2008住院医生规范化培训的医学英语重点篇章翻译.doc

The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine. Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics. Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize the occasional exceptions. Even more judgment is required in the many situations in which evidence is absent or inconclusive. Evidence also must be tempered by patients preferences, although it is a physicians responsibility to emphasize when presenting alternative options to the patient. The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.但是，不断增多的可用于指导临床诊断与治疗的随机试验资料不应当作“烹调书”使用。因为随机试验获得的现象和思路是侧重于求证具有某些特征病人而来的。实际的临床判断需要确定这些临床表现和诊断标准是否能应用于病人个体，并能找出例外。在许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。虽然医生有责任要提出选择性问题让病人回答，但病人肯定会根据自己的倾向调节临床症状。假如病人懂得基本原理和表现，对医生提出的问题，有特殊生活方式病人的固执容易被强化。Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variety of sources, some of which are of questionable reliability. The increasing use of alternative and complementary therapies is an example of patients frequent dissatisfaction with prescribed medical therapy. Physicians should keep an open mind regarding unproven options but must advise their patients carefully if such options may carry any degree of potential risks, including the risk that they may relied on to substitute for proven approaches. It is crucial for the physician to have an open dialogue with the patient and family regarding the full range of options that either may consider甚至，当医生越来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，当然，某些信息是不可靠的。替代疗法和辅助疗法的应用不断增加就是病人对常规疗法经常不满意的一个例子。医生对未证实的疗法应该保持开放的思想，但是，如果这些疗法具有任何程度的潜在风险，都必须细致地告知病人，包括可能需要用已证实的常规疗法去替代的风险。对医生来说，对病人及家属开诚布公地介绍所有可考虑的治疗选择，是非常重要的。A second way in which older adults differ from younger adults is the greater likelihood that their diseases present with nonspecific symptoms and signs. Pneumonia and stroke may present with nonspecific changes in mentation as the primary symptom. Similarly, the frequency of silent myocardial infarction increases with increasing age, as does the proportion of patients who present with a change in mental status, dizziness, or weakness rather than typical chest pain. As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally would be considered in middle-aged adults.老年与青中年的第二个差异是更容易出现非典型的症状和体症。肺炎和中风时可出现非特异性意识变化作为主要的症状。同样地，隐匿性心肌梗塞发生频度随着年龄的增大而增加，这些病人相应地频发精神状态改变、眩晕、虚弱而不是典型的胸痛症状。因此，老年病人的诊断应考虑更广泛的疾病谱，要超过通常对中年病人所考虑的范围。Finally, a serious and common outcome of chronic diseases of aging is physical disability, defined as having difficulty or being dependent on others for the conduct of essential or personally meaningful activities of life, from basic self-care (e.g., bathing or toileting) to tasks required to live independently (e.g., shopping, preparing meals, or paying bills) to a full range of activities considered to be productive and/or personally meaningful. Of