儿科病史采集和体格检查.pptxVIP

儿科病史采集和体格检查

History-takingandPhysicalExaminationforChildrenGaoJu,MD,PhDProfessorofPediatricsDepartmentofPediatricsWestChinaSecondUniversityHospitalSichuanUniversity儿病史特点及问诊技巧小儿体格检查顺序及技术小儿体格检查项目及要点History-taking:skillsandapproachesPE:sequenceandskillsPE:majoritemsandkeypoints0506主要内容

临床医师(儿科医师）的主要任务：临床医师(儿科医师）的主要任务：(PrimaryAimsaretoestablish)患儿到底存在什么问题？(诊断）（Whatiswrongwiththechild?).存在的问题对患者有什么影响？(诊断）(Howtheseproblemsimpactonthepatient’slife,medically,psychologicallyandsocially,ect.)如何解决存在的问题？（治疗）(Howtosolvetheproblems?)

为此目的，下一步该作什么？Then,whatshouldweDOnext?

(Firstly,InformationGathering)仔细的体格检查（MeticulousPhysicalExam）详尽的病史采集（DetailedHistory–Taking）相关的实验室检查（AppropriateLabInvestigations）首先，必须收集资料或信息

然后，完成“最初的医学记录”（FormulatinganInitialMedicalRecord）详尽的病史采集和体格检查诊疗计划(investigationandtreatmentplan)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-OrientedMedicalRecordPOMR:LawrenceWeed(1969)Standardizedandstructuredapproachtoclinicalrecord-keeping.InitialdatabasefordiagnosisanddifferentialdiagnosisEssentialtomultidisciplinaryteamworkPrimeresourceformedicalauditandpossiblemedicolegalsuit3214

Incaseofjudicialexamination,yourprofessionalcredibilityreliesSOLELYonthemedicalrecord,notonyourmemoryoranyotherthings.

TheACCURACYandADEQUACYofinformationgatheredisofpivotalimportancefortheprecisionofdiagnosisandtreatment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。010201

成人病史采集和体格检查

History-TakingandPhysicalExaminationinAdults病史采集(History-taking)一般介绍(Introduction)一般资料(GeneralData)主述(ChiefComplaint)现病史(HistoryofPresentIllness)过去史(PastHistory)系统回顾(SystemsReview)个人史(PersonalHistory)婚姻史(MaritalHistory)家族史(FamilyHistory)

体格检查(PhysicalExamination)望诊(Inspection)扪诊(Palpation)扣诊(Percussion)听诊(Auscultation)成人病史采集和体格检查

History-TakingandPhysicalExaminationinAdults0102

尽管儿科病史采集和体格检查的基本原则与成人相同，但是方式(Manner),顺序(Orde