儿科病史采集和体格检查

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1、儿科病史采集和体格检查History-takingandPhysicalExaminationforChildrenGaoJu,MD,PhDProfessorofPediatricsDepartmentofPediatricsWestChinaSecondUniversityHospitalSichuanUniversity主要内容小儿病史特点及问诊技巧History-taking:skillsandapproaches小儿体格检查顺序及技术PE:sequenceandskills小儿体格检查项目及要点PE:majoritemsandkeypoints临床医师(儿科医师）的主要任务：(Prim

2、aryAimsaretoestablish)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?首先，必须收集资料或信息(Firstly,InformationGathering)详尽的病史采集（DetailedH

3、istory–Taking）仔细的体格检查（MeticulousPhysicalExam）相关的实验室检查（AppropriateLabInvestigations）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)Standardizedandstr

4、ucturedapproachtoclinicalrecord-keeping.InitialdatabasefordiagnosisanddifferentialdiagnosisEssentialtomultidisciplinaryteamworkPrimeresourceformedicalauditandpossiblemedicolegalsuitIncaseofjudicialexamination,yourprofessionalcredibilityreliesSOLELYonthemedicalrecord,notonyourmemoryoranyotherthings.因

5、此，收集的资料是否充分和准确对于诊断和治疗极为重要。TheACCURACYandADEQUACYofinformationgatheredisofpivotalimportancefortheprecisionofdiagnosisandtreatment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)

6、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-TakingandPhysicalExaminationinAdults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。ChildrenareNOTjustsmall

7、adults–theirneedsareDIFFERENTandhavetoberecognized(Prof.JamesSpence,1943)目的和要求CourseObjectives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-TakinginChildren很多情况下，可仅通过病史采集明确诊断。病史采集不