older adults, 40% report difficulty with tasks requiring mobility, and difficulty with mobility predicts the future development of difficulty in instrumental activities of daily living (IADL; household management tasks) and activities of daily living (ADL; basic self-care tasks). In persons age 65 and other, difficulty with IADL is reported by 20%, and difficulty with ADL is reported by 11%; for both, the prevalence increases with age.最后，老年人慢性病严重又常见的结果是身体能力不足，描述为个人最基本的或有意义的日常活动有困难或不得不依靠别人帮助指导，从基本的自理（如洗澡或如厕）到独立生活需要的各种任务（如购物、做饭、支付各种账单），到具有集体和或个人意义的所有活动。在老年人中， 40%对需要运动的任务有困难，运动困难提示将来开展日常工具锻炼（IADL；家庭护理项目）和目常锻炼（ADL；基本自理项目）的困难。大于65岁的老人或其它人，IADL困难报导为20%，ADL困难报导为11%；随年龄增加两个都困难成为普遍现象。The initial approach to a patient with iron deficiency anemia depends on the presence of symptoms referable to either the upper or lower gastrointestinal tract. Regardless of the findings on the initial upper or lower endoscopic examination, all patients should have both upper and lower endoscopy because the complementary endoscopic examination has a yield of 6% even if the first one was positive. For premenopausal women, a positive FOBT requires full evaluation, as does iron deficiency anemia. Barium radiographs of the upper and lower gastrointestinal tract have limited utility in the setting of occult bleeding because of their inability to biopsy or treat lesions that are identified.缺铁性贫血病人的早期检查方法要根据存在的症状是提示上消化道还是下消化道。无论首次上消化道或下消化道内窥镜检查会有何发现，所有病人两个检查都应该做，因为互补的内窥镜检查有6%的再发现，即使第一次检查是阳性的。对绝经前妇女，大便隐血试验阳性需要全面分析，缺铁性贫血也一样。隐匿性出血时，上、下消化道的钡剂造影应用有限，因为它们不能活检或治疗发现的病损。When endoscopic evaluation does not detect the cause of blood loss, radiographic procedures such as scintigraphy and angiography should be considered. Provocative angiography using heparin or thrombolytic agents has been suggested by some authorities, but this approach has the potential risk of precipitating major bleeding. In the face of continued blood loss and no identified etiology, intraoperative endoscopy may provide simultaneous diagnosis and therapy. During the procedure, the surgeon plicates the bowel over the endoscope. As the scope is withdrawn, endoscopic findings can be identified for surgical resection or treatment. The yield of this procedure exceeds 70%. In some clinical situations, the site of bleelding cannot be identified, and the patient requires long-term transfusion therapy.当内窥镜检查不能发现出血病因，像闪烁造影和血管造影X线手段应该考虑。虽然使用肝素或溶栓药的刺激性血管造影被某些专家推荐，但这种方法有促发大出血的潜在风险。碰到进行性出血查不到病因，术中肠镜可能同时解决诊断和治疗。在操作中，外科医生把小肠套迭到内窥镜上。当内镜后退时，内镜发现可以决定是外科切除或（保守）治疗。这个措施的结果超过70%。某些临床情况下，出血部位无法发现，病人而要长期的输血治疗。Many aspects of palliative care, as with any specialty, are relevant to the general practice of medicine and to all clinicians who tend to dying persons. Palliative care has a role in the earliest phases of a life-threatening illness but assumes a more prominent or even dominant role in the final 3 to 6 months of common terminal conditions: advanced cancer, heart and lung failure, end-stage liver and renal disease, acquired immunodeficiency syndrome, and life-limiting neurologic diseases.