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  1. 1. Clinical Diagnostics Department of gastroenterology Ren-Ji hospital Shanghai Jiao Tong University, School of Medicine Ran Zhi Hua ( 冉志华)
  2. 2. <ul><li>Fundamental theory </li></ul><ul><li>基础理论 / 知识 </li></ul><ul><li>Techniques of diagnosing disease </li></ul><ul><li>诊断疾病的技术 </li></ul><ul><li>Mode of clinical thinking </li></ul><ul><li>临床思维的方式 </li></ul>What is Clinical Diagnostics?
  3. 3. <ul><li>Instruct a concise logical approach to recognize </li></ul><ul><li>the genius of the diseases </li></ul><ul><li>教会一种简明而又合乎逻辑的步骤去识别疾 </li></ul><ul><li>病的本质 </li></ul><ul><li>A fundamental course of clinical medicine </li></ul><ul><li>临床医学的基本课程 </li></ul>What is Clinical Diagnostics?
  4. 4. Fundamental elements of Diagnostics Diagnosis Identification Analysis
  5. 5. Diagnosis (诊断) Derived from Greek words distinguish or discern 识别 / 鉴别 认识 ☆
  6. 6. English term Diagnostic The distinguishing sign and symptoms with which it gerenally begins, continues and goes off…as it were, a history of the disease 对疾病特征的识别及对疾病的诊断 In 18th century: Nosography (病情学) 通过疾病的表现来识别疾病内在本质或属性 ☆ ☆
  7. 7. In modern usage: Identification of a disease by investigation of its signs and symptoms Medical terminology: Clinical diagnosis Laboratory diagnosis X-ray diagnosis Electrocardiographic diagnosis Gene diagnosis ☆ ☆
  8. 8. Identification: ( 识别 ) Inquiry Physical examination Laboratory tests/Special examination Analysis: ( 分析 ) Basic knowledge of medicine Overall analysis Scientific way of clinical thinking
  9. 9. Importance of Diagnostics Essential ( 基础) Bridge (桥梁) Tools (工具) Basic courses Clinical medicine
  10. 10. Content of Clinical Diagnostics Symptomatic diagnosis ( 症状诊断 ) Physical diagnosis ( 检体诊断 ) Laboratory tests or clinical ancillary tests Medical record Diagnostic processes and the way of clinical thinking
  11. 11. Symptomatic Diagnosis History taking (病史采集 )--- Interview ( 问诊) Symptoms ( 症状) --- patient‘s complaints ( 主诉 ) Symptomatic Diagnosis ( 症状诊断 )
  12. 12. Symptomatic Diagnosis Subjective sensation that patient describes Fever Cough Rash Mass Physiological & functional Pathological & morphological Symptom (症状)
  13. 13. Physical Diagnosis Abnormality observed by the physician Sign (体征) Physical examination (体格检查) Inspection ( 望 ) Palpation ( 触 ) Percussion ( 叩 ) Auscultation ( 听 ) Conducted with thoroughness, alertness to detect even slight derivations from normal
  14. 14. Laboratory test or ancillary tests <ul><li>Serum, Urine, Stool tests </li></ul><ul><li>X-ray film </li></ul><ul><li>EKG </li></ul><ul><li>Endoscopy </li></ul><ul><li>Ultrasonic imaging </li></ul><ul><li>CT </li></ul><ul><li>MRI </li></ul><ul><li>PET (Positron Emission Tomography) </li></ul>
  15. 15. 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
  16. 16. Special terms in clinical diagnosis Impression ( 初步印象) Tentative diagnosis (可能性诊断) Differential diagnosis (鉴别诊断) Evidence based medicine (循证医学)
  17. 17. Differential diagnosis <ul><li>Preliminary diagnosis/Tentative diagnosis </li></ul><ul><li>初步诊断 可能性诊断 </li></ul><ul><li>Exclusion of other diseases ( 排除其它疾病 ) </li></ul><ul><li>Selecting a number of possibilities to explain the clinical and laboratory findings in the case in question </li></ul><ul><li>The way of exclusion is called Differential diagnosis </li></ul>
  18. 18. Evidence based medicine It is the conscientious (谨慎的) , explicit (明确的) and judicious (有见解的) use of current best evidence in making decisions about the care of the individual patient It means integrating individual clinical expertise (临床专长) with the best available external clinical evidence from systematic research
  19. 19. Evidence based medicine <ul><li>One need to: </li></ul><ul><li>Be conscientious: it requires effort and thought. </li></ul><ul><li>Be explicit: decisions will need to be backed up by good evidence </li></ul><ul><li>Relate to specific problems: it is not about a hypothetical </li></ul><ul><li>&quot;average&quot; case. </li></ul><ul><li>Integrate individual clinical experience: it does not denigrate </li></ul><ul><li>clinical skills in history taking, examination and diagnosis. </li></ul><ul><li>Look for current best evidence: the perfect study may not yet have </li></ul><ul><li>been published, written up or even commenced. We may have to </li></ul><ul><li>settle for something less rigorous, but be on the look out for new </li></ul><ul><li>research that will supersede older studies. </li></ul>
