1、診斷疾病的步驟和臨床思維方法 Fundamental theory 基礎理論/知識 Techniques of diagnosing disease 診斷疾病的技術 Mode of clinical thinking 臨床思維的方式What is Clinical Diagnostics? Instruct a concise logical approach to recognize the genius of the diseases 教會一種簡明而又合乎邏輯的步驟去識別疾 病的本質 A fundamental course of clinical medicine 臨床醫學的基本課程Wh

2、at is Clinical Diagnostics?Fundamental elements of DiagnosticsDiagnosis Identification Analysis Diagnosis（診斷） Derived from Greek words distinguish or discern識別/鑒別 認識 English term DiagnosticThe distinguishing sign and symptoms with which it gerenally begins, continues and goes offas it were, a histor

3、y of the disease對疾病特征的識別及對疾病的診斷 In 18th century: Nosography（病情學） 通過疾病的表現來識別疾病內在本質或屬性 In modern usage: Identification of a disease by investigation of its signs and symptoms Medical terminology:Clinical diagnosis Laboratory diagnosisX-ray diagnosis Electrocardiographic diagnosisGene diagnosisIdentifi

4、cation: (識別識別)Inquiry Physical examination Laboratory tests/Special examination Analysis: (分析分析)Basic knowledge of medicineOverall analysisScientific way of clinical thinking Importance of DiagnosticsEssential (基礎）Bridge （橋梁）Tools （工具）Basic coursesClinical medicineContent of Clinical DiagnosticsSymp

5、tomatic diagnosis (癥狀診斷)Physical diagnosis (檢體診斷) Laboratory tests or clinical ancillary testsMedical recordDiagnostic processes and the way of clinical thinkingHistory taking（病史采集 )- Interview (問診）Symptoms (癥狀）- patients complaints (主訴)Symptomatic Diagnosis (癥狀診斷)Symptomatic DiagnosisSymptomatic Di

6、agnosisSubjective sensation that patient describesFever Cough Rash Mass Physiological & functional Pathological & morphological Symptom （癥狀）Physical DiagnosisAbnormality observed by the physicianSign （體征） Physical examination （體格檢查）Inspection (望）Palpation （觸）Percussion （叩）Auscultation （聽）Con

7、ducted with thoroughness, alertness to detect even slight derivations from normalLaboratory test or ancillary tests Serum, Urine, Stool tests X-ray film EKG Endoscopy Ultrasonic imaging CT MRI PET (Positron Emission Tomography)Medical recordMedical record is a systematized way of storing the require

8、d data, information and other relevant documentsSpecific requirement in terms of format and contentSpecial terms in clinical diagnosisImpression (初步印象）Tentative diagnosis （可能性診斷）Differential diagnosis （鑒別診斷）Evidence based medicine（循證醫學）Differential diagnosis Preliminary diagnosis/Tentative diagnosis

9、 初步診斷 可能性診斷 Exclusion of other diseases (排除其它疾病) Selecting a number of possibilities to explain the clinical and laboratory findings in the case in question The way of exclusion is called Differential diagnosisEvidence based medicineIt is the conscientious（謹慎的）, explicit （明確的）and judicious （有見解的）use

10、 of current best evidence in making decisions about the care of the individual patient It means integrating individual clinical expertise （臨床專長）with the best available external clinical evidence from systematic researchEvidence based medicineOne need to: Be conscientious: it requires effort and thou

11、ght. Be explicit: decisions will need to be backed up by good evidence Relate to specific problems: it is not about a hypothetical average case. Integrate individual clinical experience: it does not denigrate clinical skills in history taking, examination and diagnosis. Look for current best evidenc

12、e: the perfect study may not yet have been published, written up or even commenced. We may have to settle for something less rigorous, but be on the look out for new research that will supersede older studies. Important aspects-interrogation To get the history in detail of a patients illness The his

13、tory is taken at initial contact between physician and patient As some crucial points might be overlooked by the patients, one will ask many searching questions to make the history more informative and complete, who must at the same time avoid suggesting answers Occasionally to interrogate his famil

14、y memberOther important aspects The diagnostic process is very complex The number of facts that can be collected in a detailed medical history and in thorough physical examination are almost without limit The laboratory tests or specialized technical procedures that can employed are numerous and cos

15、tly Other important aspects Questions for interrogation, maneuver in P.E., laboratory test should be thoughtfully selected with the view to eliminate some of the possible diagnosis and guide the search expeditiously to a specific disease Method of approaching a diagnosis: Analysis of symptoms (癥狀分析)

16、 Recognition of the syndrome (綜合癥識別) Consideration of disease mechanisms (考慮疾病機制)Important aspects Modern & advanced ancillary techniques: have their limitations. It cant reduced the importance of certain parts of the classic P. E It should be avoided to neglect fundamental methodsInterrogationP

17、hysical examinationScientific clinical thinkingApproachesBasic knowledge learning（基礎知識的學習）Clinical practice （臨床實踐）Bedside activityStandardized patient床邊實踐標準化病人Developmental History of clinical diagnostics Western Medicine: from ancient to modern Traditional Chinese Medicine Contribution of ancient d

18、octors-WesternHippocrates Born on the island of Cos, Greece (c. 460-377 BC) The Father of medicine Hippocratic oath 希波克拉底宣言 Hippocratic corpus（文集）: a collection of 70 worksHippocratic oathContribution of ancient doctors-Western Galen His work in anatomy/physiology is notable Identified artery and ve

19、in Added greatly to knowledge of the brain, spinal cord and pulseContribution of ancient doctors-WesternAuenbrugger Born at the village of Graz, Austria (1722) Son of an innkeeper The working experiences helped him to find Percussion Author of (1761) translated as On Percussion of the chest in 1936Contribution of ancient doctors-WesternLae