ClinicalDiagnosticsCHINAMEDICALUNIVERSITYZHAOLIClinicalDiagnosticsCHINAMEDI1PhysicalDiagnosisToday’smedicalstudentsTomorrow’scliniciansPhysicalDiagnosisToday’smedi2PhysicalDiagnosisWhatisthemeaningof“Clinician〞?PhysicalDiagnosisWhatisthe3PhysicalDiagnosisWhatisthemainresponsibilityoftheclinician?MakingdiagnosisTreatadiseaseTreatapatientPhysicalDiagnosisWhatisthe4PhysicalDiagnosis

Alinkagebetweenbasicmedicalknowledgeandclinicalmedicine.Adisciplinetousebasicmedicaltheoryandskilltomakeadiagnosis.PhysicalDiagnosis

Alinkageb5ObtaininformationFromanyandeverysourcepossible.Straintohearthevoiceofthepatientinthethinreedofhiscrying.Seemostacutelyoutofthecornerofyoureye.Tohearbestwithyourinnerear.ObtaininformationFromanyand6Thecontentsofdiagnosis

VerbalobservationorhistorytakingPhysicalobservationorexaminationLaboratoryobservationThecontentsofdiagnosis

Verb7HistoryTakingObtainasmuchinformationasneededtodiagnoseandtreattheillness.Requirementsforthephysicians:Agenuine,profound,andabsorbinginterestinthepatient'swellbeingAdeep-seated,well-groundedselfconfidenceinabilitiesAthroughknowledgeofthediseasesAbilitytoseetheproblemfromthepatient'sviewpointHistoryTakingObtainasmuchi8HistoryTakingObtainingamedicalhistoryisan"art"Talkwith,rathertalktothepatient.Listenattentivelyandguideapatienteffectively.Asksearchingquestions.Interrogationoffamilyandfriendsifnecessary.HistoryTakingObtainingamedi9HistoryTakingKnowallaboutthediseaseSymptomsandsignsSymptoms:patient'scomplaints,orhisrecognitionofsomethingabnormal.Signs:findingselicitedbyphysicalexaminationPasthistoryFamilyhistorySystemsreviewHistoryTakingKnowallaboutt10PhysicalExamination

Beginswhengreetingthepatient.Sedulouslypracticingtheartofobservationmakeastudenttoaclinician.

PhysicalExamination

Beginswh11Howtoconductphysicalexamination

Applicationofthesensoryendorgantothepatient.Inarational,thorough,andaccuratefashion.Withefficiencyandminimaldiscomforttothepatient.5componentsofphysicalexamination:inspection,palpation,percussion,auscultationandsmelling.Howtoconductphysicalexamin12LaboratoryfindingsTodetectpathogenicorfunctioninginformation.Chemical,biologicalandphysiologicaltests.X-film,CT,MR.gastroscopy,angiographyandbronchoscopyetc.LaboratoryfindingsTodetectp13InterpretationoflaboratorydataLotsvariablesalterlaboratorytestsresults.Specificityandsensitivityofthetests.Overlappingbetweenthehealthyandthediseasedsubjects.Interpretationoflaboratoryd14TheIntellectualprocess

ofdiagnosisInformationrequiresclarification

andamplification.Informationmustbecarefullyweighedastoitsclinicalsignificanceanditspossiblerelationshiptothepatient'scomplaints6levelsofintellectualfunctioning：

knowledge,comprehension,application,

analysis,synthesis,andevaluationTheIntellectualprocess

ofd156levelsofintellectualfunctioningKnowledgeUneditedfactualinformationprovidedbythepatient.Maynotnecessarilybeaccurateorprecise.ComprehensionUnderstandingthefactsrelatedbythepatient.Affirmwhatthepatientsaid.ApplicationRecordingthefactsaccuratelyandinawell-organizedorder

6levelsofintellectualfunct166levelsofintellectualfunctioningAnalysisSortingoutorclassificationoftheobtaineddataintorelatedcategories.SynthesisReassemblethedataobtainedintopatternsofrecognizabledisease.EvaluationAskingquestionsthataredesignedtoeitherconfirmorexcludetentativediagnoses.Predictingthelikelyphysicalandlaboratoryfinding.6levelsofintellectualfunct17Theroleofhightechnology

