醫(yī)學(xué)英語(住院醫(yī)師規(guī)范化培訓(xùn))

PAGEPAGE80PrimaryCareMedicineRecommendations目錄PrinciplesofPrimaryCare基本醫(yī)療原則 4 4RespiratoryProblems呼吸問題 34PracticeofPrimaryeDiagnosticTess

醫(yī)療的實(shí)踐

Asthma哮喘BronchitisandPneumona管炎和肺炎HealthMaintenanceandRoleofScreening保健和篩查RiskandsTreatmentOptionsImmunization免疫接種SystemicProblems全身性問題 22

ChronicCough慢性咳嗽ChronicDyspnea慢性呼吸困難ChronicObstructivePulmonary疾患Clubbing杵狀指CommonCold普通感冒ChronicFever

性疲勞

Hemoptysis咯血InterstitialLungDies性肺病HIV-1InfectionVandyWeight消瘦CardiovascularProblems心血管問題 30AorticRegurgitation脈瓣反流Aortic動(dòng)脈瓣狹窄ArterialAsymptomaticSystolicMurmur無癥狀的收縮期雜音Atrial顫動(dòng)BacterialsCardiovascularChest胸痛CongestiveHearteDeepVeinThrombophlebits靜脈血栓鍛煉Hypercholesterolema膽固醇血癥Hypertension高血壓

業(yè)和環(huán)境性肺疾病PleuralsSleepApneaSmoking戒煙SolitaryPulmonaryTuberculosi肺結(jié)核GastrointestinalProblems胃腸道問題 36AbdominalPain腹痛AnorectalComplains門直腸不適CirrhosiandChronicLiverFailur衰竭n腹瀉DiverticulareDysphagia吞咽困難ExternalHerna疝GallstonesLegEdema下肢水腫MitralnRheumaticFeve

瓣返流

Gastrointestinal道出血Heartburnand心和反流InflammatoryBowelStable

定型心絞痛

IrritableBowel應(yīng)激綜合征Stress激試驗(yàn)SuperficialThrombophleb性淺靜脈炎

Jaundice黃疸NauseaandgSyncope暈厥ValvularHeart

瓣膜疾病

Nonulcer腺炎

潰瘍性消化不良VaricosesVenous脈機(jī)能不全VentricularIrritability

PepticUlcerDises化性潰瘍病SerumTransaminase(Aminotransferase)Eleva轉(zhuǎn)氨酶升高ViralHepatii毒性肝炎HematologicProblems血液系統(tǒng)問題 39AnticoagulantAnemia

FertilityInfertilt育癥MenopauseMenstrualorPelvicnBleeding

血問題

SecondaryAmenorrhea繼發(fā)性閉經(jīng)Erythrocytoss細(xì)胞增多

UnplannedPregnanc計(jì)劃外妊娠SickleCellDiseas

VaginalgOncologicProblems腫瘤學(xué)問題 40Bladderr胱癌BreastrCervicalr宮頸癌Colorectal腸EndometrialrEsophagealrr

VaginalDischare道分泌物Vulvar陰搔癢10GenitourinaryProblemsProstaticChlamydial原體感染Gonorrhea淋病IncontinenceandLowerUrinaryTract失禁和下尿路功能不全Hodgkin’sDiseasLung肺癌

奇金病

結(jié)石列腺炎Non-Hodgkin’aLymphoma非霍奇金淋巴瘤OralCance口腔癌OvarianCance卵巢癌PancreaticRenalCellCarcinoma(Hypernephroa腺樣瘤)Skin皮膚癌Testicular

aRenaleScrotalPain,Masses,andSexuallyTransmitted播疾病Syphili梅毒Urethritisin性尿道炎UrinarTractInfec11MusculoskeletalProblems肌肉與骨骼問題 42ThyroidNodulesandThyroid狀腺癌

腺結(jié)節(jié)和甲

AsymptomaticBack背痛

癥狀性高尿酸血癥TumorofUnknownOrigiVaginalrVulvarCance外陰癌 EndocrinologicProblemsDiabetes崩癥Diabetes尿病Galactorrheaand素血癥GlucocorticoidGynecomastia男子女性型乳房多毛癥Hypercalcemia高鈣血癥

Elbow,Wrist,andHandFibromyalgi纖維肌痛FootandAnkle和踝痛GiantCellGoutHipPain髖痛KneePain膝痛LymeDisease萊姆病MonoarticularArthrtsMuscleCramps肌肉痛性痙攣Neck頸痛Hyperthyroidis甲狀腺機(jī)能亢進(jìn)

Diseas

吉特病Hypoglycemia低血糖Hypothyroidism甲狀腺機(jī)能減退GynecologicProblemsandNipplee

PolyarticularsPolymyalgiaaRaynaud’sPhenomenon雷諾現(xiàn)象Rheumatoid風(fēng)濕性關(guān)節(jié)炎溢液 Shouldern痛12NeurologicProblemsBel’sPals面癱Dementia癡呆頭暈FocalNeurologicComplaitHeadacheMultipleScleroi發(fā)性硬化

DiabeticDry干眼ExcessiveTearing淚ExophthalmosEye目痛Glaucoma青光眼ImpairednParkinsn

sDiseas

顫麻痹

RedEye紅眼Seizures癲癇發(fā)作TransienIschemiAttackandAsymptomatic短暫性缺血發(fā)作和無癥狀性頸動(dòng)脈雜音Tremor震顫TrigeminalNeuralgia(TicDoulouru)神經(jīng)痛13DermatologicProblems皮膚病學(xué)問題 47Acne痤瘡Aphthous瘍性口炎Bites(AnimalandHuma窩織炎CornsandorContDry干性皮膚ExcessivegFungal菌感染Hair脫發(fā)HerpesSimplex單純皰疹

