The writing of clinical record
A patient’s health record plays many important roles,
? It provides a view of the patient’s health history/status
? It serves as the legal document describing the healthcare
services provided to the patient
? It provides a method for clinical communication and care
planning among the individual healthcare practitioner
serving the patient
The writing of clinical record
? It documents and substantiates the patient’s clinical care
and serves as a key source of data for outcomes research
and public health purposes
? It provides as a major resource for healthcare practitioner
education
? It serves to document evidence of the quality of patient
care
The basic requirement of clinical
records
In writing up the history and the physical examination,the
examiner should obey the following rules,
? Record all pertinent data,avoid extraneous data
? Use standard format
? Describe comprehensively,use common terms,avoid
nonstandard abbreviations
? Written in an all-round way,all items should be filled,
the hand writing should be clear,not scratchy or be
altered
? Be objective,use diagram when indicated
Special precautions
? The patient’s medical records is a legal document
? Comments regarding the patient’s behavior and attitudes
should not be part of the record unless they are important
from a medical or scientific standpoint
? A statement such as,the examination of the eyes is
normal” is much less accurate than,the fundus is normal”
? In the first case,it is not clear whether the examiner
actually attempted to look at the fundus
Types,formats and contents of
clinical records
Clinical records during
hospitalization
? The clinical records should be written during hospitalization
? It includes,
Case record
First record of admission
Record of the course of disease
Record of consultation
Record for transferring to new department
Record of discharge
Record of death
Record of surgery
Case record
The case record should be written systemically and
completely within 24 h by intern
Formats and contents of case
record
? Case record
Name Sex
Age Marital status
Nation Profession
Native place Current address
Data of admission Data of case record
Source Reliability
? Chief compliant
? History of present illness
? Past illness
? Systemic review
? Personal history
? Marriage
? Reproductive and Gynecologic history
? Family history
Physical examination
Temperature Pulse Respiratory Blood Pressure
? General appearance,
development,
nutrition (well,moderate,poor)
facial expression (acute or chronic,suffering expression,anxiety,
fear,calm)
position,gait and mental status (alert,obscure,lethargy,coma);
cooperative
Physical examination
Skin and mucous,
color (reddish,paler,cyanosis,yellowish,pigmentation)
swelling,moisture,elasticity,bleeding,rashes,subcutaneous
nodular,spider angioma,ulceration,scar,
The location,size and shape should be recorded,
Lymph note,
systemic or localized lymph notes (submaxillary,
posterior auricular,neck,armpit,groin),
Its size,number,tenderness,hardness,mobility,fistula,sacr etc,
Physical examination
Head and organs
Head,its size,shape,tenderness,mass,hair
Eye,eyebrow,eyelash,eyelid,eyeball (protrude,sunk,movement,
tremble,strabismus),conjunctiva,sclera,cornea (size,shape,
symmetry,light reflex,near reflex),
Ear,discharge,hearing,mastoid,
Nose,abnormality; tenderness of maxillary sinus,ethmoid sinus,
frontal sinus; exudation,bleeding,
Physical examination
?Oral cavity,odor,lips (color,swelling,ulceration,herpes simplex,
pigmentation); teeth; gingival; tongue (mass,ulceration,
coating of the tongue,mucus (rash,bleeding,ulceration);
tonsils; pharynx etc,
?Neck,symmetry; texture (slightly flexed and cradled in the
examiner’s hands); thyroid gland (size,hardness,
tenderness,nodular,tremble,murmur); superficial venous
distention; the position of the trachea,
Physical examination
?Chest,configuration; symmetry; local protrude; tenderness;
respiratory rate and pattern; abnormal pulsate;
breast (size,mass); venous distention
? Lung,
Inspection,respiratory movement; interspace of ribs;
Palpation,the extent of chest excursion; vocal fremitus;
Speech creates vibrations that can be heard when one
listens to the chest and lungs,These vibrations are
termed vocal fremitus,When one palpates the chest wall
while an individual is speaking,these vibrations can be
felt and are termed tactile fremitus,Pleura friction;
subcutaneous crepitus,
Physical examination
? Percussion,resonance; tympany; hyperresonance; dullness;
flatness; diaphragmatic movement
? Ausculatation,breath sounds
(tracheal,bronchial,bronchovesicular,vesicular)
Physical examination
? Heart,
Inspection,apical impulse,or its location,area and intensity
Palpation,assessing point of maximum impulse,thrills,fremitus
Percussion,percuss the heart’s borders,the relative dullness or
absolute dullness borders
Auscultation,the heart rates,rhythm,heart sounds,murmur,
abnormalities of the S1,S2,splitting of S2,systolic
clicks,diastolic opening snaps,vocal fremitus,
premature beats
Physical examination
? Radial artery,pulse rate,rhythm (regular or irregular),
pulse deficit,
The pulse may be described as normal,diminished,
increased,or double-peaked,
? Peripheral vascular signs,capillary strike signs,bruits,
abnormal artery movement,
Abdomen
? Inspection,symmetry,size,abdominal distention,
abdominal striae,pitting (concave abdomen),
respiratory movement,skin lesion,
pigmentation,surgical scar,umbilicus,hernia,
body hair,venous distention and direction of
blood flow,peristaltic waves; ecchymoses
? Palpation,the tenderness of abdominal wall,rebound
tenderness,mass (location,size,shape,texture,
