【正文】 sion(印象 ) Primary diagnosis(初步診斷 ) Data processing 數(shù)據(jù)處理 ? For example, suppose the interviewer obtains a history of dyspnea (呼吸困難 ), cough (咳嗽 ), earache (耳痛 ), and hemoptysis (咯血 ). Dyspnea, cough, and hemoptysis can be grouped together as symptoms suggestive of cardiopulmonary disease. Earache does not fit with the other three symptoms and may indicate another problem. Problem list development ? Problem list development results in a summary of the physical, mental, social, and personal conditions affecting the patient’ s health. ? The problem list may contain an actual diagnosis or only a symptom or sign that cannot be clustered with other bits of data. ? The data on which each problem developed is noted. ? This list reflects the clinician’ s level of understanding of the patient’ s problem, which should be listed in order of importance. Problem list development ? The presence of a symptom or sign related to a specific problem is a pertinent positive. ? For example, a history of gout and increased uric acid level are pertinent positives in a man suffering from excruciating back pain radiating to his testicle. ? This patient may be suffering from renal colic secondary to a uric acid kidney stone. Problem list development ? The absence of a symptom or sign that, if present, would be suggestive of a diagnosis is a pertinent negative. ? A pertinent negative may be just as important as a pertinent positive。 the fact that a key finding is not present may help rule out a certain diagnosis. ? For example, the absence of tachycardia in a women with weight loss and a tremor(震顫 ) makes a diagnosis of hyperthyroidism less than likely。 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(yù)測值和陰性預(yù)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