姑息性治疗的特性通常与药物治疗和所有治疗临终病人的医生相关的。姑息性治疗可以用于临终病人的早期治疗，但其最重要和突出的使用是针对终末期的最后3至6个月时间:如患有晚期癌症、心肺衰竭、晚期肝肾疾病，艾滋病和致命的神经系统疾病的病人。 The first signs or symptoms of cancer are frequently due to metastases to visceral or nodal sites. In most such patients, routine clinical evaluation with a comprehensive history, physical examination, complete blood cell count, screening chemistries, and directed radiologic evaluation of specific symptoms or signs identifies the primary tumor. Patients who have no primary tumor located after this routine clinical evaluation are defined as having cancer of unknown primary site. Further clinical and pathologic evaluation will identify the primary site in only a small minority of patients, and about 80% will never have a primary site identified during their subsequent clinical course.肿瘤首发症状和体征通常是由于脏器或淋巴结转移引起的。对此类病人，需要进行常规临床检查和全面的病史回顾、体格检查、全血计数、生化筛查和对特定症状体征进行放射学检查以确定原发病灶。经过常规临床检查后不能发现原发病灶的被称为原发灶不明的肿瘤。仅有小部分病人经过进一步的临床和病理检查可以确定原发病灶，约80%的病人在后续的临床诊疗中无法确定原发病灶。Since all patients with cancer of unknown primary site have advanced disease, therapeutic nihilism has been common. However, it is now evident that this heterogeneous group contains subsets of patients with widely diverse prognoses; some cancers are highly responsive to treatment, and some patients may have a substantial chance of achieving long-term survival with appropriate treatment. The initial clinical and pathologic evaluation should therefore focus on identifying a primary site when possible and on identifying patients for whom specific treatment is indicated.由于原发灶不明肿瘤病人往往为晚期病人，治疗效果往往受到质疑。但是，现在比较明确的是这类特殊患者的预后差别很大，一些癌症患者对治疗高度敏感，也有部分患者通过适当治疗生存期很长。因此临床和病理检查的出发点应当时寻找原发病灶和识别对特殊治疗有效的患者。Complications can occur for a variety of reasons. A surgeon can perform a technically perfect operation in a patient who is severely compromised by the disease process and still have a complication. Similarly, a surgeon who is sloppy, is careless, or hurries through an operation can make technical errors that account for the operative complications. Finally, the patient can be doing well nutritionally, have an operation performed meticulously, and yet suffer a complication because of the nature of the disease. The possibility of postoperative complications is a part of every surgeons thought processes-something with which all surgeons will be required to deal.外科并发症的发生有多种原因。有时，外科医生手术技术上非常成功，但病人的病情严重可导致并发症的发生。同样，手术中医生的马虎、粗心或仓促都可以导致技术上的错误从而导致手术并发症。即使病人营养状况良好，手术也很成功，疾病本身也可导致并发症的产生。手术后并发症的可能性是每一个外科医生考虑治疗计划的一个组成部分，因为所有外科医生都将面临这些并发症中的一部分。 