INTRODUCTION TO INTERNAL MEDICINE Jiyao Wang, MD. MSC. Professor Performing thorough physical examination; Using diagnostic tools judiciously, always asking whether the results will alter the management and benefit the patient. History takenIn listening to the history, the physician discovers not only something about the disease but also something about the patient. The process of history-taking provides an opportunity to observe the patients behavior and to watch for features to be pursued more. thoroughly during the physical examination.To develop effective reasoning skills Information gathering (informative history, thorough physical examination ) Problem synthesis Hypothesis generation Decision makingEssential skillLearning of Essential SkillsInquiry skills Thinking skills Problem solving skillsEssential skillDealing with clinical problemsMaking diagnosis Identify the severity of the disease According to the severity of disease, to make therapeutic protocol Follow up the results of the treatmentEvidence-based medicine, EBMDefined as:The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patientsPrinciples of Patient CareEvidence-based medicine, EBM Best research evidence basic sciences of medicine patient-centered clinical research Clinical expertise ability to use our clinical skills and past experience to rapidly identify each patients unique health state and diagnosis, their individual risks and benefits of potential interventions Patient values the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patientWhen these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life.Principles of Patient Care * Means any other lettersAND means both terms requiredCheck the question typeCheck the emphasisPractice Guidelines Evidence base clinical guidelines can provide a useful framework for managing patients with particular diagnoses or symptoms. Principles of Patient CareThe Grade & Level of EvidenceThe Grade & Level of EvidenceGrades of level ofRecommendation evidenceEtiology/Therapy/PreventionA 1aSR of RCTs1bIndividual RCT with narrow CI1cAll or noneB 2aSR of Cohort studies2b Individual Cohort study/low quality RCT2cOutcome Research3aSR of Case-control Study3b Individual Case-control StudyC 4 Case series/poor quality cohort study/ case-control study D 5 Expert opinion without critical appraisal.when a relevant evidence base is unavailable, clinical knowledge and experience together with an understanding of the patients needs, supplemented by diagnostic tools, still represent the best approach to practicing medicine.Medical Decision-Making ordering of additional tests, requests for consults, decisions regarding prognosis and treatment Medical decision-making should be evidence-based Principles of Patient CareHistoryPhysical ExaminationLaboratory Tests, imagingSpecial diagnostic studiesDiagnosisEstimationRight decision makingnecessaryselectedDiagnostic tests serve to reduce uncertainty about a diagnosis in a particular individual and to help the physician decide how best to manage that individuals condition. The Principles of Diagnostic Thinking One etiologyCommon disease firstOrganic diseases first, then functional disordersExcluding methods to do differential diagnosis The Principles for selecting Diagnostic tests & Imaging study Effectiveness, safety and price Select test with high sensitivity to exclude diagnosis Select test with high specificity to confirm diagnosis Non-invasive procedures first If the results from test is not fit the clinical considerations, detailed analysis is needed.The Principles of Therapeutic Thinking Treat the most severe case first In general, therapeutic protocol following confirmed diagnosis of disease For life-threatened disease, save life first, then to confirm the diagnosis For treatment, the simple, the best. Pay attention to drug side-effects and cross-over effectsThe Principles of Therapeutic ThinkingTreat curable disease as soon as possible Diagnostic therapy could used to confirm the clinical diagnosisAccording to principles of evidence-based medicine to make decision for treatmentAssessing the Outcome of Treatment Use objective and readily measurable parameters to judge the outcome of a therapeutic intervention. The practice of medicine requires consideration and integration of both objective and subjective outcomes. Principles of Patient CareInformed Consent and Respect for the Patients Autonomy The fundamental principles of medical ethics are to act in the patients best interest and