Refractive光手術(shù)Visual覺障礙15Ear,Nose,andThroatProblems耳鼻喉問題 s衄F(xiàn)acialPainandgsHearingLosHiccups呃逆聲嘶NasalCongestionandesssSmellDisturbancs打鼾TasteTemporomandibularHerpes

狀皰疹

Tinnitu耳鳴IntertrigoandIntertriginouss性皮膚病MinorBurns輕度燒傷

16PsychiatricandBehavioralProblems精神病學(xué)和行為問題AlcoholAbuse酗酒PigmentationDisturbance

沉著障礙

Angrytss紫癜Pyoderma

Anxiety焦慮Depression抑郁EatingDisorde失眠RosaceaandOtherAcneiform

鼻和其

Nonmalignant

惡性的痛它痤瘡樣的皮膚病ScabiesandsSkinUlceratin膚潰瘍UrticariaandWarts疣14OphthalmologicProblems眼科學(xué)問題

SexualnSubstanceAbus精神性藥物濫用17AlliedFields青春期AlternativesAge-RelatedMacular退行性改變

齡相關(guān)的黃斑CataractsContactsPracticeofPrimaryCare基本醫(yī)療的實(shí)踐Management處理OrganizePCP practicetoprovidecomprehensive,andfirstcontactandofprimarycareMedicalDxandx學(xué)診斷和治療

attributioitPCP'sclinicalorscientificofandmodelssothatpatienfeelillnescanbeunderstooandcontrolled,regardlessofits探出他們對(duì)該疾病的信念。通過初級(jí)保健醫(yī)生的對(duì)疾病的臨床或科學(xué)解釋來鞏固或更正病人的固有信念，如提供標(biāo)記，名稱，模型，這使病人感到不論對(duì)疾病的專業(yè)治療如何疾病是可以被理解和控制的。Togainpatients'fullcooperationinRx,itislearnaboutpatient'sviewsofRxandanyBymakingclinicecisioa"sharedrocessPCPfosterspartnershipthatenhancescomplianceandoutcomes.canbeunderstandingsymptomsandinfashioningrealisticstrategiesforpreventionPsychologicalDx

學(xué)診斷和治療

程來制定臨床Personalsupportofpatientsofallbackgroundsnal級(jí)保健醫(yī)生可以培養(yǎng)醫(yī)患關(guān)系以增強(qiáng)順從性illnes供個(gè)體化支持

各種背景處于各階段疾病的病人提

和預(yù)后。注意病人的社交網(wǎng)絡(luò)對(duì)了解癥狀和形成切合實(shí)際的預(yù)CommunicationofinformationaboutDx,prevention,andprognssMaintenanceofpatientswith病患者

防和治療策略至關(guān)重要。DiagnosticTests診斷性試驗(yàn)Preventionofdisabilityanddiseasethroughdetection,education,behavioralchange,ande測(cè)，教育，改變行為和預(yù)防性治療來預(yù)防殘疾和疾病

Management 處理Diagnostictestshaveseveraluses:診斷性試驗(yàn)有幾種PCP'srecognitionofandresponsetopatients'emoinlreactiontoillnescriticeterminanofqualitofprimarycare.EquallyimportantisaddressinpatienexpectationandrequestsPatients'majorandcomplyingwithRx,andindetermininghealthoutcomes.Requestsareconcretehelpingactionandbehaviorthatareidentifiypatients.makeefficientandmore

TomakeDxinpatientknowntoe做出診斷使其知道生病了Toknowndiseas為患者提供預(yù)后信息使其了解疾病Toidentifypersonwithsubclinicaldiseaseoratsubsequentdevelopmentof出患有?臨床疾病或存在將來發(fā)展為疾病的風(fēng)險(xiǎn)的人TomonitorongoingR測(cè)正在進(jìn)行的治療IneachcaseobjectiveisnotsimplytoclassifyorbuttoreduceM&Mandincreasesatisfactionandsensewell-being度和舒適感。DxprocesisinherentluncertaincertainanbeanyparticularWhenpatientsconfrontseriousillness,elicitpresent,astestresultsarebeinginteraboutthatillness.Confirmationorcorrectiosofnbothitprobabilifbeingpresenbeforetestinandthevalidifinformatioprovidebytest thadiseasbeingpresenand(1-p)/pisoddsagainst

斷的過程本身固有不確定性;這種不確定性

thatdisease.疾病的概率也可以使用疾病的預(yù)試驗(yàn)優(yōu)可以用概率來表達(dá)。正如試驗(yàn)結(jié)果所做的解釋那樣， 勢(shì)比和似然比加以校正。若p是疾病的概率與(1-當(dāng)前任何特定疾病的概率，同時(shí)取決于試驗(yàn)前的概率

pp/(

-p1-p)和試驗(yàn)結(jié)果所提供信息的可靠性。Sensitivisprobabilihatesresulwilbepositivewhenpersontested

/。Pretesoddsofdiseaultipliypositivlikelihoodratioproducesposttestoddsofdiseaseafterpositivesensitivetestcanruleoutdiseaseifis感性是指當(dāng)被試驗(yàn)的病人實(shí)際上已患該疾病時(shí)測(cè)試結(jié)果為陽性的概率。如果結(jié)果是陰性，高敏感試驗(yàn)可以排除該疾病。

