诊断学总论

Clinical Diagnostics,CHINA MEDICAL UNIVERSITY,ZHAO LI,Physical Diagnosis,Todays medical studentsTomorrows clinicians,Physical Diagnosis,What is the meaning of “Clinician”?,Physical Diagnosis,What is the main responsibility of the clinician? Making diagnosis Treat a disease Treat a patient,Physical Diagnosis,A linkage between basic medical knowledge and clinical medicine.A discipline to use basic medical theory and skill to make a diagnosis.,Obtain information,From any and every source possible.Strain to hear the voice of the patient in the thin reed of his crying.See most acutely out of the corner of your eye.To hear best with your inner ear.,The contents of diagnosis,Verbal observation or history takingPhysical observation or examinationLaboratory observation,History Taking,Obtain as much information as needed to diagnose and treat the illness. Requirements for the physicians:A genuine, profound, and absorbing interest in the patients well beingA deep-seated, well-grounded self confidence in abilities A through knowledge of the diseases Ability to see the problem from the patients viewpoint,History Taking,Obtaining a medical history is an artTalk with, rather talk to the patient. Listen attentively and guide a patient effectively. Ask searching questions. Interrogation of family and friends if necessary.,History Taking,Know all about the diseaseSymptoms and signsSymptoms: patients complaints, or his recognition of something abnormal. Signs: findings elicited by physical examinationPast historyFamily history Systems review,Physical Examination,Begins when greeting the patient.Sedulously practicing the art of observation make a student to a clinician.,How to conduct physical examination,Application of the sensory end organ to the patient.In a rational, thorough, and accurate fashion. With efficiency and minimal discomfort to the patient.5 components of physical examination: inspection, palpation, percussion ,auscultation and smelling.,Laboratory findings,To detect pathogenic or functioning information.Chemical, biological and physiological tests.X-film, CT, MR.gastroscopy, angiography and bronchoscopy etc.,Interpretation of laboratory data,Lots variables alter laboratory tests results.Specificity and sensitivity of the tests.Overlapping between the healthy and the diseased subjects.,The Intellectual process of diagnosis,Information requires clarification and amplification.Information must be carefully weighed as to its clinical significance and its possible relationship to the patients complaints6 levels of intellectual functioning： knowledge, comprehension, application, analysis, synthesis, and evaluation,6 levels of intellectual functioning,KnowledgeUnedited factual information provided by the patient.May not necessarily be accurate or precise.ComprehensionUnderstanding the facts related by the patient.Affirm what the patient said.ApplicationRecording the facts accurately and in a well-organized order,6 levels of intellectual functioning,AnalysisSorting out or classification of the obtained data into related categories. SynthesisReassemble the data obtained into patterns of recognizable disease.EvaluationAsking questions that are designed to either confirm or exclude tentative diagnoses. Predicting the likely physical and laboratory finding.,The role of high technology,Always be a tool.Can never replace the intellectual process of diagnosis.,The role of high technology,Patient is a human being, not a machine!Physician is a medical detective, not a detector!,Conclusion,Communication，observation and data recording are the key demands in medicine.Profound knowledge and smart intellectual process of thinking of medicine is the key for success of a clinician.,Only as a clinician does one become a clinician,What is Clinical Diagnostics?,Fundamental theory Techniques of diagnosing disease Mode of clinical thinking,What is Clinical Diagnostics?,Instruct a concise logical approach to recognize the genius of the diseasesA fundamental course of clinical medicine,Fundamental elements of Diagnostics,Diagnosis,Identification,Analysis,Diagnosis,Derived from Greek words distinguish or discern,English term DiagnosticThe distinguishing sign and symptoms with which it gerenally begins, continues and goes offas it were, a history of the disease In 18th century: Nosography,In modern usage: Identification of a disease by investigation of its signs and symptoms Medical terminology:Clinical diagnosis Laboratory diagnosisX-ray diagnosis Electrocardiographic diagnosisGene diagnosis,Identification:,Inquiry Physical examination Laboratory tests/Special examination,Analysis:,Basic knowledge of medicineOverall