clinicaldiagnostics(參考版)
2025-07-18 18:09本頁(yè)面
【正文】 morphological Symptom （癥狀） Physical Diagnosis Abnormality observed by the physician Sign （體征） Physical examination （體格檢查） Inspection (望 ） Palpation （ 觸 ） Percussion （ 叩 ） Auscultation （ 聽(tīng) ） Conducted with thoroughness, alertness to detect even slight derivations from normal Laboratory test or ancillary tests ? Serum, Urine, Stool tests ? Xray film ? EKG ? Endoscopy ? Ultrasonic imaging ? CT ? MRI ? PET (Positron Emission Tomography) Medical record Medical record is a systematized way of storing the required data, information and other relevant documents Specific requirement in terms of format and content Special terms in clinical diagnosis Impression (初步印象） Tentative diagnosis （可能性診斷） Differential diagnosis （鑒別診斷） Evidence based medicine（循證醫(yī)學(xué)） Differential diagnosis ? Preliminary diagnosis/Tentative diagnosis 初步診斷 可能性診斷 ? Exclusion of other diseases (排除其它疾病 ) ? Selecting a number of possibilities to explain the clinical and laboratory findings in the case in question ? The way of exclusion is called Differential diagnosis Evidence based medicine It is the conscientious（謹(jǐn)慎的） , explicit （明確的）and judicious （有見(jiàn)解的） use of current best evidence in making decisions about the care of the individual patient It means integrating individual clinical expertise （臨床專長(zhǎng)） with the best available external clinical evidence from systematic research Evidence based medicine One need to: ? Be conscientious: it requires effort and thought. ? Be explicit: decisions will need to be backe
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