Clinical Diagnostics

Department of gastroenterology
Ren-Ji hospital
Shanghai Jiao Tong University, School of
Medicine

Ran Zhi Hua ( 冉志华）

 What is Clinical
Diagnostics?
• Fundamental theory
基础理论 / 知识
• Techniques of diagnosing disease
诊断疾病的技术
• Mode of clinical thinking
临床思维的方式
 What is Clinical
Diagnostics?
• Instruct a concise logical approach to recognize
the genius of the diseases
教会一种简明而又合乎逻辑的步骤去识别
疾
病的本质

• A fundamental course of clinical medicine

临床医学的基本课程
Fundamental elements of
Diagnostics

Diagnosis

Identificatio Analysis
n
 Diagnosis
（诊断）
☆ Derived from Greek words
distinguish or discern
识别 / 鉴别 认识
☆ 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

18th century: Nosography （病情

☆ In

学）
通过疾病的表现来识别疾病内在本质或属性
☆ 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
Identification: ( 识
别)
Inquiry
Physical examination
Laboratory tests/Special examination

Analysis: ( 分
析 ) Basic knowledge of medicine
Overall analysis
Scientific way of clinical thinking
Importance of Diagnostics

Essential ( 基础）
Basic courses
Bridge （桥梁）

Tools （工具）

Clinical medicine
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
 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 )

Symptomatic Diagnosis
Symptom （症状）

Subjective sensation that patient describes

Physiological & Pathological &

functional morphological

Fever Cough Rash Mass

 Physical Diagnosis
Sign （体
征）
Abnormality observed by the physician
Physical examination （体格检查）
Conducted with thoroughness, alertness to detect even
slight derivations from normal

Inspection ( 望）
Palpation （触）
Percussion （叩）
Auscultation （听）
Laboratory test or ancillary tests
• Serum, Urine, Stool tests
• X-ray film
• EKG
• Endoscopy
• Ultrasonic imaging
• CT
• MRI
• PET (Positron Emission Tomography)
 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
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）

 Differential diagnosis
• Preliminary diagnosis/Tentative diagnosis
初步诊断 可能性诊断
• Exclusion of other diseases ( 排除其它疾病 )

• Selecting a number of possibilities to explain the

clinical and laboratory findings in the case in question

• The way of exclusion is called Differential diagnosis

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
 Evidence based medicine
One need to:

• Be conscientious: it requires effort and thought.

• Be explicit: decisions will need to be backed up by good evidence
• Relate to specific problems: it is not about a hypothetical
"average" case.

• Integrate individual clinical experience: it does not denigrate

clinical skills in history taking, examination and diagnosis.

• Look for current best evidence: the perfect study may not yet have
been published, written up or even commenced. We may have to
settle for something less rigorous, but be on the look out for new
research that will supersede older studies.
 Important aspects---
interrogation
• To get the history in detail of a patient’s illness

• The history is taken at initial contact between

physician and patient

• As some crucial points might be overlooked by the patients, one will

ask many searching questions to make the history more informative
and complete, who must at the same time avoid suggesting answers

• Occasionally to interrogate his family member

 Other important aspects
• The diagnostic process is very complex

• The number of facts that can be collected in a detailed

medical history and in thorough physical examination are
almost without limit

• The laboratory tests or specialized technical procedures

that can employed are numerous and costly
 Other important aspects
• 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

• Method of approaching a diagnosis:

Analysis of symptoms ( 症状分析 )
Recognition of the syndrome ( 综合症识别 )
Consideration of disease mechanisms ( 考虑疾病机制 )
 Important aspects
• Modern & advanced ancillary techniques:
have their limitations.
It can’t reduced the importance of certain parts
of the classic P. E
• It should be avoided to neglect fundamental
methods
Interrogation
Physical examination
Scientific clinical thinking
 Approaches

Basic knowledge learning （基础知识的学习）

Clinical practice （临床实践）

Bedside activity 床边实践

Standardized patient 标准化病人

 Developmental History of
clinical diagnostics

• Western Medicine: from ancient to modern

• Traditional Chinese Medicine

Contribution of ancient doctors---Western

Hippocrates

•Born on the island of Cos,

Greece (c. 460-377 BC)

•The Father of medicine

Hippocratic oath
希波克拉底宣言
•Hippocratic corpus （文集） :
a collection of 70 works
Hippocratic oath
Contribution of ancient doctors---Western
Galen

• c.130-c.200
• His work in
anatomy/physiology is notable
• Identified artery and vein
• Added greatly to knowledge of the
brain, spinal cord and pulse
Contribution of ancient doctors---Western
Auenbrugger

•Born at the village of Graz, Austria (1722)

•Son of an innkeeper
•The working experiences helped him to find
Percussion
•Author of <Inventum Novum>(1761)
translated as ‘On Percussion of the chest’ in 1936
Contribution of ancient doctors---Western

Laennec RTH

•A French physician
•Invented Auscultation and stethoscope
Contribution of ancient doctors---Western
Laennec RTH

1816
 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
Ultrasonic imaging
CT imaging
MRI
PET
Traditional Chinese Medicine

Wood
Wood
Fire
Fire
Earth
Earth
Metal
Metal
Water
Water
Contribution of ancient doctors---Chinese

Inspection
Interrogation
Smell
Pulse palpation

《内经》
Pay attention to:

Good medical ethics

Attach importance to clinical practice

Unit theory with practice

 Goals
• Inquiry:
Independent systemic inquiry
Comprehensive understanding of patient’s chief
complains, signs, symptoms and their interrelation
• Physical Examination:
Systemic/thorough
• Familiar with routine tests, EKG manipulation and figure
analysis
• Good case writing and propose the primary diagnosis
• Scientific clinical thinking