INTRODUCTIONTOINTERNALMEDICINE JiyaoWang MD MSC Professor ChairDept ofInternalMedicineShanghaiMedicalCollege FuDanUniversity InternalMedicine Surgery Pediatrics gynecology Pathology Microbiology Genetics Biochemistry Pharmacology Pathologic physiology Diagnostics Immunology HowtoTeachInternalMedicine 2005 2 7 Lecture Bilingualteaching 2005 9 2006 1Bedsideteaching rotationfor6weeks includingRespiratorysystem Cardiovascularsystem Gastrointestinalsystem Kidneyandurinarysystem Endocrinology Hematology etc BedsideTeaching Cardiovascularsystem 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 diarrhea 腹泻原因待查 Acutepancreatitis 急性胰腺炎 abdominalpain 腹痛待查 BedsideTeaching Kidneyandurinarysystem 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 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2005 Howtolearn 1 Tocombineinternalmedicinewithbasicscientificknowledge2 Tocombinetheorywithpractice Start ToldwhatweNeedtoknow Learnit Givenproblemtoillustratehowtouseit Subjectbasedlearning Lectures ApproachtopatientsPathogenesisPathologic physiology ClinicalfeaturesDiagnosisTreatment Basictheory Basicknowledge Essentialskill Start Problemposed IdentifywhatWeneedtoknow Learnit Applyit Problem basedlearning ToLearnHowToLearn Aneducationalmethodthatallowyoutolearnaboutmedicineasyouattempttodealwithreal lifemedicinesituations Todevelopeffectivereasoningskillsthrough InformationgatheringProblemsynthesisHypothesisgenerationDataanalysisDecisionmaking Learningofskills InquiryskillsThinkingskillsProblemsolvingskills Clinicaldecisionmaking 4stepsfordealingwithclinicalproblems MakingdiagnosisIdentifytheseverityofthediseaseAccordingtotheseverityofdisease tomaketherapeuticprotocolFollowuptheresultsofthetreatment Clinicalthinking 临床思维 Diagnostic 诊断思维 Therapeutic 治疗思维 Diagnosticthinkingskills HistoryTakingPhysicalexaminationHypothesisofdiagnosisdevelopingadifferentialdiagnosisSearchingtheevidenceSelecttherelatedlab testsandothertechniques A45year oldmanpresentedonJan 28 2004totheemergencydepartmentwithmelenaforthreetimesandvomitingofblood KeyinformationProblemHypothesisRx45yr MGIulcerGIbleedingcancervaricesdrug induced ThePrinciplesofDiagnosticThinking 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 ThePrinciplesofTherapeuticThinking 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 明确病因再后用药力求简单重视药物的毒副作用和交互作用 ThePrinciplesofTherapeuticThinking 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 EBM Bestresearchevidencebasicsciencesofmedicinepatient centeredclinicalresearchClinicalexpertiseabilitytouseourclinicalskillsandpastexperiencetorapidlyidentifyeachpatient suniquehealthstateanddiagnosis theirindividualrisksandbenefitsofpotentialinterventionsPatientvaluestheuniquepreferences concernsandexpectationseachpatientbringstoaclinicalencounterandwhichmustbeintegratedintoclinicaldecisionsiftheyaretoservethepatient Whenthesethreeelementsareintegrated cliniciansandpatientsformadiagnosticandtherapeuticalliancewhichoptimizesclinicaloutcomesandqualityoflife Howtopracticeevidence basedmedicine Convertinformationneedintoananswerablequestion Whatisexpectedofthephysician Nogreateropportunity responsibility orobligationcanfalltothelotofahumanbeingthantobecomeaphysician Inthecareofthesuffering heneedstechnicalskill scientificknowledge andhumanunderstanding Hewhousesthesewithcourage withhumility andwithwisdomwillprovideauniqueserviceforhisfellowman andwillbuildanenduringedificeofcharacterwithinhimself Thepatient physicianrelationship Physiciansneedtoapproachpatientsnotas cases or diseases butasindividualswhoishuman Fearful andhopeful seekingrelief helpandreassurance Tact sympathyandunderstandingareexpectedofphysician Ifyoucannotdothethingsyouliketodo youshouldlikethethingsyouhavetodo 1 进入病房学习前 对照大纲和示教的重点病例复习内科学的相关章节 准备在病例讨论中提出和回答问题 2 进入病房后尽快熟悉重点讨论的病例 争取第一时间采集病史 进行体格检查 考虑相应的诊疗处理措施 以备讨论 3 注重理论联系实际 重点是培养临床思维能力 七年制床旁教学学习过程中几个需要注意的事项 4 尊重患者 对待患者要热情 富有同情心 5 注重与患者及其家属的沟通 注意谈话方式 不刺激患者 对于不能回答的问题应找相应的病房医护人员来解决 不能敷衍了事或简单的回答 不知道 6 体检时动作应轻柔 对危重患者 应事先征得床位医生及患者同意方能进行 必要时由床位医生陪同进行 考核方式 床旁示教占30 书面考试占70 床旁示教考核由带教老师根据学生表现 从5个方面进行打分 纪律及对患者态度 病例讨论时回答问题情况 问病史 体格检查 病史书写等 每个病区评分总分为5分 共计30分 6周结束时进行书面考试 总分70分 其中20分左右为与病例讨论及示教相关的病例分析题 50分为本学期上的大课内容 Thankyou