DIAGNOSIS CASE HISTORY AND INQUIRY WU SHUMING MD
DIAGNOSIS CASE HISTORY AND INQUIRY WU SHUMING MD
Importance of Inquiry x Gaining clinical information and collecting case history based on systemic inquiry x Base of clinical practice xK60-80% diagnosis could be induced from interview between patient and physician x New form: consultation by phone, in internet
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 internet
Successful treatment is reinforced by a confidently established and maintained doctor-patient relationship s benefits to patients compliance x benefits to improve doctor s clinical skill and confidence
Successful treatment is reinforced by a confidently established and maintained doctor-patient relationship benefits to patient`s compliance 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
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 x to collect information x to respond to the patient's emotional state x to educate the patient and influence patient ehavior
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
热 咽喉痛 咳嗽]口皮疹p医节瘫头腰背痛小便腹痛郾辐射 几 几 气急发疹性病毒「前倾 尿感 咳痰疾病感染恶心 肾盂 急腹疹中暑 呕吐 肾炎 眩晕 意 肺炎支 气管关节痛 /脑膜炎)(腹泻 脑炎 病毒 感染 胃肠炎
发 热 关节痛 头痛 咽喉痛 咳嗽 皮疹 腰背痛 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 急腹疹 中暑 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 发作网疼痛叫腹泻腰背部右季肋烧灼痛伴暴饮 类似 放射痛部痛皮肤压痛暴食 /ERD吐周肠炎发热胆石状泡疹胰腺炎 PU发热IBS FD|腹痛 皮肤过敏胃炎 胆囊炎/腹坡 肾炎尿石症 肠梗阻 阑尾炎 穿孔
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 单一-4---4--4--单一-------1-- 煤 General item 煤 Past his 兴 Chief complain 紫 Systemic review 兴 Present his.: onset of※ Individual life illness, characteristic of x Marriage status main symptoms, etc月经史生育史 家属史
CONTENTS General item Chief complain 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 of communication Skill of collection x Suitable environment x Emphasis chief complain 紫 Greeting patient 紫 Opening& closing questioning 煤 Active listener 紫 Simple to complicate 戏 Language&term 紫 Avoiding med,term ※Non- language xk Avoiding irritable term communication xK Skillful induce sensitive Ending talk topic xK respect 煤Kind& careful
METHODS &SKILL Skill of communication Suitable environment Greeting patient Active listener Language & term Non-language communication Ending talk respect Skill of collection Emphasis chief complain Opening & closing questioning Simple to complicate Avoiding med. term Avoiding irritable term Skillful induce sensitive topic Kind & careful
Guiding principles x Ethical principles that guide the successful 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
Guiding Principles Ethical principles that guide the successful 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