乘以陽性似然比得到試驗(yàn)后疾病的優(yōu)勢(shì)比。Positivlikelihoatiisprobabilif(orgivenpresenceofSpecificityisprobabilitythattestresultwillbyprobabilityofthatresultgivenabwhenpersonnothavedisease.rulein時(shí)測(cè)試結(jié)果為陰性的概率。如果結(jié)果是陽性的，高特異性試驗(yàn)可以診斷該疾病。Whentesresulreknown,probabilitsdiseasoritabsenceinlighofthesresulremostn

ofPositivelikelihoodratioisthereforeratioof1elikelihooratiisratioffalse-negatiate(i.e.,1-sensitivity)tospecificity.PretestoddsPCPsandpatients.Predictivevaluepositiveisprynegativlikelihoatiproduceposttestofdiseaswithpositivtest(Probabilihadiseasis

oddsof

性似然比absentdespitepositivetestcanbethoughtofasprobabiliffalsalarm.Predictialuenegativisprobabilifnodiseasewithanegativtest(Thecanbethoughtofasoftheseprobabilitedeterminebyprobabilifdiseasebeforetestwasorderedandspecificityof

1檢測(cè)結(jié)果之后試驗(yàn)前疾病的優(yōu)勢(shì)比乘以陰性似然比得到試驗(yàn)后疾病的優(yōu)勢(shì)比。Publishedtestprovideoptimisticquestion.PCPscanavoidbeingmisleadbypayingattentiotocommonproblemsinstudydesign,gunrealistxpectatioboutpredictialuebecauseofhigherdiseaseprevalenceinstudypopulationthan的概率。(結(jié)果為陰性時(shí)而疾病又存在的概率能被認(rèn)為

預(yù)測(cè)值的不切實(shí)際的期望，因?yàn)槌霈F(xiàn)了研率和試驗(yàn)的敏感性和特異性所決定。

究人群比實(shí)際有更高的患病率;unrealisticestimatesofsensitivityandspecificityImportanceofpretestprobabilityofdiseaseininvrlapintesbeingevaluateandtest(sedtosuch definepresenceofpatients)fordeterminingpredictivevaluesoftessotn因?yàn)槌霈F(xiàn)了正在評(píng)估中的測(cè)試和用于界定notfullyappreciatedandmayleadtotclinicalperformance

unrealiststimateofsensitivenpopulatiowithdiseaseinstudyhasmoresevereandmoredetectablediseasethanthoseinProbabilitiesofdiseasecanalsoberevisedusingtoddsofdiseaseandlikelihoodratios.Ifpisprosstimateofspecificihenpopulationdisease,ratioofpto(1-p),orp/(1-p)isstudyistoowellandmorefreeofbeconfusedwithquestion todetectdiseaseduringthanthosein

被研究的未患病人群比在實(shí)

asymptomaticperiod在無癥狀期檢測(cè)疾病的試驗(yàn)足際中更健康，可能與正研究中的疾病相混淆，會(huì)出現(xiàn)對(duì)疾病特異性不切實(shí)際的估計(jì);

夠敏感Sufficientpecifitoprovideacceptablpredictiveunrealisticestimatesofclinicalvalueoftestwhenlupositiv試驗(yàn)有足夠特異性能提供可接受的陽notmuchnewprovidedbycomparedwithprovidedbyothertest

性預(yù)測(cè)值A(chǔ)cceptabletopatins可接受Characteristicsofpopulation

的特征的試驗(yàn)與其他試驗(yàn)相比提供了多少新的信息時(shí)，會(huì)出現(xiàn)對(duì)實(shí)驗(yàn)的臨床應(yīng)用價(jià)值不切實(shí)際的估計(jì)。Sensitivtestorlesstringeriteror

Sufficientighdiseasprevalenc高withsubsequentdiagnosticresultinglowfalse-negativerateshouldbefavoredtsandnecessarx后的診斷性試驗(yàn)和必要的forconditionexistsandcostoflostopportunitisgreatHighspecificirmorecriterordiseasandresultiowfalse-posittearemostimportantwhenpositiveresultdoesnot

治療有可接受的順應(yīng)性CONDITIONS THAT WARRANT EVALUATIONINALLPATIENTSOFAPPROPRIATEAGEAND GENDER 所有年齡和性別適當(dāng)?shù)幕颊叨家猻ignificantlyinfluenceRxoroutcomeandmaybe周期性評(píng)估的情況：forpatient.某疾病在有條件時(shí)能被有效治療而失去要求更嚴(yán)格。

HTN:seenia:seeHypercholesterolma高膽固醇血癥章節(jié)Smoking:seeSmokingCessato煙：見戒煙章節(jié)Coloncancer:seeColorectal腸癌章節(jié)Breastcancer:seeBreastrCervicalcancer:seevCance宮頸癌：見子宮頸癌章節(jié)HealthMaintenanceandRoleofScreening

Alcoholism:seeAlcohol

：見酒精濫用章節(jié)保健和篩查Differential別診斷CRITERIAFORSCREENING 篩選標(biāo)Characteristicsofthe特征

CONDITIONS THAT WARRANT PERIODICEVALUATION INSELECTED PATIENTS被選定的部Rubella易感性Riskfactorsanticipatregnancyandriskgroupmembership;occupation(healthcareworker);Significanteffectonqualityor

life

見;免疫接種章節(jié)量和壽命有重大影響Prevalencesufficientlyhighto病率導(dǎo)致可觀的花費(fèi)

HIVnRiskandriskmembership;bloodtransfusio1978-1985;seeHIV-1AcceptableRxavaila

受的有效治療

險(xiǎn)因素：預(yù)期懷孕和風(fēng)險(xiǎn)組成員;1978-1985AsymptomaticperioduringwhichdetectioandRx HIV-1感染章節(jié)significanduceM&M 在無癥狀期間進(jìn)行檢測(cè)和

