1、1Chapter 1 Patient-Physician Interaction 医患沟通The patient-physician interaction proceeds through many phases of clinical reasoning and decision making. 医患沟通在临床诊断和治疗决策的许多时期进行着。The interaction begins with an elucidation of complaints or concerns, followed by inquiries or evaluation to address these con
2、cerns in increasingly precise ways.这种沟通开始于病人主诉或所关注问题的述说，然后通过交流、评估不断精确地确定这些问题。The process commonly requires a careful history or physical examination, ordering of diagnostic tests, integration of clinical findings with the test results, understanding of the risks and benefits of the possible courses
3、of action, and careful consultation with the patient and family to develop future plans.这个过程通常需要细致的病史询问和体格检查，开具诊断性化验医嘱，综合临床发现和化验结果，理解分析拟行治疗过程中的风险和疗效，然后与病人及家属反复磋商以完善治疗方案 Physicians increasingly can call on a growing literature of evidence-based medicine to guide the process so that benefit is maximiz
4、ed, while respecting individual variations among different patients 尽管考虑到不同病人中个体差异是存在的，但医生们越来越容易查阅不断增长的循证医学文献来指导这个过程，使得疗效最大化。The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine 但是，不断增多的可用于指导临床诊断与治疗的随机试验资料不应当作“
5、烹调书”使用。Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics.因为随机试验获得的现象和思路是侧重于求证具有某些特征病人而来的。Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize
6、the occasional. 实际的临床判断需要确定这些临床表现和诊断标准是否能应用于病人个体，并能找出例外。Even more judgment is required in the many situations in which evidence is absent or inconclusive.在许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。 Evidence also must be tempered by patients preferences, although it is a physicians responsibility to emphasize when
7、presenting alternative options to the patient. 虽然医生有责任要提出选择性问题让病人回答，但病人肯定会根据自己的倾向调节临床症状。The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.假如病人懂得基本原理和表现，对医生提出的问题，有特殊生活方式病人的固执容易被强化。To care
8、for a patient as an individual, the physician must understand the patient as a person. 为了把病人作为一个个体进行治疗，医生必须理解病人是一个人（不是一群人） 。This fundamental precept of doctoring includes an understanding of the patients social situation, family issues, financial concerns, and preferences for different types of care
9、 and outcomes, ranging from maximum prolongation of life to the relief of pain and suffering. 这个最基本的行医原则包括了解病人的社会地位，家庭问题，资金状况以及正确理解病人对不同治疗方法、不同治疗结果的选择，从最大限度地延长生命到临时缓解疼痛和折磨。If the physician does not appreciate and address these issues, the science of medicine cannot be applied appropriately, and even
10、 the most knowledgeable physician fails to achieve appropriate outcomes. 假如医生没有正确理解和重视这个问题，医学就不可能恰当地应用于临床，甚至一个知识渊博的医生也不能取得理想的治疗结果。Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variety of sources, some of which are of questionable re
11、liability.甚至，当医生越来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，当然，某些信息是不可靠的。The increasing use of alternative and complementary therapies is an example of patients frequent dissatisfaction with prescribed medical therapy.替代疗法和辅助疗法的应用不断增加就是病人对常规疗法经常不满意的一个例子。Physicians should keep an open mind regarding unproven op
12、tions but must advise their patients carefully if such options may carry any degree of potential risks, including the risk that they may relied on to substitute for proven approaches 医生对未证实的疗法应该保持开放的思想，但是，如果这些疗法具有任何程度的潜在风险，都必须细致地告知病人，包括可能需要用已证实的常规疗法去替代的风险。It is crucial for the physician to have an o
13、pen dialogue with the patient and family regarding the full range of options that either may consider 对医生来说，对病人及家属开诚布公地介绍所有可考虑的治疗选择，是非常重要的。The physician does not exist in a vacuum but rather as part of a complicated and extensive system of medical care and pubic health.医生不是生存在真空中，而是复杂而庞大的医疗和公共健康体系中的