Alwaysbeatool.Canneverreplacetheintellectualprocessofdiagnosis.Theroleofhightechnology

Al18TheroleofhightechnologyPatientisahumanbeing,notamachine!Physicianisamedicaldetective,notadetector!TheroleofhightechnologyPat19Conclusion

Communication，observationanddatarecordingarethekeydemandsinmedicine.Profoundknowledgeandsmartintellectualprocessofthinkingofmedicineisthekeyforsuccessofaclinician.Conclusion

Communication，obser20Onlyasacliniciandoes

onebecomeaclinicianOnlyasaclinician21WhatisClinicalDiagnostics?Fundamentaltheory

Techniquesofdiagnosingdisease

Modeofclinicalthinking

WhatisClinicalDiagnostics?22WhatisClinicalDiagnostics?InstructaconciselogicalapproachtorecognizethegeniusofthediseasesAfundamentalcourseofclinicalmedicineWhatisClinicalDiagnostics?23FundamentalelementsofDiagnosticsDiagnosisIdentificationAnalysisFundamentalelementsofDiagn24DiagnosisDerivedfromGreekwords

distinguishordiscern☆DiagnosisDerivedfromG25

Englishterm

DiagnosticThedistinguishingsignandsymptomswithwhichitgerenallybegins,continuesandgoesoff…asitwere,ahistoryofthedisease

In18thcentury:

Nosography☆☆Englishterm☆☆26Inmodernusage:IdentificationofadiseasebyinvestigationofitssignsandsymptomsMedicalterminology:ClinicaldiagnosisLaboratorydiagnosisX-raydiagnosisElectrocardiographicdiagnosisGenediagnosis☆☆I(lǐng)nmodernusage:☆☆27Identification:InquiryPhysicalexaminationLaboratorytests/SpecialexaminationAnalysis:BasicknowledgeofmedicineOverallanalysisScientificwayofclinicalthinking

Identification:Inquiry28ImportanceofDiagnosticsEssentialBridgeToolsBasiccoursesClinicalmedicineImportanceofDiagnosticsEssen29ContentofClinicalDiagnosticsSymptomaticdiagnosis(病癥診斷)Physicaldiagnosis(檢體診斷)LaboratorytestsorclinicalancillarytestsMedicalrecordDiagnosticprocessesandthewayofclinicalthinkingContentofClinicalDiagnostic30Historytaking〔病史采集)---Interview(問(wèn)診〕Symptoms(病癥〕---patient‘scomplaints(主訴)SymptomaticDiagnosis(病癥診斷)SymptomaticDiagnosisHistorytaking〔病史采集)---Inter31SymptomaticDiagnosisSubjectivesensationthatpatientdescribesFeverCoughRashMassPhysiological&functional

Pathological&morphological

Symptom〔病癥〕SymptomaticDiagnosisSubjectiv32PhysicalDiagnosisAbnormalityobservedbythephysicianSign〔體征〕Physicalexamination〔體格檢查〕Inspection(望〕Palpation〔觸〕Percussion〔叩〕Auscultation〔聽(tīng)〕Conductedwiththoroughness,alertnesstodetectevenslightderivationsfromnormalPhysicalDiagnosisAbnormality33LaboratorytestorancillarytestsSerum,Urine,StooltestsX-rayfilmEKGEndoscopyUltrasonicimagingCTMRIPET(PositronEmissionTomography)Laboratorytestorancillaryt34MedicalrecordMedicalrecordisasystematizedwayofstoringtherequireddata,informationandotherrelevantdocumentsSpecificrequirementintermsofformatandcontentMedicalrecordMedicalrecordi35SpecialtermsinclinicaldiagnosisImpression(初步印象〕Tentativediagnosis〔可能性診斷〕Differentialdiagnosis〔鑒別診斷〕Evidencebasedmedicine〔循證醫(yī)學(xué)〕Specialtermsinclinicaldiag36DifferentialdiagnosisPreliminarydiagnosis/Tentativediagnosis