Endocarditis

炎易感性治療能大大減少患病率和死亡率Rxinasymptomaticphase

Riskfactors:valvularheartdisease;seeBacterialEndocarditisresultthandoesRxdelayeduntilsymptoms癥狀階段治療比延遲到出現(xiàn)癥狀時(shí)治療能夠獲得更

Rheumaticfever

的易感性好的治療效果 Riskfactors:rheumaticfeverHx;seeRheumaticCharacteristicst特性 危險(xiǎn)因素：風(fēng)濕熱病見風(fēng)濕熱章節(jié)TB(PPDreactivitRiskfactorccupationaexposureseeOccupationallungeRiskfactorccupationxposureseeOccupational

aRiskfactorspregnancykidneystonesseeTractLowerurinarytract路癌癥andEnvironmentalRespiratory因素：職 Riskfactors:occupationalexposuretoaromaticSusceptibilitytoB型肝炎病毒易感性Riskfactorale;(healthcareworker);seeViral

(e.gyestuffeathetanningrubber)seeBladderCancerTesticularcane丸癌性同性戀接觸職業(yè)衛(wèi)生保健工作者見病毒性肝 Riskfactors:cryptorchidism;seeScrotalPain,炎章節(jié)Anemia貧血

andSwelling;TesticularCneRiskfactors:pregnancy;see

質(zhì)疏松癥性貧血章節(jié)Sicklecell細(xì)胞的特性

RiskseeOsteoporosis險(xiǎn)Riskfactors:African-Americanofinge險(xiǎn)因素：生育年齡的非洲裔美國人 Riskage,TIAHx;seeTransientGeneticcounselingmustbeacceptable;seeAttackandAsymptomaticCarotidtDisease遺傳咨詢必須是可被接受的;見鐮狀細(xì)胞病章節(jié)ThyroidrRiskfactoradiatifheadandneck;seeNodulesandThyroidCancer危險(xiǎn)因素：頭部和頸部受過輻射;見甲狀腺結(jié)節(jié)和甲狀腺癌章節(jié)Diabetes糖尿病

素：老年，短暫性腦缺血發(fā)作病史;見短暫性腦缺血發(fā)作和無癥狀性頸動(dòng)脈雜音章節(jié)SkinrRiskfactoraiskinsunexposurefamilyHx;SkinGlaucoma青光眼Riskfactors:familyHx;advancedage;seeGlaucomaRiskfactors:pregnancy;familyHxofDM;obesity;ofgestationiabetesseeDiabeteMellitu危險(xiǎn)因 Oralcancr腔癌見糖尿病章節(jié)Endometrialcancr宮內(nèi)膜癌

Riskfactors:alcohol;tobacco;see素：酒精，煙草，見口腔癌章節(jié)Decreasedg

ncerRiskfactorsexogenousestrogensseeCancerVaginalrRiskfactornuterodiethylstilbesosuresee

Riskage;excessivenoise;HearingLosVaginal癌章節(jié)Syphili梅毒

RiskandPrognosis風(fēng)險(xiǎn)和預(yù)后Riskfactors:malehomosexual;pregnancy;otherSTDs;seeSyphilsChlamydialgenitourinaryn染

Management 處理Doctor-patieialogueaboutfutureimplicationofillnerrisfactoareoftemomentousrFewtasksofprimarycarearemoreimportant.Riskfactors:otherSTDs;womenofchildbearingaboutuncertainfuturemust beseeChlamydialn育齡婦女;見衣原體感染章節(jié)

communicatedwithclarity,compassion,andappreciatioforuniquenesofeachpatienteeds疾病或危險(xiǎn)因素的醫(yī)患對(duì)話往往對(duì)患者非常重要。很少有其他初級(jí)衛(wèi)生保健的工作比這更重要。在對(duì)未來不確定信息進(jìn)行溝通時(shí)必須明確，有同情心，并個(gè)體化。

來的，他們往往有別于在初級(jí)保健站中所見到的患者群。Communicatingriskandprognosiscanbedifficult.ImportantsourceofconfusionisPatientsvarysignificantlyindesireforandabsoluterisk.EffectofriskfactorsisfuturePCPshouldelicndhonoreAlsothattheyshouldbepreparetoexprestheipreferenceforhavingornothavingothercliniciansinvolvedinToavoidbeingmisledandmustunderstandbiasesthatcanbesuboptimalmethodsareusedtohelppredictfuueSomeproblemsarespecifitocase-contrtudiethat

expresseasrelatiiskorriskratioandeffectofinterventioreusuallyexpressedaslow,cangiveanunrealistiewofpotentiaharmsandwayofriskfactoistocitrisattributaborisfactoorreductionattributabletoanintervention.Attributablisdifferenetweenincidencamongexposedpeopleandincidenceamongthosewhoarenotcompareratesof"exposure"toriskfactorsamongwithdiseaseoroutcomeandthosewithoutsameeoroutcome.Theseratesareusedtoproduceanapproachtosummarizingthiskindofiswhichoutcomewithrisfactocomparedto

citnumberofpatiennewouldneedtotreato一種來總結(jié)這類的數(shù)orderforoddsratiotobeaccurateestimateofediseaseoroutcomeinquestionmuste病例對(duì)照研究是特異的，即在哪些有疾病或結(jié)果與沒有同樣的疾病或結(jié)果之間對(duì)危險(xiǎn)因素的暴露率相比較。這些比率可用來產(chǎn)生一個(gè)優(yōu)勢(shì)比，這是估計(jì)在伴與不伴隨風(fēng)險(xiǎn)因素相比較時(shí)疾病和后果的相對(duì)風(fēng)險(xiǎn)。為了使優(yōu)勢(shì)比能對(duì)相對(duì)危險(xiǎn)度準(zhǔn)確估計(jì)，疾病或后果必須是罕見的。Accuracyofretrospectiase-contromethodorofretrospectiohorstudies

