余静问诊英文1(双语)

1、DIAGNOSTICS Part 2: INQUIRY ( HISTORYTAKING)Lanzhou University Second HospitalYu JingREVIEWThe main contents of diagnosticsnhistory takingnsymptoms and signsnphysical examinationsnlaboratory examinationsnassistant examinationsnWrite-upnPrinciples and methods to make diagnosisSymptomAbnormal (uncomfo

2、rtable) feeling because of any diseasenSubjective: pain, palpitation, dizziness.nSubjective and objective: fever, abdominal mass, constipation.SignAbnormal findings detected by physical examinationnDifferentiate normal and abnormalnClinical significance of signs nSigns in what disease(Disease: what

3、signs) Probability: how common ?The four cardinal principles of physical examinationnInspection nPalpationnPercussionnAuscultationBasic method!The basic principles of clinical thinkingnThe principle of realisticnThe principle of “monism”nTaking diagnosis according the morbidity and spectrum of a dis

4、easenOrganic disease first and functional disease secondn The principle of “ simplify “Order of general clinical diagnosis1、Etiological diagnosis2、Pathological diagnosis3、Pathophysiological diagnosis4、Typing and staging of disease5、The diagnosis of complication6、The diagnosis of accompany diseasenTo

5、days Class History takingTo patientrespectbe patientcarefulImportance of InquirynGaining clinical information and collecting case history based on the systemic inquiry nFoundation of clinical practicen6080% diagnosis could be confirmed from the interview to a patient by physician Traditional and maj

6、or:nface to faceNew pattern：nconsultation by telephone,nconsultation through internetStyle OBJECTIVE OF INQUIRYThe medical interview serves three functions: nTo collect information, nRealize patients emotional state, nTo educate patient and influence patients behavior. Contents of inquiryThe acquiri

7、ng skill of specific situationCase discussionMethods and skills1. METHODS &SKILLSSkill of communicationnSuitable environmentnGreeting patientnActive listenernAvoided force or hint patientnLanguage & termnNon-language communicationnEnding talkn Introduce yourself 介绍自己介绍自己nTell patient your ro

8、le/position说明自己的身份说明自己的身份nCall patient by suitable title 恰当称呼病人恰当称呼病人Prologue 开场白开场白 Introduction 1.METHODS &SKILLSkill of collectionnEmphasis chief complainnOpening & closing questioningnSimple to complicatenAvoiding complicated medical termnAvoiding irritable termnSkillful induce sensitive

9、 topic1.METHODS &SKILLnAvoid leading questions避免避免 诱导性提问诱导性提问nAvoid why questions避免避免诘难性提问诘难性提问nAvoid multiple questions避免避免连续多个提问连续多个提问Is the color of your stool blackIs the color of your stool black？Does the pain radiate to your right shoulder?Does the pain radiate to your right shoulder?Did y

10、ou feel headache with nausea and vomitingDid 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重点问诊的方法重点问诊的方法nPurpose: emergenc

11、y and outpatient clinicnSelected contentsnFocus 1-2 main points and develop them nForm the hypothesis of diagnosisnArrange the proper chemical examination and assistant examinationnObserve the development of a disease nReconfirm the diagnosisWhich part did you feel upset？Whats wrong with you?e.ge.g：

12、stomachachefevercoughe.ge.g：puffiness (edema)skin stained yellow（jaundice）mass (tumor) of neckContents of inquiryThe acquiring skill of specific situationCase discussionMethods and skills2.CONTENTS OF INQUIRYnGeneral itemsGeneral items（data)data)nChief complains (C.C)Chief complains (C.C)nPresent hi

13、story (P. H)Present history (P. H)nPast history include systemic reviewPast history include systemic reviewnPersonal historyPersonal historynMarital historyMarital historynMenstrual historyMenstrual history（MHMH） and childbearing historyand childbearing historynFamily medical historyFamily medical h

14、istory（FMHFMH）2.1 General Data 一般资料一般资料nAsk patients name, age, nationality, address, etc. n全名、年龄、民族、住址等全名、年龄、民族、住址等Formats and contents of case recordnName nGendernAge nMarital statusnNative placenNationality nProfessionnWorking placenCurrent addressnDate of admission nDate of case recordnStatus of

15、 admissionnSource nReliability Case record2.2 Chief complaint, CC 主诉主诉CC: a sentence that describe patients main uncomfortable and their duration by patients words 用病人自己的语言概括用病人自己的语言概括主要症状和主要症状和/ /或体征及其时间或体征及其时间。Two key points of chief complaint main un-comfort duration Examples of Chief complainnAc

16、tivated palpitation 4 years, worsen and accompanied by puffiness of lower extremities for 2 weeks.n活动后心悸活动后心悸4年，加重伴下肢水肿年，加重伴下肢水肿2周。周。 Examples of Chief complain进食后上腹痛半年，加重三天。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 complainPersistent chest