Pneumonia and influenza (P+I)- related deaths fluctuate annually, with peaks in the winter months. When such P+I deaths exceed the predicted number, it is due to influenza A or occasionally to influenza B virus or respiratory syncytial virus activity. Although mortality is greatest during pandemics, substantial total mortality occurs with epidemics. Over 85% of P+I deaths occur among persons aged 65 and older. Other cardiopulmonary and chronic diseases also result in increased mortality after influenza epidemics, so that overall influenza-associated mortality is about two- to four fold higher than P+I deaths. 与肺炎和流感(P+I)相关的死亡每年都在波动，冬季达到高峰。当P+I的死亡超过了预期数值，是由于A型流感或者偶尔因为B型或者呼吸道合胞病毒的活动性所致。尽管大流行的时候病死率最高，普通流行时候的病死率也非常可观。超过85%的P+I死亡发生于65岁以上的人群。流感流行之后，其它心肺疾病和慢性病同样导致病死率有所增高，以至于总体流感相关的病死率比P+I导致的病死率高出2-4倍。MRI can be useful for the cooperative patient in renal failure who cannot receive intravenous contrast material because it can provide tissue and vascular detail not achievable without contrast-enhanced CT. Patient cooperation is required because of the longer imaging times and respiratory motion artifacts. MRI is also useful in specific situations to image the biliary tree, liver parenchyma, and male and female pelvis.在病人合作的情况下，磁共振对于无法接受静脉造影剂的肾衰病人是有用的，因为它能提供组织和血管的细节，而这些细节不借助增强造影CT就无法看到。因为需要长时间的成像以及呼吸运动伪差，病人的合作对于MRI成像是有必要的。在一些特定情况下，MRI对于胆道系统、肝脏实质以及男性或女性骨盆的成像检查同样是有用的。In assessing prognosis and planning a treatment strategy, it is useful to classify SCD as either primary (without a clear trigger) or secondary. A primary episode has a 10 to 30% 1-year recurrence rate, whereas most secondary episodes are associated with recurrence rates of less than 2%. Identifiable reversible precipitants of secondary ventricular fibrillation (VF) include transient ischemia possibly related to vasospasm; hypokalemia resulting from diuretics; hyperkalimia secondary to renal failure, angiotensin-converting enzyme inhibitors, prostaglandin inhibitors,or potassium-sparing diuretics; proarrhythmia secondary to antiarrhythmics, tricyclics, and antihistamines; or substance abuse with drugs such as cocaine and amphetamines. Therapy is directed toward removing or treating the acute precipitant. SCD related to acute ischemia in the absence of prior MI often is associated with severe proximal occlusive disease, normal left ventricular function, normal signal-averaged ECG, and noninducibility absence of ventricular tachycardia (VT) during electrophysiologic study.在估计预后和制定治疗方案时，将心源性猝死分为原发性（无明确的诱发因素）或继发性是实用的。原发性发作的在1年内有1030的复发率，而大多数继发性的复发率小于2%。已知的可逆性继发性心室颤动（VF）的发作包括可能是血管痉挛性的短暂缺血；利尿剂引起的低钾血症；肾功能衰竭、血管紧张素转化酶抑制因子、前列腺素抑制因子、或保钾利尿剂所致的高钾血症；抗心律失常药、三环类药和抗组胺类药引起的心律失常；或可卡因或安非他明类药物的滥用。治疗是直接消除或处理急性发作。缺乏心肌梗死前兆的急性缺血性心源性猝死经常与严重的近端梗阻性疾病有关，这种病人左心室功能正常，心电图信号正常普通，电生理研究时无法诱异VT（缺乏室性心动过速）。