儿科病史采集和体格检查.ppt

儿科病史采集和体格检查 History-taking and Physical Examination for Children,Gao Ju, MD, PhD Professor of Pediatrics Department of Pediatrics West China Second University Hospital Sichuan University,主要内容,小儿病史特点及问诊技巧 History-taking: skills and approaches 小儿体格检查顺序及技术 PE: sequence and skills 小儿体格检查项目及要点 PE: major items and key points,临床医师(儿科医师）的主要任务： (Primary Aims are to establish) 患儿到底存在什么问题？(诊断） （What is wrong with the child?). 存在的问题对患者有什么影响？ (诊断） (How these problems impact on the patients life, medically, psychologically and socially, ect.) 如何解决存在的问题？（治疗） ( How to solve the problems?),为此目的，下一步该作什么？ Then, what should we DO next?,首先，必须收集资料或信息 (Firstly, Information Gathering) 详尽的病史采集 （Detailed HistoryTaking） 仔细的体格检查 （Meticulous Physical Exam） 相关的实验室检查 （Appropriate Lab Investigations）,然后，完成“最初的医学记录” （Formulating an Initial Medical Record） 详尽的病史采集和体格检查 诊疗计划(investigation and treatment plan) 并非“静止” (static) ，而为“动态”(dynamic)的过程，诊疗过程中收集的新信息应随时加入。,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，收集的资料是否充分和准确对于诊断和治疗极为重要。 The ACCURACY and ADEQUACY of information gathered is of pivotal importance for the precision of diagnosis and treatment,成人病史采集和体格检查 History-Taking and Physical Examination in Adults,病史采集 (History-taking) 一般介绍 (Introduction) 一般资料 (General Data) 主述(Chief Complaint) 现病史 (History of Present Illness) 过去史 (Past History) 系统回顾 (Systems Review) 个人史 (Personal History) 婚姻史 (Marital History) 家族史 (Family History),体格检查 (Physical Examination) 望诊 (Inspection) 扪诊 (Palpation) 扣诊 (Percussion) 听诊 (Auscultation),成人病史采集和体格检查 History-Taking and Physical Examination in Adults,尽管儿科病史采集和体格检查的基本原则与成人相同，但是方式(Manner), 顺序( Order)和重点(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,了解病史采集对儿童疾病诊断的重要性。 熟悉儿童与成人病史采用的主要差别。 掌握儿童病史采用和体格检查的要点。,儿科病史采集 History-Taking in Children,很多情况下，可仅通过病史采集明确诊断。 病史采集不准确和完整是误诊(misdiagnosis)和延误诊断(delayed diagnosis)的重要原因。 如何进行病史采集决定了所收集信息的质和量(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.,初学者面临的挑战 Apprentice: Challenges,不知如何接触患儿及其家长 （How to approach the patient or parents） 不知从何开始病史采集 （How to get started） 不知问些什么问题 （What kind of questions to ask） 不能抓住主要问题 （How to focus on the primary problem）,初学者面临的挑战 Apprentice: Challenges,不知如何结束病史采集(How to conclude)。 病史采集后不能形成一个完整的印象或初步诊断(whole story)。 They are uncomfortable, unconfident, shy and frustrated. They are just “passive” listener.,如何成为一个合格的病史采集者？ How to become a COMPETENT history taker？,Genuine children “lover” 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,病史采集的基本内容,自我介绍 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.,家长的信任和好感是医师获得准确病史的先决条件。