tenderness,motion,mobility)
Abdomen
? Liver,size,character,surface,edge,tenderness,motion,
? Gallbladder,size,shape,tenderness
? Spleen,size,character,tenderness,surface,edge
? Kidney,size,shape,character,tenderness,mobility
? Bladder,distention,costovertebral angle tenderness
Abdomen
? Percussion,liver dullness borders,hepatic tenderness over
the right upper quadrant,shifting dullness
? Auscultation,bowel sounds,vascular bruits
?Anus and rectum,anal fissure,anal fistula,pile,digital
rectal examination,
Genitalia
? Male,penis,testicles,epididymis,glans penisseminal
vesicle,pubes
? Female,
(external) pubes,vagina,urethral meatus,hymen,labia
minora,labia majora,clitoris,
(internal) ovary,uterus,fallopian tube
Physical examination
? Spine,tenderness,abnormal spinal extension/ratation,
lateral deviation
? Extremities,deformity,venous distention,stiffness,
limitation of motion,joint,strength
? Nervous system,
biceps tendon reflex,triceps tendon reflex,patellar
tendon reflex,Achilles tendon reflex,abdominal
superficial reflex,cremasteric superficial reflex
test for abnormal reflexes (e.g.,babinski sign,
chaddock’s sign,hoffmann’s sign)
? Specialized subject,such as surgery,ophthalmology,
gynecology etc,
Physical examination
Laboratory and other special
examinations
? Laboratory tests,
record all those data that are associated with diagnosis,
including three routing tests and other laboratory tests
24 h after admission,
? Special exam,gastroscopy,barium enema,X-ray etc,
Summary
? Combining with the case history,physical examination and
laboratory data,propose the the evidences of diagnosis,and
final set up the diagnosis
?Preliminary diagnosis
? Signature or stamps
Common medical documents
? Record of admission
? Record of the course of disease
? Record of consultation
? Record for transferring to new department
? Record of discharge
? Record of death
? Others
Record of admission
? The record of admission is the abstract form of full case
record,The key points should be emphasized,and it
should be written concisely or compendiously,and
should be finished with 24 h after admission by resident,
? The chief complain and present illness are written in the
same form as full case record,the others could be
written in the short form,without the abstract,
? The format and content of record of admission
The format and content of record of
admission
? General information of the patient
? Chief complaint
? Present history of illness
? Past history in summary
? Physical examination
Vital signs
General appearance and systemic organs
Laboratory tests
? Preliminary diagnosis
? Signature
Record of the course of disease
? It records the progression and treatment of the whole
courses of patient’s disease during one’s admission,It
should be recorded with trueness,promptly,with
prospective analysis,It actually reflects the quality of
the medical treatment,
? It can be written once a day according to the changes of
the disease,For those severe cases,it should be written
several times per day,For those patients with mild
illness,however,it might be written every 2~3 day,
The content of records are
generally including
? The patient’s complains (about his/her discomfort,
moods,physiological status,food,sleep,relieve oneself,
those can be further selected according to the need for
the progression of the disease,
? The changes of disease,including signs and symptoms,
or any new discovery,the results of various laboratory
or other adjuvant examinations,the analysis,evaluations,
or remarks on those data,
The content of records are
generally including
? The records of various manipulations,such as plural
puncture,abdominal puncture,lumber puncture,
endoscopy,cardiac catheter exam,various radiography,
? Reinforce or amend the clinical diagnosis,amend the
evidences fur the diagnosis,
? The opinion of senior doctor about the diagnosis and
differential diagnosis,
? The treatment,drug use and its efficacy or side effects,
? Opinion of consultation of other department,
The content of records are
generally including
? Information from patient’s relatives (their hope,desire,
and reflection; the information that the doctor induced to
the patient’s relatives
? Monthly brief phase summary
? Time of record and signature
The first record of the course of
disease
? The first record of the course of the disease should be
recorded at the same day as admission,its content and
format are different from that of other record of course of
the disease,including
① patient’s name,sex,age,chief complain,prominent
signs and symptoms,results of those adjuvant
examination,that are highly summarize and
emphasizing the key profiles,
② Propose the preliminary diagnosis,differential
diagnosis and their evidences,based upon above data,
The first record of the course of
disease
③ Propose some other special examinations in order to
further confirm the diagnosis
④ Propose the treatment and diagnostic planning
according to the actual situation of patients’ illness on
admission
Record of consultation
? If the patient presents other system disease,or
symptoms difficult to diagnose,other specialist may be
invited for consultation,
? In general,the consultant opinion will be written in
consultant sheet,
? The consultant opinion includes brief description of case
record,specialized examinations,the analysis and
diagnosis of the disease,propose his opinion for further
more precise examinations,
Record of consultation
? If the opinions are collectively,record all those doctors
participating the consultation,their analysis,
examination,and treatment,
Record for transferring to new