者在群體患者中的人數(shù)?；颊叩娜藬?shù)在單個(gè)患者將有一個(gè)預(yù)期效應(yīng)。ProportioofpeoplewithparticulaconditiowhoofthecaseSomeindicationofdurationofsurvivalmaybeincludebydescribingsurvivalatpointintimeafterDxsurvivalrate).Simplerateshaveadvantageofbeingtorememberandcommunicate.However,valuabledistributiofofscrutinybeappliedtoHxofcaseseventsovertime,issummarizedbysinglera病例對(duì)照方法或回顧性隊(duì)列研究的精確度需要對(duì)病例 Morecompletepictureofprognosisiscapturedin組與對(duì)照組病史同樣程度的細(xì)致檢查。

死率是在特定條件下最終死于這種疾PerhapsmostforPCPsto病的人口比例。一些持續(xù)生存的指標(biāo)可用治療之后某studiesofprognosishasbeentermedreferralroccurfrequentsresuloffacthapatiennmany 率有易于記憶和交流的優(yōu)勢(shì)。然而隨著時(shí)間的推移分publishedreportshavebeendescribedbecausethey不確定性事件，通過單一的比率來總結(jié)預(yù)后會(huì)丟beenacademictheyarethoseseenin

失有價(jià)值的信息數(shù)據(jù)。通過生存曲線可獲得對(duì)預(yù)后更完整的描述。Sometimes,proportionofpeoplewhoexperiencerathethanproportiowhoareevent-fresplotteonverticxisSuchcumulativincidenccurvesconveysameinformatioorecompletepicturpresentebysurvivalcurve,includinglow

isolateeffectofexperimentaRx時(shí)，對(duì)特定患者的治療效果仍不確定，這反映了用臨incidenceofrecurrenceinnearterm,maybemore中使用的方法去衡量經(jīng)驗(yàn)治療的無關(guān)的后果。topatieneopleresponddifferentosameriskA1%riskforstrokeduring5-or10-yrperiodmaybethreateniosomebutinconsequentioothersThiscanbeexplainedbyveryrealcompetingrisksthat

PCPmustbeconcernedbothaboutinternalidiftrialastestofeffectivenessorefficacyofintervenspecifiopulatioundercontrollircumstanceandaboutitsexternalvalidity:theextenttowhichapplicabletodifferentpatientsseenntice.性即測(cè)試對(duì)于受控情況下的特殊人群進(jìn)行干涉的效果或效力，和外部真實(shí)性：試驗(yàn)結(jié)果應(yīng)用范圍，能適用于在實(shí)際中遇到的不同患者。這兩點(diǎn)初級(jí)保健醫(yī)師都必須關(guān)心。differentpeoplefacebecauseofothermedicalofrelativescarcityofrandomized-controltriortheenvironmentinwhichtheylive.Similarly,oftenrelyonquasi-experimentalclinicaltrpeoplehaveorpresentornearfutureanddistantfuture.Puttingbeusedinsideforsomepossiblegoodsensetosomebutlittle

observationastudietopatiencare.patiencharacteristongalternatixgroupsmaysensetoothers.Again,competingrisksexplaintoerroneousconclusionsaboutRxiveness.thesedifferencs5101是種威脅而對(duì)其他人卻無關(guān)緊要。由于其他醫(yī)療條件或居住環(huán)境的不同，這可以用不同的人所面對(duì)的非常實(shí)際的競爭風(fēng)險(xiǎn)來解釋。同樣，不同的人在權(quán)衡選擇當(dāng)前與不久的將來和遙遠(yuǎn)的未來時(shí)有不同的態(tài)度。為了未來可能的受益現(xiàn)在忍受副作用或不便，這對(duì)有些人非常有意義但對(duì)其他人卻沒有意義ChoosingTreatmentOptions治療的選擇Management處理Randomized-controclinicriarovidbesevidenceregardinRxeffectiveneenmultipltrialhavebeenmostcomprehensiveissuesUnfortunatelandomized-controstudiesarerelativearformanycommonillnessndtheiRx.隨機(jī)對(duì)照臨床試驗(yàn)為治療效應(yīng)提供了最佳證據(jù)。當(dāng)多個(gè)試驗(yàn)已經(jīng)完成，對(duì)這些試驗(yàn)進(jìn)行概述，或進(jìn)行薈萃分析，能提供對(duì)該事件最全面的理解。不幸的是，許多常見疾病和其治療的隨機(jī)對(duì)照研究比較少見。

