儿科病史采集和体格检查.ppt

儿科病史采集和体格检查History-taking and Physical Examination for Children
主要内容
小儿病史特点及问诊技巧
History-taking: skills and approaches
小儿体格检查顺序及技术
PE: sequence and skills
小儿体格检查项目及要点
PE: major items and key points
临床医师(儿科医师)的主要任务:
(Primary Aims are to establish)
患儿到底存在什么问题?(诊断)
(What is wrong with the child?).
存在的问题对患者有什么影响? (诊断)
(How these problems impact on the patient’s life, medically, psychologically and socially, ect.)
如何解决存在的问题?(治疗)
( How to solve the problems?)
为此目的,下一步该作什么?
Then, what should we DO next?
首先,必须收集资料或信息
(Firstly, Information Gathering)
详尽的病史采集
(Detailed History–Taking)
仔细的体格检查
(Meticulous Physical Exam)
相关的实验室检查
(Appropriate Lab Investigations)
然后,完成“最初的医学记录”
(Formulating an Initial Medical Record)
详尽的病史采集和体格检查
诊疗计划(investigation and treatment plan)
并非“静止”(static) ,而为“动态”(dynamic)的过程,诊疗过程中收集的新信息应随时加入。
Problem-Oriented Medical Record
POMR: Lawrence Weed(1969)
Standardized and structured approach to clinical record-keeping.
Initial database for diagnosis and differential diagnosis
Essential to multidisciplinary team work
Prime resource for medical audit and possible medicolegal suit
In case of judicial examination, your professional credibility relies SOLELY on the medical record, not on your memory or any other things.
因此,收集的资料是否充分和准确对于诊断和治疗极为重要。
The ACCURACY and ADEQUACY of information gathered is of pivotal importance for the precision of diagnosis and treatment
成人病史采集和体格检查History-Taking and Physical Examination in Adults
病史采集(History-taking)
一般介绍(Introduction)
一般资料(General Data)
主述(plaint)
现病史(History of Present Illness)
过去史(Past History)
系统回顾(Systems Review)
个人史(Personal History)
婚姻史(Marital History)
家族史(Family History)