department
? During the periods of hospitalization,the patient may
present symptoms of other systems (department),With
the approval of doctor of other department,the patient
can now be transferred to the new department,
? It can be written in the record of the course of deisase’s
sheet,
? The content may include the major cause of disease,
treatment,the reasons for transferring,the precaution
notes etc,
Record for transferring to new
department
? If the patient is transferred from other department,
resident should write the record of transferring,the
content of the record is similar to that of record of
admission,
Record of discharge
When the patient is going to be discharged,the record
of discharge should be written,and give to the patient on
the data of discharge,The content includes,
? Name,sex,age,diagnosis on admission,data of
admission,diagnosis on discharge,data of discharge,
days of hospitalization,
? Various numbers of special examination (number of
hospitalization,number of X-ray,CT,pathology,ECK
etc,
Record of discharge
? Briefly introduce the reason of admission,present
illness,the data of major examinations,the progression
and treatment of the disease during hospitalization,
? The condition of patient on discharge,including signs
and symptoms,results of major examination and
treatment (recover,improve,no effect,exacerbate,
complication,sequelae),
? The treatment advice on discharge,notes for precaution
Record of death
? The record of death should be recorded immediately
after death of patient,The content and format of death
record are similar to that of discharge record,It includes
case summary,hospitalization,diagnosis and treatment,
the causes for disease’s progression,the rescue course,
time of death,causes of death,and final diagnosis,
? For all death patients,particularly those cases the
diagnosis are uncertain,one should persuade the
relatives of death patient to perform the autopsy,the
anatomicalpathological results will be also recorded,
Others
? The routine medical documents also include summary
of preoperation,record of post-operation,record of
surgery etc,
? The format is consistent with the record of course of
disease,
? Summary of pre-operation may emphasize to record the
disease condition,reasons of operation,types of
operation,the possible complications/situations occurred
post-operation,and methods toward to these
complications,
Others
? Post-operation records should record the condition of
surgery,findings during surgery,name of surgery,
disease progression during surgery,types of anesthetics,
response of anesthetics,treatment advice for post-
operation etc,
? The record of surgery should be written by surgeon who
performed the surgery,
Others
? Its content include presurgery diagnosis,position,
methods of anesthesia,skin sterilization,position of
incision,name and length of incision,steps of surgery,
finding during operation,types of surgery,the changes
of patient’s condition,and methods of treatment,time
of the start and end of surgery,results of examination of
surgical specimens,
Case record of readmission
If the patient is readmitted,the number of admission
should be noted in the case record,It may also include the
following contents,
? If the patient is readmitted for the same disease,it is
necessary to record the case summary of the past and
the outcome of the disease between last discharge and
current readmission,Whilst the past history,systemic
review and personal history can be further summarized
or even be neglected,The new condition should be
added,
Case record of readmission
? If the patient suffered from a new disease,the case
record should be written according to the format of first
case record,The past disease can then be categorized
into past history or systemic review,
Table format of case record
Detailed in the text
Case record of out-patient
? It should be written with perspicuity,stressing on the
keystone
? The diagnosis can be made after the patient’s first visit
to physician or further consultation with the physician,
If the definite diagnosis can’t be made,the patient can
be treated as symptom causes unknown,such as
,abdominal pain causes unknown”,“fever of unknown
origin”,In addition,one or more suspected diagnosis
can also be made,
Case record of out-patient---
requirement
? In the department of emergency,the record should
include the precise time of consultation,Apart from the
present history of illness and most important signs,the
vital signs including BP,pulses,breath rates,
temperature,conscience,treatment regimes,and course
of treatment,If the treatment is failed,e.g.,the patient
died,time of death,diagnosis and causes of death
should be also included,
? Signature of the physician (hand writing,or stamp)
Case record of out-patient---
content
? The cover should be filled with patient’s name,sex,age,
marriage,profession,address,numbers of some
important examinations (such as X-ray,ECK,CT et al),
telephone number,drug allergy
? Day of the service
? Chief complaint
? History of illness (present,associated past history,
personal history or family history)
? Physical examination (positive signs and important
negative signs)
Case record of out-patient---
content
? Laboratory examinations or special examinations
? Preliminary diagnosis
? Treatment (further exams,drugs,time,suggestions)
? Signature
Further consultation
? Time of consultation
? Record the changes of those initial signs and symptoms
and the efficacy of the treatment
? To perfect the history
? Physical examination (focus on the initial positive signs
and new positive signs)
? To perfect the laboratory data
