內(nèi)科學(xué)概述王吉耀

INTRODUCTIONTOINTERNALMEDICINEJiyaoWang,MD.MSC.Professor&ChairDept.ofInternalMedicineShanghaiMedicalCollege,FuDanUniversity第1頁InternalMedicineSurgeryPediatricsgynecologyPathologyMicrobiologyGeneticsBiochemistryPharmacologyPathologic-physiologyDiagnosticsImmunology第2頁Howtolearn1.Tocombineinternalmedicinewithbasicscientificknowledge2.Tocombinetheorywithpractice第3頁LecturesIntroductionPathogenesisPathologyPathophysiologyClinicalfeaturesDiagnosisTreatment,PreventionBasictheoryBasicknowledgeEssentialskill第4頁BedsideTeaching第5頁WhatisexpectedofthephysicianNogreateropportunity,responsibility,orobligationcanfalltothelotofahumanbeingthantobecomeaphysician.

Tact,sympathyandunderstandingareexpectedofphysician.第6頁TebeagoodDoctor

Inthecareofthesuffering,physicianneedstechnicalskill,scientificknowledge,andhumanunderstanding.

Thecombinationofmedicalknowledge,intuition,experience,andjudgmentdefinestheartofmedicine,whichisessentialtothepracticeofmedicine.

第7頁Thepatient-physicianrelationshipPhysiciansneedtoapproachpatientsnotas“cases”or“diseases”,butasindividualswhoishuman,fearful,andhopeful,seekingrelief,helpandreassurance.第8頁Idealpatient-physicianrelationshipBasedon:ThoroughknowledgeofthepatientMutualtrustAbilitytocommunicate第9頁ClinicalSkillsTakinginformativehistory;Performingthoroughphysicalexamination;Usingdiagnostictoolsjudiciously,alwaysaskingwhethertheresultswillalterthemanagementandbenefitthepatient.第10頁HistorytakenInlisteningtothehistory,thephysiciandiscoversnotonlysomethingaboutthediseasebutalsosomethingaboutthepatient.

Theprocessofhistory-takingprovidesanopportunitytoobservethepatient'sbehaviorandtowatchforfeaturestobepursuedmore.thoroughlyduringthephysicalexamination.第11頁TodevelopeffectivereasoningskillsInformationgathering(informativehistory,thoroughphysicalexamination)ProblemsynthesisHypothesisgenerationDecisionmakingEssentialskill第12頁LearningofEssentialSkillsInquiryskillsThinkingskillsProblemsolvingskillsEssentialskill第13頁DealingwithclinicalproblemsMakingdiagnosisIdentifytheseverityofthediseaseAccordingtotheseverityofdisease,tomaketherapeuticprotocolFollowuptheresultsofthetreatment第14頁Evidence-basedmedicine,EBMDefinedas:Theconscientious,explicitandjudicioususeofcurrentbestevidenceinmakingdecisionsaboutthecareofindividualpatientsPrinciplesofPatientCare第15頁Evidence-basedmedicine,EBMBestresearchevidencebasicsciencesofmedicinepatient-centeredclinicalresearchClinicalexpertiseabilitytouseourclinicalskillsandpastexperiencetorapidlyidentifyeachpatient’suniquehealthstateanddiagnosis,theirindividualrisksandbenefitsofpotentialinterventionsPatientvaluestheuniquepreferences,concernsandexpectationseachpatientbringstoaclinicalencounterandwhichmustbeintegratedintoclinicaldecisionsiftheyaretoservethepatientWhenthesethreeelementsareintegrated,cliniciansandpatientsformadiagnosticandtherapeuticalliancewhichoptimizesclinicaloutcomesandqualityoflife.PrinciplesofPatientCare

第16頁*MeansanyotherlettersANDmeansbothtermsrequiredCheckthequestiontypeChecktheemphasis第17頁PracticeGuidelines

Evidencebaseclinicalguidelinescanprovideausefulframeworkformanagingpatientswithparticulardiagnosesorsymptoms.PrinciplesofPatientCare第18頁TheGrade&LevelofEvidence

GradesoflevelofRecommendationevidence Etiology/Therapy/PreventionA 1a SRofRCTs 1b IndividualRCTwithnarrowCI 1c AllornoneB 2a SRofCohortstudies 2bIndividualCohortstudy/lowqualityRCT 2c OutcomeResearch 3a SRofCase-controlStudy 3b IndividualCase-controlStudyC 4 Caseseries/poorqualitycohortstudy/case-controlstudyD 5 Expertopinionwithoutcriticalappraisal第19頁.whenarelevantevidencebaseisunavailable,clinicalknowledgeandexperiencetogetherwithanunderstandingofthepatient'sneeds,supplementedbydiagnostictools,stillrepresentthebestapproachtopracticingmedicine.第20頁MedicalDecision-Making

orderingofadditionaltests,requestsforconsults,decisionsregardingprognosisandtreatmentMedicaldecision-makingshouldbeevidence-basedPrinciplesofPatientCare第21頁HistoryPhysicalExaminationLaboratoryTests,imagingSpecialdiagnosticstudiesDiagnosisEstimationRightdecisionmakingnecessaryselectedDiagnostictestsservetoreduceuncertaintyaboutadiagnosisinaparticularindividualandtohelpthephysiciandecidehowbesttomanagethatindividual'scondition.第22頁ThePrinciplesofDiagnosticThinking

OneetiologyCommondiseasefirstOrganicdiseasesfirst,thenfunctionaldisordersExcludingmethodstododifferentialdiagnosis第23頁ThePrinciplesforselectingDiagnostictests&ImagingstudyEffectiveness,safetyandpriceSelecttestwithhighsensitivitytoexcludediagnosisSelecttestwithhighspecificitytoconfirmdiagnosisNon-invasiveproceduresfirstIftheresultsfromtestisnotfittheclinicalconsiderations,detailedanalysisisneeded.第24頁ThePrinciplesofTherapeuticThinkingTreatthemostseverecasefirstIngeneral,therapeuticprotocolfollowingconfirmeddiagnosisofdiseaseForlife-threateneddisease,savelifefirst,thentoconfirmthediagnosisFortreatment,thesimple,thebest.Payattentiontodrugside-effectsandcross-overeffects第25頁ThePrinciplesof

TherapeuticThinkingTreatcurablediseaseassoonaspossibleDiagnostictherapycouldusedtoconfirmtheclinicaldiagnosisAccordingtoprinciplesofevidence-basedmedicinetomakedecisionfortreatment第26頁AssessingtheOutcomeofTreatment

Useobjectiveandreadilymeasurableparameterstojudgetheoutcomeofatherapeuticintervention.Thepracticeofmedicinerequiresconsiderationandintegrationofbothobjectiveandsu