初步診斷可能性診斷

Exclusionofotherdiseases(排除其它疾病)SelectinganumberofpossibilitiestoexplaintheclinicalandlaboratoryfindingsinthecaseinquestionThewayofexclusioniscalledDifferentialdiagnosisDifferentialdiagnosisPrelimi37EvidencebasedmedicineItistheconscientious〔慎重的〕,explicit〔明確的〕andjudicious〔有見(jiàn)解的〕useofcurrentbestevidenceinmakingdecisionsaboutthecareoftheindividualpatient

Itmeansintegratingindividualclinicalexpertise〔臨床專長(zhǎng)〕withthebestavailableexternalclinicalevidencefromsystematicresearchEvidencebasedmedicineItist38EvidencebasedmedicineOneneedto:Beconscientious:itrequireseffortandthought.Beexplicit:decisionswillneedtobebackedupbygoodevidenceRelatetospecificproblems:itisnotaboutahypothetical"average"case.Integrateindividualclinicalexperience:itdoesnotdenigrateclinicalskillsinhistorytaking,examinationanddiagnosis.Lookforcurrentbestevidence:theperfectstudymaynotyethavebeenpublished,writtenuporevencommenced.Wemayhavetosettleforsomethinglessrigorous,butbeonthelookoutfornewresearchthatwillsupersedeolderstudies.EvidencebasedmedicineOnenee39Importantaspects---interrogationTogetthehistoryindetailofapatient’sillnessThehistoryistakenatinitialcontactbetweenphysicianandpatientAssomecrucialpointsmightbeoverlookedbythepatients,onewillaskmanysearchingquestionstomakethehistorymoreinformativeandcomplete,whomustatthesametimeavoidsuggestinganswersOccasionallytointerrogatehisfamilymemberImportantaspects---interrogat40OtherimportantaspectsThediagnosticprocessisverycomplexThenumberoffactsthatcanbecollectedinadetailedmedicalhistoryandinthoroughphysicalexaminationarealmostwithoutlimitThelaboratorytestsorspecializedtechnicalproceduresthatcanemployedarenumerousandcostly

OtherimportantaspectsThedi41OtherimportantaspectsQuestionsforinterrogation,maneuverinP.E.,laboratorytestshouldbethoughtfullyselectedwiththeviewtoeliminatesomeofthepossiblediagnosisandguidethesearchexpeditiouslytoaspecificdiseaseMethodofapproachingadiagnosis:Analysisofsymptoms(病癥分析)Recognitionofthesyndrome(綜合癥識(shí)別)Considerationofdiseasemechanisms(考慮疾病機(jī)制)OtherimportantaspectsQuesti42ImportantaspectsModern&advancedancillarytechniques:havetheirlimitations.Itcan’treducedtheimportanceofcertainpartsoftheclassicP.EItshouldbeavoidedtoneglectfundamentalmethodsInterrogationPhysicalexaminationScientificclinicalthinkingImportantaspectsModern&adv43ApproachesBasicknowledgelearning〔根底知識(shí)的學(xué)習(xí)〕Clinicalpractice〔臨床實(shí)踐〕BedsideactivityStandardizedpatient床邊實(shí)踐標(biāo)準(zhǔn)化病人ApproachesBasicknowledgelear44DevelopmentalHistoryofclinicaldiagnosticsWesternMedicine:fromancienttomodernTraditionalChineseMedicineDevelopmentalHistoryofclini45Contributionofancientdoctors---WesternHippocratesBornontheislandofCos,Greece(c.460-377BC)TheFatherofmedicineHippocraticoath希波克拉底宣言Hippocraticcorpus〔文集〕:acollectionof70worksContributionofancientdoctor46HippocraticoathHippocraticoath47Contributionofancientdoctors---WesternGalenc.130-c.200Hisworkinanatomy/physiologyisnotableIdentifiedarteryandveinAddedgreatlytoknowledgeofthebrain,spinalcordandpulseContributionofancientdoctor48Contributionofancientdoctors---WesternAuenbruggerBornatthevillageofGraz,Austria(1722)SonofaninnkeeperTheworkingexperienceshelpedhimtofindPercussionAuthorof<InventumNovum>(1761)translatedas‘OnPercussionofthechest’in1936Contributionofancientdoctor49Contributionofancientdoctors---WesternLaennecRTHAFrenchphysicianInventedAuscultationandstethoscopeContributionofancientdoctor50Contributionofancientdoctors---WesternLaennecRTH1816Contributionofancientdoctor51ContributionofWesternPhysician17th~19thcenturyLeenwenhockMicroscopy(endof17thcentury)FahrenheitThermometer(1724)(體溫計(jì))LudwigHematomanometer(1847)(血壓計(jì))WelcherHematinometer(1854)(血細(xì)胞計(jì)數(shù)儀)20thcenturyX-rayfilmEKGEndoscopyCTPETContributionofWesternPhysic52UltrasonicimagingUltrasonicimaging53CTimagingCTimaging54MRIMRI55PETPET56TraditionalChineseMedicineWood