14、一部分。In premodern times and even today in some developing countries, basic hygiene, clean water, and adequate nutrition have been the most important ways to promote health and reduce disease.在未发达时代，甚至当今在一些发展中国家，基本卫生条件、清洁饮用水和最低营养保障是促进健康减少疾病的最重要方法。In developed countries, the adoption of healthy lifesty
15、les, including better diet and appropriate exercise, are cornorstones to reducing the epidemics of obesity, coronary disease, and diabetes.在发达国家中，健康的生活方式包括合理饮食和适当锻练，是减少肥胖、冠心病和糖尿病盛行的基础。Public health interventions to provide immunizations and to reduce injuries and the use of tobacco, illicit drugs, a
16、nd excess alcohol collectively can produce more health benefit than nearly any other imaginable health intervention.公共健康干预如进行疫苗接种、减少损伤、减少吸烟、减少吸毒、减少酗酒等措施共同产生的健康效果几乎比可想象的任何其它健康干预措施都要好得多。Chapter 5 Clinical Preventive Services 临床预防服务Clinical preventive services include counseling, immunization, screenin
17、g tests, and reduction of the susceptibility to disease by interventions such as therapeutic lifestyle changes and pharmacotherapy.临床预防服务包括对疾病的咨询、防疫、筛查和通过治疗性的生活习惯改变和药物治疗来减少易感性。Preventive service often are classified as primary, secondary, or tertiary. 临床预防服务常分为一级预防、二级预防和三级预防。 Primary prevention is d
18、irected toward preventing disease or injury before it develops, whereas secondary prevention deals with early detection and treatment to impede the progress of overt disease.Primary prevention is directed toward preventing disease or injury before it develops, whereas secondary prevention deals with
19、 early detection and treatment to impede the progress of overt disease.一级预防是直接针对疾病或损伤发生前的预防，而二级预防是解决疾病或损伤发生后早期发现和早期治疗，以防止已有临床表现的疾病进一步发展。In contrast, tertiary prevention refers to rehabilitative activities after the onset of disease to minimize complications and disability.对比之下，三级预防是指疾病发作后的康复治疗，以减少并发
20、症和病残。Because of considerable overlap, distinguishing among these phases of prevention may be confusing. 因为（三级预防之间）有相当大的交叉，这些预防阶段的区分可能有些混淆。Detecting and treating hypertension could be considered secondary prevention of hypertensive 2cardiovascular disease but primary prevention of heart failure and s
21、troke. 发现和治疗高血压可以考虑是对高血压性心血管疾病的二级预防，但也认为是对心力衰竭和中风的一级预防。Prevention may be perceived best along a continuum from modification of predisposing factors, to preventing a disease, to avoiding premature death and disability.长期持续地减少易感因素被认为是对疾病预防、避免早死早残最好的预防。The sooner the prevention, the more likely unneces
22、sary illness, disability, and premature death can be avoided. 预防得越早，越不易发生不必要的疾病，病残和早死就能够避免。Increasing emphasis has been placed on preventing risk factors themselves.现在越来越强调对危险因素直接预防。The term primordial prevention has been introduced for this concept.术语-根本性预防（根源预防、病因预防）已经引进了这个概念。Indiscriminate screen
23、ing for risk factors or disease without adequate advice and follow-up serves no useful purpose.没有引导和随访的毫无选择地隔离（远离、筛选、回避）危险因素或疾病是没有实用价值的预防。The periodic health examination has evolved from an annual, broad-based, uniform protocol to an approach that s the prevention, detection, and treatment of specif
24、ic diseases or risk factors for particular age, gender, and ethnic groups at appropriate intervals. 定期体检逐渐从一年一度的、全面的、统一的规定项目改进成以恰当的周期对特定年龄、性别和种群的特殊疾病或危险因素有目的地预防、发现和治疗。Current recommendations by the U.S. Preventive Services Task Force are based on systematic evidence reviews that distinguish procedur
25、es likely to prove effective and to have substantially more benefit than harm.美国预防服务特别局的最近建议是基于全面的回顾分析，这些分析选出了易于证明有效、确实是利大于弊的预防措施。Changes in the health care system and the development of national guidelines for management of disease are likely to draw greater attention to health promotion, disease p
