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目的为了更好的提高住院医师选择鉴别诊断的能力,着重讲述了如何正确选择鉴别诊断的思路和方法。方法本文从首次病程记录、现病史、体格检查三方面进行鉴别诊断思路和步骤的分析。结果对住院医师进行如何写好鉴别诊断的讲座,对正确的选择被鉴别的疾病有重要的启示。结论怎样写好鉴别诊断,使其有明确的针对性和鉴别诊断意义;如何正确的、合理的选择被鉴别的疾病、现病史如何提炼重要的阴性鉴别症状等,是住院医师在病历书写中亟待提高的问题。
Objective To better improve the ability of residents to choose differential diagnosis, focusing on how to choose the correct diagnosis of ideas and methods. Methods This article from the first record of course of disease, medical history, physical examination three aspects of differential diagnosis ideas and steps analysis. The results of the residency on how to write a good differential diagnosis of lectures, the right choice to be identified diseases have important implications. Conclusion How to write a good differential diagnosis, so that it has a clear relevance and differential diagnosis; how to choose the correct and reasonable disease to be identified, the current history of how to extract the important negative identification of symptoms, is the resident in the medical records writing urgently needed Improve the problem.