家庭医学临床应诊技巧_lap version 20141009.pdf

1 （1）LAP 问题 医生在诊治病人过程中的不同阶段，需要思考三组问题医生在诊治病人过程中的不同阶段，需要思考三组问题 1、 在初步讯问病历（采集病史）之后 AT THE END OF INITIAL HISTORY TAKING ① 在这个阶段你初步的诊断包括哪几种可能性？ What are your diagnostic hypotheses at this stage? ② 你为何为何树立这样的诊断？ Why have you erected these hypotheses? ③ 你准备进行何种体格检查？原因何在？原因何在？ What physical examination do you intend to carry out and why? 2、 在体格检查之后 AFTER PHYSICAL EXAMINATION: ① 通过检查你有什么发现？ What did you find on examination of the patient? ② 这些检查的结果，对你的诊断有何影响？ How have these findings affected your thoughts? 3、 在病人离开之后 AFTER THE PATIENT HAS LEFT ① 试问自己，为何为何选择这样的诊疗计划？ Why did you choose your management plan? 这一系列的问题，是基于激励反复思考的教育方法。

使医生深切了解自己思思 维的步骤维的步骤而这种思维步骤，奠定了他对临床情况及诊治行为的基础诊治行为的基础 2 （2）LAP 内容 Category H: INTERVIEWING/HISTORY TAKING 问诊问诊/病史采集病史采集 COMPETENCE 能力能力 Code 编码编码 RECOMMENDED STRATEGY 推荐的策略推荐的策略 Code 编码编码 Introduces self to patients 向病人自我介绍 HA1 Always ensure the patient knows who you are and why you are there 确保让病人知道你是谁，你在这里担当的角色 HAR1 Put patients at ease 让病人放松下来 HB1 Welcome the patient, e.g. mention the patient’s name, establish eye contact, give indication where to sit 招呼病人，比如称呼病人的名字，用眼神交流，请病人坐下 HBR1 Allows patient to elaborate presenting problems fully 让病人充分表达自己的问题 HC1 Start with open questions, e.g. “What can I do for you?” “How can I help” “Tell me in your own words about…………” 以开放式的提问开始， 比如“我能为您做点什么”， “我可以怎样帮助你”, “告诉我你…的想法” HCR1 Use prompts as appropriate 适当时，给与提示。

HCR2 At this stage, resist the temptation to interrupt 此时，不要打断病人的叙述 HCR3 Listen attentively 专心聆听 HD1 Demonstrate to the patient that you are listening e.g. by eye contact, nodding etc. 让病人知道你在聆听, 例如藉身体语言: 目光的接触, 点头等等 HDR1 Try to understand the message that the patient is trying to convey 试图了解病人想表达的信息 HDR2 Don’t display the listening task by formulating the next question 不要以下一个问题来取代细心倾听 HDR3 Seeks clarification of words used by patients as appropriate HE1 If you don’t understand what the patient means, ask them to explain 如果你不明白病人要表达的意思, 要求他做进一步的解释 HER1 需要时弄清楚病人用语的意思， 留意病人的用语、用词 Don’t assume the patient’s use and understanding of medical or technical terms always correlates with your understanding of such terms 不要期盼病人会理解医生所用的医学或技术性词汇。

HER2 Phrases questions simply and clearly 简单清晰地提问 HF1 Don’t use jargon 不要使用专业术语 HFR1 Avoid using leading and /or double questions 避免使用引导性的问题, 或双重的提问 HFR2 Tailor questions to level of patient’s understanding 把问题调整到病人能理解的水平 HFR3 Ensure the patient can hear you e.g. speak louder to patients with reduced hearing 确保病人能听到你说的比如，对有听力障碍的病人说话声音要大些 HFR4 Uses silence appropriately 恰当的时候保持沉默 HG1 Try to tolerate the discomfort of appropriate silences, e.g. if the patient is having difficulty telling his story and/or is distressed, allow him time to compose himself 尝试容忍片刻沉静所造成的不安，例如：当病人有困难讲述他的情况, 或陷入悲伤痛苦中，情绪不稳定，给与病人一点时间让他平静下来。

HGR1 Recognises patients’ verbal cues 留意病人言语的表现，说话表达的意 思、含义 HH1 Be aware of, and sensitive to, apparently incongruous or mismatched language or behaviour by patients, e.g. patients may say one thing but their body language might indicate another; the infrequent attender with an apparently trivial presentation 留意，关注，病人前后不一致或不相配的语言或行为例如，病人也 许会说一件事，但是他们的肢体语言或许会表达另一方面的意思又 例如一个不常来看病的病人, 为了一点琐碎的事来求诊 HHR1 3 Recognizes patients’ non-verbal cues 留意病人非言语的表现 HH2 Always consider the patient’s demeanour and mood, e.g. happy or sad, tense or relaxed, angry or embarrassed 一定要留意病人的行为和情绪。

例如：开心或难过，紧张或放松，生 气或尴尬 HHR2 Identifies patients’ reasons for consultation 明确病人来就诊的原因 HK1 In every consultation you must be satisfied that you have established the patient’s reason for the consultation. The answers to the following three questions need to be elicited: Why have you come? What do you think is wrong with you? What do you want me to do about it? Sometimes, you may have to ask these questions explicitly 你需要明确每一个病人前来就诊的原因找出以下三个问题的答案： 你为什么来求诊？你认为哪里出问题了？你想我能帮你做什么？有的 时候你也许要清楚地作出这些提问 HKR1 Elicit the patient’s ideas, concerns and expectations in every consultation: this may require gentle but persistent probing/questioning.在诊疗过程中 应诊时，列出病人的看法，忧虑和期待。

要达到这个目标，就需要耐 心的咨询和提问 HKR2 Considers physical social and psychological factors as appropriate 从生理心理社会三方面的因素做出恰 当考虑 HM1 Always bear in mind the triple diagnosis 心中永远铭记三维诊断理念 HMR1 When satisfied that physical disease is present always consider its impact on the social and psychological well being of the patient 明确了生理上的疾病的同时, 一定要考虑到其对病人社会和心理方面 的影响 HMR2 Consider the impact on the patient of other social and psychological factors in their family, job, etc. 考虑到病人家庭及工作上的其它心理社会因素怎样影响病人 HMR3 Elicits relevant and specific information from patients’ records to help distinguish between working diagnoses. 从病人的记录中找出相关和特殊的资 料，帮助作出各种诊断 Elicits relevant and specific information from patients to help distinguish between working diagnoses. 从病人身上找出相关和特殊精确的资 料，帮助辨别各种诊断 HP1 Prior to the consultation always scrutinize the patient’s record to elicit previous patterns of illness behaviour, individual and family circumstances, significant previous medical history, including current medication, and dat。