除了举止友善、态度温和以外，夸奖孩子往往是拉近距离的最好途径。,一般资料 GENERAL DATA,姓名（Name） 年龄（Age） 性别（Gender） 出生地点（Place of inhabitancy） 民族（Race） 病史提供者（Informant, relationship to patient and history reliability） 通讯地址（Correspondence）,年龄,儿童与成人，以及不同年龄段儿童疾病谱(Disease spectrum)有所不同，年龄对儿童疾病的诊断极为重要。 婴幼儿多见先天畸形和遗传代谢性疾病 幼儿和学龄前儿童容易发生意外（accidents） 婴幼儿易发生佝偻病和IDA 生后24小时内发生的黄疸： 出生3天后发生的黄疸：,新生儿：精确到小时 写法：1天 65/24天 其他婴儿：精确到天 写法：72/30月 幼儿及以上：精确到月 写法：97/12岁,年龄的记录 Age Documentation,性别,是儿童病史采集中的重要内容之一。 某些疾病具有显著的性别分布差异。 性连锁遗传性疾病（sex-linked genetic disorders） 进行性肌营养不良（muscular dystrophy）：男性 蚕豆病（Favism）： 男性 血友病（Hemophilia A/B） ： 男性 其他疾病 甲状腺疾病：女性多见 SLE： 女性多见,民族和居住地,疟疾 (Malaria): 分布在热带和亚热带 (malaria belt)。 地中海贫血 (Thalassemia): 中国主要分布在长江以南的省分; 世界分布同疟疾(thalassemia belt) 。 地方性伯基特淋巴瘤(endemic Burkitts lymphoma): 非洲儿童最常见的恶性肿瘤。 镰形细胞性贫血 (sickle cell anemia) 黑热病：四川仅分布在阿坝州某些县 (汶川等)。,疟疾和地中海贫血的世界分布 (Malaria / Thalassemia Belts),地中海贫血 (Thalassemia),皮肤弹性过多症,Burkitts Lymphoma,病史提供者(informant),患儿家长或保育员：学龄前期及以下年龄 患儿或患儿家长：学龄期及以后年龄,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): 促使患者就医最突出的症状或体征，及其持续时间。 (the most disturbing symptom or sign, which promotes patient to medical care and its duration) 是诊断和鉴别诊断的重要线索，有时主述可直接指明诊断。 主述的记录应简明扼要 (clearly stated and concise)。 对患者提供的主述应进行客观分析和判断（Assess and judge）,现病史 HISTORY OF PRESENT ILLNESS,现病史(History of Present Illness, HPI) 是病史采集中最重要的内容（Main body and cornerstone of history）。 应反映出疾病发生发展的全貌（The whole course ，story or picture of present illness (panoramas, chain of events) 如何起病。 有无诱因。 如何进展。 对患者影响如何 (medically and psychologically) 既往诊治情况及其反应,症状的客观表现：如头痛、腹痛。 病情演化：从零散的叙述中找到时间脉络 主次症状：对一个系统疾病的多个系统表现进行归纳。 一般状况：小儿精神状况、食欲、睡眠、体力活动等情况客观反映病情，较成人更具诊断意义。,现病史的主要内容,起病 (onset): 急性起病或起病隐匿? 可为诊断提供重要线索。 例如： 仅持续1-2天的贫血：提示“急性溶血或急性失血”。 自幼起病，而且进行性加重，提示先天性或遗传性贫血（如地中海贫血）。,症状的客观表现（以发热为例） 明确病前体温是否正常? 热型如何？ 持续时间。 有无诱因或加重/缓解的因素? 如何进展或演进？ 有无伴随症状或并存症？ 重要阴性症状如何?(鉴别诊断的重要依据) 既往诊治情况如何？ 病后一般情况。,个儿史 PERSONAL HISTORY,个儿史包括： 出生史/分娩史（history of labor and delivery) 喂养史（feeding history） 生长发育史（growth and development） 免疫接种史（immunization）,成人患者，个儿史在过去史和系统回顾后采集，而儿童病例，则在现病史后采集。 个儿史对儿童，尤其是婴幼儿疾病的诊断具有十分重要的意义。,例如：3岁先天性心脏病（VSD）患儿，个 儿史应仔细询问： 母亲妊娠早期有无感染? 有无喂养困难、体重不增和喂养时呼吸困难？ 有无生长发育落后、营养状况差等。 有无 易疲乏和活动耐量降低。,过去史 PAST HISTORY,Past history is important to place the current illness in the context of past events, which are often related.,详尽的过去史有助于确定或排除诊断。 患儿存在发热和麻疹样皮疹： 如过去史明确表明既往曾累患麻疹，麻疹的诊断几乎不可能。 过去史表明存在蚕豆病，进食蚕豆或解热镇痛药物后发生急性血管内溶血（葡萄酒尿），几乎可以肯定诊断。