兒科病史采集和體格檢查.ppt

兒科病史采集和體格檢查 History-taking and Physical Examination for Children,Gao Ju, MD, PhD Professor of Pediatrics Department of Pediatrics West China Second University Hospital Sichuan University,主要內(nèi)容,小兒病史特點(diǎn)及問(wèn)診技巧 History-taking: skills and approaches 小兒體格檢查順序及技術(shù) PE: sequence and skills 小兒體格檢查項(xiàng)目及要點(diǎn) PE: major items and key points,臨床醫(yī)師(兒科醫(yī)師）的主要任務(wù)： (Primary Aims are to establish) 患兒到底存在什么問(wèn)題？(診斷） （What is wrong with the child?). 存在的問(wèn)題對(duì)患者有什么影響？ (診斷） (How these problems impact on the patients life, medically, psychologically and socially, ect.) 如何解決存在的問(wèn)題？（治療） ( How to solve the problems?),為此目的，下一步該作什么？ Then, what should we DO next?,首先，必須收集資料或信息 (Firstly, Information Gathering) 詳盡的病史采集 （Detailed HistoryTaking） 仔細(xì)的體格檢查 （Meticulous Physical Exam） 相關(guān)的實(shí)驗(yàn)室檢查 （Appropriate Lab Investigations）,然后，完成“最初的醫(yī)學(xué)記錄” （Formulating an Initial Medical Record） 詳盡的病史采集和體格檢查 診療計(jì)劃(investigation and treatment plan) 并非“靜止” (static) ，而為“動(dòng)態(tài)”(dynamic)的過(guò)程，診療過(guò)程中收集的新信息應(yīng)隨時(shí)加入。,Problem-Oriented Medical Record,POMR: Lawrence Weed(1969) Standardized and structured approach to clinical record-keeping. Initial database for diagnosis and differential diagnosis Essential to multidisciplinary team work Prime resource for medical audit and possible medicolegal suit,In case of judicial examination, your professional credibility relies SOLELY on the medical record, not on your memory or any other things.,因此，收集的資料是否充分和準(zhǔn)確對(duì)于診斷和治療極為重要。 The ACCURACY and ADEQUACY of information gathered is of pivotal importance for the precision of diagnosis and treatment,成人病史采集和體格檢查 History-Taking and Physical Examination in Adults,病史采集 (History-taking) 一般介紹 (Introduction) 一般資料 (General Data) 主述(Chief Complaint) 現(xiàn)病史 (History of Present Illness) 過(guò)去史 (Past History) 系統(tǒng)回顧 (Systems Review) 個(gè)人史 (Personal History) 婚姻史 (Marital History) 家族史 (Family History),體格檢查 (Physical Examination) 望診 (Inspection) 捫診 (Palpation) 扣診 (Percussion) 聽(tīng)診 (Auscultation),成人病史采集和體格檢查 History-Taking and Physical Examination in Adults,盡管兒科病史采集和體格檢查的基本原則與成人相同，但是方式(Manner), 順序( Order)和重點(diǎn)(Emphasis)有所不同。,Children are NOT just small adults their needs are DIFFERENT and have to be recognized (Prof. James Spence, 1943),目的和要求 Course Objectives,了解病史采集對(duì)兒童疾病診斷的重要性。 熟悉兒童與成人病史采用的主要差別。 掌握兒童病史采用和體格檢查的要點(diǎn)。,兒科病史采集 History-Taking in Children,很多情況下，可僅通過(guò)病史采集明確診斷。 病史采集不準(zhǔn)確和完整是誤診(misdiagnosis)和延誤診斷(delayed diagnosis)的重要原因。 如何進(jìn)行病史采集決定了所收集信息的質(zhì)和量(quality and quantity)。,病史采集的重要性,The history is the most important part of the patients assessment as it provides 80% of the information required for a diagnosis.,初學(xué)者面臨的挑戰(zhàn) Apprentice: Challenges,不知如何接觸患兒及其家長(zhǎng) （How to approach the patient or parents） 不知從何開(kāi)始病史采集 （How to get started） 不知問(wèn)些什么問(wèn)題 （What kind of questions to ask） 不能抓住主要問(wèn)題 （How to focus on the primary problem）,初學(xué)者面臨的挑戰(zhàn) Apprentice: Challenges,不知如何結(jié)束病史采集(How to conclude)。 