  20. 20. Important aspects---interrogation <ul><li>To get the history in detail of a patient’s illness </li></ul><ul><li>The history is taken at initial contact between </li></ul><ul><li>physician and patient </li></ul><ul><li>As some crucial points might be overlooked by the patients, one will </li></ul><ul><li>ask many searching questions to make the history more informative </li></ul><ul><li>and complete, who must at the same time avoid suggesting answers </li></ul><ul><li>Occasionally to interrogate his family member </li></ul>
  21. 21. Other important aspects <ul><li>The diagnostic process is very complex </li></ul><ul><li>The number of facts that can be collected in a detailed medical history and in thorough physical examination are almost without limit </li></ul><ul><li>The laboratory tests or specialized technical procedures that can employed are numerous and costly </li></ul>
  22. 22. Other important aspects <ul><li>Questions for interrogation, maneuver in P.E., laboratory test should be thoughtfully selected with the view to eliminate some of the possible diagnosis and guide the search expeditiously to a specific disease </li></ul><ul><li>Method of approaching a diagnosis: </li></ul><ul><li>Analysis of symptoms ( 症状分析 ) </li></ul><ul><li>Recognition of the syndrome ( 综合症识别 ) </li></ul><ul><li>Consideration of disease mechanisms ( 考虑疾病机制 ) </li></ul>
  23. 23. Important aspects <ul><li>Modern & advanced ancillary techniques: </li></ul><ul><li>have their limitations. </li></ul><ul><li>It can’t reduced the importance of certain parts </li></ul><ul><li>of the classic P. E </li></ul><ul><li>It should be avoided to neglect fundamental </li></ul><ul><li>methods </li></ul><ul><li>Interrogation </li></ul><ul><li>Physical examination </li></ul><ul><li>Scientific clinical thinking </li></ul>
  24. 24. Approaches Basic knowledge learning (基础知识的学习) Clinical practice (临床实践) Bedside activity Standardized patient 床边实践 标准化病人
  25. 25. Developmental History of clinical diagnostics <ul><li>Western Medicine: from ancient to modern </li></ul><ul><li>Traditional Chinese Medicine </li></ul>
  26. 26. Contribution of ancient doctors---Western <ul><li>Hippocrates </li></ul><ul><li>Born on the island of Cos, </li></ul><ul><li>Greece (c. 460-377 BC) </li></ul><ul><li>The Father of medicine </li></ul><ul><li>Hippocratic oath </li></ul><ul><li>希波克拉底宣言 </li></ul><ul><li>Hippocratic corpus (文集) : </li></ul><ul><li>a collection of 70 works </li></ul>
  27. 27. Hippocratic oath
  28. 28. Contribution of ancient doctors---Western <ul><li>Galen </li></ul><ul><li>c.130-c.200 </li></ul><ul><li>His work in </li></ul><ul><li>anatomy/physiology is notable </li></ul><ul><li>Identified artery and vein </li></ul><ul><li>Added greatly to knowledge of the </li></ul><ul><li>brain, spinal cord and pulse </li></ul>
  29. 29. Contribution of ancient doctors---Western <ul><li>Auenbrugger </li></ul><ul><li>Born at the village of Graz, Austria (1722) </li></ul><ul><li>Son of an innkeeper </li></ul><ul><li>The working experiences helped him to find </li></ul><ul><li>Percussion </li></ul><ul><li>Author of <Inventum Novum>(1761) </li></ul><ul><li>translated as ‘ On Percussion of the chest ’ in 1936 </li></ul>
  30. 30. Contribution of ancient doctors---Western <ul><li>Laennec RTH </li></ul><ul><li>A French physician </li></ul><ul><li>Invented Auscultation and stethoscope </li></ul>
  31. 31. Contribution of ancient doctors---Western Laennec RTH 1816
  32. 32. Contribution of Western Physician 17th~19th century Leenwenhock Microscopy (end of 17th century) Fahrenheit Thermometer (1724)( 体温计 ) Ludwig Hematomanometer (1847)( 血压计 ) Welcher Hematinometer (1854) ( 血细胞计数仪 ) 20th century X-ray film EKG Endoscopy CT PET
  33. 33. Ultrasonic imaging
  34. 34. CT imaging
  35. 35. MRI
  36. 36. PET
  37. 37. Traditional Chinese Medicine Wood Fire Earth Metal Water
  38. 38. Contribution of ancient doctors---Chinese Inspection Interrogation Smell Pulse palpation 《内经》
  39. 39. Pay attention to: Good medical ethics Attach importance to clinical practice Unit theory with practice
  40. 40. Goals <ul><li>Inquiry: </li></ul><ul><li>Independent systemic inquiry </li></ul><ul><li>Comprehensive understanding of patient’s chief </li></ul><ul><li>complains, signs, symptoms and their interrelation </li></ul><ul><li>Physical Examination: </li></ul><ul><li>Systemic/thorough </li></ul><ul><li>Familiar with routine tests, EKG manipulation and figure </li></ul><ul><li>analysis </li></ul><ul><li>Good case writing and propose the primary diagnosis </li></ul><ul><li>Scientific clinical thinking </li></ul>