于隨機(jī)對(duì)照試驗(yàn)相對(duì)缺少，初級(jí)保健醫(yī)師必須經(jīng)常依賴準(zhǔn)經(jīng)驗(yàn)性的臨床試驗(yàn)或沒有對(duì)照的臨床觀察研究。然而把臨床觀察研究的結(jié)論應(yīng)用于病人保健時(shí)應(yīng)十分謹(jǐn)慎。替代治療組中病人特征方面的差異可能會(huì)導(dǎo)致對(duì)于治療效果的錯(cuò)誤結(jié)論。Thereisampleevidencepatients'expectatioegardineffectivenefRxhasprofoundRxoutcome.Itisnotatallunusualforshamsurgicalprocedurestoreportanimprovementinsymptoms.TherearealsoexamplesofwhichhavecomplyfaithfullywithprescribedregimendobetterpatientwhodonotThese"complianceffectccurregardlefwhetherregimenincludeactivagentor的期望對(duì)治療結(jié)果有著深刻的影響。這并不罕見于接受無活性藥物(安慰劑)或假手術(shù)操作治療的病人報(bào)告其癥狀有改善。也有一些研究例子中，對(duì)處方治療忠實(shí)順應(yīng)的高期望患者比相反的病人效果好。不論是否有活性藥物或真實(shí)的操作療法，這些“順應(yīng)效應(yīng)”都會(huì)發(fā)生。EvenifprobabilitifoutcomescontingentonalternativeRxchoicescanbeestimatedprecisely,stillmuchworktobedonetoensurewiseRxchoiceEvenwhenrandomizedtrialsareperformed,uncertaipnatryticularpatient.DifferentpatientshavedifferentremainsabouteffectivenefRxforspecifipatients,

samealsocanalsowhichreflectsmethodsusedinclinicaltrialstosamelevelofriskorsametrade-offsovertime.Therightchoice,therefore,rnstravelioareainwhichinfluenzactivitybetweenPCPandwhatpossibleoutcomeswillmeanforthatpatient'squalityoflifeovere

amongpeoplefromworldinwhichtheriscurreninfluenzactivit流感活動(dòng)區(qū)旅游的健康后果不同的患者有不同的反應(yīng)。隨著時(shí)間的過 Previousanaphylacticreactiontothisvaccine,to去他們對(duì)相同的風(fēng)險(xiǎn)水平或相同的權(quán)衡選擇也能也有不同的看法。因此，正確的選擇，需要初級(jí)保健醫(yī)師和病人對(duì)于可預(yù)見的未來的生活質(zhì)量來說可能的預(yù)后意味著什么進(jìn)行認(rèn)真的溝通。

itscomponents,orto任何組分、對(duì)雞蛋有過過敏反應(yīng)。Moderateorsevereacuteilns計(jì)劃表GiveneveryyeaInImmunization免疫接種

isoptimaltimetoreceiveannualflushottomaximizbegivenanytimeduringinfluenzseason(typicalecember-March)oratManagement 處理

othertimeswhenriskofinfluenza

SUMMARYOFSUMMARYOFRECOMMENDATIONSFORROUTINEADULTIMMUNIZATIONS常規(guī)成人免疫Forwhomrecommended推薦接種的人

帶，10-11月是接受每年流感疫苗注射獲得最大保護(hù)的最佳時(shí)機(jī)，但疫苗可以在流感季節(jié)的任何時(shí)間給與(代表性的12-3月份)或當(dāng)流感風(fēng)險(xiǎn)存在的任何時(shí)間。MaybegivenwithatseparateAdultsaged

齡>=65歲的成人

site.可以與任何其他疫苗同時(shí)給與但要在不同部Peopleaged6mos-65yrswithmedicalproblemssuch位。asheartdisease,lungdisease,diabetesnrenal dysfunction,hemoglobinopathies,and665

IM肌注PneumococcalForwhomrecommended和免疫抑制；生活在長期護(hù)理場所的人。

Peopleaged2-65whohavechronicillnessorotherPeopleaged>=6mosworkngorat-risk.與有風(fēng)險(xiǎn)的人一起工作生活的年齡大于6

chroniccardiacorpulmonarydiseaseschronilivediseasealcoholismDM,and月的人。

CSFleaks;andpersonslivinginspecialenvironmentsAllworkersandthosewhoprovidekey

orsocialsettings(includingAlaskanativesandcommunityservices

有的健康護(hù)理工作人員和那

AmericanIndianpopulations).Thoseathighestrisk些提供關(guān)鍵社區(qū)服務(wù)的人。

fatalpneumococcalinfectionarepersonswithanatomiHealthypregnantwomenwhowillbeinsecondorthfunctionaaspleni(includinsicklceldisease);trimesteuringinfluenzseason23Pregnantwomen whohaveunderlyingmedicalbefluregardlessofstateof

immunocompromisedpersons,includingthosewithHIVinfect,leukemia,lymphoma,Hodgkin'smultiplemyeloma,thosereceivingimmunosuppressive chemotherapy (including時(shí)期，需要在流感季節(jié)到來前接收疫苗接種的處于

corticosteroids);andthosewhohavereceivedan潛在醫(yī)學(xué)情況的孕婦。

orbonemarrow265Anyonewhowishestoreducelikelihoodofbecoming性病或其他風(fēng)險(xiǎn)因素，包括慢性心臟或肺疾病，慢influenza能性的人

何希望減少由于流感而生病可

性肝病，酗酒，糖尿病，CSF缺乏；生活在特殊環(huán)腫瘤、慢

員有家庭接觸或性伴侶；使用違法的注射用藥物；61Previousanaphylacticreactiontothisvaccine,toyitscomponents,orto

All

的青少年任何組分、對(duì)雞蛋有過過敏反應(yīng)。Moderateorsevereacuteilns

Note:In1997,NIH ConsensusDevelopmentConference,apanelofnationalexperts,recommendedSchedule計(jì)劃表

thathepatits

giventoallpersonsRoutinelygivenas1-timedose;administerifprevectedwithC1997vaccinationHx1苗接種史不清楚時(shí)給與。