? To improve the diagnosis
? Treatment
? Signature
Diagnostic reasoning in physical
diagnosis
? This is one of the most important topics in the clinical
diagnosis,because it considers the methods and
concepts of evaluating the signs and symptoms involved
in diagnostic reasoning,
? The previous topics discuss the,science” of medicine
by explaining the techniques for interviewing and
performing the physical examination,
Diagnostic reasoning in physical
diagnosis
? The ability to make the,best” decision in the face of
uncertainty is the, art” of medicine,But there are rules
and standards for the practice of this art,and these are
the focus of topic
? The primary steps in the process involve the following
Data collection
Data processing
Problem list development
Data collection
? Data collection is the product of the history and the
physical examination,These can be augmented with
laboratory and other test results such as blood
chemistry profiles,complete blood counts,bacterial
cultures,electrocardiograms,and chest x-ray films,This
history,which is the most important element of the
database,accounts for more than 70% of the problem
list,
Data processing
? Data processing is the clustering of data obtained from
the history,physical examination,and laboratory and
imaging studies,
? It is rare for patients to have a solitary symptom or sign
of a disease,
? They more commonly complain of multiple symptoms,
and the examiner may find several related signs during
the physical examination,
Data processing
? It is the job of the astute observe to fit as many of these
clues together into a meaningful pathophysiologic
relationship,
? This is data processing,
Hypothesis
Impression
Primary diagnosis
Data processing
? For example,suppose the interviewer obtains a history
of dyspnea,cough,earache,and hemoptysis,Dyspnea,
cough,and hemoptysis can be grouped together as
symptoms suggestive of cardiopulmonary disease,
Earache does not fit with the other three symptoms and
may indicate another problem,
Problem list development
? Problem list development results in a summary of the
physical,mental,social,and personal conditions
affecting the patient’s health,
? The problem list may contain an actual diagnosis or
only a symptom or sign that cannot be clustered with
other bits of data,
? The data on which each problem developed is noted,
? This list reflects the clinician’s level of understanding of
the patient’s problem,which should be listed in order of
importance,
Problem list development
? The presence of a symptom or sign related to a specific
problem is a pertinent positive,
? For example,a history of gout and increased uric acid
level are pertinent positives in a man suffering from
excruciating back pain radiating to his testicle,
? This patient may be suffering from renal colic secondary to
a uric acid kidney stone,
Problem list development
? The absence of a symptom or sign that,if present,would
be suggestive of a diagnosis is a pertinent negative,
? A pertinent negative may be just as important as a
pertinent positive; the fact that a key finding is not present
may help rule out a certain diagnosis,
? For example,the absence of tachycardia in a women with
weight loss and a tremor makes a diagnosis of
hyperthyroidism less than likely; the presence of
tachycardia would strengthen the diagnosis of
hyperthyroidism
Diagnostic reasoning
? Unfortunately,decisions in medicine can be rarely be
made with 100% certainty
? Probability weights the decision
? Only if the cluster of symptoms,signs,and test results is
unequivocal can the clinician be certain of a diagnosis
? This does not occur often
? How,then,can the clinician make the,best” decision---
best in light of current knowledge and research?
Diagnostic reasoning
? Laboratory tests immediately come to mind,
? But signs and symptoms obtained from the patient’s
history and physical examination perform the same
function as laboratory tests,and the information and
results obtained from signs,symptoms,and tests are
evaluated in the same way and are subject to the same
rules and standards of evidence for diagnostic reasoning,
? And signs and symptoms actually account for more of
the developing problem list (>90%) than do laboratory
test results (<10%)
Others
? Sensitivity and Specificity
? Likelihood ratio
? Ruling in and Ruling out Disease
? Positive and Negative Predictive Values
? Prevalence
Decision analysis
? Diagnostic reasoning is only the first step in clinical
decision-making,
?After reaching a decision about a diagnosis,the clinician
must decide on a plan of treatment and management for
the particular patient,
?These decisions must take into account the probability
and utility (i,.e.,worth or value) of each possible
outcome of the treatment or management plan,given the
patient’s population (gender,age,ethnicity,inpatient or
outpatient,and so forth),
Decision analysis
? Similarly,the clinician may need to decide whether to
order laboratory tests to confirm a diagnosis only
suggested by the signs and symptoms elicited during the
clinical examination,
The ways of clinical thinking
? It refers the ways of investigation of disease,processing
the clinical data and making the decision etc,
? It is the basic method in the processes of clinical
diagnosis,
? It,however,reflexes the clinician’s abilities of clinical
diagnosis
? Two basic elements include in the ways of clinical
thinking,
clinical practice
scientifically clinical thinking
The steps of clinical thinking
? From Anatomical point of view,is there any
anatomical abnormality?
? From pathological point of view,is there any
functional changes?
