1、INTRODUCTION TO INTERNAL MEDICINE Jiyao Wang, MD. MSC.Professor & ChairDept. of Internal MedicineShanghai Medical College,Fu Dan UniversityInternal MedicineSurgeryPediatricsgynecologyPathologyMicrobiologyGeneticsBiochemistryPharmacologyPathologic-physiologyDiagnosticsImmunologyHow to learn1. To comb
2、ine internal medicine with basic scientific knowledge2. To combine theory with practiceLecturesIntroductionPathogenesisPathologyPathophysiology Clinical featuresDiagnosis Treatment, PreventionBasic theoryBasic knowledgeEssential skillBedside TeachingBedside TeachingWhat is expected of the physicianN
3、o greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician. Tact, sympathy and understanding are expected of physician.Te be a good Doctor In the care of the suffering, physician needs technical skill, scientific knowledge, and human understa
4、nding. The combination of medical knowledge, intuition, experience, and judgment defines the art of medicine, which is essential to the practice of medicine. The patient-physician relationshipPhysicians need to approach patients not as “cases” or “diseases”, but as individuals who is human, fearful,
5、 and hopeful, seeking relief, help and reassurance.Ideal patient-physician relationshipBased on:Thorough knowledge of the patientMutual trustAbility to communicate Clinical Skills Taking informative history; Performing thorough physical examination;Using diagnostic tools judiciously, always asking w
6、hether 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 an
7、d 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 synthesisHypothesis generation Decision makingEssential skillLearning of Essential SkillsInq
8、uiry skillsThinking skillsProblem solving skillsEssential skillDealing with clinical problems1. Making diagnosis2. Identify the severity of the disease3. According to the severity of disease, to make therapeutic protocol4. Follow up the results of the treatmentEvidence-based medicine, EBMDefined as:
9、 The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patientsPrinciples of Patient CareEvidence-based medicine, EBMBest research evidence basic sciences of medicine patient-centered clinical researchClinical expertise ability to use
10、 our clinical skills and past experience to rapidly identify each patients unique health state and diagnosis, their individual risks and benefits of potential interventionsPatient values the unique preferences, concerns and expectations each patient brings to a clinical encounter and which must be i
11、ntegrated 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 term
12、s 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 CareGrades of level ofRecommendation evidenceEtiology/Therapy/Prevention A 1aSR o
13、f RCTs 1bIndividual RCT with narrow CI 1cAll or none B 2aSR of Cohort studies 2b Individual Cohort study/low quality RCT 2cOutcome Research 3aSR of Case-control Study 3b Individual Case-control Study C 4 Case series/poor quality cohort study/ case-control study D 5 Expert opinion without critical ap
14、praisal.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
15、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 unc
16、ertainty 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
17、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, d
18、etailed 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
19、to drug side-effects and cross-over effectsThe Principles of Therapeutic ThinkingTreat curable disease as soon as possibleDiagnostic therapy could used to confirm the clinical diagnosisAccording to principles of evidence-based medicine to make decision for treatmentAssessing the Outcome of Treatment
20、 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 fundame
21、ntal principles of medical ethics are to act in the patients best interest and to respect the patients autonomy When patients require diagnostic and therapeutic procedures that are painful and that pose some risk, they are generally required to sign a consent form. Continued Learning It is the responsibility of a physician to pursue new knowledge continually by reading, attending conferences and courses, and consulting colleagues and the Internet. Continued learning is an integral part of being a physician and must be given the highest priority. Thank you