26、revention, and the interface of physician-based medical care with the public health care system.卫生保健系统的改进和疾病控制（国家）政策的完善使人们更重视健康促进、疾病预防以及医疗人员为主的公共卫生系统的保健服务。Physicians should consider each disorder in terms of the potential for prevention, including the possibility of adverse effects and cost-effectiv
27、eness.医生应该以可能需要预防的角度考虑每一种疾病状况，包括可能发生的副作用和付出代价的效益。A concept useful for clinical decision making is the number of patients needed to treat to prevent one adverse event, which is based on absolute risk reduction.一个对临床决策有用的理念是需要治疗的病人数量决定一个不利因素是否要预防，这是基于绝对风险的下降。This number is based on efficacy and is cal
28、culated as the reciprocal of the difference in event rates between control and treatment groups for a specified period.这个数量是以效能为基础，是对特定时期内对照组和治疗组之间发生率差异的倒数进行统计。Ample evidence connects identifiable and often preventable factors to the morbidity and mortality associated with major health problems.大量的证
29、据找出了可确认的又常可预防的与主要健康问题相关的发病和死亡因素。About half of all deaths, morbidity, and disability can be attributed to such nongenetic factors.约一半死亡、发病、和病残与这些非遗传性因素有关。Many lifestyle changes benefit multiple systems and disorders.许多生活习惯改变有利于多个系统和紊乱的改善。Cigarette smoking has been estimated to contribute to one in fi
30、ve deaths in the United States; dietary habits may affect the occurrence of cardiovascular disease, diabetes, osteoporosis, and cancer.美国五分之一的死亡估计与吸烟有关，饮食习惯可能影响心血管疾病，糖尿病、骨质疏松症和癌症的发生。Other important personal behavior factors influencing health include physical activity, alcohol intake, illicit drug u
31、se, sexual practices, and exposure to environmental toxins.其它影响健康的重要个人行为因素有锻炼、饮酒、吸毒、性行为以及环境毒物的接触。The identification of informative DNA polymorphisms (e.g., single nucleotide polymorphisms) and further elucidation of candidate genes allow for detection of susceptible individuals and possible institut
32、ion of measures to prevent the expression of these harmful genetic traits.携带信息DNA 多态性（例如，单核苷酸多态性）的认识和候选基因的进一步阐明允许我们发现易感人群和可能采取的措施，预防这些有害的基因特性表达。Several common misconceptions impede preventive health care.好几种错误观念妨碍了预防保健。Many believe that diseases with a strong heritable component cannot be altered, b
33、ut susceptibility to disease often requires the interaction of multiple genes and environmental factors for expression.许多人认为有很强遗传性的疾病是无法改变的，但是对疾病的易感性经常需要多种基因和环境因素的相互作用才能表达。In addition, chronic diseases are multifactorial, so other factors can be changed to compensate for an elevated genetic risk.另外，
34、慢性疾病是多因素的，所以，可以改变其它因素来弥补高基因风险。Although gene therapy holds much promise, preventive measures currently offer the best possibilities for limiting gene expression and avoiding disease.虽然基因疗法有着很大的希望，目前的预防措施最有可能提供的是限制基因表达来避免疾病。The notion that prevention is less useful in older persons excludes many who w
35、ould benefit most from prevention because elderly patients generally have a greater absolute risk of disease and have been shown to adhere and respond favorably to preventive measures.对老年人预防几乎无用的观念排除了在预防上本应极为受益的许多人，因为老年病人一般有更高患病风险，并且一直对预防措施极为支持、反应极积。Also, life expectancy frequently is underestimated
36、 in the elderly; individuals who reach age 75 now can expect to live an average of 11 more years.并且，老年人的预期寿命经常是低估的，现在将到 75 岁的老人可以预期平均再活 11 年多。Chapter 8 Why Geriatric Patients Are Different 老年病人的特殊性Older patients differ from young or middle-aged adults with the same disease in many ways, one of which
37、 is the frequent occurrence of comorbidities and of subclinical disease.同样的疾病，老年病人在许多方面与青中年病人是有区别的，其中之一是并存病多和亚临床疾病多。As a function of the high prevalence of disease, comorbidity (or the co-occurrence of two or more diseases in the same individual) is also common. 作为高发疾病的结果，并存病（两个或更多的疾病在同一个体同时发生）也是常见的
38、。Of people age 65 and older, 50% have two or more chronic disease, and these diseases can confer additive risk of adverse outcomes, such as mortality. 65 岁以上的老年人中，50% 患有两种以上的慢性疾病，这些疾病能够增加不利预后的风险，如死亡的风险。In some patients, cognitive impairment may mask the symptoms of important conditions. 在一些病人中，认知损害可