病史采集后不能形成一個(gè)完整的印象或初步診斷(whole story)。 They are uncomfortable, unconfident, shy and frustrated. They are just “passive” listener.,如何成為一個(gè)合格的病史采集者？ How to become a COMPETENT history taker？,Genuine children “l(fā)over” Keen and watchful observer Enthusiastic and active listener Good thinker and judger Be aware of the special aspects of history taking for children Intensive training and practice to be a master,病史采集的基本內(nèi)容,自我介紹 SELF-INTRODUCTION,(1). Who are you and what are you going to do?,Tell patient, parents or guardian your identity and responsibility. PCP (primary care physician) Diagnosis maker Treatment plan maker and implementer Progress follower Prognosis predictor Take full responsibility for diagnosis and management-challenging!,Tell patient, parents or guardian your identity and responsibility. Intern (apprentice) History elicitor (collector) and PE performer. Recorder Progress follower Although a learner, but plays very ACTIVE role in the whole process-challenging and rewarding!,(2). Brief Chat at the Beginning,Get to know the patient (parents) Their background (education, occupation and even personality) Helps to: Set up an easy-going atmosphere Set up physician-patient (parent) rapport Gain trust: confident in your diagnostic ability Decide the approach to them (language and manner) Appease crying children and make them easy.,Atmosphere and Setting,Easy-going Give patient (parent) full freedom to describe his/her problems and express his/her fears and concerns. Show your full attention and sympathy. Let them know that the information they provide would be kept confidential.,Harmonious Physician-Patient Relationship: Rapport,Show your respect, sympathy and concern. Be an attentive and patient listener. Be polite, warm, considerate and well-mannered and well-dressed. Skillful communicator.,First impression you give to patient (parents) really matters. Appear friendly, but professionally. Patients must have confidence in your ability to act on their behalf, and therefore be willing to provide you detailed information.,家長(zhǎng)的信任和好感是醫(yī)師獲得準(zhǔn)確病史的先決條件。除了舉止友善、態(tài)度溫和以外，夸獎(jiǎng)孩子往往是拉近距離的最好途徑。,一般資料 GENERAL DATA,姓名（Name） 年齡（Age） 性別（Gender） 出生地點(diǎn)（Place of inhabitancy） 民族（Race） 病史提供者（Informant, relationship to patient and history reliability） 通訊地址（Correspondence）,年齡,兒童與成人，以及不同年齡段兒童疾病譜(Disease spectrum)有所不同，年齡對(duì)兒童疾病的診斷極為重要。 嬰幼兒多見(jiàn)先天畸形和遺傳代謝性疾病 幼兒和學(xué)齡前兒童容易發(fā)生意外（accidents） 嬰幼兒易發(fā)生佝僂病和IDA 生后24小時(shí)內(nèi)發(fā)生的黃疸： 出生3天后發(fā)生的黃疸：,新生兒：精確到小時(shí) 寫(xiě)法：1天 65/24天 其他嬰兒：精確到天 寫(xiě)法：72/30月 幼兒及以上：精確到月 寫(xiě)法：97/12歲,年齡的記錄 Age Documentation,性別,是兒童病史采集中的重要內(nèi)容之一。 