Prophylactic antibiotic therapy is clearly more effective when begun preoperatively and continued through the intraoperative period, with the aim of achieving therapeutic blood levels throughout the operative period. This produces therapeutic levels of the antibiotic agents at the operative site in any seromas and hematomas that may develop. Antibiotics started as late as 1 to 2 hours after bacterial contamination are markedly less effective, and it is completely without value to start prophylactic antibiotics after the wound is closed. Failure of prophylactic antibiotic agents occurs in part through a neglect of the importance of the timing and dosage of these agents, which are critical determinants.起始于手术前以及持续于手术中的预防性抗生素治疗，对于贯穿整个手术阶段达到抗生素治疗剂量血药浓度显然十分有效。这可以使得在手术区域出现的浆液肿以及血肿中的抗生素达到治疗浓度。抗生素用于细菌污染后1-2小时候则有效性会大大降低，而伤口闭合后进行预防性抗生素治疗已毫无价值。预防性抗生素治疗的失败部分归咎于忽略了时机和给药剂量的重要性，而这两点正是关键的决定性因素。Many patients fail to receive needed prophylactic antibiotics because the system for their administration is complex at the time of multiple events just before a major operation. This problem has been made worse by the trend of admitting patients directly to the OR for planned operations, which intensifies the pressures to accomplish a large number of procedures during a short interval before the operation. The possibility that prophylactic antibiotics will be unintentionally omitted can be minimized by establishing a system with a checklist. One member of the operative team(usually the preoperative nurse or a member of the anesthesia team) should be responsible for initialing a portion of the operative record that states either that the patient received indicated prophylactic antibiotics or that the surgeon has determined that antibiotics are not indicated for the procedure. 许多病人并未给予预防性抗生素，这是由于在一个主要手术前的多种事件中，他们的管理系统过于复杂。由于允许病人直接去手术室进行计划内的手术，这个问题越来越严重，这加剧了手术前短时间内完成大量操作规程的压力。可以通过建立一个带有清单的系统来尽量减少预防性抗生素被无意识遗漏的可能性。手术组中的一员（通常是术前护士或者麻醉组成员之一）应当负责草签手术记录当中的一部分，以阐明病人是否接受了指定的预防性抗生素或外科医生已经决定不采用抗生素。Some patients with clear findings of the acute abdomen may be treated without surgical operation. For example, patients with perforated duodenal ulcer who seek attention late in the course of their disease after they have been sick for several days may be treated best by careful supportive care including nasogastric suction, intravenous fluids, and pain relief. Certain patients with empyema of the gallbladder, especially those with other serious concomitant illnesses, can be treated by percutaneous drainage of the infected gallbladder and careful supportive care rather than with cholecystectomy.一些有清楚检查结果的急腹症病人可以并不需要手术处理。例如十二指肠溃疡穿孔的病人在病后数日才来就诊的，可以进行细心的支持治疗包括鼻胃管吸出、静脉输液和止痛。某些病人伴有胆囊积脓，尤其那些伴有严重并发症的病人，可以对感染的胆囊进行经皮引流并予以仔细周到的支持治疗，这要胜过胆囊切除术。