問診的臨床操作技巧——症狀的勳態變化與時序

The Clinical Operative Skill Of Inquiry-The Dynamic Change And Progress Of Symptoms

中醫的診察主要是利用望、聞、問、切四診由病患身上獲得相關訊息，這些訊息包括由望、聞、切三種需由醫師專業操作的診法，所獲得的客觀訊息叫作體徵；而藉由問診詢問病患的主觀感覺所獲得的訊息叫作症狀。因為症狀的獲得是病患的主觀感覺，可能因醫師問不得法或因病患不了解醫師所問內容而會錯意，故其臨床可信度相對偏低，所以有些醫師怕被干擾因而捨棄了問診，以為如此就萬無一失，殊不知如此便掉入了辨證的陷阱中。所謂辨證的陷阱，就是醫師常把「體質辨證」項與「疾病辨證」項混雜在一起，特別是初診病患，醫師操作望、聞、切三種診法所獲得的病患體徵相關訊息是代表疾病的發生或者是病患的體質？臨床上非常難以區別，大都只憑藉醫師個人的自由心證。若能藉由問診詢問病患相關症狀的出現或變化——「症狀動態變化」與症狀的時間長久和先後順序——「症狀時序」，便能避免此項盲點。因此，問診不但是蒐集病患資訊的方法，也是病機邏輯推演的主要工具。以主訴症狀為主軸且具思路性的問診可幫助臨床醫師進一步區分體質辨證項與疾病辨證項，而具邏輯性的症狀時序關係和症狀動態變化則為思路性問診的關鍵。除此之外，建立邏輯性的問診流程模式更有助於鑑別分析病情和病機邏輯推演。 The Chinese medicine doctors obtain information of the patients by four examinations including inspection, listening and smelling, inquiry, and palpation. The objective information which is obtained by inspection, listening and smelling and palpation is called sign. The subjective information which is obtained by inquiry is called symptom. The clinical confidence level of symptoms is lower because symptoms are obtained by the subjective feeling of the patients, inappropriate inquiry or misunderstand between patients and doctors. Therefore, some doctors forgive inquiry for avoidance of low clinical confidence level which may fall into the trap of pattern identification. The trap of pattern identification means that doctors mix the symptoms of constitution and disease especially for first-visit patients. It is difficult to differentiate the constitutional symptoms and symptoms of disease only by signs and the doctors may differentiate them by free evaluation of evidence. If we obtain the dynamic change and progress of symptoms, we will avoid the mistake. Therefore, inquiry is not only a method of collecting the information of the patients, but the main skill for approaching the logic pathogenesis. The inquiry with thinking process helps doctors to differentiate the constitutional symptoms and symptoms of disease. The logic progress and dynamic change of symptoms are the key of inquiry. Besides, setting up the flow-path model of logic inquiry is helpful to differentiate diagnosis and approach the logic pathogenesis.