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1、儿科病史采集和体格检查 History-taking and Physical Examination for Children,Gao Ju, MD, PhD Professor of Pediatrics Department of Pediatrics West China Second University Hospital Sichuan University,主要内容,小儿病史特点及问诊技巧 History-taking: skills and approaches 小儿体格检查顺序及技术 PE: sequence and skills 小儿体格检查项目及要点 PE: major
2、items and key points,临床医师(儿科医师）的主要任务： (Primary Aims are to establish) 患儿到底存在什么问题？(诊断） （What is wrong with the child?).存在的问题对患者有什么影响？ (诊断） (How these problems impact on the patients life, medically, psychologically and socially, ect.)如何解决存在的问题？（治疗） ( How to solve the problems?),为此目的，下一步该作什么？ Then, wh
3、at should we DO next?,首先，必须收集资料或信息(Firstly, Information Gathering)详尽的病史采集 （Detailed HistoryTaking）仔细的体格检查 （Meticulous Physical Exam）相关的实验室检查（Appropriate Lab Investigations）,然后，完成“最初的医学记录” （Formulating an Initial Medical Record）详尽的病史采集和体格检查 诊疗计划(investigation and treatment plan)并非“静止” (static) ，而为“动态
4、”(dynamic)的过程，诊疗过程中收集的新信息应随时加入。,Problem-Oriented Medical Record,POMR: Lawrence Weed(1969) Standardized and structured approach to clinical record-keeping. Initial database for diagnosis and differential diagnosis Essential to multidisciplinary team work Prime resource for medical audit and possible
5、medicolegal suit,In case of judicial examination, your professional credibility relies SOLELY on the medical record, not on your memory or any other things.,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。 The ACCURACY and ADEQUACY of information gathered is of pivotal importance for the precision of diagnosis and treat
6、ment,成人病史采集和体格检查 History-Taking and Physical Examination in Adults,病史采集 (History-taking) 一般介绍 (Introduction) 一般资料 (General Data) 主述(Chief Complaint) 现病史 (History of Present Illness) 过去史 (Past History) 系统回顾 (Systems Review) 个人史 (Personal History) 婚姻史 (Marital History) 家族史 (Family History),体格检查 (Physi
7、cal Examination) 望诊 (Inspection) 扪诊 (Palpation) 扣诊 (Percussion) 听诊 (Auscultation),成人病史采集和体格检查 History-Taking and Physical Examination in Adults,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( Order)和重点(Emphasis)有所不同。,Children are NOT just small adults their needs are DIFFERENT and have to be recognized(Pr
8、of. James Spence, 1943),目的和要求 Course Objectives,了解病史采集对儿童疾病诊断的重要性。熟悉儿童与成人病史采用的主要差别。掌握儿童病史采用和体格检查的要点。,儿科病史采集 History-Taking in Children,很多情况下，可仅通过病史采集明确诊断。 病史采集不准确和完整是误诊(misdiagnosis)和延误诊断(delayed diagnosis)的重要原因。 如何进行病史采集决定了所收集信息的质和量(quality and quantity)。,病史采集的重要性,The history is the most important
9、part of the patients assessment as it provides 80% of the information required for a diagnosis.,初学者面临的挑战 Apprentice: Challenges,不知如何接触患儿及其家长（How to approach the patient or parents） 不知从何开始病史采集（How to get started） 不知问些什么问题（What kind of questions to ask） 不能抓住主要问题（How to focus on the primary problem）,初学
10、者面临的挑战 Apprentice: Challenges,不知如何结束病史采集(How to conclude)。 病史采集后不能形成一个完整的印象或初步诊断(whole story)。 They are uncomfortable, unconfident, shy and frustrated. They are just “passive” listener.,如何成为一个合格的病史采集者？ How to become a COMPETENT history taker？,Genuine children “lover” Keen and watchful observer Enthu
11、siastic and active listener Good thinker and judger Be aware of the special aspects of history taking for children Intensive training and practice to be a master,病史采集的基本内容,自我介绍 SELF-INTRODUCTION,(1). Who are you and what are you going to do?,Tell patient, parents or guardian your identity and respon
12、sibility. PCP (primary care physician) Diagnosis maker Treatment plan maker and implementer Progress follower Prognosis predictorTake full responsibility for diagnosis and management-challenging!,Tell patient, parents or guardian your identity and responsibility. Intern (apprentice) History elicitor
13、 (collector) and PE performer. Recorder Progress followerAlthough a learner, but plays very ACTIVE role in the whole process-challenging and rewarding!,(2). Brief Chat at the Beginning,Get to know the patient (parents) Their background (education, occupation and even personality) Helps to:Set up an
14、easy-going atmosphere Set up physician-patient (parent) rapportGain trust: confident in your diagnostic abilityDecide the approach to them (language and manner)Appease crying children and make them easy.,Atmosphere and Setting,Easy-going Give patient (parent) full freedom to describe his/her problem
15、s and express his/her fears and concerns. Show your full attention and sympathy. Let them know that the information they provide would be kept confidential.,Harmonious Physician-Patient Relationship: Rapport,Show your respect, sympathy and concern. Be an attentive and patient listener. Be polite, wa
16、rm, considerate and well-mannered and well-dressed. Skillful communicator.,First impression you give to patient (parents) really matters. Appear friendly, but professionally. Patients must have confidence in your ability to act on their behalf, and therefore be willing to provide you detailed information.,家长的信任和好感是医师获得准确病史的先决条件。除了举止友善、态度温和以外，夸奖孩子往往是拉近距离的最好途径。,一般资料 GENERAL DATA,姓名（Name） 年龄（Age） 性别（Gender） 出生地点（Place of inhabitancy） 民族（Race） 病史提供者（Informant, relationship to patient and history reliability） 通讯地址（Correspondence）,
