DIAGNOSIS
CASE HISTORY AND INQUIRY
WU SHUMING MD
Importance of Inquiry
Gaining clinical information and collecting case history based on systemic inquiry
Base of clinical practice
60~80% diagnosis could be induced from interview between patient and physician
New form:consultation by phone, in
essful treatment is reinforced by a confidently established and maintained doctor-patient relationship
benefits to patient`pliance
benefits to improve doctor`s clinical skill and confidence
世界医学教育联合组织 爱丁堡宣言(1988)
每个病人都有权利希望医生被训练成为注意力集中的倾听者、仔细的观察者、感情细腻的交谈者和高效的临床医生。
OBJECTIVE OF INQUIRY
The medical interview serves three functions:
to collect information,
to respond to the patient's emotional state,
to educate the patient and influence patient behavior.
发热
头痛
关节痛
咽喉痛
皮疹
腰背痛
咳嗽
小便
腹痛
热辐射
气急
咳痰
前倾
恶心
呕吐
眩晕
意识
病毒
感染
发疹性
疾病
尿感
肾盂
肾炎
中暑
急腹疹
肺炎支
气管炎
关节痛
病毒
感染
脑膜炎
脑炎
腹泻
胃肠炎
wsm:
腹痛
类似
发作
腹泻
腰背部
放射痛
右季肋
部痛
烧灼痛伴
皮肤压痛
暴饮
暴食
疼痛
呕吐
发热
腹痛
腹块
胃肠炎
IBS
发热
胆石症
带状泡疹
皮肤过敏
胰腺炎
胃炎
肠梗阻
阑尾炎
穿孔
胆石症
肾盂
肾炎
尿石症
GERD
PU
FD
IBD
胆囊炎
CONTENTS
General item
plain
Present his.:onset of illness,characteristic of main symptoms, etc
Past his.
Systemic review
Individual life
Marriage status
月经史生育史
家属史
METHODS &SKILL
Skill munication
Suitable environment
Greeting patient
Active listener
Language & term
Non-munication
Ending talk
respect
Skill of collection
Emphasis plain
Opening & closing questioning
Simple plicate
Avoiding med. term
Avoiding irritable term
Skillful induce sensitive topic
Kind & careful
Guiding Principles
Ethical principles that guide the essful approach to diagnosis and treatment are honesty, beneficence, justice, avoidance of conflict of interest, and the pledge to do no harm. Increasingly, Western medicine involves patients in important decisions about medical care, including how far to proceed with treatment of patients with terminal illnesses
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