diagnosis七年制中英文技术报告.doc

What is diagnosis? 什么叫诊断？ Diagnosis is investigation and judgment. 诊断就是诊察和判断Investigation is data collecting. 诊察是收集疾病信息Judgment is synthesis and analyze data to determine the nature of illness. 判断是综合分析信息 确定所患疾病The diagnosis is taking about the method of data collecting and how to make a correct judgment. 诊断学讲述收集信息和正确判断疾病的方法 Steps of Diagnosis诊断步骤Data collecting history intervewing physical examination laboratory examination assistant examinationData analyzingDetermination of the nature of the illness 收集信息资料 采集病史 体格检查 实验室检查 辅助检查推理分析判断确定所患疾病 Classification of Clinical Diagnosis临床诊断的分类Etiologic diagnosis Virus hepatitis Rheumatic heart disease Pathological-anatomic diagnosis Aortic regurgitation Liver cirrhosisPathophysiologic diagnosis Shock Uremia 病因诊断 病毒性肝炎 风湿性心脏病 病理解剖诊断 主动脉瓣 关闭不全 肝硬化 病理生理诊断 休克 尿毒症 Inquiry问诊Inquiry is one method from the interview between doctor and patient or relative for disease history, and making the clinical determination by analyzing history. 通过对患者或相关人员的询问获取病史资料 经过综合分析作出临床判断 Contents of Questioning 问诊的内容Identifying informationSource and reliabilityChief complaintsPresent illnessPast medical historyPersonal historyMarital history Menstrual and obstetric history in womenFamily history 患者个人信息叙述者和可信度主诉现病史既往史个人史婚姻史月经生育史家族史 Identifying Information 患者个人信息NameSex and AgeNative placeBirth placeNationalityMarriageAddress Work placeOccupation 姓名性别和年龄籍贯出生地国籍或民族婚姻住址工作地点职业Others Information其他相关信息 Chief Complaint主诉 Main discomfort and its duration Make sure to be: concise sequential persisting headache for 3 days Make sure to avoid using: onset time of the disease diagnostic terms dialects 主要痛苦+经过时间 书写注意 要简明扼要 要按时间先后顺序 持续头痛3天 三不要 不要用起病时间 不要用诊断术语 不要用方言土语 Present Illness现病史 Further description of the main complaint, including the whole disease processOnset and duration and Predisposin