,过去史的主要内容 既往疾病史（Past illnesses） 传染性和感染性疾病(麻疹、腮腺炎、肺炎、败血症等） 严重疾病（肾脏疾病、糖尿病、心脏疾病等） 意外/外伤或手术史 过敏史：食物和药物过敏史,系统回顾 SYSTEMS REVIEW,家族史 FAMILY HISTORY,家族历史对某些疾病的诊断具有十分重要的意义 遗传性疾病 进行性肌营养不良(DMD):某一家庭中 3个男孩均累患本病-family tragedy 蚕豆病(Favism): mostly in boys 血友病（Hemophilia A/B):英国皇室最为出名（Hemophilia A family aggregation in British royal family）,DMD: 腓肠肌假性肥大,Hemophilia,Hemophilia,Hemophilia,Hemophilic arthropathy,家族历史对某些疾病的诊断具有十分重要的意义 感染/传染性疾病 暴露于共同的环境不良因素 共同的遗传易感性 相似的生活条件或生活习惯,结语或总结 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. 首先必须热情、礼貌，举止和衣着端庄得体。(warm，polite, and well-mannered) 2. 对患者及其家长应尊敬、同情和理解。 (Be respectful, sympathetic and considerate) 3. 真正喜爱儿童、仔细的观察者和耐心的倾听者。(Genuine children “lover”, keen and watchful observer, attentive and patient listener.),4. 以“开放式提问”(open-ended questions)开始问诊。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. 耐心倾听患者或者家长讲述疾病发生发展的整个过程(gives patient or parents freedom to tell you the whole story)，切忌轻易打断患儿或家长的陈述 (never be a rude interruptor)，引起它们的不信任甚至反感 (distrust and antipathy)。 6. 避免“先入为主”(avoids your prejudices)。,7. 如陈述“离题太远”，应给予“引导” ( 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. 逐渐过渡到 “closed questions”， 以了解某些症状更为详尽的信息。例如： 活动时有无胸痛？ 餐后腹痛是否加重或减轻？ 9. 避免“诱导性提问”(leading questions)。 10. 对年长儿，尤其是teenagers，应让他们自己陈述病史。家长可适当补充相关信息，但绝对不能“主宰”病史陈述，除非患儿存在意识障碍等情况。(Parents should not dominate the interview)。,Children know their OWN problems better than their parents do!,11. 儿科急症多，病情危重时不宜过分强调采集完整病史资料，应重点问诊，且在查体时同步进行，以便尽快初诊并及时抢救。病情稳定后再补充问诊。 12. 收集病史时应有一定的系统性（systematic), 同时根据具体情况又有一定可变性（flexible）。 13. 对采集的现病史资料要进行“加工” (process)和“分析评估”(assess)，分清主次，形成一个完整的印象(integrated overview) 。 Good thinker and judger,儿童体格检查 Physical Examination in Children,目的和要求 Course Objectives,了解体格检查对儿童疾病诊断和鉴别诊断的重要性。 熟悉儿童体格检查的特点。 掌握儿童体格检查的要点。尤其是新生儿和婴幼儿体格检查要点。,儿童体格检查的重要性,儿科医师的基本功（Basic skill） 医疗记录重要的信息源 明确或排除诊断的重要依据,5岁幼儿，出现发热、进行性面色苍白和皮肤出血点，外周血象示“全血细胞减少”。 如体格检查发现“脾大”，诊断急性白血病的可能性大。 体格检查未发现“脾大”，诊断再生障碍性贫血的可能性大。,儿童体格检查的特点 PE in children: characteristics,儿童(尤其是婴幼儿)往往惧怕医院和医生，把医院看成“打针”的地方，把医生看成“魔鬼”(monsters)。They just HATE it. 他们往往十分不安、恐惧和哭闹(uneasy, fearful and crying)。 某些儿童甚至“故意”隐藏他们的症状。 查体往往不合作(uncooperative)。,儿童体格检查方法和技巧,消除紧张，让其放松 (Make them easy)。 与年长儿进行交谈。 使用玩具逗婴幼儿。 鼓励或夸奖孩子。 手法快速轻柔，暴露充分。 对不同年龄段的儿童采用不同的体位。 年长儿检查顺序同成人 婴幼儿则首先检查易受哭闹影响的项目(呼吸、脉搏、心脏听诊和腹部扪诊)，咽部等刺激性检查最后进行。,要有系统性，避免遗漏重要检查项目。 注意阳性体征和重要的阴性体征。 仔细观察 (Be a watchful observer ).,儿童体格检查的内容和要点,仔细观察 (察言观色),接触患儿后立即仔细观察。 对患儿的健康状况形成“第一印象” (first impression) (对经验丰富的医师，第一印象非常重要，而且往往正确) 。 急性病、慢性病或急症？ 诊断的重要依据。