某些疾病具有顯著的性別分布差異。 性連鎖遺傳性疾病（sex-linked genetic disorders） 進(jìn)行性肌營(yíng)養(yǎng)不良（muscular dystrophy）：男性 蠶豆?。‵avism）： 男性 血友?。℉emophilia A/B） ： 男性 其他疾病 甲狀腺疾病：女性多見(jiàn) SLE： 女性多見(jiàn),民族和居住地,瘧疾 (Malaria): 分布在熱帶和亞熱帶 (malaria belt)。 地中海貧血 (Thalassemia): 中國(guó)主要分布在長(zhǎng)江以南的省分; 世界分布同瘧疾(thalassemia belt) 。 地方性伯基特淋巴瘤(endemic Burkitts lymphoma): 非洲兒童最常見(jiàn)的惡性腫瘤。 鐮形細(xì)胞性貧血 (sickle cell anemia) 黑熱?。核拇▋H分布在阿壩州某些縣 (汶川等)。,瘧疾和地中海貧血的世界分布 (Malaria / Thalassemia Belts),地中海貧血 (Thalassemia),皮膚彈性過(guò)多癥,Burkitts Lymphoma,病史提供者(informant),患兒家長(zhǎng)或保育員：學(xué)齡前期及以下年齡 患兒或患兒家長(zhǎng)：學(xué)齡期及以后年齡,Informants: A category,Keen observer Often well educated Knows lot of “medicine” by Internet surfing Anxious. Sometimes rambling, probing and pricky Negligent observer Less educated Divorced parents Far-reaching: irrelevant info provider,For the educated informant, use “educated language” You can even use medical jargon if parents are medical professionals Use everyday language (even slang) while talking to less-educated informant. This will facilitate communication greatly.,主述 CHIEF COMPLAINT,主述 (Chief complaint,CC): 促使患者就醫(yī)最突出的癥狀或體征，及其持續(xù)時(shí)間。 (the most disturbing symptom or sign, which promotes patient to medical care and its duration) 是診斷和鑒別診斷的重要線索，有時(shí)主述可直接指明診斷。 主述的記錄應(yīng)簡(jiǎn)明扼要 (clearly stated and concise)。 對(duì)患者提供的主述應(yīng)進(jìn)行客觀分析和判斷（Assess and judge）,現(xiàn)病史 HISTORY OF PRESENT ILLNESS,現(xiàn)病史(History of Present Illness, HPI) 是病史采集中最重要的內(nèi)容（Main body and cornerstone of history）。 應(yīng)反映出疾病發(fā)生發(fā)展的全貌（The whole course ，story or picture of present illness (panoramas, chain of events) 如何起病。 有無(wú)誘因。 如何進(jìn)展。 對(duì)患者影響如何 (medically and psychologically) 既往診治情況及其反應(yīng),癥狀的客觀表現(xiàn)：如頭痛、腹痛。 病情演化：從零散的敘述中找到時(shí)間脈絡(luò) 主次癥狀：對(duì)一個(gè)系統(tǒng)疾病的多個(gè)系統(tǒng)表現(xiàn)進(jìn)行歸納。 一般狀況：小兒精神狀況、食欲、睡眠、體力活動(dòng)等情況客觀反映病情，較成人更具診斷意義。,現(xiàn)病史的主要內(nèi)容,起病 (onset): 急性起病或起病隱匿? 可為診斷提供重要線索。 例如： 僅持續(xù)1-2天的貧血：提示“急性溶血或急性失血”。 自幼起病，而且進(jìn)行性加重，提示先天性或遺傳性貧血（如地中海貧血）。,癥狀的客觀表現(xiàn)（以發(fā)熱為例） 明確病前體溫是否正常? 熱型如何？ 持續(xù)時(shí)間。 有無(wú)誘因或加重/緩解的因素? 如何進(jìn)展或演進(jìn)？ 有無(wú)伴隨癥狀或并存癥？ 重要陰性癥狀如何?(鑒別診斷的重要依據(jù)) 既往診治情況如何？ 病后一般情況。,個(gè)兒史 PERSONAL HISTORY,個(gè)兒史包括： 出生史/分娩史（history of labor and delivery) 喂養(yǎng)史（feeding history） 生長(zhǎng)發(fā)育史（growth and development） 免疫接種史（immunization）,成人患者，個(gè)兒史在過(guò)去史和系統(tǒng)回顧后采集，而兒童病例，則在現(xiàn)病史后采集。 個(gè)兒史對(duì)兒童，尤其是嬰幼兒疾病的診斷具有十分重要的意義。,例如：3歲先天性心臟?。╒SD）患兒，個(gè) 兒史應(yīng)仔細(xì)詢(xún)問(wèn)： 母親妊娠早期有無(wú)感染? 有無(wú)喂養(yǎng)困難、體重不增和喂養(yǎng)時(shí)呼吸困難？ 有無(wú)生長(zhǎng)發(fā)育落后、營(yíng)養(yǎng)狀況差等。 有無(wú) 易疲乏和活動(dòng)耐量降低。,過(guò)去史 PAST HISTORY,Past history is important to place the current illness in the context of past events, which are often related.,詳盡的過(guò)去史有助于確定或排除診斷。 