? Based upon the pathophysiological point of view,
propose the possible mechanisms of
pathological changes and pathogenesis of the
disease
? Considering the possible causes of the disease
The steps of clinical thinking
? Considering the possible causes of the disease
? Evaluating the severity of the disease
? Proposing one or two special hypothesis
? Verifying the trueness of the hypothesis
? Considering the differential diagnosis based on
the special clustering of symptoms
? Focusing on the most possible diagnosis
? Proposing the further examination and treatment
The basic rules of clinical
thinking
? The rules of seeking the truth from facts
? The rules of monism
? The rules of using the prevalence and spectrum
of the disease to make the diagnostic decision
? The diagnosis of organic diseases is in priority,
the functional diseases are considered only those
organic diseases have been ruled out
The basic rules of clinical
thinking
? The curable diseases are in priority
? The rules of simplifying thinking procedure
? Evidence based medicine
The common causes of
misdiagnosis
? Incomplete and/or uncertain clinical data
? Rough observation or laboratory errors
? Subjective and groundless conclusion
? Lack of clinical experience
Types of clinical diagnosis
? Direct diagnosis
? Excluding diagnosis
? Differential diagnosis
Contents of clinical diagnosis
? Pathogenic diagnosis
? Anatomicopathological diagnosis
? Pathophysilogical diagnosis
? The diagnosis of complications
? The diagnosis of coincide diseases
A patient’s health record plays many important roles,
? It provides a view of the patient’s health history/status
? It serves as the legal document describing the healthcare
services provided to the patient
? It provides a method for clinical communication and care
planning among the individual healthcare practitioner
serving the patient
The writing of clinical record
? It documents and substantiates the patient’s clinical care
and serves as a key source of data for outcomes research
and public health purposes
? It provides as a major resource for healthcare practitioner
education
? It serves to document evidence of the quality of patient
care
The basic requirement of clinical
records
In writing up the history and the physical examination,the
examiner should obey the following rules,
? Record all pertinent data,avoid extraneous data
? Use standard format
? Describe comprehensively,use common terms,avoid
nonstandard abbreviations
? Written in an all-round way,all items should be filled,
the hand writing should be clear,not scratchy or be
altered
? Be objective,use diagram when indicated
Special precautions
? The patient’s medical records is a legal document
? Comments regarding the patient’s behavior and attitudes
should not be part of the record unless they are important
from a medical or scientific standpoint
? A statement such as,the examination of the eyes is
normal” is much less accurate than,the fundus is normal”
? In the first case,it is not clear whether the examiner
actually attempted to look at the fundus
Types,formats and contents of
clinical records
Clinical records during
hospitalization
? The clinical records should be written during hospitalization
? It includes,
Case record
First record of admission
Record of the course of disease
Record of consultation
Record for transferring to new department
Record of discharge
Record of death
Record of surgery
Case record
The case record should be written systemically and
completely within 24 h by intern
Formats and contents of case
record
? Case record
Name Sex
Age Marital status
Nation Profession
Native place Current address
Data of admission Data of case record
Source Reliability
? Chief compliant
? History of present illness
? Past illness
? Systemic review
? Personal history
? Marriage
? Reproductive and Gynecologic history
? Family history
Physical examination
Temperature Pulse Respiratory Blood Pressure
? General appearance,
development,
nutrition (well,moderate,poor)
facial expression (acute or chronic,suffering expression,anxiety,
fear,calm)
position,gait and mental status (alert,obscure,lethargy,coma);
cooperative
Physical examination
Skin and mucous,
color (reddish,paler,cyanosis,yellowish,pigmentation)
swelling,moisture,elasticity,bleeding,rashes,subcutaneous
nodular,spider angioma,ulceration,scar,
The location,size and shape should be recorded,
Lymph note,
systemic or localized lymph notes (submaxillary,
posterior auricular,neck,armpit,groin),
Its size,number,tenderness,hardness,mobility,fistula,sacr etc,
Physical examination
Head and organs
Head,its size,shape,tenderness,mass,hair
Eye,eyebrow,eyelash,eyelid,eyeball (protrude,sunk,movement,
tremble,strabismus),conjunctiva,sclera,cornea (size,shape,
symmetry,light reflex,near reflex),
Ear,discharge,hearing,mastoid,
Nose,abnormality; tenderness of maxillary sinus,ethmoid sinus,
frontal sinus; exudation,bleeding,
Physical examination
?Oral cavity,odor,lips (color,swelling,ulceration,herpes simplex,
pigmentation); teeth; gingival; tongue (mass,ulceration,
coating of the tongue,mucus (rash,bleeding,ulceration);
tonsils; pharynx etc,
?Neck,symmetry; texture (slightly flexed and cradled in the
examiner’s hands); thyroid gland (size,hardness,
tenderness,nodular,tremble,murmur); superficial venous
distention; the position of the trachea,
Physical examination
?Chest,configuration; symmetry; local protrude; tenderness;
respiratory rate and pattern; abnormal pulsate;
breast (size,mass); venous distention
? Lung,
Inspection,respiratory movement; interspace of ribs;
Palpation,the extent of chest excursion; vocal fremitus;
Speech creates vibrations that can be heard when one
listens to the chest and lungs,These vibrations are
termed vocal fremitus,When one palpates the chest wall
while an individual is speaking,these vibrations can be
felt and are termed tactile fremitus,Pleura friction;
subcutaneous crepitus,
Physical examination
? Percussion,resonance; tympany; hyperresonance; dullness;
flatness; diaphragmatic movement
? Ausculatation,breath sounds
(tracheal,bronchial,bronchovesicular,vesicular)
Physical examination
? Heart,
Inspection,apical impulse,or its location,area and intensity
Palpation,assessing point of maximum impulse,thrills,fremitus
Percussion,percuss the heart’s borders,the relative dullness or
absolute dullness borders
Auscultation,the heart rates,rhythm,heart sounds,murmur,
