循环系统-内科学绪论

INTRODUCTIONTOINTERNALMEDICINEWuqingmingInternalMedicineSurgeryPediatricsgynecologyPathologyMicrobiologyGeneticsBiochemistryPharmacologyPathologic-physiologyDiagnosticsImmunologyHowtoTeachInternalMedicine

Lecture(Bilingualteaching)

Bedsideteaching:includingRespiratorysystem,Cardiovascularsystem,Gastrointestinalsystem,Kidneyandurinarysystem,Endocrinology,Hematology,etc.BedsideTeachingCardiovascularsystem：Heartfailure(心衰)；CHD(冠心病)/Hypertension(高血压)；Cardiomyopathy(心肌病)/pericarditis(心包炎)；

Arrhythmia(心律失常)；Respiratorysystem

：ARDS(呼衰)/COPD；Pneumonia(肺炎)；TB(肺结核)/Hydrothorax(胸腔积液)；LungCancer(肺癌)；Gastrointestinalsystem

：Cirrhosis(肝硬化)；Pepticulcer(消化性溃疡)/upperGIbleeding(上消化道出血)；IBD(炎症性肠病)；Acutepancreatitis(急性胰腺炎)/abdominalpain(腹痛待查)；BedsideTeachingKidneyandurinarysystem

：Glomerulonephritis(primaryandsecondary)(原发性肾小球疾病；继发性肾小球疾病)；ChronicRenalFailure(尿毒症)；urinarytractinfection(尿路感染)Hematology

：Leukemia(白血病)；Anemia(贫血)；Lymphoma(淋巴瘤)；Disordersofhemostasis(出血性疾病)Endocrinology

：DiabetesMellitus(糖尿病)；Hyperthyroidism(甲亢)；hypothyroidism(甲减)。

TimeMon.Tues.Wes.Thurs.Fri.Mor-ning7:30-9:45Takehistoryandphysicalexamination,andfollowmorninground10:0011:30BedsideteachingAfternoon1:30-4:30LectureCaseStudyLectureLecture确保床旁教学质量组织上落实是开展床旁教学的必要条件

经过反复讨论和修正，制订计划，保证了组织上落实。6个科各派出一位专职老师参加床旁带教工作。内分泌科和心内科师生在进行病例讨论ReferenceBooks希氏内科学精要CecilEssentialsofMedicineHarrison’sPrinciplesofInternalMedicine现代内科学英语精要人民卫生出版社2002陈灏珠主编.实用内科学.人民卫生出版社2005王吉耀主编内科学试题与题解上海科学技术文献出版社，2002王吉耀主编内科临床病例分析－双语学习,

人民卫生出版社2005Howtolearn1.Tocombineinternalmedicinewithbasicscientificknowledge2.TocombinetheorywithpracticeStartToldwhatweNeedtoknowLearnitGivenproblemtoillustratehowtouseitSubjectbasedlearningLecturesApproachtopatientsPathogenesisPathologic-physiology&ClinicalfeaturesDiagnosisTreatmentBasictheoryBasicknowledgeEssentialskillStartProblemposedIdentifywhatWeneedtoknowLearnitApplyitProblem-basedlearningToLearnHowToLearnAneducationalmethodthatallowyoutolearnaboutmedicineasyouattempttodealwithreal-lifemedicinesituations.TodevelopeffectivereasoningskillsthroughInformationgatheringProblemsynthesisHypothesisgenerationDataanalysisDecisionmakingLearningofskillsInquiryskillsThinkingskillsProblemsolvingskillsClinicaldecisionmaking4stepsfordealingwithclinicalproblems:MakingdiagnosisIdentifytheseverityofthediseaseAccordingtotheseverityofdisease,tomaketherapeuticprotocolFollowuptheresultsofthetreatmentClinicalthinking(临床思维)Diagnostic(诊断思维)Therapeutic(治疗思维)DiagnosticthinkingskillsHistoryTakingPhysicalexaminationHypothesisofdiagnosisdevelopingadifferentialdiagnosisSearchingtheevidenceSelecttherelatedlab.testsandothertechniquesA45year-oldmanpresentedonJan.28,2004totheemergencydepartmentwithmelenaforthreetimesandvomitingofblood.KeyinformationProblemHypothesisRx45yr.MGIulcerGIbleedingcancervaricesdrug-inducedThePrinciplesofDiagnosticThinking

