DIAGNOSIS
CASE HISTORY AND
INQUIRY
WU SHUMING MD
Importance of Inquiry
Gaining clinical information and collecting
case history based on systemic inquiry
Base of clinical practice
60~80% diagnosis could be induced from
interview between patient and physician
New form,consultation by phone,in
internet
Successful treatment is reinforced by a
confidently established and maintained
doctor-patient relationship
benefits to patient`s compliance
benefits to improve doctor`s clinical skill
and confidence
世界医学教育联合组织
爱丁堡宣言（ 1988）
每个病人都有权利希望医生被训练成
为注意力集中的倾听者、仔细的观
察者、感情细腻的交谈者和高效的
临床医生。
OBJECTIVE OF INQUIRY
The medical interview serves three
functions,
to collect information,
to respond to the patient's emotional state,
to educate the patient and influence patient
behavior,
发 热
头痛 关节痛
咽喉痛
皮疹 腰背痛 咳嗽 小便 腹痛 热辐射
气急
咳痰
前倾
恶心
呕吐
眩晕
意识
病毒
感染
发疹性
疾病
尿感
肾盂
肾炎
中暑 急腹疹
肺炎支
气管炎 关节痛
病毒
感染
脑膜炎
脑炎 腹泻
胃肠炎
wsm,
腹 痛
类似
发作 腹泻
腰背部
放射痛
右季肋
部痛
烧灼痛伴
皮肤压痛
暴饮
暴食
疼痛
呕吐
发热
腹痛
腹块
胃肠炎
IBS 发热 胆石症 带状泡疹 皮肤过敏 胰腺炎 胃炎
肠梗阻
阑尾炎
穿孔
胆石症
肾盂
肾炎
尿石症
GERD
PU
FD
IBD
胆囊炎
CONTENTS
General item
Chief complain
Present his.,onset of
illness,characteristic of
main symptoms,etc
Past his,
Systemic review
Individual life
Marriage status
月经史生育史
家属史
METHODS &SKILL
Skill of communication
Suitable environment
Greeting patient
Active listener
Language & term
Non-language
communication
Ending talk
respect
Skill of collection
Emphasis chief complain
Opening & closing
questioning
Simple to complicate
Avoiding med,term
Avoiding irritable term
Skillful induce sensitive
topic
Kind & careful
Guiding Principles
Ethical principles that guide the successful
approach to diagnosis and treatment are honesty,
beneficence,justice,avoidance of conflict of
interest,and the pledge to do no harm,
Increasingly,Western medicine involves patients
in important decisions about medical care,
including how far to proceed with treatment of
patients with terminal illnesses
The importance of the empathic clinician in
helping patients and their families bear the
burden of serious illness and death cannot
be overemphasized,
"To cure sometimes,to relieve often,and to
comfort always"
"The secret of the care of the patient is in
caring for the patient."
?Discussing psychosocial issues and forgoing
clinician domination of the encounter increase
patient satisfaction,
?Any diagnostic procedures ordered at this time
should be chosen after consideration of the test
characteristics (sensitivity and specificity),disease
incidence and prevalence,potential risk,and cost-
benefit profile.,
CASE HISTORY AND
INQUIRY
WU SHUMING MD
Importance of Inquiry
Gaining clinical information and collecting
case history based on systemic inquiry
Base of clinical practice
60~80% diagnosis could be induced from
interview between patient and physician
New form,consultation by phone,in
internet
Successful treatment is reinforced by a
confidently established and maintained
doctor-patient relationship
benefits to patient`s compliance
benefits to improve doctor`s clinical skill
and confidence
世界医学教育联合组织
爱丁堡宣言（ 1988）
每个病人都有权利希望医生被训练成
为注意力集中的倾听者、仔细的观
察者、感情细腻的交谈者和高效的
临床医生。
OBJECTIVE OF INQUIRY
The medical interview serves three
functions,
to collect information,
to respond to the patient's emotional state,
to educate the patient and influence patient
behavior,
发 热
头痛 关节痛
咽喉痛
皮疹 腰背痛 咳嗽 小便 腹痛 热辐射
气急
咳痰
前倾
恶心
呕吐
眩晕
意识
病毒
感染
发疹性
疾病
尿感
肾盂
肾炎
中暑 急腹疹
肺炎支
气管炎 关节痛
病毒
感染
脑膜炎
脑炎 腹泻
胃肠炎
wsm,
腹 痛
类似
发作 腹泻
腰背部
放射痛
右季肋
部痛
烧灼痛伴
皮肤压痛
暴饮
暴食
疼痛
呕吐
发热
腹痛
腹块
胃肠炎
IBS 发热 胆石症 带状泡疹 皮肤过敏 胰腺炎 胃炎
肠梗阻
阑尾炎
穿孔
胆石症
肾盂
肾炎
尿石症
GERD
PU
FD
IBD
胆囊炎
CONTENTS
General item
Chief complain
Present his.,onset of
illness,characteristic of
main symptoms,etc
Past his,
Systemic review
Individual life
Marriage status
月经史生育史
家属史
METHODS &SKILL
Skill of communication
Suitable environment
Greeting patient
Active listener
Language & term
Non-language
communication
Ending talk
respect
Skill of collection
Emphasis chief complain
Opening & closing
questioning
Simple to complicate
Avoiding med,term
Avoiding irritable term
Skillful induce sensitive
topic
Kind & careful
Guiding Principles
Ethical principles that guide the successful
approach to diagnosis and treatment are honesty,
beneficence,justice,avoidance of conflict of
interest,and the pledge to do no harm,
Increasingly,Western medicine involves patients
in important decisions about medical care,
including how far to proceed with treatment of
patients with terminal illnesses
The importance of the empathic clinician in
helping patients and their families bear the
burden of serious illness and death cannot
be overemphasized,
"To cure sometimes,to relieve often,and to
comfort always"
"The secret of the care of the patient is in
caring for the patient."
?Discussing psychosocial issues and forgoing
clinician domination of the encounter increase
patient satisfaction,
?Any diagnostic procedures ordered at this time
should be chosen after consideration of the test
characteristics (sensitivity and specificity),disease
incidence and prevalence,potential risk,and cost-
benefit profile.,