患兒存在發(fā)熱和麻疹樣皮疹： 如過(guò)去史明確表明既往曾累患麻疹，麻疹的診斷幾乎不可能。 過(guò)去史表明存在蠶豆病，進(jìn)食蠶豆或解熱鎮(zhèn)痛藥物后發(fā)生急性血管內(nèi)溶血（葡萄酒尿），幾乎可以肯定診斷。,過(guò)去史的主要內(nèi)容 既往疾病史（Past illnesses） 傳染性和感染性疾病(麻疹、腮腺炎、肺炎、敗血癥等） 嚴(yán)重疾?。I臟疾病、糖尿病、心臟疾病等） 意外/外傷或手術(shù)史 過(guò)敏史：食物和藥物過(guò)敏史,系統(tǒng)回顧 SYSTEMS REVIEW,家族史 FAMILY HISTORY,家族歷史對(duì)某些疾病的診斷具有十分重要的意義 遺傳性疾病 進(jìn)行性肌營(yíng)養(yǎng)不良(DMD):某一家庭中 3個(gè)男孩均累患本病-family tragedy 蠶豆病(Favism): mostly in boys 血友?。℉emophilia A/B):英國(guó)皇室最為出名（Hemophilia A family aggregation in British royal family）,DMD: 腓腸肌假性肥大,Hemophilia,Hemophilia,Hemophilia,Hemophilic arthropathy,家族歷史對(duì)某些疾病的診斷具有十分重要的意義 感染/傳染性疾病 暴露于共同的環(huán)境不良因素 共同的遺傳易感性 相似的生活條件或生活習(xí)慣,結(jié)語(yǔ)或總結(jié) CLOSURE,Integral part of interviewing Ask for patients or parents concerns: what do they worry about? Understand their expectations: what does the patient (parent) think is going to happen to his/her future health?,Ask patient (parent) at the end of consultation if there is anything else they wish to discuss. Reassure the patient (parents). Tell them what you are going to do and what you expect them to do next.,病史采集技巧 Interviewing Skills,1. 首先必須熱情、禮貌，舉止和衣著端莊得體。(warm，polite, and well-mannered) 2. 對(duì)患者及其家長(zhǎng)應(yīng)尊敬、同情和理解。 (Be respectful, sympathetic and considerate) 3. 真正喜愛(ài)兒童、仔細(xì)的觀察者和耐心的傾聽(tīng)者。(Genuine children “l(fā)over”, keen and watchful observer, attentive and patient listener.),4. 以“開(kāi)放式提問(wèn)”(open-ended questions)開(kāi)始問(wèn)診。例如： Tell me about your sons problem. What is wrong with your child? What brought your son to the hospital? What are your (your childs)symptoms?,5. 耐心傾聽(tīng)患者或者家長(zhǎng)講述疾病發(fā)生發(fā)展的整個(gè)過(guò)程(gives patient or parents freedom to tell you the whole story)，切忌輕易打斷患兒或家長(zhǎng)的陳述 (never be a rude interruptor)，引起它們的不信任甚至反感 (distrust and antipathy)。 6. 避免“先入為主”(avoids your prejudices)。,7. 如陳述“離題太遠(yuǎn)”，應(yīng)給予“引導(dǎo)” ( smartly and politely ) 。Be an expert pace controller and conductor Conduct interview smoothly, comfortably. Do not interrupt too early and too frequently. Pause if necessary. Summarize and verify at end of each section Use transitional words between subsections: what, why.,It is a matter of judgment when to start interrupting and to ask closed questions, but as a general rule, think twice before interrupting a patient in full flow. If specific questions are introduced too early, vital information may never come to light.,A common mistake made by students (doctors) is to intervene too early. A combination of art, experience and patience determines when and how to interrupt a patient (parent) in full flow.,8. 逐漸過(guò)渡到 “closed questions”， 以了解某些癥狀更為詳盡的信息。例如： 活動(dòng)時(shí)有無(wú)胸痛？ 餐后腹痛是否加重或減輕？ 9. 避免“誘導(dǎo)性提問(wèn)”(leading questions)。 10. 對(duì)年長(zhǎng)兒，尤其是teenagers，應(yīng)讓他們自己陳述病史。家長(zhǎng)可適當(dāng)補(bǔ)充相關(guān)信息，但絕對(duì)不能“主宰”病史陳述，除非患兒存在意識(shí)障礙等情況。