和治疗的经过 General situation since the illness 患病以来的一般情况,Explore Pain in detail,What was the patient doing immediately before the episode? Speed of onset? Time of onset? Duration? Feature of pain? Radiation? (to be continued),example,Explore Pain in detail (cont.),Associated symptoms? Aggravating features? Relieving factors? Recovery? Remain symptoms? Effect of any intervention? Previous episodes?,example,4. Past history 过去史,Health status in the past 既往的健康情况 Illness suffered in the past 过去患过的疾病 Previous hospital admissions 既往住院史 History of surgical operations, trauma and vaccines 手术、外伤、预防接种史 History of allergic disorders 过敏史,5 System Review 系统回顾 Respiratory system Cardiovascular system Digestive system Urinary system Blood system Endocrine system and metabolism Nervous system Muscle skeleton system,5. Review of Systems 系统回顾,Aims: avoid missing significant symptoms, suggest other disorders A few main symptoms for each system: screening questions Be familiar with the symptoms in each system,of screening questions,Cardiovascular system Chest pain Palpitation Dyspnoea Cough Ankle swelling Fatigue,Example,6. Personal history 个人史,Social experiences 社会经历 Occupation, working conditions, exposure to toxins，education 职业和工作条件，毒物接触史,教育 Habit, food, smoking, drink alcohol, drug abuse, etc. 习惯和嗜好，饮食、烟、酒、毒品,duration age - LMP (or age of menopause) days of circle pregnancy, abortion, family plan, etc.,7. Menstrual period and childbearing history 月经和婚育史,8. Family history 家族史,Esp. for young pt. and those with a suspected inherited disease. Some diseases have a single-genetic inheritance: cystic fibrosis, color blindness; Some have a multi-genetic component: hypertension, ischemic heart disease, schizophrenia, breast cancer Family tree when necessary,Closure 结束语,Let patient ask questions 让病人提问 Discuss with patients 讨论 Ask patients requirements 病人的期望 Patient education 健康教育 Explain what to do next for both physician and patient 说明医生和病人下一步的工作,3. Skills in special situations,Children Patients with mental disorders Silence and sadness Anxiety and depression Over-talking and garrulous behavior Anger and hostility,3. Skills in special situations,Patients with multiple symptoms Poor cultural background or pt. with limited intelligence Severely ill, end/advanced stage patient Handicaps: mute, blind or deaf For elder patients Foreign people,Case1 一般资料(general information):,姓名：张晓兰 性别：女性 年龄：32岁 职业：农民 出生地：甘肃岷县 民族：汉族 婚姻：已婚,单位：无 住址：甘肃岷县长依村 入院日期：2011,8,24,3pm 记录日期：2011,8,24,3pm 入院状态：扶入 叙述者：本人 可靠程度：可靠,主诉(chief complaint,CC)：劳累性胸闷、气短3年，加重伴心慌2月。 现病史(present history)：患者3年前上坡及担水时气短，未重视。2月前气短渐加重，走平路也憋气。有时夜间睡眠后憋醒，坐起5分钟后缓解，并出现心慌，尿少，下肢浮肿。无胸痛、咳嗽咳痰，无头晕。在诊所就诊服用过“氢氯噻嗪”，浮肿减轻，为进一步诊治就诊，门诊以“心力衰竭”收住。患病以来，食欲减退，睡眠尚可，尿少，大便正常。 既往史(past history,PH)：10年前患风湿性关节炎，12年前行阑尾切除术，无外伤手术史，预防接种史不祥。,Case1,Respiratory system（呼吸系统）无胸痛、咳嗽、咳痰、咯血及发热等。 Cardiovascular system（心血管系统）祥见病历。 Digestive system（消化系统）无腹泻、便血、呕吐等。 Urinary system（泌尿系统）无尿频、尿急、尿痛及排尿不畅等。,Review of Systems，r of s 系统回顾,Blood system：（血液系统）无鼻纽、面色苍白、皮肤出血及紫斑等。 Endocrine system and metabolism：（内分泌和代谢系统）无多饮、多尿、消瘦及情绪变化等。 Nervous system：（神经系统）无抽搐、失语及意识丧失等。 Muscle skeleton system：（肌肉骨骼系统）无肌肉疼痛、活动障碍等。,Review of Systems，r of s 系统回顾,case1,个人史（personal history）生于原籍，未到过外地，初中文化，不抽烟及饮酒。 月经及婚育史(menstrual period and childbearing history )：25岁结婚，育有1 女，体健。月经16 2011.8.24，经 量中等，无痛经，白带正常。,5天,30天,Diagnosis order,1. Valvular heart disease（Etiological diagnosis） mitral stenosis and insufficientia（Pathological diagnosis） cardiac dilatation （Pathological diagnosis） arhythmia atrial-fibrilation; (Pathophysiological diagnosis) NYHA heart function stage III (Typing and staging of disease) No (The diagnosis of complication) 2. Appendectomy for 10 years (The diagnosis of accompany disease),Case 2 一般资料(general information):,姓名：王留一 性别：男性 年龄：72岁 职业：退休干部 出生地：浙江金华 民族：汉族 婚姻：丧偶,单位：兰州十五中学 住址：兰州市金塔巷30号 入院日期：2011,8,24,3pm 记录日期：2011,8,24,3pm 入院状态：扶入 叙述者：本人 可靠程度：可靠,Case 2,主诉(chief complaint,CO)：间断头疼头晕12年，劳累性心前区憋闷3年。 现病史(present history)：12年前因间断头疼头晕就诊发现血压高，最高为180/70mmHg，间断用复方降压片，未规律测血压，无发作性头疼心悸出汗，无尿急少尿等。三年前上三楼后气短，心前区憋闷，含硝酸甘油后5分钟缓解。服用过卡托普利但因咳嗽停用，现用心痛定1片，bid，麝香保心丸5粒，tid。为进一步诊治就诊，门诊以高血压收住。患病以来，食欲减退，睡眠尚可，尿少，大便正常。 既往史(past history,PH)：父患高血压56岁脑卒中去世，患者