1、INTRODUCTION TO INTERNAL MEDICINE Internal MedicineSurgeryPediatricsgynecologyPathologyMicrobiologyGeneticsBiochemistryPharmacologyPathologic-physiologyDiagnosticsImmunologyHow to Teach Internal Medicine Lecture(Bilingual teaching)Bedside teaching:including Respiratory system,Cardiovascular system,G
2、astrointestinal system,Kidney and urinary system,Endocrinology,Hematology,etc.Bedside Teaching Cardiovascular system：Heart failure(心衰)；CHD(冠心病)/Hypertension(高血压)；Cardiomyopathy(心肌病)/pericarditis(心包炎)；Arrhythmia(心律失常)；Respiratory system：ARDS(呼衰)/COPD；Pneumonia(肺炎)；TB(肺结核)/Hydrothorax(胸腔积液)；Lung Cance
3、r(肺癌)；Gastrointestinal system：Cirrhosis(肝硬化)；Peptic ulcer(消化性溃疡)/upper GI bleeding(上消化道出血)；IBD(炎症性肠病)；Acute pancreatitis(急性胰腺炎)/abdominal pain(腹痛待查)；Bedside Teaching Kidney and urinary system：Glomerulonephritis(primary and secondary)(原发性肾小球疾病；继发性肾小球疾病)；Chronic Renal Failure(尿毒症)；urinary tract infect
4、ion(尿路感染)Hematology：Leukemia(白血病)；Anemia(贫血)；Lymphoma(淋巴瘤)；Disorders of hemostasis(出血性疾病)Endocrinology：Diabetes Mellitus(糖尿病)；Hyperthyroidism(甲亢)；hypothyroidism(甲减)。TimeMon.Tues.Wes.Thurs.Fri.Mor-ning7:30-9:45Take history and physical examination,and follow morning round10:0011:30Bedside teachingAft
5、ernoon1:30-4:30LectureCase StudyLectureLecture确保床旁教学质量确保床旁教学质量内分泌科和心内科师生在进行病例讨论Reference Books 希氏内科学精要 Cecil Essentials of Medicine Harrisons Principles of Internal Medicine 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 王吉耀王吉耀主编 内科临床病例分析双语学习内科临床病例分析双语学习,人民卫生出版社 2
6、005How to learn1.To combine internal medicine with basic scientific knowledge2.To combine theory with practiceStartTold what we Need to knowLearn itGiven problem to illustrate how to use itSubject based learningLectures Approach to patients Pathogenesis Pathologic-physiology&Clinical features Diagno
7、sis TreatmentBasic theoryBasic knowledgeEssential skillStartProblem posedIdentify what We need to knowLearn itApply itProblem-based learningTo Learn How To Learn An educational method that allow you to learn about medicine as you attempt to deal with real-life medicine situations.To develop effectiv
8、e reasoning skills through Information gathering Problem synthesis Hypothesis generation Data analysis Decision makingLearning of skills Inquiry skills Thinking skills Problem solving skillsClinical decision making4 steps for dealing with clinical problems:1.Making diagnosis2.Identify the severity o
9、f the disease3.According to the severity of disease,to make therapeutic protocol4.Follow up the results of the treatmentClinical thinking(临床思维)Diagnostic(诊断思维)Therapeutic(治疗思维)Diagnostic thinking skills History Taking Physical examination Hypothesis of diagnosis developing a differential diagnosis S
10、earching the evidence Select the related lab.tests and other techniques A 45 year-old man presented on Jan.28,2004 to the emergency department with melena for three times and vomiting of blood.Key information Problem Hypothesis Rx 45 yr.M GI ulcer GI bleeding cancer varices drug-inducedThe Principle
11、s of Diagnostic Thinking 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The principles for selecting Diagnostic tests 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The Principles of Therapeutic Thinking 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
12、交互作用The Principles of Therapeutic Thinking 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-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 ea
13、ch 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 patie
14、ntWhen these three elements are integrated,clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life.How to practice evidence-based medicineConvert information need into an answerable questionTracking down the best evidenceIntegrate the
15、evidence with clinical expertise,patient values and feasibilityCritically appraise the evidenceEvaluate and improve the process for future use医学观念的进展医学观念的进展 循证医学循证医学Evidence-based medicine,EBM 以国际上最新临床科研成果以国际上最新临床科研成果,和目前的最佳证据和目前的最佳证据(Evidence)为每个患者制定诊疗方案为每个患者制定诊疗方案 英国流行病学家英国流行病学家 Archie Cochrane ，2
16、0世纪世纪70年代提出，年代提出，现有的临床诊治措施中仅现有的临床诊治措施中仅20被证明有效，急呼临床实践需被证明有效，急呼临床实践需要证据，要证据，20世纪世纪90年代循证医学被公认是医学的重要领域年代循证医学被公认是医学的重要领域 。随机、双盲对照、多中心试验是随机、双盲对照、多中心试验是EBM的基石的基石（Randomised Controlled Trials RCTs）荟萃分析是对多个设计良好的荟萃分析是对多个设计良好的RCT的综合分析及其评价的综合分析及其评价Professor Archibald Leman Cochrane,(1909-1988)He stressed the
17、importance of using evidence from Randomised Controlled Trials (RCTs)医学观念的进展医学观念的进展 循证医学循证医学Evidence-based medicine,EBMLevel of evidenceClass A 由随机、双盲对照、广泛人群大样本、由随机、双盲对照、广泛人群大样本、金标准定义的病例、前瞻性研究提供的金标准定义的病例、前瞻性研究提供的证据证据 Class B 证据来自小范围人群的前瞻性研究；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、金或证据来自一个设计良好的大样本、金标准标准 定义的病
18、例、回顾性对照研究定义的病例、回顾性对照研究Class C 证据来自小范围人群的、双盲对照、证据来自小范围人群的、双盲对照、回回 顾性研究顾性研究Class D 证据来自非双盲对照试验；或单纯为证据来自非双盲对照试验；或单纯为专专 家意见；或个案报导家意见；或个案报导What is expected of the physician No greater opportunity,responsibility,or obligation can fall to the lot of a human being than to become a physician.In the care of t
19、he suffering,he needs technical skill,scientific knowledge,and human understanding.He who uses these with courage,with humility,and with wisdom will provide a unique service for his fellow man,and will build an enduring edifice of character within himself.The patient-physician relationship Physician
20、s need to approach patients not as“cases”or“diseases”,but as individuals who is human.Fearful,and hopeful,seeking relief,help and reassurance.Tact,sympathy and understanding are expected of physician.“If you can not do the things you like to do，you should like the things you have to do”。Stem cell Re
21、generation medicine Biopsychosocial medical model BPS1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。床旁教学学习过程中几个需要注意的床旁教学学习过程中几个需要注意的事项事项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”
22、；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；一个优秀的医生 扎实的医学知识、先进的医学科技 根据“循证医学”的原则办事 面对具体患者个体进行深入交流与互动 综合运用医学科学知识、社会知识、丰富的临床经验进行综合判断与决策 科学与人文精神 医学的科学与艺术（the science and art of medicine）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。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。