17、 pain for 2 hours2.3 Present History现病史现病史The main problems at present 病人目前的主要问题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）诱因发病的原因和（或）诱因(3) main symptoms CharacteristicsnCharacteristics特点特点nLocation 部位部位nProperties 性质性质nFr

18、equency of episodes 发作频率发作频率nDurations 持续时间持续时间nIntensity 强度强度nRadiation 放射区放射区nFactors that worsen or relieve the symptom 加重和缓减的因素加重和缓减的因素(4) Progress of the illness 病情的发生和演变病情的发生和演变(5) Other symptoms 伴随症状伴随症状(6) Negative symptoms 有临床意义的阴性症状有临床意义的阴性症状(7) History of diagnosis and treatment 诊断和治疗的经过诊

19、断和治疗的经过(8) General situation since the illness 患病以患病以来的一般情况来的一般情况 Explore Pain in detailnWhat was the patient doing immediately before the episode?nSpeed of onset?nTime of onset?nDuration?nFeature of pain? nRadiation? (to be continued)exampleExplore Pain in detail (cont.)nAssociated symptoms?nAggrav

20、ating features?nRelieving factors?nRecovery?nRemain symptoms?nEffect of any intervention?nPrevious episodes?example4. Past history 过去史过去史Health status in the past Health status in the past 既往的健康情况既往的健康情况Illness suffered in the past Illness suffered in the past 过去患过的疾病过去患过的疾病Previous hospital admissi

21、ons Previous hospital admissions 既往住院史既往住院史History of surgical operations, trauma and History of surgical operations, trauma and vaccines vaccines 手术、外伤、预防接种史手术、外伤、预防接种史History of allergic disorders History of allergic disorders 过敏史过敏史5 System Review系统回顾系统回顾nRespiratory systemnCardiovascular systemn

22、Digestive systemnUrinary systemnBlood systemnEndocrine system and metabolismnNervous systemnMuscle skeleton system5. Review of Systems系统回顾系统回顾nAims: avoid missing significant symptoms, suggest other disordersnA few main symptoms for each system: screening questionsnBe familiar with the symptoms in e

23、ach system of screening questionsCardiovascular systemnChest painnPalpitationnDyspnoeanCoughnAnkle swellingnFatigueExample6. Personal history 个人史个人史(1)Social experiences 社会经历社会经历(2)Occupation, working conditions, exposure to toxins，education 职业和工作条件，毒物接触史职业和工作条件，毒物接触史,教育教育(3)Habit, food, smoking, dr

24、ink alcohol, drug abuse, etc. 习惯和嗜好，饮食、烟、习惯和嗜好，饮食、烟、酒、毒品酒、毒品duration age - LMP (or age of menopause)days of circlepregnancy, abortion, family plan, etc.7. Menstrual period and childbearing history 月经和婚育史月经和婚育史8. Family history 家族史家族史nEsp. for young pt. and those with a suspected inherited disease.nS

25、ome diseases have a single-genetic inheritance: cystic fibrosis, color blindness;nSome have a multi-genetic component: hypertension, ischemic heart disease, schizophrenia, breast cancernFamily tree when necessaryClosure 结束语结束语nLet patient ask questions 让病人提问让病人提问nDiscuss with patients 讨论讨论nAsk patie

26、nts requirements 病人的期望病人的期望nPatient education 健康教育健康教育nExplain what to do next for both physician and patient 说明医生和病人下一步的工作说明医生和病人下一步的工作Contents of inquiryThe acquiring skill of specific situationCase discussionMethods and skills3. Skills in special situationsnChildrennPatients with mental disorders

27、nSilence and sadnessnAnxiety and depressionnOver-talking and garrulous behaviornAnger and hostility 3. Skills in special situationsnPatients with multiple symptomsnPoor cultural background or pt. with limited intelligencenSeverely ill, end/advanced stage patientnHandicaps: mute, blind or deafnFor el

28、der patientsnForeign peopleContents of inquiryThe acquiring skill of specific situationCase discussionMethods and skillsCase1 一般资料一般资料(general information):(general information):n姓名：张晓兰n性别：女性n年龄：32岁n职业：农民n出生地：甘肃岷县n民族：汉族n婚姻：已婚n单位：无单位：无n住址：甘肃岷县长依村住址：甘肃岷县长依村n入院日期：入院日期：2011,8,24,3pmn记录日期：记录日期：2011,8,24,

29、3pmn入院状态：扶入入院状态：扶入n叙述者：本人叙述者：本人n可靠程度：可靠可靠程度：可靠n主诉主诉(chief complaint,CC)(chief complaint,CC)：劳累性胸闷、气短劳累性胸闷、气短3 3年，加年，加重伴心慌重伴心慌2 2月。月。n现病史现病史(present history)(present history)：患者患者3 3年前上坡及担水时气年前上坡及担水时气短，未重视。短，未重视。2 2月前气短渐加重，走平路也憋气。有时夜月前气短渐加重，走平路也憋气。有时夜间睡眠后憋醒，坐起间睡眠后憋醒，坐起5 5分钟后缓解，并出现心慌，尿少，分钟后缓解，并出现心慌，尿少

