临床诊断学学习手册.doc

一般醫學訓練 臨床診斷學 學習手冊 長庚紀念醫院林口總院內科部 編印 長 庚 大 學 醫學系 中華民國 一○三年一月臨床診斷學學習手冊 前言: 教學門診及病房實習須知 ------------------------------------- ------3 如何維持優質的醫病關係 ------------------------------------------ 5 實習醫學生臨床實習指引 ------------------------------------------11 Part I 病史探問 History Taking ------------------------------------------ 15 Part II 教學門診規範 ------------------------------------------------------- 20 問診LQQOPERA概念之實際應用 --------------------- 24 Part II 身體診察 Physical Examination -------------------------------- 26 General Appearance, Vital Signs, HEENT Neck Exam Chest and Thorax Exam Cardiac and Peripheral Vascular Exam Abdominal Exam Screening Neurological Exam 婦產科身體診察 婦產科病史詢問 婦產科骨盆腔身體診察 婦產科骨盆腔身體診察自我檢測要點 耳鼻喉科身體診察 眼科身體診察 Part III身體診察自我檢測要點 Physical Examination checklist----62 1. Checklist of Cardiovascular Physical Examination 2. Checklist of Chest Physical Examination 3. Checklist of Gastrointestinal Physical Examination 4. Checklist of Nephrology Physical Examination 5. Checklist of Hema-oncology Physical Examination Checklist of Rheumatology Physical Examination Checklist of Metabolism/Endocrinology Physical Examination Checklist of Throid Physical Examination Checklist of Acromegaly Examination Checklist of Neurologic Examination Checklist of Dermatology Examination Checklist of Eye Examination Checklist of Urological Examination Checklist of Gynecology Examination Checklist of Otolaryngology-Head and Neck Examination Part IV 住院病歷書寫參考範本 -----------------------------------------79 Admission Note書寫範本 -------------------------------------- 86 Part V 口述病例報告注意事項 ----------------------------------------- 90 病例報告 Case presentation ----------------------------------- 92 Evidence-based Medicine by Sackett DL New case presentation presentation of an “old” case for “follow-up” rounds Part VI 內科常見疾病之診斷書寫記錄範本 ------------------------ 95 Part VII 醫學訓練六大核心能力與健康照護矩陣 ------------------ 99 Part VIII 用藥安全 ------------------------------------------------------- 102 Part IX