一元论多考虑常见病先考虑器质性疾病，后考虑功能性诊断用排除法作鉴别诊断TheprinciplesforselectingDiagnostictests先了解所选试验的有效性、安全性和价格排除诊断时，选敏感度高的试验肯定诊断时，选特异度高的试验首选无创伤性的检查当检查结果与临床不符时，应作详细分析而不能片面依赖实验检查结果ThePrinciplesof

TherapeuticThinking分清轻重缓急一般而言，先明确诊断，再作出治疗计划危重疾病应抢救在先，明确病因再后处理用药力求简单重视药物的毒副作用和交互作用ThePrinciplesof

TherapeuticThinking可治性疾病应尽早治疗有时可用试验性治疗来进一步验证临床诊断制订治疗计划时应遵照循证医学的原则Evidence-basedmedicine,EBMBestresearchevidencebasicsciencesofmedicinepatient-centeredclinicalresearchClinicalexpertiseabilitytouseourclinicalskillsandpastexperiencetorapidlyidentifyeachpatient’suniquehealthstateanddiagnosis,theirindividualrisksandbenefitsofpotentialinterventionsPatientvaluestheuniquepreferences,concernsandexpectationseachpatientbringstoaclinicalencounterandwhichmustbeintegratedintoclinicaldecisionsiftheyaretoservethepatientWhenthesethreeelementsareintegrated,cliniciansandpatientsformadiagnosticandtherapeuticalliancewhichoptimizesclinicalesandqualityoflife.Howtopracticeevidence-basedmedicineConvertinformationneedintoananswerablequestionTrackingdownthebestevidenceIntegratetheevidencewithclinicalexpertise,patientvaluesandfeasibilityCriticallyappraisetheevidenceEvaluateandimprovetheprocessforfutureuse医学观念的进展

循证医学Evidence-basedmedicine,EBM

以国际上最新临床科研成果,和目前的最佳证据(Evidence)为每个患者制定诊疗方案英国流行病学家ArchieCochrane，20世纪70年代提出，现有的临床诊治措施中仅20％被证明有效，急呼临床实践需要证据，20世纪90年代循证医学被公认是医学的重要领域

。

随机、双盲对照、多中心试验是EBM的基石（RandomisedControlledTrialsRCT‘s）

荟萃分析是对多个设计良好的RCT的综合分析及其评价ProfessorArchibaldLemanCochrane,(1909-1988)HestressedtheimportanceofusingevidencefromRandomisedControlledTrials(RCT's)医学观念的进展

循证医学Evidence-basedmedicine,EBMLevelofevidenceClassA由随机、双盲对照、广泛人群大样本、金标准定义的病例、前瞻性研究提供的证据ClassB证据来自小范围人群的前瞻性研究；或证据来自一个设计良好的大样本、金标准定义的病例、回顾性对照研究ClassC证据来自小范围人群的、双盲对照、回顾性研究ClassD证据来自非双盲对照试验；或单纯为专家意见；或个案报导WhatisexpectedofthephysicianNogreateropportunity,responsibility,orobligationcanfalltothelotofahumanbeingthantoeaphysician.Inthecareofthesuffering,heneedstechnicalskill,scientificknowledge,andhumanunderstanding.Hewhousesthesewithcourage,withhumility,andwithwisdomwillprovideauniqueserviceforhisfellowman,andwillbuildanenduringedificeofcharacterwithinhimself.Thepatient-physicianrelationshipPhysiciansneedtoapproachpatientsnotas“cases”or“diseases”,butasindividualswhoishuman.Fearful,andhopeful,seekingrelief,helpandreassurance.Tact,sympathyandunderstandingareexpectedofphysician.“Ifyoucannotdothethingsyouliketodo，youshouldlike