【正文】 esonance dullness flatness diaphragmatic movement ? Auscultation: breath sounds tracheal bronchial bronchovesicular vesicular Physical examination ? Heart: Inspection: apical impulse, or its location, area and intensity Palpation: assessing point of maximum impulse, thrills, fremitus Percussion: percuss the heart’ s borders, the relative dullness or absolute dullness borders Auscultation: the heart rates, rhythm, heart sounds, murmur（ 雜音 ） , abnormalities of the S1, S2, splitting of S2, systolic clicks, diastolic opening snaps, vocal fremitus, premature beats（ 早搏 ） Physical examination ? Radial artery (橈動脈 ): pulse rate, rhythm (regular or irregular), pulse deficit（ 脈搏短促 ） . The pulse may be described as normal, diminished, increased, or doublepeaked. ? Peripheral vascular signs: capillary strike signs, bruits（ 雜音 ） , abnormal artery movement. Abdomen ? Inspection: symmetry, size, abdominal distention, pitting (concave abdomen), respiratory movement, skin lesion, pigmentation, surgical scar, umbilicus, hernia（ 疝 ） , body hair, venous distention and direction of blood flow, peristaltic waves（ 蠕動波 )。 the presence of tachycardia would strengthen the diagnosis of hyperthyroidism Diagnostic reasoning 診斷的論證 ? Unfortunately, decisions in medicine can be rarely be made with 100% certainty ? Probability(可能性 ) weights the decision Others ? Sensitivity and Specificity ? Likelihood ratio ? Ruling in and Ruling out Disease ? Positive and Negative Predictive Values (陽性預測值和陰性預測值 ) ? Prevalence Decision analysis ? Diagnostic reasoning is only the first step in clinical decisionmaking. ?After reaching a decision about a diagnosis, the clinician must decide on a plan of treatment and management for the particular patient. ?These decisions must take into account the probability(概率 ) and utility (i,.e., worth or value) of each possible oute of the treatment or management plan Decision analysis ? Similarly, the clinician may need to decide whether to order laboratory tests to confirm a diagnosis only suggested by the signs and symptoms elicited during the clinical examination. The ways of clinical thinking 臨床思維方法 ? It refers the ways of investigation of disease, processing the clinical data and making the decision etc. ? It is the basic method in the processes of clinical diagnosis. ? It, however, reflexes the clinician’ s abilities of clinical diagnosis ? Two basic elements include in the ways of clinical thinking: clinical practice scientifically clinical thinking The steps of clinical thinking ? From Anatomical point of view, is there any anatomical abnormality? ? From pathological point of view, is there any functional changes? ? Based upon the pathophysiological point of view, propose the possible mechanisms of pathological changes and pathogenesis of the disease ? Considering the possible causes of the disease The steps of clinical thinking ? Considering the possible causes of the disease ? Evaluating the severity of the disease ? Proposing one or two special hypothesis ? Verifying the trueness of the hypothesis ? Considering the differential diagnosis based on the special clustering of symptoms ? Focusing on the most possible diagnosis ? Proposing the further examination and treatment The basic rules of clinical thinking ? The rules of seeking the truth from facts 實事求是原則 ? The rules of monism 一元論原則 ? The rules of using the prevalence and spectrum of the disease to make the diagnostic decision 用發(fā)病率和疾病譜觀點優(yōu)選診斷原則 The basic rules of clinical thinking ? The diagnosis of anic diseases is in priority, the functional diseases are considered only those anic diseases have been ruled out ? The curable diseases are in priority ? The rules of simplifying thinking procedure The basic rules of clinical thinking ? Evidence based medicine The mon causes of misdiagnosis ? Inplete and/or uncertain clinical data ? Rough observation or laboratory errors ? Subjective and groundless conclusion ? Lack of clinical experience Types of clinical diagnosis ? Direct diagnosis ? Excluding diagnosis ? Differential diagnosis Contents of clinical diagnosis ? Pathogenic diagnosis ? Anatomicopathological diagnosis ? Pathophysilogical diagnosis ? The diagnosis of plications ? The diagnosis of coincide diseases