中国卫生标准管理
中國衛生標準管理
중국위생표준관리
CHINA HEALTH STANDARD MANAGEMENT
2015年
10期
56-57
,共2页
病史%体检及辅助检查%内科疾病
病史%體檢及輔助檢查%內科疾病
병사%체검급보조검사%내과질병
History%Physical examination and auxiliary examination%Department of internal medicine disease
目的：探讨内科门诊患者的病史、体格检查及辅助检查对疾病诊断的意义。方法将我院内科门诊的185例患者纳入本研究。所有患者由同一位主治医师进行病史询问、体格检查及辅助检查，同时做出诊断信心评分。12个月后由两位内科副主任医师重新复习病历资料，根据随访结果做出最终诊断。结果120例（70.59%）通过询问病史得到的初步诊断与最终诊断一致。21例（12.35%）患者通过体格检查得到的初步诊断与最终诊断一致，24例（14.12%）患者通过辅助检查得到的初步诊断与最终诊断一致。5例患者通过随访得到最终诊断与最初诊断不一致。信心指数分别是（7.24±1.32）、（7.89±1.18）、（8.57±0.72）。结论病史、体检及辅助检查三者缺一不可，临床工作者在借助辅助检查的基础上，关键是要有扎实的临床技能及沟通技能，优化医患关系的同时更好的服务于患者。
目的：探討內科門診患者的病史、體格檢查及輔助檢查對疾病診斷的意義。方法將我院內科門診的185例患者納入本研究。所有患者由同一位主治醫師進行病史詢問、體格檢查及輔助檢查，同時做齣診斷信心評分。12箇月後由兩位內科副主任醫師重新複習病歷資料，根據隨訪結果做齣最終診斷。結果120例（70.59%）通過詢問病史得到的初步診斷與最終診斷一緻。21例（12.35%）患者通過體格檢查得到的初步診斷與最終診斷一緻，24例（14.12%）患者通過輔助檢查得到的初步診斷與最終診斷一緻。5例患者通過隨訪得到最終診斷與最初診斷不一緻。信心指數分彆是（7.24±1.32）、（7.89±1.18）、（8.57±0.72）。結論病史、體檢及輔助檢查三者缺一不可，臨床工作者在藉助輔助檢查的基礎上，關鍵是要有扎實的臨床技能及溝通技能，優化醫患關繫的同時更好的服務于患者。
목적：탐토내과문진환자적병사、체격검사급보조검사대질병진단적의의。방법장아원내과문진적185례환자납입본연구。소유환자유동일위주치의사진행병사순문、체격검사급보조검사，동시주출진단신심평분。12개월후유량위내과부주임의사중신복습병력자료，근거수방결과주출최종진단。결과120례（70.59%）통과순문병사득도적초보진단여최종진단일치。21례（12.35%）환자통과체격검사득도적초보진단여최종진단일치，24례（14.12%）환자통과보조검사득도적초보진단여최종진단일치。5례환자통과수방득도최종진단여최초진단불일치。신심지수분별시（7.24±1.32）、（7.89±1.18）、（8.57±0.72）。결론병사、체검급보조검사삼자결일불가，림상공작자재차조보조검사적기출상，관건시요유찰실적림상기능급구통기능，우화의환관계적동시경호적복무우환자。
Objective To explore the significance of medical history,physical examination and auxiliary examination for disease diagnosis of internal medicine outpatients. Methods Selected 185 cases of patients in internal medicine clinic. Al patients were asked history,examined physical and auxiliary by the same physician. Then the physician made the diagnosis confidence scores. After 12 months,two internal medicine of doctors of vice director reviewed the medical records,and made the final diagnosis according to the results of the fol ow-up. Results The number of the consistent about primary diagnosis through the inquiry medical history with final diagnosis was 120(70.59%). The number of the consistent about primary diagnosis by physical examination with final diagnosis was 21(12.35%). The number of the consistent about Primary diagnosis by auxiliary examination with final diagnosis was 24(14.12%). Fol ow-up found primary diagnosis and final diagnosis of 5 cases were different. The confidence scores were respectively(7.24±1.32)、(7.89±1.18)and(8.57±0.72). Conclusion Medical history,physical examination and auxiliary examination are essential. On the basis of with the aid of auxiliary examination,clinical staff key master the solid clinical skil s and communication skil s,optimize the doctor-patient relationship and better serve the patients.