院共識(shí)發(fā)展會(huì)議，一個(gè)國內(nèi)專家組建議所有感染丙型肝炎病毒的人給與乙型肝炎病毒性疫苗。One-timerevaccinationisrecommended5yrslateritorotePerformserologiscreeninforpeopleinfectionorrapidantibodyloss(e.g.renaldiseaseandfor

whohaveemigratedfromendemicareas.WhenHbsAg-positivepersonsarepeopleaged>65iffirstdosewasgivenbeforeagepropriatdiseasmanagement.Inadditionscreenand>=5yrshaveelapsedsincee. theirhouseholdmembersandintimatecontactsand,于處于致命性肺炎球菌感染最高風(fēng)險(xiǎn)的或快速抗體

foundsusceptiblaccinat

輯按：對(duì)流行區(qū)移民65歲以前給與>=565人。Maybegivenwithatseparate位。RouteofnIMorSQ肌注或皮下HepatitisBForwhomrecommended推薦接種的人

來的人進(jìn)行血清學(xué)篩查。為被查出HbsAg陽性的人提供適當(dāng)?shù)募膊√幚?。另外，篩查他們的家庭成員和親密接觸者并對(duì)易感者行免疫接種。aitscomponents,orto何組分、對(duì)雞蛋有過過敏反應(yīng)。Moderateorsevereacuteilns計(jì)劃表3dosesneededon0-,1-,6-mos第High-riskadults,includinghouseholdcontactsande1，6HbsAg-positivepersons;usersofillicit Alternatetimingoptionsforvaccinationinclude0,injectabledrugs;heterosexualswith>1sexpartnem;0,1,4mos.免疫接種的替換時(shí)間選擇包括第mos;menwhohavesexwithmen;peoplewithrecentl0y-，2-，4-月；第0-，1-，4-月。diagnosedSTDs;Theremustbe4wksbetweendoses1and2,and8wkspatienithrenadiseasthamayresulindialysis; betweendoses2and3.Overall,theremustbe>=4moscertainbloodproducts;healthcare betweendoses1and.第12workersandpublicsafetyworkerswhoareexposedo4238blood;clientsandstaffofdevelopmentallydisabled;inmatesoflong-term

總的來講在第1與第3針之間必須至少間隔>=4月。Scheduleforthosewhohavefallenbehind:ifseriesdelayedbetweendoses,donotstartseriesover.berecommended

Continuefromwhereyou

dependingonspecifileveofriskorHbsAg陽性人

劃的人：如果系列在兩針之間被延遲，沒必要從頭開始系列。繼續(xù)從拉了的那針開始。Maybegivenwithatseparate位。RouteofnIMOthercomments其他注釋Brandsmaybeusedinterchangeaby以互換

第1與第2針之間至少間隔6月。Ifdose2not1.dose21僅打第2針就可以了。Maybegivenwithatseparate位。RouteofnIMHepatitis

A型病毒性肝炎

Othercomments其他注釋Forwhomrecommended推薦接種的人 Brandsmaybeused牌子之間可PeoplewhotraveloutsideU.S.(exceptforwesternEurope,NewZealand,Australia,Canada,and

美國以外旅游的人(除了歐洲北部和西部，

新西蘭，澳大利?，加拿大和日本)Peoplewith

Forwhomrecommended推薦接種的人AlladolescentsandwithHCVinfection,peoplewithhepatitisBwhoprimaryserieshasbeencompleted,boosterdosechronicliverdisease,illicitdrugusers,menwhoarecommendedq10yrs.Makesurepatienthavesexwithmen,peoplewithclottinfactodisorders,

receivedprimaryseriesof

peoplewhoworkwithHAVinsettinthidoesnotrefetoroutinmedical

成后，推薦每10年加強(qiáng)1針。確保病人已經(jīng)接受了3針基礎(chǔ)系列。andfoodprivate Boosterdoseasearlyas5yrslatermaybeneededfoemployersdeterminevaccinationtobemanagement,soconsultACIPrecommendations.慢性肝病的人，包括丙肝感染者，有伴有乙肝的慢性肝病的人，使用違法的注射用藥物，男性與男性性交，有凝血因子機(jī)能紊亂的人，在有甲肝病毒試

對(duì)于傷口處理的加強(qiáng)針，最早要在上一針5年以后，所以請(qǐng)查閱免疫實(shí)踐咨詢委員會(huì)的推薦。和衛(wèi)生當(dāng)局或私營雇主決定疫苗注射是有成本效益 Previousanaphylacticreactiontothisvaccine,to時(shí)的健康食品加工人員。Note:Prevaccinationtestingislikelytobecost-effectrpersonsaged>40aswellas

itscomponents,orto任何組分、對(duì)雞蛋有過過敏反應(yīng)。Moderateorsevereacuteilnsyoungerpersonsincertaingroupswithhighofnof40甲肝感染率組的年輕人一樣，在接種疫苗前進(jìn)行檢測(cè)有成本效益。

IM肌注Measles,Mumps,RubellaForwhomrecommendedAdultsbornin1957orareaged>=18(includinthosebornoutsidU.S.)shouldPreviousanaphylacticreactiontothisvaccine,todoseofMMRifthereisnoserologicproofofitscomponents,orto任何組分、對(duì)雞蛋有過過敏反應(yīng)。Moderateorsevereacuteilnsbenefitagainspotentiisk

immunityordosegivenonorfirsbirthday111957或以后出生的年齡大于18歲的成人(包括那些在美國以外出生的)應(yīng)該接受至少1針MMR。定，所以請(qǐng)權(quán)衡利弊。 Adultsinhigh-riskgroups,suchashealthcare計(jì)劃表 studentsenteringcollegesandothereducational2doses.要2針。 institutionsafterhighschool,andinternationalMinimumintervalbetweendoses1and2ismos.shouldreceive22生保健工作人員，進(jìn)入大學(xué)和其他高中以上教育機(jī)構(gòu)的學(xué)生，和國際旅行者。Allwomenofchildbearigeandpremenopausaladultwomen)whodonothave

