physical diagnostics

诊断方法与病历书写
Diagnosing Method and Case Writing

diagnosing technique
诊断方法
 case records writing

病历书写
Diagnosing Technique

诊断方法

 steps of diagnosing
诊断步骤
 principle and foundation of diagnosin

g
诊断的原则和基础
 method and content of diagnosing

诊断的方法和内容
Three Steps of Diagnosing
诊断步骤三步曲
 Investigation and collecting data through inquire history,
physical and assistant examination
调查研究 收集资料 询问病史 体格检查 辅助检
查
 Bring forward diagnosis through analysis and integration
using learnt knowledge and clinical experience
分析综合 提出诊断 用所学知识临床经验推理判断
 Establishing diagnosis through clinical practice, emending
and perfecting based on diagnosis and treat complexion
临床实践 确立诊断 根据诊疗情况修订和完善诊断
 Case Report
病例
25 years male.
男性 25 岁
Suddenly high fever with chill, cou
gh, sputum and chest pain afte 受凉后突发寒战高热
r catching cold. 伴咳嗽 咳痰 胸痛
find tactile fremitus increased, per 查体右上肺
cussion dullness, tubular breath 触觉语颤增强
sound and moist rales heard in 叩诊呈浊音
check up right upper lung. 可闻及管状呼吸音 湿啰
Find WBC count and neutral granul 音
ocyte ratio increased in blood r 血化验 白细胞数增高常规
outine test
中性粒细胞比值增高
Attentive Problem in Collect Data
收集资料时注意的问题
 Authentic: inquire and examine carefully, analyse in imper
sonal, judgement in preciseness.
真实性 : 仔细问诊 细致体检
客观唯物的分析 正确科学判断
 Systemic: data sequence and relation accord with arises a
nd developing course of disease, tidy up data systematize
d to form primary diagnosis.
系统性 : 资料顺序及其内在联系符合疾病发生发展过程
对资料整理使之系统化归纳综合形成初
步诊断
 General: illness history, order examination and data range
to avoid important tache missed.
全面性 : 病史 体检顺序 检查资料排列
避免重要环节的遗漏
Attentive Problem in Analyse and Judgement
分析判断时注意的问题 (1)
 Pay attention to the main symptom and clinical phen
omenon.
抓主要矛盾 病人主要痛苦和突出临床表现
 Pay attention to the difference meaning of symptom i
n patient because he’s or her’s dissimilar feeling, diff
erent exhibition in one disease and same exhibition i
n different disease.
矛盾的普遍性与特殊性
病人的主观感受 共性与个性不同的
一个疾病有各种表现 不同疾病可有相同表现
 Attentive Problem in Analyse and Judgement

分析判断时注意的问题 (2)
 Thinking the relationship of internal pathology from phenome
non such as symptom, sign and test examination, and patholo
gic change formed through reciprocity between body and injur
y factors.
透过现象看本质 疾病症状体征化验检查改变有内在联系
人体与致病因素相互作用形成病理改变
 It is an effective method of diagnosing disease that speculate
pathologic course through clinical phenomenon.
通过临床表现推测病理过程是诊断疾病的有效方法
 Relationship of influence between local and general disorders
局部与整体
局部病变影响全身 全身病变又会在某一局部表现出来
Attentive Problem in establishing diagnosis
确立诊断时应注意的问题
 Principle of diagnosis
诊断的原则
 Foundation of diagnosis
诊断的基础
 Course of diagnosis
诊断的过程
 Method of diagnosis
诊断的方法
 Content of diagnosis
诊断的内容
Principle of Diagnosis
诊断的原则
 Principle of monism “ 一元论”原则
 Principle of higher incidence of disease in the first consid
ering place
发病率高的疾病首先考虑的原则
 Principle of organic disease in the first considering place
器质性疾病首先考虑的原则
 Principle of cured disease in the first considering place
可治性疾病首先考虑的原则
 Principle of being practical and realistic
实事求是的原则
 Principle of predigesting thinking process
简化思维程序的原则
Foundation of Diagnosis
诊断的基础
 Being good at finding key of disorders such as abnormal
symptom, sign and test examination.
善于发现疾病的征象 症状 体征 化验检查的异常
 Being good at considering diversified diseases of charact
eristics in clinical expression manifestation.
善于认识疾病 各种疾病临床表现的特点
 Accumulating experience ceaselessly and coming into bei
ng habit of occupation.
不断积累经验 培养形成职业习惯
 Course of Diagnosis
诊断的过程
when having possibility of s
 See a doctor 因症就诊 everal diseases, arrange it in fi
inquiry history le of probability.
问病史 症状及诊疗经过 有几种疾病可能时
check-up 按可能性大小依次排列概
率
体格检查 发现阳性体征
lab and assistant examination
 Trial therapy and supplied exa
mine
化验检查 发现体内变化
试验治疗及补充检查
 Primary diagnosis 初步诊断
observe curative effect an
put forward possible diagnosis
d supplied examine result
提出可能的诊断
观察疗效及补充检查结果
 Finally establish diagnosis
最后确立诊断
Method of Diagnosis
诊断的方法

 The method of eliminating 排除法

arrange all possible diseases and eliminate o
ne by one
排列出可能的疾病逐一加以排除
 The method of tracing 追踪法
get hold of important clue to investigate and
fulfill deeply
抓住重要线索深入查证落实
Content of Diagnosis
诊断的内容 (1)

Whole diagnosis in one disease including

一个疾病完整的诊断应尽可能包括
 Etiologic diagnosis
病因诊断
 Pathological-anatomic diagnosis
病理解剖诊断
 Pathophysiologic diagnosis
病理生理诊断
Content of Diagnosis
诊断的内容 (2)

