INTRODUCTIONTOINTERNALMEDICINEJiyaoWang,MD.MSC.Professor&ChairDept.ofInternalMedicineShanghaiMedicalCollege,FuDanUniversityInternalMedicineSurgeryPediatricsgynecologyPathologyMicrobiologyGeneticsBiochemistryPharmacologyPathologic-physiologyDiagnosticsImmunologyHowtoTeachInternalMedicine2005.2-7:Lecture(Bilingualteaching)2005.9-2006.1Bedsideteaching:rotationfor6weeks,including

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

Arrhythmia(心律失常)；Respiratorysystem：ARDS(呼衰)/COPD；Pneumonia(肺炎)；TB(肺結(jié)核)/Hydrothorax(胸腔積液)；LungCancer(肺癌)；Gastrointestinalsystem：Cirrhosis(肝硬化)；Pepticulcer(消化性潰瘍)/upperGIbleeding(上消化道出血)；IBD(炎癥性腸病)/diarrhea(腹瀉原因待查)；

Acutepancreatitis(急性胰腺炎)/abdominalpain(腹痛待查)；BedsideTeachingKidneyandurinarysystem：Glomerulonephritis(primaryandsecondary)(原發(fā)性腎小球疾??；繼發(fā)性腎小球疾病)；ChronicRenalFailure(尿毒癥)；urinarytractinfection(尿路感染)Hematology：Leukemia(白血病)；Anemia(貧血)；Lymphoma(淋巴瘤)；Disordersofhemostasis(出血性疾病)Endocrinology：DiabetesMellitus(糖尿病)；Hyperthyroidism(甲亢)；hypothyroidism(甲減)。

TimeMon.Tues.Wes.Thurs.Fri.Mor-ning7:30-9:45Takehistoryandphysicalexamination,andfollowmorninground10:0011:30BedsideteachingAfternoon1:30-4:30LectureCaseStudyLectureLecture確保床旁教學(xué)質(zhì)量組織上落實(shí)是開(kāi)展床旁教學(xué)的必要條件

經(jīng)過(guò)反復(fù)討論和修正，制訂計(jì)劃，保證了組織上落實(shí)。6個(gè)科各派出一位專職老師參加床旁帶教工作。內(nèi)分泌科和心內(nèi)科師生在進(jìn)行病例討論ReferenceBooks希氏內(nèi)科學(xué)精要CecilEssentialsofMedicineHarrison’sPrinciplesofInternalMedicine現(xiàn)代內(nèi)科學(xué)英語(yǔ)精要人民衛(wèi)生出版社2002陳灝珠主編.實(shí)用內(nèi)科學(xué).人民衛(wèi)生出版社2005王吉耀主編內(nèi)科學(xué)試題與題解上?？茖W(xué)技術(shù)文獻(xiàn)出版社，2002王吉耀主編內(nèi)科臨床病例分析－雙語(yǔ)學(xué)習(xí),人民衛(wèi)生出版社2005Howtolearn1.Tocombineinternalmedicinewithbasicscientificknowledge2.TocombinetheorywithpracticeStartToldwhatweNeedtoknowLearnitGivenproblemtoillustratehowtouseitSubjectbasedlearningLecturesApproachtopatientsPathogenesisPathologic-physiology&ClinicalfeaturesDiagnosisTreatmentBasictheoryBasicknowledgeEssentialskillStartProblemposedIdentifywhatWeneedtoknowLearnitApplyitProblem-basedlearningToLearnHowToLearnAneducationalmethodthatallowyoutolearnaboutmedicineasyouattempttodealwithreal-lifemedicinesituations.TodevelopeffectivereasoningskillsthroughInformationgatheringProblemsynthesisHypothesisgenerationDataanalysisDecisionmakingLearningofskillsInquiryskillsThinkingskillsProblemsolvingskillsClinicaldecisionmaking4stepsfordealingwithclinicalproblems:MakingdiagnosisIdentifytheseverityofthediseaseAccordingtotheseverityofdisease,tomaketherapeuticprotocolFollowuptheresultsofthetreatmentClinicalthinking(臨床思維)Diagnostic(診斷思維)Therapeutic(治療思維)DiagnosticthinkingskillsHistoryTakingPhysicalexaminationHypothesisofdiagnosisdevelopingadifferentialdiagnosisSearchingtheevidenceSelecttherelatedlab.testsandothertechniquesA45year-oldmanpresentedonJan.28,2004totheemergencydepartmentwithmelenaforthreetimesandvomitingofblood.

KeyinformationProblemHypothesisRx45yr.MGIulcerGIbleedingcancer

varices

drug-inducedThePrinciplesofDiagnosticThinking

一元論多考慮常見(jiàn)病先考慮器質(zhì)性疾病，后考慮功能性診斷用排除法作鑒別診斷TheprinciplesforselectingDiagnostictests先了解所選試驗(yàn)的有效性、安全性和價(jià)格排除診斷時(shí)，選敏感度高的試驗(yàn)肯定診斷時(shí)，選特異度高的試驗(yàn)首選無(wú)創(chuàng)傷性的檢查當(dāng)檢查結(jié)果與臨床不符時(shí)，應(yīng)作詳細(xì)分析而不能片面依賴實(shí)驗(yàn)檢查結(jié)果ThePrinciplesof

TherapeuticThinking分清輕重緩急一般而言，先明確診斷，再作出治療計(jì)劃危重疾病應(yīng)搶救在先，明確病因再后用藥力求簡(jiǎn)單重視藥物的毒副作用和交互作用ThePrinciplesof

TherapeuticThinking可治性疾病應(yīng)盡早治療有時(shí)可用試驗(yàn)性治療來(lái)進(jìn)一步驗(yàn)證臨床診斷制訂治療計(jì)劃時(shí)應(yīng)遵照循證醫(yī)學(xué)的原則Evidence-basedmedicine,EBMBestresearchevidencebasicsciencesofmedicinepatient-centeredclinicalresearchClinicalexpertiseabilitytouseourclinicalskillsandpastexperiencetorapidlyidentifyeachpatient’suniquehealthstateanddiagnosis,theirindividualrisksandbenefitsofpotentialinterventionsPatientvaluestheuniquepreferences,concernsandexpectationseachpatientbringstoaclinicalencounterandwhichmustbeintegratedintoclinicaldecisionsiftheyaretoservethepatientWhenthesethreeelementsareintegrated,cliniciansandpatientsformadiagnosticandtherapeuticalliancewhichoptimizesclinicaloutcomesandqualityoflife.Howtopracticeevidence-basedmedicineConvertinformationneedintoananswerablequestionTrackingdownthebestevidenceIntegratetheevidencewithclinicalexpertise,patientvaluesandfeasibilityCriticallyappraisetheevidenceEvaluateandimprovetheprocessforfutureuseWhatisexpectedofthephysicianNogreateropportunity,responsibility,orobligationcanfalltothelotofahumanbeingthantobecomeaphysician.Inthecareofthesuffering,heneedstechnicalskill,scientificknowledge,andhumanunderstanding.Hewhousesthesewithcourage,withhumility,andwithwisdomwillprovideauniqueserviceforhisfellowman,andwillbuildanenduringedificeofcharacterwithinhimself.Thepatient-physicianrelationshipPhysiciansneedtoapproachpatientsnotas“cases”or“diseases”,butasindividualswhoishuman.Fearful,andhopeful,seekingrelief,helpandreassura