,一般情况,Many diagnoses can be made from an initial observation. Most endocrine diseases are diagnosed by first look.,General Appearance,myxedema,thyrotoxicosis,体形或体格 (Body Build),体重 肥胖 (Obesity) 消瘦 (Weight loss) 身高 身材矮小 (Turner's syndrome, achondroplastic, hypopituitarism, Fanconi anemia) 身材高大 (Gigantism) 身材瘦高 (Marfans Syndrome),Marfans Syndrome,Fanconi Anemia,注意： 精神状况(Mental status)：嗜睡，意识不清等。 体格发育情况。 营养状况。 姿势和步态。 活动情况：energetic, fatigue 面容： 黄疸或面色苍白。,举例,2岁幼儿，严重咳嗽。 烦躁不安（Restlessness） 呼吸急促（Tachypnea: air-hunger） 呼吸困难（Dyspnea）：三凹征（triple retractions） 发绀 （Cyanosis) 表明存在严重缺氧（低氧血症), 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,扪诊 PALPATION,皮肤 Skin 淋巴结 Lymph nodes 前囟 Anterior fontanel 颈部 Neck 肢体和脊柱 Limbs and spine,体重测量：Rules of Thumb,6月：出生值 + 4.2 +（月龄-6）×0.4 2岁后：年龄×2+8,身长测量: Rules of Thumb,出生平均值：50cm 6月：出生值+15+（月龄-6）×1.5 2岁后：年龄×7+70,头围测量: Rules of Thumb,出生平均值：34 cm 6月：6月值+ 24 cm 1岁平均值：46 cm 2岁平均值：48 cm 5岁平均值：50 cm,生命体征,呼吸频率和脉搏,频率：随年龄增长而逐渐降低。 形态：婴幼儿以腹式呼吸为主；年长儿 以胸式呼吸为主,呼吸,血压测定,Systolic pressure=Age(years) ×2 +80(mmHg) Diastolic Pressure23 of systolic P Hypertension: with systolic pressure 20 mmHg of normal upper limits Extended pulse pressure: PDA, aortic insufficiency,皮肤和皮下脂肪,皮肤 颜色 面色苍白： 贫血 黄疸：溶血，肝脏疾病等 发绀： 呼吸系统、心血管系统或中枢神经系统疾病 皮疹： 出血性或充血性皮疹 出血点（petechiae）：直径 5mm 皮肤弹性 （turgor）: 反映有无脱水的重要体征,海绵状血管瘤,Cough, running nose, photophobia, lacrimination and conjunctivitis,Conjunctivitis,Koplik spot: white spot inside the mouse,Measles pharyngitis in an adult,Measles face,Measles eruption,Characteristic red blotchy pattern on child's buttocks during third day of the measles rash,Head and shoulders of boy with measles,Measles eruption,Roseola,Scarlet Fever,Diffuse and finely papular rash with “goose-flesh” texture on an erythematous base,Chickenpox,Chickenpox,Kawasaki Disease,Kawasaki Disease,Kawasaki Disease-peeling,Kawasaki Disease-coronary artery,蚕豆病-血红蛋白尿,淋巴结,淋巴结,面容,颅骨,caput quadratum,pressure alopecia,前囟（1.52cm）,前囟： 12-18个月闭合；后囟： 3个月左右闭合 ；骨缝：6个月闭合。,扁桃体,扁桃体,增殖体,腭扁桃体是一对扁卵圆形的淋巴器官，位于口咽外侧壁在腭咽弓和腭舌弓之间的三角形扁桃体窝内。 增殖体位于鼻咽顶壁与后壁交界处，类似半个剥了皮的橘子，生后逐渐长大，57岁时达高峰，15岁后逐渐萎缩。,腭扁桃体,胸腔,funnel chest,pigeon chest,Harrison's groove,Rib rosary,呼吸频率、节律及方式 呼吸困难 注意事项： 小儿胸壁薄，听诊时呼吸音比成人响 哭闹时听诊在哭后吸气时进行 重点听诊区在肺底、腋下及肩胛区,肺脏,望诊：心尖搏动位置、强度及弥散程度,心脏,叩诊：心界 小儿心脏一般只叩左右界，5岁以上叩全心界。,正常心界,扪诊,震颤的意义 先心病震颤常见部位,听诊,心音低钝与心音遥远 心脏杂音分类与分级,听诊,ASD,PS,PDA,VSD,脊柱,Kyphosis 脊柱后凸,Scoliosis 脊柱侧弯,肢体,Bowleg,X-Leg,Hand bracelet,Leg bracelet,新生儿体格检查,Term baby,Premature baby,rooting reflex,Sucking reflex,Moro reflex,Thanks,