Physical diagnosis should not be ignored

Physical diagnosis should not be ignored
The clinical practice of BJ Union Hospital is Wu DongAdvanced medical instrument and equipment are coming out constantly, improve the ability of clinical diagnosis and treat competence greatly in recent years. But many doctors can not understand correctly that diagnose the meaning tested, overestimate auxiliary examination to the value diagnosed, especially represent in the auxiliary examination of excessive application, and the basic physical diagnosis skill is thought to be already out of date, ignored day by day, even the inclination of despising physical diagnosis has appeared in clinical teaching. It is not only unfavorable to improving the clinical level, but also will waste medical resources ignoring physical diagnosis, influence medical quality, in rain to increase the patient to bear.In physical diagnosis, it is most important to gather the medical historyThe famous authority, a filial piety Qian Professor of internal medicine department, of our country says: "In fact, can obtain and diagnose or diagnose the clue from the medical history tentatively in more than 50% of the cases, 30% of the cases are simple and can diagnose, check simply through testing through physical sign (including some modern very complete inspections) Only 20% diagnosed. By the look of this, should pay special attention to gathering the medical history. "Famous inner scientist Lawrence M of U.S.A.. Tierney professor has said: "Meet and diagnose the unidentified difficult case, the greatest one is the medical history to diagnosing help, medical history, or medical history. " Two domestic and foreign internal medicine department masters have sent out the appeal of paying attention to physical diagnosis simultaneously, among them meaning is provoking.The advantage of physical diagnosis lies in that it is cheap to spend, convenient and fast, can repeat at any time, help to find the condition change in time. Physical diagnosis still requires the doctor to come by the bed directly, gather the medical history completely, check the body carefully, this makes the doctor have more time to get along with the patient. Do not have high expectations for external condition, can stint on expenses for the patient in physical diagnosis, it is its another advantage.The inferior position of physical diagnosis lies in repeatability is not strong, accuracy and sensitiveness are inferior to auxiliary examination sometimes, can't totally avoid the subjective factor at the same time. These are advantages of auxiliary examination exactly, can remedy the natural limitation of clinician's sense organ, further improve the accuracy of clinical diagnosis.Want auxiliary examination? Physical diagnosis has the final sayAuxiliary examination can express the meaning diagnosed with Bayes formula:Probability to * before testing Likelihood than =Probability than test,Among them: Probability than =Ill probability /(a probability) ; Positive likelihood than =Sensitivity /(a degree) ; Negative likelihood than =(1 - sensitivity) /Peculiar degree.Probability is doctor's estimation to the ill probabilistic patient before diagnosing the test before testing, probability is to learn that diagnoses patient's ill probability after the test result after testing. Than depend on sensitivity and peculiar degree tested to diagnose, reflect diagnosis of test this render a service likelihood. Positive likelihood than 5, mean, diagnose, test masculine gender, ill probability 5 times of probability more; Negative likelihood than 0.2, mean, diagnose, test negative, ill probability 1/5 of probability more. Can be found out from Bayes formula, probability not merely depends on diagnosing sensitivity and peculiar degree tested after testing, probabilistic influence before still testing by disease.We prove with the following examples: It suppose by that one item auxiliary examination peculiar degree is for 99%,sensitivity is for 100%, likelihood positive than getting more difficult to have being so an ideal more inspection very in 100 (in real work) . Only for 1/1000 (have 1 ill example only in the 1000) probability test, of disease ,Should check for being positive, it probability about 9% (11 case positive only too test, among them there is only an example to be ill) . This simple calculation shows, diagnose probability exerted a tremendous influence before the meaning of the test result is tested, go on, test while being indiscriminate, reduce probability test, greatly, even highly peculiar checking will present a lot false and positive, give result explain, cause difficult, may mislead direction of making a diagnosis. For example it is positive to resist the nuclear antibody not only sees at systemic lupus erythematosus, but also can be seen at other one's own immune diseases, infection, tumour, even normal crowd. If measure blindly, will resist the nuclear antibody positively, the positive expecting value that should be checked will drop notably.Through physical diagnosis, the doctor forms preliminary diagnosis to estimate, narrow and distinguish the range, probability before going on pertinence, checking and then on this basis, can improve and test, thus give full play to and examine the effectiveness.Cure statistics of the SCTE according to U.S.A.'s emergency call, go to a doctor in 2,100,000 patients of the emergency call because of having a headache every year, serious organic disease only accounts for 5.5%. Probability so low test, make or CT to all patient waist wear check obviously unrealistic. But discover, if it is violent to have a headache, and in order to take place recently, probability rises to 10% to 15% before organic disease is tested; Age is greater than 50 years person probability increases by 3.3 times (95% CI before testing 1.2 ~ 9.3) ; The person who has physical sign of unusual nervous system increases by 3.0 times (95% CI 2.3 ~ 4.0) . Check on the basis of above-mentioned symptom and physical sign, pertinence is much stronger.Physical diagnosis is constructing and diagnosing the foundation stone in the mansionWhether the condition is complicated or simple, intact medical history and the exhaustive first step checking the body diagnoses correctly, construct and diagnose the foundation stone in the mansion. Some important physical sign very useful to to diagnose, so long as sufficient attention can find, but auxiliary examination can contribute perhaps. For example characteristic pointing, fricative,etc. of rash, spider's mole, annular erythema, poke of infectious disease. Patient as to the blood, the simple rectum means that examining can find rectum pathological change sometimes, but the colon mirror or angiography may leak and examine. Moreover, the result of auxiliary examination must consult medical history and physical sign to be explained correctly sometimes.MRI reveals intervertebral disc pathological change is very clear, Zeng someone recommends the sieve that uses it for the intervertebral disc and stresses to be checked. But subsequent research shows, the outstanding MRI detection rate of intervertebral disc of adult's waist is up to 25% ~ 50%, Among them the overwhelming majority has no symptom, do not need to treat either. Only when the patient has waist having a backache or neural root oppression to behave, the discovery of MRI is meaningful.Some symptoms and physical sign sensitiveness or specificity are very high, diagnose value is not second to auxiliary examination. For example strange pulse diagnose heart sensitiveness filled in to pigeonhole up to 98%, S3 galloping horse rate diagnoses the specificity that the acute left heart declines is up to 90%~97%,etc.. A lot of critical patient's conditions are changed very fast, need judging and intervening rapidly. Auxiliary examination is time-consuming sometimes more, not practical enough, but the physical diagnosis ability really up to the mark can play a key role. Park suddenly by heartbeat, tension pneumothorax acute disease nearly totally rely on the medical history and check the body makes diagnosis, could win valuable rescue time.The patient has complicated, difficult to choose the direction checked condition sometimes, but physical diagnosis can arise to and " dispel the clouds and see the sun " Function. For example one is shown as obstinate shock, hyperpyrexia and patient going into a coma, it is not clear to diagnose, the condition is very critical. Check carefully body finds a patient body mao are sparse, do not neglect this detail through managing a doctor, inquire relative learn patient have, pass have a headache vigorously, appetite fail hereafter once one year ago, physical power obviously drops. Therefore expect the hypophyseal apoplexy to cause the crisis of renal gland, through supplementing glucocorticoid in time, the patient pulls through. Determine with MRI checking, proving clinically, judging through hormone finally.
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