(Parents should not dominate the interview)。,Children know their OWN problems better than their parents do!,11. 兒科急癥多，病情危重時(shí)不宜過(guò)分強(qiáng)調(diào)采集完整病史資料，應(yīng)重點(diǎn)問(wèn)診，且在查體時(shí)同步進(jìn)行，以便盡快初診并及時(shí)搶救。病情穩(wěn)定后再補(bǔ)充問(wèn)診。 12. 收集病史時(shí)應(yīng)有一定的系統(tǒng)性（systematic), 同時(shí)根據(jù)具體情況又有一定可變性（flexible）。 13. 對(duì)采集的現(xiàn)病史資料要進(jìn)行“加工” (process)和“分析評(píng)估”(assess)，分清主次，形成一個(gè)完整的印象(integrated overview) 。 Good thinker and judger,兒童體格檢查 Physical Examination in Children,目的和要求 Course Objectives,了解體格檢查對(duì)兒童疾病診斷和鑒別診斷的重要性。 熟悉兒童體格檢查的特點(diǎn)。 掌握兒童體格檢查的要點(diǎn)。尤其是新生兒和嬰幼兒體格檢查要點(diǎn)。,兒童體格檢查的重要性,兒科醫(yī)師的基本功（Basic skill） 醫(yī)療記錄重要的信息源 明確或排除診斷的重要依據(jù),5歲幼兒，出現(xiàn)發(fā)熱、進(jìn)行性面色蒼白和皮膚出血點(diǎn)，外周血象示“全血細(xì)胞減少”。 如體格檢查發(fā)現(xiàn)“脾大”，診斷急性白血病的可能性大。 體格檢查未發(fā)現(xiàn)“脾大”，診斷再生障礙性貧血的可能性大。,兒童體格檢查的特點(diǎn) PE in children: characteristics,兒童(尤其是嬰幼兒)往往懼怕醫(yī)院和醫(yī)生，把醫(yī)院看成“打針”的地方，把醫(yī)生看成“魔鬼”(monsters)。They just HATE it. 他們往往十分不安、恐懼和哭鬧(uneasy, fearful and crying)。 某些兒童甚至“故意”隱藏他們的癥狀。 查體往往不合作(uncooperative)。,兒童體格檢查方法和技巧,消除緊張，讓其放松 (Make them easy)。 與年長(zhǎng)兒進(jìn)行交談。 使用玩具逗嬰幼兒。 鼓勵(lì)或夸獎(jiǎng)孩子。 手法快速輕柔，暴露充分。 對(duì)不同年齡段的兒童采用不同的體位。 年長(zhǎng)兒檢查順序同成人 嬰幼兒則首先檢查易受哭鬧影響的項(xiàng)目(呼吸、脈搏、心臟聽(tīng)診和腹部捫診)，咽部等刺激性檢查最后進(jìn)行。,要有系統(tǒng)性，避免遺漏重要檢查項(xiàng)目。 注意陽(yáng)性體征和重要的陰性體征。 仔細(xì)觀察 (Be a watchful observer ).,兒童體格檢查的內(nèi)容和要點(diǎn),仔細(xì)觀察 (察言觀色),接觸患兒后立即仔細(xì)觀察。 對(duì)患兒的健康狀況形成“第一印象” (first impression) (對(duì)經(jīng)驗(yàn)豐富的醫(yī)師，第一印象非常重要，而且往往正確) 。 急性病、慢性病或急癥？ 診斷的重要依據(jù)。,一般情況,Many diagnoses can be made from an initial observation. Most endocrine diseases are diagnosed by first look.,General Appearance,myxedema,thyrotoxicosis,體形或體格 (Body Build),體重 肥胖 (Obesity) 消瘦 (Weight loss) 身高 身材矮小 (Turners syndrome, achondroplastic, hypopituitarism, Fanconi anemia) 身材高大 (Gigantism) 身材瘦高 (Marfans Syndrome),Marfans Syndrome,Fanconi Anemia,注意： 精神狀況(Mental status)：嗜睡，意識(shí)不清等。 體格發(fā)育情況。 營(yíng)養(yǎng)狀況。 姿勢(shì)和步態(tài)。 活動(dòng)情況：energetic, fatigue 面容： 黃疸或面色蒼白。,舉例,2歲幼兒，嚴(yán)重咳嗽。 煩躁不安（Restlessness） 呼吸急促（Tachypnea: air-hunger） 呼吸困難（Dyspnea）：三凹征（triple retractions） 發(fā)紺 （Cyanosis) 表明存在嚴(yán)重缺氧（低氧血癥), 提示可能存在肺炎或急性喉炎伴喉梗阻。,INSPECTION,General appearance Body build Mental Status Complexion and facial expression Respiration Nutritional status,捫診 PALPATION,皮膚 Skin 淋巴結(jié) Lymph nodes 前囟 Anterior fontanel 頸部 Neck 肢體和脊柱 Limbs and spine,體重測(cè)量：Rules of Thumb,6月：出生值 + 4.2 +（月齡-6）0.4 2歲后：年齡2+8,身長(zhǎng)測(cè)量: Rules of Thumb,出生平均值：50cm 6月：出生值+15+（月齡-6）1.5 2歲后：年齡7+70,頭圍測(cè)量: Rules of Thumb,出生平均值：34 cm 6月：6月值+ 24 cm 1歲平均值：46 cm 2歲平均值：48 cm 5歲平均值：50 cm,生命體征,呼吸頻率和脈搏,頻率：隨年齡增長(zhǎng)而逐漸降低。 形態(tài)：嬰幼兒以腹式呼吸為主；年長(zhǎng)兒 以胸式呼吸為主,呼吸,血壓測(cè)定,Systolic pressure=Age(years) 2 +80(mmHg) Diastolic Pressure23 of systolic P Hypertension: with systolic p