周后。Maybegivenwithatseparate位。acceptableevidenceofrubellaimmunityorvaccinaricellvaccineandMMR (orotherliveviral所有無可接受的風(fēng)疹免疫力或疫苗接種證據(jù)的育齡 vaccinessuchasyellowfevervaccine)areneededimmune,butproofofimmunitymaybedesirablfor1957

arenotadministeredonsameday,spacethem>=4wksapart.如果水痘疫苗和MMR(或其他活病毒疫苗如黃熱病疫苗)都需要接種并沒有在同一天接種時(shí)，它們需要間隔4周。RouteofnSQ皮下VaricellaForwhomrecommended推薦接種的人Previousanaphylacticreactiontothisvaccineorlsceptibdultandadolescentakespecialofitscomponents.(Anaphylacticreactiontoeggstovaccinatesusceptiblepersonswhohaveclolongercontraindicationto

對(duì)這個(gè)疫苗、

contactwithpersonsathighriskforserious對(duì)它的任何組分有過過敏反應(yīng)。(對(duì)雞蛋的過敏反應(yīng)不再被認(rèn)為是MMR的禁忌癥。)Pregnancyorpossibilifpregnancywithin33

complication(e.g.healtcareworkersandfamilycontactsofimmunocompromised persons)andareathighexposure(e.geacherofyoungchildreayeHIVpositivityisnotacontraindicationtoMMRexcreepstidentsandstaffininstitutionsaelttingssuchasforthosewhoareseverelyimmunocompromsd. collegesandcorrectionalinstitutionilitary病病毒陽性不是用MMR 的禁忌癥除非那些嚴(yán)重免 personnel,adolescentsandadultslivingwithchildre疫妥協(xié)的人。Immunocompromisecausedbycancer,leukemia,

nonpregnantwomen ofchildbearingage,andinternationravelehodonothaveelymphoma,andimmunosuppressivedrugRx,includingimmunity).所有易感的成人和青少年。要特別努力high-dosesteroidsor淋巴瘤和免疫抑制劑治療，包括高劑量類固醇或放療治療導(dǎo)致的免疫妥協(xié)。Ifbloodimmunehavebeenadministeredduringpast11mos,consultACIPrecommendationsregardingtimetowait

去給那些與會(huì)有嚴(yán)重并發(fā)癥高風(fēng)險(xiǎn)人群接觸的易感

過去11個(gè)月里接受過血制品或免疫

接種。球蛋白治療，查閱免疫實(shí)踐咨詢委員會(huì)的關(guān)于疫苗接種前等待的時(shí)間的推薦。Moderateorsevereacuteilns.重急性疾病Note:MMRisnotcontraindicatedifPPDtestdonerecently.PPDshouldbedelayedfor4-6MMR hasbeen注意：如果最近做過PPD試驗(yàn)，麻腮風(fēng)疫苗不是禁忌癥。如果接種過MMR 么PPD試驗(yàn)需推后4~6周。Schedule計(jì)劃表1or2dosesneedd1或2針。

Note:Assumeimmunityinpeoplewithreliabxofchickenpox(e.g.,self-reportorparentalreportofForadultwithoureliabx,serologitestinmaybemostadultswithnegativeortainHxofvaricellaareimnaIfdose2isrecommended,giveitnosoonerthan4anaphylacticreactiontothisvaccineorto1.如果推薦打第2針，至少在第1針的4 ofits前對(duì)這個(gè)疫苗對(duì)它的任何組分有過過敏反應(yīng)。 于年>=18歲的人不常規(guī)推薦。Pregnancyorpregnancywithin1mo Note:AdultslivingintheU.S.whoneverreceived3mos).妊娠或可能在1 completedprimaryseriesofpoliovaccineneednot個(gè)月內(nèi)懷生產(chǎn)商推薦為3個(gè)月。Immunocompromisecausedbymalignanciesandprimaryoracquiredcellularimmunodeficiency,Note:Forthoseonhigh-doseimmunosuppressive Rx, consult ACIPrecommendationsregardingdelaytime.由于惡性腫瘤，和原發(fā)或獲得性細(xì)胞免疫缺陷，包括艾滋病病毒感染或艾滋病患者。注意對(duì)那些使用高劑量免疫抑制劑治療的人，查閱免疫實(shí)踐咨詢委員會(huì)的關(guān)于

exposuretowild-typevirusisreceive1boosterdoseiftravelingtopolio-endemicra延遲時(shí)間的推薦。

RefertoACIPrecommendations

免疫實(shí)IfbloodproductsorIGhavebeenadministeredpast5mos,recommendationsregarding 計(jì)劃表timetowaitbefore

5個(gè)月里接受

RefertoACIPrecommendationsregardingunique過血制品或免疫球蛋白治療，查閱免疫實(shí)踐咨詢委員會(huì)的關(guān)于疫苗接種前等待的時(shí)間的推薦。ModerateorsevereacuteilnsNote:Manufacturerrecommendsavoidedfor6wksvaricella

situatioshedulesanddosinginformatio疫實(shí)踐咨詢委員會(huì)的關(guān)于特殊情況，時(shí)間表，和劑量信息的推薦。MaybegivenwithatseparatevaccinebecauseoftheoreticalriskofReye'se.6周內(nèi)使用水楊酸鹽。Schedule計(jì)劃表doses2Dose2isgiven4-8wksafterds.針4-8周

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