39、以掩盖重要病情的症状。Treatment for one disease may affect another adversely, as in the use of aspirin to prevent stroke in individuals with a history of peptic ulcer disease. 对一种疾病的治疗可能加重另一种疾病，例如，对有消化性溃疡病史的病人使用阿斯匹林预防中风。The risk for becoming disabled or dependent also increases with the number of diseases pres
40、ent. 病残或生活不能自理的发生率也随着并存的疾病数而增高。Specific pairs of diseases can increase synergistically the risk of disability. 特殊的成对疾病可以协同增加病残的风险。Arthritis and heart 3disease coexist in 18% of older adults; although the odds of developing disability are increased by three-fold to four-fold with either disease alone
41、, the risk of disability increases 14-fold if both are present. 有 18%的老年人同时患有关节炎和心脏病，虽然每个疾病可以增加 34 倍的病残率，但两个疾病同时存在，可使病残率提高 14 倍。A second way in which older adults differ from younger adults is the greater likelihood that their diseases present with nonspecific symptoms and signs. 老年与青中年的第二个差异是更容易出现非
42、典型的症状和体症。Pneumonia and stroke may present with nonspecific changes in mentation as the primary symptom. 肺炎和中风时可出现非特异性意识变化作为主要的症状。Similarly, the frequency of silent myocardial infarction increases with increasing age, as does the proportion of patients who present with a change in mental status, dizz
43、iness, or weakness rather than typical chest pain. 同样地，隐匿性心肌梗塞发生频度随着年龄的增大而增加，这些病人相应地频发精神状态改变、眩晕、虚弱而不是典型的胸痛症状。As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally would be considered in middle-aged adults.因此，老年病人的诊断应考虑更广泛的疾病谱，要超过通常对中年病
44、人所考虑的范围。A third condition that is found primarily in older adults is frailty, frailty is thought to be a wasting syndrome that presents with multiple symptoms and signs, including reduced muscle mass, weight loss, weakness, poor exercise tolerance, slowed motor performance, and low physical activity
45、. 主要出现在老年人的第三个情况是衰弱，衰弱被认为属于衰竭综合症，它有许多症状和体征，包括肌肉萎缩、体重下降、虚弱、运动耐受差、动作慢、身体活动少。Some estimates indicate that the full syndrome is found in 7% of community-dwelling people age 65 and older, and in 25%of community-dwelling people age 85 and older. 一些人估计 7%的 65 岁以上社区老人和 25%的 85 岁以上社区老人这些症状全部出现。 Many institut
46、ionalized older adults also are frail.许多老人院里的老人也是衰弱的。Frailty is a state of decreased reserve and increased vulnerability to all kinds of stress, from acute infection or injury to hospitalization, and may identify individuals who cannot tolerate invasive therapies. 衰弱是对各种压力耐受下降、易于损害的一种状态，从急性感染、损伤到住院治
47、疗，都可以发现一些老人不能忍受侵入性诊疗措施。The syndrome of frailty is associated with high risk of falls, needs for hospitalization, disability, and mortality. 衰弱症状与高病倒率、高住院率、高病残率、高死亡率是密切相关的。There is early evidence that a core component of frailty is sarcopenia, or loss of muscle mass associated with aging, which occur
48、s in 13 to 24% of persons age 65 to 70 and in 60% of persons age 80 and older. 衰弱早期征象中的一个主要变化是肌减少症，或者说随年龄增长的肌肉减少，它发生在 1324%的 6570 岁的老人，60%的 80 岁以上的老人。 It is likely that dysregulation of multiple physiologic systems, including inflammation, hormonal status, and glucose metabolism, underlies the syndr
49、ome, with resulting decreased ability to maintain homeostasis in the face of stress. （衰弱时）多种生理系统易于失调，包括炎症、激素状态、糖的代谢，在症状的背后，伴随的结果是在压力面前保持内环境稳定的能力下降。Subclinical disease (e.g., atherosclerosis), end-stage chronic disease (e.g., heart failure), or a combination of comorbid diseases may precipitate the syndrome. 亚临床疾病(如动脉粥样硬化), 晚期慢性疾病(如心力衰竭） ，或多种疾病并存可共同形成症状。Evidence from randomized, controlled trials shows that resistance exercise, with or without nutritional supplements, and home-based physical therapy can increase lean body mass and strength in even the frailest older adults. 随机对照试