abnormalities of the S1,S2,splitting of S2,systolic
clicks,diastolic opening snaps,vocal fremitus,
premature beats
Physical examination
? Radial artery,pulse rate,rhythm (regular or irregular),
pulse deficit,
The pulse may be described as normal,diminished,
increased,or double-peaked,
? Peripheral vascular signs,capillary strike signs,bruits,
abnormal artery movement,
Abdomen
? Inspection,symmetry,size,abdominal distention,
abdominal striae,pitting (concave abdomen),
respiratory movement,skin lesion,
pigmentation,surgical scar,umbilicus,hernia,
body hair,venous distention and direction of
blood flow,peristaltic waves; ecchymoses
? Palpation,the tenderness of abdominal wall,rebound
tenderness,mass (location,size,shape,texture,
tenderness,motion,mobility)
Abdomen
? Liver,size,character,surface,edge,tenderness,motion,
? Gallbladder,size,shape,tenderness
? Spleen,size,character,tenderness,surface,edge
? Kidney,size,shape,character,tenderness,mobility
? Bladder,distention,costovertebral angle tenderness
Abdomen
? Percussion,liver dullness borders,hepatic tenderness over
the right upper quadrant,shifting dullness
? Auscultation,bowel sounds,vascular bruits
?Anus and rectum,anal fissure,anal fistula,pile,digital
rectal examination,
Genitalia
? Male,penis,testicles,epididymis,glans penisseminal
vesicle,pubes
? Female,
(external) pubes,vagina,urethral meatus,hymen,labia
minora,labia majora,clitoris,
(internal) ovary,uterus,fallopian tube
Physical examination
? Spine,tenderness,abnormal spinal extension/ratation,
lateral deviation
? Extremities,deformity,venous distention,stiffness,
limitation of motion,joint,strength
? Nervous system,
biceps tendon reflex,triceps tendon reflex,patellar
tendon reflex,Achilles tendon reflex,abdominal
superficial reflex,cremasteric superficial reflex
test for abnormal reflexes (e.g.,babinski sign,
chaddock’s sign,hoffmann’s sign)
? Specialized subject,such as surgery,ophthalmology,
gynecology etc,
Physical examination
Laboratory and other special
examinations
? Laboratory tests,
record all those data that are associated with diagnosis,
including three routing tests and other laboratory tests
24 h after admission,
? Special exam,gastroscopy,barium enema,X-ray etc,
Summary
? Combining with the case history,physical examination and
laboratory data,propose the the evidences of diagnosis,and
final set up the diagnosis
?Preliminary diagnosis
? Signature or stamps
Common medical documents
? Record of admission
? Record of the course of disease
? Record of consultation
? Record for transferring to new department
? Record of discharge
? Record of death
? Others
Record of admission
? The record of admission is the abstract form of full case
record,The key points should be emphasized,and it
should be written concisely or compendiously,and
should be finished with 24 h after admission by resident,
? The chief complain and present illness are written in the
same form as full case record,the others could be
written in the short form,without the abstract,
? The format and content of record of admission
The format and content of record of
admission
? General information of the patient
? Chief complaint
? Present history of illness
? Past history in summary
? Physical examination
Vital signs
General appearance and systemic organs
Laboratory tests
? Preliminary diagnosis
? Signature
Record of the course of disease
? It records the progression and treatment of the whole
courses of patient’s disease during one’s admission,It
should be recorded with trueness,promptly,with
prospective analysis,It actually reflects the quality of
the medical treatment,
? It can be written once a day according to the changes of
the disease,For those severe cases,it should be written
several times per day,For those patients with mild
illness,however,it might be written every 2~3 day,
The content of records are
generally including
? The patient’s complains (about his/her discomfort,
moods,physiological status,food,sleep,relieve oneself,
those can be further selected according to the need for
the progression of the disease,
? The changes of disease,including signs and symptoms,
or any new discovery,the results of various laboratory
or other adjuvant examinations,the analysis,evaluations,
or remarks on those data,
The content of records are
generally including
? The records of various manipulations,such as plural
puncture,abdominal puncture,lumber puncture,
endoscopy,cardiac catheter exam,various radiography,
? Reinforce or amend the clinical diagnosis,amend the
evidences fur the diagnosis,
? The opinion of senior doctor about the diagnosis and
differential diagnosis,
? The treatment,drug use and its efficacy or side effects,
? Opinion of consultation of other department,
The content of records are
generally including
? Information from patient’s relatives (their hope,desire,
and reflection; the information that the doctor induced to
the patient’s relatives
? Monthly brief phase summary
? Time of record and signature
The first record of the course of
disease
? The first record of the course of the disease should be
recorded at the same day as admission,its content and
format are different from that of other record of course of
the disease,including
① patient’s name,sex,age,chief complain,prominent
signs and symptoms,results of those adjuvant
examination,that are highly summarize and
emphasizing the key profiles,
② Propose the preliminary diagnosis,differential
diagnosis and their evidences,based upon above data,
The first record of the course of
disease
③ Propose some other special examinations in order to
further confirm the diagnosis
④ Propose the treatment and diagnostic planning
according to the actual situation of patients’ illness on
admission
Record of consultation
? If the patient presents other system disease,or
symptoms difficult to diagnose,other specialist may be
invited for consultation,
? In general,the consultant opinion will be written in
consultant sheet,
? The consultant opinion includes brief description of case
record,specialized examinations,the analysis and
diagnosis of the disease,propose his opinion for further
more precise examinations,
Record of consultation
? If the opinions are collectively,record all those doctors
participating the consultation,their analysis,
examination,and treatment,
Record for transferring to new
department
