(规培)英语重点.doc

临床英语考试要点（2011年）Chapter 1 patient-physician interaction（第二四段）The increasing availability of evidence from 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, evidence when presenting alternative potions 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。Chapter 4 (第二段)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。Chapter 8(第二段，末段部分)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).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。Chapter 12(第三六段)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 bath 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。A new device for visualizing the entire gastrointestinal mucosa consists of images to receivers attached to the patients abdomen and mapped to identify the location of the image. The diagnostic yield of capsule enteroscopy is not yet clear, but this approach may potentially visualize segments of the small bowel that were previously inaccessible. No therapeutic maneuvers are possible with the device.一种新的装置能显示全部胃肠粘膜，这种装置由一颗装有小型摄像机能咽下的胶囊组成，它将（数字）影像信号传到附着在病人腹部的接收器，并绘制出图像来识别影像的位置。胶囊小肠镜的诊断效率现在还不清楚，但是，这种方法可能显示出以前难以接近的小肠肠管。但这个装置不可能有任何治疗性操作。Chapter 25(第1、4章)DefinitionThe 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。Chapter 28(第二段)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 surgeon s 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。Chapter 30 (末段)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 fourfold 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。当肺炎和流感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。Chapter 35（末段）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. 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。Chapter 41(第二段部分)In assessing prognosis and planning a treatment strategy, it is useful to classify SCD sa 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, hyperkalemia secondary to renal failure, angiotensin-converting enzyme inhibitors, prostaglandin secondary to antiarrhythmics, tricyclics, and antihistamines; or substance abuse with drugs such as cocaine and amphetamines.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。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。Chapter 43 (第1、3段)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 operations, 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 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。Chapter 45 (第3段)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 nasogatric 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。Chapter 47 (第五段)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,