Clinical Diagnostics英文版教材整理.docx
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Clinical Diagnostics英文版教材整理.docx
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ClinicalDiagnostics英文版教材整理
AnIntroductiontoClinicalDiagnostics
Afteryoufinishyourpremedicalcourses,youarenowgoingtotouchpatients.Theclinicaldiagnosisservesasabridgebetweenpremedicalandclinicalmedicine.Itincludesphysicaldiagnosis,Laboratorydiagnosisandsomeinstrumentalexamination.Formerlythesearetaughtseparatelybutnowourcountrytheyarecombinedtoformonecourse,whichisnowcalledclinicaldiagnosis.
Themedicalstudentsarethephysiciansoftomorrow,andassuch,youneedinformationfromeverysourcetounravelthemysteryofthepatients’illness.Physicaldiagnosisdealswithsuchinformationthroughthetwomostfundamentalskills,theinterrogationandphysicalexamination.
Interrogationmeanstogetthehistoryindetailofapatient’sillnessandthebestwayastoletthepatienttellhisstoryinhisown.Assomecrucialpointsmightbeoverlookedbythepatients,youwillaskmanysearchingquestionstomakethehistorycompleteandmoreinformative.
Occasionallyapatientwillnotorcannotgiveastraightstory,youmayinterrogatehis(her)familymembersorfriendstogetmoreinformationdate.
Thenextstepisthentodoaphysicalexamination.Thebodyofthepatientwillbeexaminedmeticulouslyineverywaypossiblebyyou,usingallofyourfivesenses.Aphysicalexaminationusuallyincludesinspection,palpation,percussion,andauscultation.Hereourancientdoctorshadgivengreatcontributions.Almosttwothousandyearsagotheyhaddevelopedinspection,interrogation,smellandpulsepalpationtomakediagnosisanddevelopmanysyndromeswhicharestillusefulclinicallytoday.Afterthatyoucanmakeapreliminaryanalysis,correlatingthehistorywithpositivephysicalsigns,determiningtheorgansinvolvedandevensetdownapreliminarydiagnosis,whichweusuallycallitanimpressionbutnotadefinitediagnosis.Adefinitediagnosiswillbemadewiththehelpofotherspecialinvestigativeaidssuchaslaboratorytest,Xrayfilms,EKG,endoscopy,ultrasonicimaging,CTscanningetc,toaddfurthercluesorevidencestothefirstimpressionobtainedfromphysicaldiagnosis.Amongthem,onlylaboratorydiagnosisandsomeinstrumentalexaminationsareincludedinthecourseofclinicaldiagnosisasotheraidsaretoomuchspecialisticandareusuallytaughtseparately.
Laboratorydiagnosisisasciencedealingwithvariouskindsoflaboratoryexaminationsandtests.Aslaboratorydiagnosisissocomplexthatitisimpossibletoapplyallitscontentstoasinglepatient,youshouldselecttheproperonesaccordingtotheimpressionyouobtainfromphysicaldiagnosis.Thelaboratorydiagnosisusuallycontainstwoparts,theroutineexaminationandthespecialtests.Theroutineexaminationsincludeblood,urineandstoolroutineexaminationsandthespecialtestsusuallydirecttocertainspecialorgans.
Theabovearethegeneralwaysyouwillapproachapatientwhenyougototheward.Infactthisisakindofbedsidemedicine.Youshouldstudyhardandtrytomasterthetechnic.Bythiswayyouwillunderstandwhatishealthandwhatisdisease.Bythiswayyouwilllearntheprocedurestodoaclinicalanalysiswhichshouldbefittingtodialecticmaterialism,thatis,inanobjectiveway.Further,youshouldalwayskeepinmindyouaredealingwiththediseasedmanbutnotthedisease,soyoushouldgivesympathytothepatient,andhavealoftymindofservingthepeopleheartandsoul.
PartI
Symptoms
Chapter1Fever
Thecorebodytemperatureiskeptconstant(36.3-37.2o).Undernormalcircumstances,itistightlyregulated,withcircadianvariationsoverarangethatusuallydoesnotexceed1oCandameanvalueof37oC(thenormal“setpoint”).Feverisdefinedasanelevationofcorebodytemperatureabovethenormalrange.
Pathogenesis
Itisimportanttorealizethatfeverisnotequivalenttoanelevatedcoretemperaturebuttoanelevatedset-point.Theneuropathysresponsibleforthermoregulationoriginateinthehypothalamus.Alocalsensingmechanismexistswhereinthetemperatureofbloodiscoupledtothedevelopmentofautonomicdischarge.
Twotypesofpyrogen:
exogenouspyrogenandendogenouspyrogen
1.Exogenouspyrogen:
variousmicroorganisms(suchasendotoxin),mostlyarepolysaccharides,cancausemusclecontractionandrigor.
2.Endogenous:
polymorphonuclearmyelocytesandmonocytes,activatedbyexogenouspyrogen,synthesizecytokines,whichcauseliberationofPGEfromhypothalamus.ThePGEisbelievedtoresetthehypothalamicthermoregulatorycenterbypromptinganelevationincorebodytemperature.
Etiologyandclassification
1.Infectivefever:
Afterinfection,metabolitesfromorganismorpyrogenfromWBCcausefever.
2.Non-infectivefever:
1).Absorptionofnecroticsubstances:
injury;ischemicnecrosis;cellnecrosis
2).Allergy
3).Endocrineandmetabolicdisturbances:
hyperthyroidismanddehydration
4).Decreasedeliminationofheatfromskin:
heatfailure
5).Dysfunctionofcentralheatregulation:
a:
Physical,asheatstroke;
b:
chemical,asbarbituratepoisoning;
c:
Mechanical,ascerebralhemorrhage.