The order arrangement in a few of diseases

几种疾病并存时次序的排列
 Main disease
主要疾病
 Complicating disease
并发病
 Accompanied disease
伴发病
Give an Example of Diagnosis
诊断举例 (1)
 Rheumatic heart disease
风湿性心脏病
aortic insufficiency
主动脉瓣关闭不全
the third degree of cardiac function
心功能 III 级
 Subacute infectious endocarditis
亚急性感染性心内膜炎
 Ringworm in foot
足癣
 Ascariasis in intestines
肠道蛔虫病
Give an Example of Diagnosis
诊断举例 (2)
 Portal cirrhosis
门脉性肝硬化
liver function in decompensation
肝功能失代偿期
 Spontaneous peritonitis
自发性腹膜炎
 Chronic bronchitis
慢性支气管炎
 Decayed tooth
龋齿
Medical History Writing
病历书写

 kind type of case histor

y
病历的种类
 content of case records

病历内容
 caution of writing

书写注意事项
Kind type of Case Records
病历的种类
 Out-patient case records: include first visit and further consu
ltation with a doctor
门诊病历 : 初诊病历 复诊病历
 In-patient case records: first and again case records
住院病历 : 首次住院病历 再次住院病历
in again case records can leave out past history etc whe
n same disease and record last time disease on past history
when differing disorders
同一个病省略既往史等 不同病将上次疾病记入既往史
 Table case records: only in special disease or office departm
ent
表格病历 单一病种或特殊科室
Content of In-patient Records
住院病历内容
 Medical history
病历
 Course of diseases records: first, daily and special r
ecords
病程记录 : 首次 日常和特殊记录
 Doctor’s advice paper
医嘱单
 Lab and examination reports
化验检查报告单
 Temperature paper
体温单
 Case Record of Admission
入院病历
 History: including chief complain, present illness, past history, perso
nal history, marital history, menstruation and childbearing history a
nd family history.
病史 : 主诉 现病史 既往史 个人史 婚姻史 月经生育史 家族
史
 Physical examination: including vital signs, general appearance, hea
d, neck, chest, abdomen, spinal, extremities, nervous system exami
nation.
体格检查 : 生命体征 一般情况 头颈 胸腹 脊柱四肢 神经系统
 Laboratory and instrument findings
实验室及器械检查
 Primary diagnosis 初步诊断
 Recorder signature 医师签名
Course of diseases in First Record
首次病程记录
 History abstract: chief complain and main symptom, sign or la
b examination result.
病历摘要 : 主诉及最主要的症状 体征和实验室检查结果
 Primary diagnosis, evidence and distinguishing diagnosis: anal
yse information primarily and write out possible diagnosis, ev
idence, other disease requiring distinguished, including suppo
rt and nonsupport point.
初步诊断 诊断依据及鉴别诊断 : 对资料进行初步分析
写出可能的诊断及诊断依据和需要鉴别的疾病
包括支持点和不支持点
 Diagnosing plan and therapy step
诊断计划和治疗措施
 Course of diseases in Daily
日常病程记录
 State variation of illness
病情变化
 Idea of superior senior physician in diagnosis and t
herapy
上级医师查房意见
 Consultation idea
会诊意见
 Records of diagnosis and treatment or operation
诊疗操作记录
 Alteration condition of diagnosis and treatment
诊断治疗的变更情况
Special Records
特殊记录
 handing over records
交班或接班记录
 Change section office records
转科 ( 转入或转出 ) 记录
 Leave hospital or death records: admission condition
and primary diagnosis, check-up and treat course in
hospital, present condition and final diagnosis, next t
reatment or salve course and death diagnosis.
出院或死亡记录 : 入院时情况及诊断
住院诊疗经过 目前情况及诊断
下一步诊疗措施 或抢救经过和死亡诊断
Advice, Test Report and Temperature Chart
医嘱 化验报告和体温单
 Doctor’s advice paper: persistent and temporary
医嘱单 : 长期医嘱 临时医嘱
 Test paper and examining report paper: test paper
of blood, urine, feces and body fluid test; report p
aper of pathology and instrument examination.
化验检查报告单 :
血尿粪和体液化验单
病理及器械检查报告单
 Body temperature paper: record body temperature
, pulse, respiratory rate, blood pressure or number
s of emiction and defecate.
体温单 : 体温 脉搏 呼吸 血压 大小排尿排便
Importance and Attentive Proceeding
病历书写的重要性和注意事项
 Case history is the medical and legal document, also
science datum.
病历是医疗文件 法律文件 科学资料
 Notice in writing: according to ordained content and f
ormat, words in focus and no altering, using medical
term, obvious emphases, consecution clarity and sent
ence smooth.
书写注意事项 : 按规定内容和格式
字迹规整不得随意涂改
用医学术语
重点突出 条理清楚 语句通顺畅
Word in End
结束语
 Diagnostics is a subject of very doughty practice.
诊断学是一门实践性很强的学科
 It is the basic skill with clinical physician in inquire history an
d physical examination.
询问病史和体格检查是临床医师的基本功
 Symptoms and signs are the keys of diagnosis.
症状和体征是诊断疾病的线索
 The core of diagnosing is analyse, illation and think.
分析推理思考是诊断疾病的核心
 Correct diagnosis is premise of cured disease.
正确的诊断是治愈疾病的前提
 Improving capacity of diagnosis must get through iterative st
udy and practice.
反复的学习和实践才能不断提高疾病的诊断水平
祝同学们取得好成绩

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