Develop a series of diagnosis-based hypotheses. Because pain may result from disease at the pain site or be referred from other parts of the body, it may be helpful to list all the possibilities for the site of origin, particularly when the pain has been resistant to therapy. Persistent rib pain in a patient with metastatic cancer despite radiation therapy to the lesion in that rib would raise the possibility of referred pain from thoracic epidural tumor, which can be imaged and treated. For each potential site of the lesion, the list of the common disease processes in that area can be considered.发展一系列基于诊断方法的假说。因为疼痛可以来自疼痛部位的疾病或者源于机体其它部位的牵涉疼，那么罗列出疼痛原发部位的所有可能性就会有所帮助，尤其当疼痛对治疗无效时。转移癌患者的持续性肋骨疼痛，尽管放疗对该肋骨的损害会增高可以照相和治疗的胸膜瘤导致的牵涉疼的可能性。对每种潜在的损害部位，可以考虑列举出那个区域的通常的疾病过程。第1篇 医患沟通（掌握）医患沟通经历很多诸如临床判断和作出决定等阶段。沟通从解释抱怨或关注开始，然后，询问或用更为精确的办法对所陈述的关注作出评估。此过程通常需要仔细回顾历史或做身体检查，安排诊断性检测，整合临床发现和检测结果，了解可能采取措施的风险和好处，并耐心征求病人及其家人的意见，做出计划安排。医生在尊重病人个体差异的前提下，充分利用以事实为基础的治疗方法来引导该进程，使治疗效果达到最佳状态。 用从随机抽样试验中的证据来指导诊断和治疗应当不等同于“菜谱”式治疗。从中得到的证据和指导原则强调对病人的方法应具有个性。要判断这些证据和指导原则是否适应病人个体并认识到偶尔的例外，医生要做重大的症疗判断。在很多证据不足或不能得出结论情况下，则需要作出更多的判断。虽然医生的职责是在给病人提供治疗方案的时候应该强调证据，但这些证据且必须根据病人的情况被缓和。假如病人同样知道医生提供的治疗方案背后的基础原理和证据，则病人很有可能遵循一种特别的养生之道. 把病人当作个体来关心，医生必须把病人当作一个完整的人。这种基本的行医原则包括了解病人的社会地位，家庭组织，经济状况和不同的治疗方法和结果的期盼。这种期盼可以是最大限度地延长寿命到减轻疼痛和受罪。假如医生不关注和致力于这些问题，医疗科学将无法合理地被利用，即使是最有学问的医生都无法达到最佳的效果。 尽管医生越来越多地掌握新的发现，但是病人也能够从不同的渠道得到他们自己的信息，虽然有些信息可信度值得怀疑。越来越多地利用其他的和补充的治疗方法是病人对处方治疗不满的一个例子。医生必须保持开明的头脑尚接受未临床实验的治疗方法，但在建议病人时，必须小心，如果这些方法带有一定的潜在风险，包括他们依赖于来代替原方法的风险。因此，医生和病人及其家人在涉及各方能够考虑到的各种治疗方案时，进行坦诚地沟通就变得十分重要了。 医生并不是真空的，而是复杂而广泛的医疗和公共卫生系统的一部分。在近代甚至当今，在一些发展中国家，基础卫生、洁净水和充足的营养是促进健康和减少疾病的最重要的途径。在发达国家，采取健康的生活方式，包括良好的饮食和合理的运动是减少肥胖症、冠心病、糖尿病等流行性疾病的基础。通过公共健康干预来提供免疫接种、降低伤害事故、控制烟草、违法毒品和过度的熏酒，比起其他任何想象中的健康干预，都能带来更多的健康。第22篇 气促（掌握） “接不上气”、“感到不能呼吸到足够的氧气”或“呼吸费力”等等都是用与描述病人呼吸困难的用词。导致呼吸困难可能是肺病、循环系统疾病或两种疾病同时存在的原因。医生的职责就是要弄明白产生气促的机理，从而采取得当的诊断和治疗措施。气促的常见症状为：由于气道阻力增大而致的呼吸动作次数增加，这往往出现在哮喘、慢性支气管炎和肺气肿等疾病中；或，在间质纤维化反应疾病中肺部舒张能力减弱。在间质纤维化反应疾病中，为了让肺部充气，病人需要不断呼吸使胸膜腔产生较高的负压。这种为了克服气流阻碍或肺部舒张能力减弱而引起的肺部机械动作的增加，常被视为病人不断努力呼吸而产生呼吸困难的症状。 被迫增加通气的动力也可能引起呼吸困难。这种刺激物包括缺氧，这时动脉血氧张力通常低于mmHg; 和肺部实质炎症，如：细菌性肺炎和肺泡炎，炎症促动大脑的呼吸中枢。这些刺激物常常使余留的二氧化碳压力将降到正常水平（mmHg）之下而产生呼吸困难，这在微弱病况中特别会发生。 通过正常的光照片，带有肺部栓子的病人经常会出现气促。被栓塞的肺部气体交换低效，其特征为死腔增大，需要用非正常的高频通气来维持正常的动脉二氧化碳压力。除非肺部梗塞的特殊征兆被发现，梗塞疾病往往要到病人突然死亡或经历由于肺部高压和右心室衰竭引发的根本无法承受的痛苦时才会被发现。 由于在普通人群中心脏疾病和心衰竭发病率很高，很多呼吸困难病人往往心脏异常。呼吸困难最根本原因是左心室的充盈压过高，从而导致左房压过高、肺部毛细血管压过高和肺部动脉血压过高。肺部动脉血压过高相反就会引起肺部充血而降低肺的顺应性。若肺毛细血管压在mmHg之间，毛细血管液会渗透到肺部基质，因而降低肺部的顺应性，增加呼吸，引起呼吸困难。超声心动图通常可以诊断异常的心室和心瓣功能。在呼吸困难病因还不清晰的病人中应采用该诊断措施。第23篇 糖尿病性肾病（掌握） 糖尿病性肾病是导致终末期肾脏疾病及最终死亡的重要原因之一. 特别是在I型糖尿病人中间有近30%-35%的美国病人受到此病影响.尽管在II型糖尿病也大约有近一半的病人会患肾病(部分病人寿命就此减短),II型糖尿病人仍然占据寻求终末期肾脏疾病治疗的大部分. 总体说来,在美国, 糖尿病是导致终末肾脏疾病的主要原因. 病例数量超过1/3. 在II型糖尿病中肾病症状不十分明显,但在I型糖尿病中,糖尿病性肾病发展过程清晰.诊断期间最明显的特征就是肾小球超过滤. 在此期间, ,出现肾脏肿大,肾脏血流量增加,肾小球血流量增高和通过肾小球的血流压力梯度增大，导致肾小球滤过率增高. 重要的是, 这些变化在一定程度上依赖于高血糖含量. 在糖尿病特殊治疗过程中, 上述变化会慢慢减轻. 在诊断后3-5年中,早期出现的肾小球损伤,表现为肾小球毛细血管基底膜增厚,肾小球系膜基质增大及小动脉硬化. 在早期肾小球变化中,白蛋白排泄率保持较低水平.然而, 随着病理变化,肾小球丧失其整体功能,导致肾小球滤过缺陷, 渗透性增强. 尽管常规肾脏功能检测结果(肌酐水平和尿分析)保持正常,但会出现尿微量白蛋白(30300mg/每天)。在此期间，在超过50%的病例中出现高血压。 几年以后，大部分糖尿病人都会出现弥漫性肾小球硬化。虽然小部分病人也会出现Kimmeslstei 和Wilson 所发现的糖尿病特异性结节