6).Dysfunctionofvegetativenervoussystem;asthecasesofsympatheticoveractivity.
Clinicalmanifestations:
1.Thegradeoffever
Lowgradefever:
37.3~38oC
Moderatefever:
38~39oC
Highfever:
39.1~41oC
Hyperthermiafever:
over41oC
2.Theclinicalcourseandcharacteroffever
Theclinicalcoursesoffeverareconsistedofthefollowingthreesteps
1).Onsetoffever
a:
Suddenonset:
feverriseswithinfewhours,aspneumonia,upto39~40oC
b:
Gradualonset:
feverrisesgraduallyforfewdays,astyphoid
2).Persistenceoffever:
maybea:
continued
b:
remittent
c:
intermittent
d:
recurrent
e:
undulant
f:
irregulartype
3).Subsidenceoffever:
maybesubsidebycrisisorlysis
Associatedsymptoms
1.Chillsorrigor:
asinsepticemiaandanyacuteinfections
2.Congestionofconjunctiva:
asinhemorrhagicfever
3.Herpessimplex:
causedbyherpesvirus,frequentlyseenincasesoflobarpneumonia
4.Bleedingtendency:
insevereinfectionashepatitisandblooddyscrasiaasleukemia
5.Lymphnodeenlargement:
incasesoflymphoma,ofmetastasisofcancer
6.Enlargementofliverandspleen:
incasesofhepatitis,leukemia
7.Arthralgia:
ingout,rheumticdisease
8.Rash:
drugrash,measles
9.Coma:
inbarbituratepoisoning,cerebralhemorrhage
Diagnosticpoints
Acutefeveroflessthantwoweeksaremostofinfectiousorigin,withaninflammatoryfocus.Thus,eitherhistoryorphysicalexaminationwouldshowsomesuggestivepointsaboutthecauseoffever.
PartII
Inquisition
Chapter1Importanceofinquisition(askinghisttory)
1.Inquisitionisanimportantpartofdiagnosticprocedurethroughtheconversationbetweenthepatientanddoctor.
2.Itisusefultounderstandtheactualhistoryofanillness,nootherdiagnostictechnologycantakeitsplace.
3.Foranexperiencedphysicianwithprofoundknowledge,diagnosisorimpressioncanbemadesimplybyinquisition.Asthediseasedorganwouldgivesomecluebyitspathophysiologicalchanges.
4.Aninaccurateorroughhistorywouldleadyoutomakeawrongdiagnosis.
Methodofinquisition
1.Physicianshouldbepatientandkindtothepatientandtreathimasoneofhis/herfamilymember.Theatmosphereshouldbeinvariablybenevolent.Therefore,thepatientcantrusthim/her.
2.Inquisitionusuallybeginwiththepatient’schiefcomplain.Itisapproachedgraduallyandsystematically.
3.Askquestionsinthemostdirectandsimplelanguage.Afterthepatienthasrelatedinhisownwaythestoryofhisillness,itwillbenecessarytoaskmorespecificquestionstoelicitfurtherinformationortoclarifytheexactnatureofhiscomplaints.
4.Neverforcethepatienttorelatedsymptoms,whichisdifficulttoanswer.Asksomeeasyquestionsfirst,suchas“howisyourfeelingwhentheillnessstarts?
”.Andthen,addsomequestionssuchas“anythinghappenedbeforetheillness?
”.
5.Hintstothepatientsuchas“didyouvomitduringheadache”areavoided.Instead,justask“anythinghappenedduringyourheadache?
”.Questionsshouldbeobjective.
6.Thefollowingaspectsshouldbenoted:
(1).Foracriticalcase,theinquiryshouldbeshortandemergencytreatmentstartedasearlyaspossible.
(2).Wordsusedduringinquiryshouldbeunderstoodbythepatient.Trynottousemedicaltermssuchasoccultbleeding,tonesmus,opistaxis.
(3).Historyshouldbetakenfromthepatienthimself,fromhisrelativesorfriendsonlywhenpatientisincriticalstatusand/orunabletotalk.
Chapter2Contentsofinquisition
1.Generaldata:
suchasname,sex,age,native,birthplace,profession,maritalstatus,sourceofhistoryandestimateofreliabilityetc.
2.Chiefcomplaints:
Itshouldconstituteinafewsimplewordsthemainreasonswhythepatientconsultedhisphysician,whichusuallyincludessymptomsorsignthepatientissuffering.
3.Historyofpresentillness:
Itshouldbeawell-organized,sequentiallydevelopedelaborationofpatient’schiefcomplaintorcomplaints.Agoodhistorywillreflectthefactsthatyourdiagnosisorimpressionisgoingtobemade.
Itincludesthefollowingaspects:
(1).Onsetanddurationofthedisease.
(2).Mainsymptoms,locationandtheircharacter.
(3).Etiologyandprovokingfactors.
(4).Evolutionofdisease
(5).Associatedsymptoms.
(6).Treatmentanditseffects.
(7).Generalcondition,especiallythedietaryhabit.
4.Pasthistory:
Healthconditionanddiseasewhichthepatientsufferedbeforethepresentillness.Infectiousdisease,surgery,allergyareessentialpartofthecasehistory.
5.Systemsreview:
Thepurposeofthisreviewistwofold:
(1):
Athor
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