FireEarthMetalWaterTraditionalChineseMedicineWo57Contributionofancientdoctors---ChineseInspectionInterrogationSmellPulsepalpation?內(nèi)經(jīng)?Contributionofancientdoctor58Payattentionto:GoodmedicalethicsAttachimportancetoclinicalpracticeUnittheorywithpracticePayattentionto:Goodmedical59GoalsInquiry:IndependentsystemicinquiryComprehensiveunderstandingofpatient’schiefcomplains,signs,symptomsandtheirinterrelationPhysicalExamination:Systemic/thoroughFamiliarwithroutinetests,EKGmanipulationandfigureanalysisGoodcasewritingandproposetheprimarydiagnosisScientificclinicalthinkingGoalsInquiry:60ClinicalDiagnosticsCHINAMEDICALUNIVERSITYZHAOLIClinicalDiagnosticsCHINAMEDI61PhysicalDiagnosisToday’smedicalstudentsTomorrow’scliniciansPhysicalDiagnosisToday’smedi62PhysicalDiagnosisWhatisthemeaningof“Clinician〞?PhysicalDiagnosisWhatisthe63PhysicalDiagnosisWhatisthemainresponsibilityoftheclinician?MakingdiagnosisTreatadiseaseTreatapatientPhysicalDiagnosisWhatisthe64PhysicalDiagnosis

Alinkagebetweenbasicmedicalknowledgeandclinicalmedicine.Adisciplinetousebasicmedicaltheoryandskilltomakeadiagnosis.PhysicalDiagnosis

Alinkageb65ObtaininformationFromanyandeverysourcepossible.Straintohearthevoiceofthepatientinthethinreedofhiscrying.Seemostacutelyoutofthecornerofyoureye.Tohearbestwithyourinnerear.ObtaininformationFromanyand66Thecontentsofdiagnosis

VerbalobservationorhistorytakingPhysicalobservationorexaminationLaboratoryobservationThecontentsofdiagnosis

Verb67HistoryTakingObtainasmuchinformationasneededtodiagnoseandtreattheillness.Requirementsforthephysicians:Agenuine,profound,andabsorbinginterestinthepatient'swellbeingAdeep-seated,well-groundedselfconfidenceinabilitiesAthroughknowledgeofthediseasesAbilitytoseetheproblemfromthepatient'sviewpointHistoryTakingObtainasmuchi68HistoryTakingObtainingamedicalhistoryisan"art"Talkwith,rathertalktothepatient.Listenattentivelyandguideapatienteffectively.Asksearchingquestions.Interrogationoffamilyandfriendsifnecessary.HistoryTakingObtainingamedi69HistoryTakingKnowallaboutthediseaseSymptomsandsignsSymptoms:patient'scomplaints,orhisrecognitionofsomethingabnormal.Signs:findingselicitedbyphysicalexaminationPasthistoryFamilyhistorySystemsreviewHistoryTakingKnowallaboutt70PhysicalExamination

Beginswhengreetingthepatient.Sedulouslypracticingtheartofobservationmakeastudenttoaclinician.

