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1、,Diagnostics 2nd Affiliated Hospital China Medical University 内科 郑长青,What is Diagnostics? Diagnostics is a bridge subject, this subject is in a position between preclinical medicine and clinical medicine.,The contents of diagnostics include symptomatology inquiry physical examination laboratory elec
2、trocardiogram ultrasonic,Inquiry history taking by questioning to take a history The importance of inquiry for example: peptic ulcer gastric ulcer duodenal ulcer,Peptic ulcer has three clinical characteristics chronicity several years periodicity special seasons late autumn early spring rhythmicity
3、of epigastric pain pain meal relief duodenal ulcer meal pain relief gastric ulcer,The contents of inquiry 1 general data 2 chief complaints 3 present illness 4 past medical history 5 systems review 6 personal history 7 marital history 8 menstrual history 9 childbearing history 10 family history,1 Ge
4、neral Data Name Native place Sex Working unit Age Date of admission Race Date of record Occupation Narrator Marriage Reliability Address,2 Chief Complaints The chief complaints should constitute in a few simple words: symptom(s) plus time. The main reasons why the patient consults a doctor. The chie
5、f complaints should be stated as nearly as possible in the patients own words.,For example: sore throat, high fever for two days chill, fever, right chest pain, cough for three days recurrent epigastric pain for eight years, it has been getting worse over the past two weeks.,The chief complaint shou
6、ld not include diagnostic terms or disease entities such as: diabetes heart disease hypertension,Diabetes: polydipsia polyphagia polyuria weight loss Heart disease: palpitation short of breath Hypertension: dizziness headache,3 History of Present Illness (1) Onset and Duration (2) Features of chief
7、symptoms (3) Causes of illness and Precipitating factors (4) Progression of the illness (5) Accompanied symptoms (6) Previous treatment (7) General condition,Onset and Duration sudden: acute myocardial infarction acute pancreatitis insidious: cancer of the colon,Duration minutes hours days months ye
8、ars for example: Severe precardiac pain for twenty minutes -acute myocardial infarction,(2) Features of Chief Symptoms for example: pain location frequency duration intensity quality (blunt colic distention burning ) radiation alleviating and aggravating factors.,(3) Causes of Illness and Precipitat
9、ing Factors causes: infection trauma precipitating factors: climate change environmental change emotive change irregular meals,(4) Progression of the Illness the development of main symptom and appearance of new symptoms. pulmonary emphysema(short of breath) severe dyspnea pneumothorax angina pector
10、is (severe chest pain) myocardial infarction,(5) Accompanied Symptoms for example: diarrhea accompanied by vomiting food poisoning diarrhea accompanied by tenesmus dysentery,(6) Previous Treatment medication dosage effects (7) General Conditions mental state after illness appetite body weight sleepi
11、ng urine bowel movement,4 Past Medical History past health status past illness mainly indicate infections contagious diseases such as Tuberculosis(TB) Hepatitis,any illness relevant to present illness, such asoperations injuries vaccinations allergies,5 Systems Review (1) respiratory system (2) card
12、iovascullar system (3) gastrointestinal system (4) urinary systems (5) hematopoietic system (6) endocrine system (7) neurological system (8) musculoskeletal system,(1) Respiratory System cough character of the cough dry cough pleurisy bronchial TB productive cough chronic bronchitis bronchiectasis,t
13、ime of cough morning and going to bed at night: chronic bronchitis at night: pulmonary congestion due to left heart failure or mitral stenosis,Sputum: amount consistency color hemoptysis: amount color dyspnea: nature intensity onset of time chest pain location nature intensity duration ,(2) Cardiovascullar System palpitation: time the pain of precordial region feature extent radiation precipitating factors edema: location lower extremities congestive heart failure breath lessness: on exertion heart failure,