30、，下肢浮肿。无胸痛、咳嗽咳痰，无头晕。在诊所就诊服下肢浮肿。无胸痛、咳嗽咳痰，无头晕。在诊所就诊服用过用过“ “氢氯噻嗪氢氯噻嗪” ”，浮肿减轻，为进一步诊治就诊，门诊以，浮肿减轻，为进一步诊治就诊，门诊以“ “心力衰竭心力衰竭” ”收住。患病以来，食欲减退，睡眠尚可，尿少，收住。患病以来，食欲减退，睡眠尚可，尿少，大便正常。大便正常。n既往史既往史(past history,PH)(past history,PH)：1010年前患风湿性关节炎，年前患风湿性关节炎，1212年前行阑尾切除术，无外伤手术史，预防接种史不祥。年前行阑尾切除术，无外伤手术史，预防接种史不祥。Case1nRespira

31、tory system（呼吸系统）无胸痛、咳嗽、（呼吸系统）无胸痛、咳嗽、咳痰、咯血及发热等。咳痰、咯血及发热等。nCardiovascular system（心血管系统）祥见病历。（心血管系统）祥见病历。nDigestive system（消化系统）无腹泻、便血、呕（消化系统）无腹泻、便血、呕吐等。吐等。nUrinary system（泌尿系统）无尿频、尿急、尿痛（泌尿系统）无尿频、尿急、尿痛及排尿不畅等。及排尿不畅等。Review of Systems，r of s 系统回顾系统回顾nBlood system：（血液系统）无鼻纽、面色苍白、（血液系统）无鼻纽、面色苍白、皮肤出血及紫斑等。皮

32、肤出血及紫斑等。nEndocrine system and metabolism：（内分泌和（内分泌和代谢系统）无多饮、多尿、消瘦及情绪变化等。代谢系统）无多饮、多尿、消瘦及情绪变化等。nNervous system：（神经系统）无抽搐、失语及（神经系统）无抽搐、失语及意识丧失等。意识丧失等。nMuscle skeleton system：（肌肉骨骼系统）无肌（肌肉骨骼系统）无肌肉疼痛、活动障碍等。肉疼痛、活动障碍等。Review of Systems，r of s 系统回顾系统回顾case1n个人史（个人史（personal history）生于原籍，未到生于原籍，未到过外地，初中文化，不抽

33、烟及饮酒。过外地，初中文化，不抽烟及饮酒。n月经及婚育史月经及婚育史(menstrual period and childbearing history )：25岁结婚，育有岁结婚，育有1 女，体健。月经女，体健。月经16 2011.8.24，经，经 量中等，无痛经，白带正常。量中等，无痛经，白带正常。5天30天Diagnosis order1. Valvular heart disease（Etiological diagnosis） mitral stenosis and insufficientia（Pathological diagnosis） cardiac dilatation （

34、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 2一般资料一般资料(general information):(general informati

35、on):n姓名：王留一姓名：王留一n性别：男性性别：男性n年龄：年龄：7272岁岁n职业：退休干部职业：退休干部n出生地：浙江金华出生地：浙江金华n民族：汉族民族：汉族n婚姻：丧偶婚姻：丧偶n单位：兰州十五中学单位：兰州十五中学n住址：兰州市金塔巷住址：兰州市金塔巷30号号n入院日期：入院日期：2011,8,24,3pmn记录日期：记录日期：2011,8,24,3pmn入院状态：扶入入院状态：扶入n叙述者：本人叙述者：本人n可靠程度：可靠可靠程度：可靠Case 2n主诉主诉(chief complaint,CO)(chief complaint,CO)：间断头疼头晕间断头疼头晕1212年，劳年

36、，劳累性心前区憋闷累性心前区憋闷3 3年。年。n现病史现病史(present history)(present history)：1212年前因间断头疼头晕就年前因间断头疼头晕就诊发现血压高，最高为诊发现血压高，最高为180/70mmHg180/70mmHg，间断用复方降压，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，含硝酸少尿等。三年前上三楼后气短，心前区憋闷，含硝酸甘油后甘油后5 5分钟缓解。服用过卡托普利但因咳嗽停用，现分钟缓解。服用过卡托普利但因咳嗽停用，现用心痛定用心痛定1 1片，片

37、，bidbid，麝香保心丸，麝香保心丸5 5粒，粒，tidtid。为进一步。为进一步诊治就诊，门诊以高血压收住。患病以来，食欲减退，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。睡眠尚可，尿少，大便正常。n既往史既往史(past history,PH)(past history,PH)：父患高血压父患高血压5656岁脑卒中去岁脑卒中去世，患者排尿时间延长，诊为前列腺增生。世，患者排尿时间延长，诊为前列腺增生。nRespiratory system（呼吸系统）无胸痛、咳嗽、（呼吸系统）无胸痛、咳嗽、咳痰、咯血及发热等。咳痰、咯血及发热等。nCardiovascular system（心血管系统）祥见病历。（心血管系统）祥见病历。nDige