各系统病历分析诊断公式.docVIP

各系统病历分析诊断公式 病史采集答题要领 （一） 现病史 1根据主诉及相关鉴别询问 （1） 病因、诱因（受凉、饮食、药物、外伤、精神因素等） （2） 主要症状的特点（变化部分：程度、类型、性状、次数、缓解与加重的因素、颜色、 部位、量、时间） （3） 伴随症状（变化部分：其他17个症状） （4） 全身状态，即发病后一般状态（饮食、睡眠、二便、体重、精神状态等） 2诊疗经过 （1） 是否到其他医院就诊过，做过哪些检查，血尿便常规、x线、心电图、B超等 （2） 治疗用药情况，疗效如何（应具体询问治疗方法和药物，有无疗效） （二） 既往史 1药物过敏史、手术史、传染病史、吸烟史、饮酒史、家族史、冶游史 2相关病史（变化部分：本系统相关疾病和并发症） ··············································································· 呼吸系统疾病 一、诊断公式： 急性上呼吸道感染=咽痛+咳嗽+发热 ··············································································· 肺炎 大叶性肺炎=成人+受凉+高热+咳铁锈色痰 ··············································································· 克雷伯杆菌肺炎=咳砖红色痰+X线片空洞 ··············································································· 支原体肺炎=儿童+刺激性干咳+关节痛+抗生素无效 ··············································································· 支气管肺炎=婴幼儿+发热+呼吸困难症状（鼻翼扇动、三凹征阳性） ··············································································· 金黄色葡萄球菌肺炎=高热+胸痛+脓血痰+X线片状影 ··············································································· 结核病 肺结核=青壮年+咯血+午后低热+夜间盗汗+抗生素治疗无明显疗效 ··············································································· 结核性胸膜炎=结核+心包积液体征（心前区痛+呼吸困难+上腹部闷胀+下肢水肿） ··············································································· 肠结核=结核+腹部症状（腹痛、腹泻、右下腹部肿块） ··············································································· 结核性腹膜炎=结核+腹部炎症（腹痛、腹泻、腹壁柔韧感） ··············································································· 肾结核=结核+膀胱刺激征+肾实质变薄并有破坏 ··············································································· 支气管扩张=童年有麻疹百日咳或支气管肺炎迁延不愈病史+咳嗽+脓痰+咯血 ··············································································· COPD=老年人（吸烟史）+咳、痰、喘+桶状胸+肺功能检查+FEV1/FVC70% ··············································································· 肺脓肿=脓臭痰+高热+X线片/CT显示液平 ··············································································· 肺癌=中老年人+痰中带血+刺激性咳嗽+消瘦+X线毛刺 ···································