? During the periods of hospitalization,the patient may
present symptoms of other systems (department),With
the approval of doctor of other department,the patient
can now be transferred to the new department,
? It can be written in the record of the course of deisase’s
sheet,
? The content may include the major cause of disease,
treatment,the reasons for transferring,the precaution
notes etc,
Record for transferring to new
department
? If the patient is transferred from other department,
resident should write the record of transferring,the
content of the record is similar to that of record of
admission,
Record of discharge
When the patient is going to be discharged,the record
of discharge should be written,and give to the patient on
the data of discharge,The content includes,
? Name,sex,age,diagnosis on admission,data of
admission,diagnosis on discharge,data of discharge,
days of hospitalization,
? Various numbers of special examination (number of
hospitalization,number of X-ray,CT,pathology,ECK
etc,
Record of discharge
? Briefly introduce the reason of admission,present
illness,the data of major examinations,the progression
and treatment of the disease during hospitalization,
? The condition of patient on discharge,including signs
and symptoms,results of major examination and
treatment (recover,improve,no effect,exacerbate,
complication,sequelae),
? The treatment advice on discharge,notes for precaution
Record of death
? The record of death should be recorded immediately
after death of patient,The content and format of death
record are similar to that of discharge record,It includes
case summary,hospitalization,diagnosis and treatment,
the causes for disease’s progression,the rescue course,
time of death,causes of death,and final diagnosis,
? For all death patients,particularly those cases the
diagnosis are uncertain,one should persuade the
relatives of death patient to perform the autopsy,the
anatomicalpathological results will be also recorded,
Others
? The routine medical documents also include summary
of preoperation,record of post-operation,record of
surgery etc,
? The format is consistent with the record of course of
disease,
? Summary of pre-operation may emphasize to record the
disease condition,reasons of operation,types of
operation,the possible complications/situations occurred
post-operation,and methods toward to these
complications,
Others
? Post-operation records should record the condition of
surgery,findings during surgery,name of surgery,
disease progression during surgery,types of anesthetics,
response of anesthetics,treatment advice for post-
operation etc,
? The record of surgery should be written by surgeon who
performed the surgery,
Others
? Its content include presurgery diagnosis,position,
methods of anesthesia,skin sterilization,position of
incision,name and length of incision,steps of surgery,
finding during operation,types of surgery,the changes
of patient’s condition,and methods of treatment,time
of the start and end of surgery,results of examination of
surgical specimens,
Case record of readmission
If the patient is readmitted,the number of admission
should be noted in the case record,It may also include the
following contents,
? If the patient is readmitted for the same disease,it is
necessary to record the case summary of the past and
the outcome of the disease between last discharge and
current readmission,Whilst the past history,systemic
review and personal history can be further summarized
or even be neglected,The new condition should be
added,
Case record of readmission
? If the patient suffered from a new disease,the case
record should be written according to the format of first
case record,The past disease can then be categorized
into past history or systemic review,
Table format of case record
Detailed in the text
Case record of out-patient
? It should be written with perspicuity,stressing on the
keystone
? The diagnosis can be made after the patient’s first visit
to physician or further consultation with the physician,
If the definite diagnosis can’t be made,the patient can
be treated as symptom causes unknown,such as
,abdominal pain causes unknown”,“fever of unknown
origin”,In addition,one or more suspected diagnosis
can also be made,
Case record of out-patient---
requirement
? In the department of emergency,the record should
include the precise time of consultation,Apart from the
present history of illness and most important signs,the
vital signs including BP,pulses,breath rates,
temperature,conscience,treatment regimes,and course
of treatment,If the treatment is failed,e.g.,the patient
died,time of death,diagnosis and causes of death
should be also included,
? Signature of the physician (hand writing,or stamp)
Case record of out-patient---
content
? The cover should be filled with patient’s name,sex,age,
marriage,profession,address,numbers of some
important examinations (such as X-ray,ECK,CT et al),
telephone number,drug allergy
? Day of the service
? Chief complaint
? History of illness (present,associated past history,
personal history or family history)
? Physical examination (positive signs and important
negative signs)
Case record of out-patient---
content
? Laboratory examinations or special examinations
? Preliminary diagnosis
? Treatment (further exams,drugs,time,suggestions)
? Signature
Further consultation
? Time of consultation
? Record the changes of those initial signs and symptoms
and the efficacy of the treatment
? To perfect the history
? Physical examination (focus on the initial positive signs
and new positive signs)
? To perfect the laboratory data
? To improve the diagnosis
? Treatment
? Signature
Diagnostic reasoning in physical
diagnosis
? This is one of the most important topics in the clinical
diagnosis,because it considers the methods and
concepts of evaluating the signs and symptoms involved
in diagnostic reasoning,
? The previous topics discuss the,science” of medicine
by explaining the techniques for interviewing and
performing the physical examination,
Diagnostic reasoning in physical
diagnosis
? The ability to make the,best” decision in the face of
uncertainty is the, art” of medicine,But there are rules
and standards for the practice of this art,and these are
the focus of topic
? The primary steps in the process involve the following
Data collection
Data processing
Problem list development