analysisScientific way of clinical thinking,Importance of Diagnostics,Essential Bridge Tools,Basic courses,Clinical medicine,Content of Clinical Diagnostics,Symptomatic diagnosis (症状诊断),Physical diagnosis (检体诊断),Laboratory tests or clinical ancillary tests,Medical record,Diagnostic processes and the way of clinical thinking,History taking（病史采集 )- Interview (问诊）,Symptoms (症状）- patients complaints (主诉),Symptomatic Diagnosis (症状诊断),Symptomatic Diagnosis,Symptomatic Diagnosis,Subjective sensation that patient describes,Fever,Cough,Rash,Mass,Physiological & functional,Pathological & morphological,Symptom （症状）,Physical Diagnosis,Abnormality observed by the physician,Sign （体征）,Physical examination （体格检查）,Inspection (望）,Palpation （触）,Percussion （叩）,Auscultation （听）,Conducted with thoroughness, alertness to detect even slight derivations from normal,Laboratory test or ancillary tests,Serum, Urine, Stool tests X-ray film EKG Endoscopy Ultrasonic imaging CT MRI PET (Positron Emission Tomography),Medical record,Medical record is a systematized way of storing the required data, information and other relevant documents,Specific requirement in terms of format and content,Special terms in clinical diagnosis,Impression (初步印象）,Tentative diagnosis （可能性诊断）,Differential diagnosis （鉴别诊断）,Evidence based medicine（循证医学）,Differential diagnosis,Preliminary diagnosis/Tentative diagnosis 初步诊断 可能性诊断 Exclusion of other diseases (排除其它疾病) Selecting a number of possibilities to explain the clinical and laboratory findings in the case in question The way of exclusion is called Differential diagnosis,Evidence based medicine,It is the conscientious（谨慎的）, explicit （明确的）and judicious （有见解的）use of current best evidence in making decisions about the care of the individual patient It means integrating individual clinical expertise （临床专长）with the best available external clinical evidence from systematic research,Evidence based medicine,One need to: Be conscientious: it requires effort and thought. Be explicit: decisions will need to be backed up by good evidence Relate to specific problems: it is not about a hypothetical average case. Integrate individual clinical experience: it does not denigrate clinical skills in history taking, examination and diagnosis. Look for current best evidence: the perfect study may not yet have been published, written up or even commenced. We may have to settle for something less rigorous, but be on the look out for new research that will supersede older studies.,Important aspects-interrogation,To get the history in detail of a patients illness The history is taken at initial contact between physician and patient As some crucial points might be overlooked by the patients, one will ask many searching questions to make the history more informative and complete, who must at the same time avoid suggesting answers Occasionally to interrogate his family member,Other important aspects,The diagnostic process is very complex The number of facts that can be collected in a detailed medical history and in thorough physical examination are almost without limit The laboratory tests or specialized technical procedures that can employed are numerous and costly,Other important aspects,Questions for interrogation, maneuver in P.E., laboratory test should be thoughtfully selected with the view to eliminate some of the possible diagnosis and guide the search expeditiously to a specific disease Method of approaching a diagnosis: Analysis of symptoms (症状分析) Recognition of the syndrome (综合症识别) Consideration of disease mechanisms (考虑疾病机制),Important aspects,Modern & advanced ancillary techniques: have their limitations. It cant reduced the importance of certain parts of the classic P. E It should be avoided to neglect fundamental methodsInterrogationPhysical examinationScientific clinical thinking,Approaches,Basic knowledge learning（基础知识的学习）,Clinical practice （临床实践）,Bedside activity,Standardized patient,床边实践,标准化病人,Developmental History of clinical diagnostics,Western Medicine: from ancient to modern Traditional Chinese Medicine,Contribution of ancient doctors-Western,HippocratesBorn on the island of Cos, Greece (c. 460-377 BC)The Father of medicine Hippocratic oath 希波克拉底宣言Hippocratic corpus（文集）: a collection of 70 works,Hippocratic oath,Contribution of ancient doctors-Western,Galen c.130-c.200 His work in anatomy/physiology is notable Identified artery and vein Added greatly to knowledge of the brain, spinal cord and pulse,Contribution of ancient doctors-Western,AuenbruggerBorn at the village of Graz, Austria (1722)Son of an innkeeperThe working experiences helped him to find PercussionAuthor of (1761) translated as On Percussion of