PhysicalExamination

Beginswh71Howtoconductphysicalexamination

Applicationofthesensoryendorgantothepatient.Inarational,thorough,andaccuratefashion.Withefficiencyandminimaldiscomforttothepatient.5componentsofphysicalexamination:inspection,palpation,percussion,auscultationandsmelling.Howtoconductphysicalexamin72LaboratoryfindingsTodetectpathogenicorfunctioninginformation.Chemical,biologicalandphysiologicaltests.X-film,CT,MR.gastroscopy,angiographyandbronchoscopyetc.LaboratoryfindingsTodetectp73InterpretationoflaboratorydataLotsvariablesalterlaboratorytestsresults.Specificityandsensitivityofthetests.Overlappingbetweenthehealthyandthediseasedsubjects.Interpretationoflaboratoryd74TheIntellectualprocess

ofdiagnosisInformationrequiresclarification

andamplification.Informationmustbecarefullyweighedastoitsclinicalsignificanceanditspossiblerelationshiptothepatient'scomplaints6levelsofintellectualfunctioning：

knowledge,comprehension,application,

analysis,synthesis,andevaluationTheIntellectualprocess

ofd756levelsofintellectualfunctioningKnowledgeUneditedfactualinformationprovidedbythepatient.Maynotnecessarilybeaccurateorprecise.ComprehensionUnderstandingthefactsrelatedbythepatient.Affirmwhatthepatientsaid.ApplicationRecordingthefactsaccuratelyandinawell-organizedorder

6levelsofintellectualfunct766levelsofintellectualfunctioningAnalysisSortingoutorclassificationoftheobtaineddataintorelatedcategories.SynthesisReassemblethedataobtainedintopatternsofrecognizabledisease.EvaluationAskingquestionsthataredesignedtoeitherconfirmorexcludetentativediagnoses.Predictingthelikelyphysicalandlaboratoryfinding.6levelsofintellectualfunct77Theroleofhightechnology

Alwaysbeatool.Canneverreplacetheintellectualprocessofdiagnosis.Theroleofhightechnology

Al78TheroleofhightechnologyPatientisahumanbeing,notamachine!Physicianisamedicaldetective,notadetector!TheroleofhightechnologyPat79Conclusion

Communication，observationanddatarecordingarethekeydemandsinmedicine.Profoundknowledgeandsmartintellectualprocessofthinkingofmedicineisthekeyforsuccessofaclinician.Conclusion

Communication，obser80Onlyasacliniciandoes

onebecomeaclinicianOnlyasaclinician81WhatisClinicalDiagnostics?Fundamentaltheory

Techniquesofdiagnosingdisease

Modeofclinicalthinking

WhatisClinicalDiagnostics?82WhatisClinicalDiagnostics?InstructaconciselogicalapproachtorecognizethegeniusofthediseasesAfundamentalcourseofclinicalmedicineWhatisClinicalDiagnostics?83FundamentalelementsofDiagnosticsDiagnosisIdentificationAnalysisFundamentalelementsofDiagn84DiagnosisDerivedfromGreekwords

distinguishordiscern☆DiagnosisDerivedfromG85

Englishterm

DiagnosticThedistinguishingsignandsymptomswithwhichitgerenallybegins,continuesandgoesoff…asitwere,ahistoryofthedisease

In18thcentury:

Nosography☆☆Englishterm☆☆86Inmodernusage:IdentificationofadiseasebyinvestigationofitssignsandsymptomsMedicalterminology:ClinicaldiagnosisLaboratorydiagnosisX-raydiagnosisElectrocardiographicdiagnosisGenediagnosis☆☆I(lǐng)nmodernusage:☆☆87Identification:InquiryPhysicalexaminationLaboratorytests/SpecialexaminationAnalysis:BasicknowledgeofmedicineOverallanalysisScientificwayofclinicalthinking

Identification:Inquiry88ImportanceofDiagnosticsEssentialBridgeToolsBasiccoursesClinicalmedicineImportanceofDiagnosticsEssen89ContentofClinicalDiagnosticsSymptomaticdiagnosis(病癥診斷)Physicaldiagnosis(檢體診斷)LaboratorytestsorclinicalancillarytestsMedicalrecordDiagnosticprocessesandthewayofclinicalthinkingContentofClinicalDiagnostic90Historytaking〔病史采集)---Interview(問(wèn)診〕Symptoms(病癥〕---patient‘scomplaints(主訴)SymptomaticDiagnosis(病癥診斷)SymptomaticDiagnosisHistorytaking〔病史采集)---Inter91SymptomaticDiagnosisSubjectivesensationthatpatientdescribesFeverCoughRashMassPhysiological&functional