Data collection
? Data collection is the product of the history and the
physical examination,These can be augmented with
laboratory and other test results such as blood
chemistry profiles,complete blood counts,bacterial
cultures,electrocardiograms,and chest x-ray films,This
history,which is the most important element of the
database,accounts for more than 70% of the problem
list,
Data processing
? Data processing is the clustering of data obtained from
the history,physical examination,and laboratory and
imaging studies,
? It is rare for patients to have a solitary symptom or sign
of a disease,
? They more commonly complain of multiple symptoms,
and the examiner may find several related signs during
the physical examination,
Data processing
? It is the job of the astute observe to fit as many of these
clues together into a meaningful pathophysiologic
relationship,
? This is data processing,
Hypothesis
Impression
Primary diagnosis
Data processing
? For example,suppose the interviewer obtains a history
of dyspnea,cough,earache,and hemoptysis,Dyspnea,
cough,and hemoptysis can be grouped together as
symptoms suggestive of cardiopulmonary disease,
Earache does not fit with the other three symptoms and
may indicate another problem,
Problem list development
? Problem list development results in a summary of the
physical,mental,social,and personal conditions
affecting the patient’s health,
? The problem list may contain an actual diagnosis or
only a symptom or sign that cannot be clustered with
other bits of data,
? The data on which each problem developed is noted,
? This list reflects the clinician’s level of understanding of
the patient’s problem,which should be listed in order of
importance,
Problem list development
? The presence of a symptom or sign related to a specific
problem is a pertinent positive,
? For example,a history of gout and increased uric acid
level are pertinent positives in a man suffering from
excruciating back pain radiating to his testicle,
? This patient may be suffering from renal colic secondary to
a uric acid kidney stone,
Problem list development
? The absence of a symptom or sign that,if present,would
be suggestive of a diagnosis is a pertinent negative,
? A pertinent negative may be just as important as a
pertinent positive; the fact that a key finding is not present
may help rule out a certain diagnosis,
? For example,the absence of tachycardia in a women with
weight loss and a tremor makes a diagnosis of
hyperthyroidism less than likely; the presence of
tachycardia would strengthen the diagnosis of
hyperthyroidism
Diagnostic reasoning
? Unfortunately,decisions in medicine can be rarely be
made with 100% certainty
? Probability weights the decision
? Only if the cluster of symptoms,signs,and test results is
unequivocal can the clinician be certain of a diagnosis
? This does not occur often
? How,then,can the clinician make the,best” decision---
best in light of current knowledge and research?
Diagnostic reasoning
? Laboratory tests immediately come to mind,
? But signs and symptoms obtained from the patient’s
history and physical examination perform the same
function as laboratory tests,and the information and
results obtained from signs,symptoms,and tests are
evaluated in the same way and are subject to the same
rules and standards of evidence for diagnostic reasoning,
? And signs and symptoms actually account for more of
the developing problem list (>90%) than do laboratory
test results (<10%)
Others
? Sensitivity and Specificity
? Likelihood ratio
? Ruling in and Ruling out Disease
? Positive and Negative Predictive Values
? Prevalence
Decision analysis
? Diagnostic reasoning is only the first step in clinical
decision-making,
?After reaching a decision about a diagnosis,the clinician
must decide on a plan of treatment and management for
the particular patient,
?These decisions must take into account the probability
and utility (i,.e.,worth or value) of each possible
outcome of the treatment or management plan,given the
patient’s population (gender,age,ethnicity,inpatient or
outpatient,and so forth),
Decision analysis
? Similarly,the clinician may need to decide whether to
order laboratory tests to confirm a diagnosis only
suggested by the signs and symptoms elicited during the
clinical examination,
The ways of clinical thinking
? It refers the ways of investigation of disease,processing
the clinical data and making the decision etc,
? It is the basic method in the processes of clinical
diagnosis,
? It,however,reflexes the clinician’s abilities of clinical
diagnosis
? Two basic elements include in the ways of clinical
thinking,
clinical practice
scientifically clinical thinking
The steps of clinical thinking
? From Anatomical point of view,is there any
anatomical abnormality?
? From pathological point of view,is there any
functional changes?
? Based upon the pathophysiological point of view,
propose the possible mechanisms of
pathological changes and pathogenesis of the
disease
? Considering the possible causes of the disease
The steps of clinical thinking
? Considering the possible causes of the disease
? Evaluating the severity of the disease
? Proposing one or two special hypothesis
? Verifying the trueness of the hypothesis
? Considering the differential diagnosis based on
the special clustering of symptoms
? Focusing on the most possible diagnosis
? Proposing the further examination and treatment
The basic rules of clinical
thinking
? The rules of seeking the truth from facts
? The rules of monism
? The rules of using the prevalence and spectrum
of the disease to make the diagnostic decision
? The diagnosis of organic diseases is in priority,
the functional diseases are considered only those
organic diseases have been ruled out
The basic rules of clinical
thinking
? The curable diseases are in priority
? The rules of simplifying thinking procedure
? Evidence based medicine
The common causes of
misdiagnosis
? Incomplete and/or uncertain clinical data
? Rough observation or laboratory errors
? Subjective and groundless conclusion
? Lack of clinical experience
Types of clinical diagnosis
? Direct diagnosis
? Excluding diagnosis
? Differential diagnosis
Contents of clinical diagnosis
? Pathogenic diagnosis
? Anatomicopathological diagnosis
? Pathophysilogical diagnosis
? The diagnosis of complications
? The diagnosis of coincide diseases