Pathological&morphological

Symptom〔病癥〕SymptomaticDiagnosisSubjectiv92PhysicalDiagnosisAbnormalityobservedbythephysicianSign〔體征〕Physicalexamination〔體格檢查〕Inspection(望〕Palpation〔觸〕Percussion〔叩〕Auscultation〔聽(tīng)〕Conductedwiththoroughness,alertnesstodetectevenslightderivationsfromnormalPhysicalDiagnosisAbnormality93LaboratorytestorancillarytestsSerum,Urine,StooltestsX-rayfilmEKGEndoscopyUltrasonicimagingCTMRIPET(PositronEmissionTomography)Laboratorytestorancillaryt94MedicalrecordMedicalrecordisasystematizedwayofstoringtherequireddata,informationandotherrelevantdocumentsSpecificrequirementintermsofformatandcontentMedicalrecordMedicalrecordi95SpecialtermsinclinicaldiagnosisImpression(初步印象〕Tentativediagnosis〔可能性診斷〕Differentialdiagnosis〔鑒別診斷〕Evidencebasedmedicine〔循證醫(yī)學(xué)〕Specialtermsinclinicaldiag96DifferentialdiagnosisPreliminarydiagnosis/Tentativediagnosis

初步診斷可能性診斷

Exclusionofotherdiseases(排除其它疾病)SelectinganumberofpossibilitiestoexplaintheclinicalandlaboratoryfindingsinthecaseinquestionThewayofexclusioniscalledDifferentialdiagnosisDifferentialdiagnosisPrelimi97EvidencebasedmedicineItistheconscientious〔慎重的〕,explicit〔明確的〕andjudicious〔有見(jiàn)解的〕useofcurrentbestevidenceinmakingdecisionsaboutthecareoftheindividualpatient

Itmeansintegratingindividualclinicalexpertise〔臨床專長(zhǎng)〕withthebestavailableexternalclinicalevidencefromsystematicresearchEvidencebasedmedicineItist98EvidencebasedmedicineOneneedto:Beconscientious:itrequireseffortandthought.Beexplicit:decisionswillneedtobebackedupbygoodevidenceRelatetospecificproblems:itisnotaboutahypothetical"average"case.Integrateindividualclinicalexperience:itdoesnotdenigrateclinicalskillsinhistorytaking,examinationanddiagnosis.Lookforcurrentbestevidence:theperfectstudymaynotyethavebeenpublished,writtenuporevencommenced.Wemayhavetosettleforsomethinglessrigorous,butbeonthelookoutfornewresearchthatwillsupersedeolderstudies.EvidencebasedmedicineOnenee99Importantaspects---interrogationTogetthehistoryindetailofapatient’sillnessThehistoryistakenatinitialcontactbetweenphysicianandpatientAssomecrucialpointsmightbeoverlookedbythepatients,onewillaskmanysearchingquestionstomakethehistorymoreinformativeandcomplete,whomustatthesametimeavoidsuggestinganswersOccasionallytointerrogatehisfamilymemberImportantaspects---interrogat100OtherimportantaspectsThediagnosticprocessisverycomplexThenumberoffactsthatcanbecollectedinadetailedmedicalhistoryandinthoroughphysicalexaminationarealmostwithoutlimitThelaboratorytestsorspecializedtechnicalproceduresthatcanemployedarenumerousandcostly

OtherimportantaspectsThedi101OtherimportantaspectsQuestionsforinterrogation,maneuverinP.E.,laboratorytestshouldbethoughtfullyselectedwiththeviewtoeliminatesomeofthepossiblediagnosisandguidethesearchexpeditiouslytoaspecificdiseaseMethodofapproachingadiagnosis:Analysisofsymptoms(病癥分析)Recognitionofthesyndrome(綜合癥識(shí)別)Considerationofdiseasemechanisms(考慮疾病機(jī)制)OtherimportantaspectsQuesti102ImportantaspectsModern&advancedancillarytechniques:havetheirlimitations.Itcan’treducedtheimportanceofcertainpartsoftheclassicP.EItshouldbeavoidedtoneglectfundamentalmethodsInterrogationPhysicalexaminationScientificclinicalthinkingImportantaspectsModern&adv103ApproachesBasicknowledgelearning〔根底知識(shí)的學(xué)習(xí)〕Clinicalpractice〔臨床實(shí)踐〕BedsideactivityStandardizedpat