1、1Primary Care Medicine Recommendations目录1 Principles of Primary Care 基本医疗原则 4Practice of Primary Care 基本医疗的实践Diagnostic Tests 诊断性试验Health Maintenance and Role of Screening 保健和筛查Risk and Prognosis 风险和预后Choosing Treatment Options 治疗的选择Immunization 免疫接种2 Systemic Problems 全身性 问题 22Chronic Fatigue 慢性疲劳F
2、ever 发热HIV-1 Infection HIV 感染 Lymphadenopathy 淋巴结病Overweight and Obesity 超重和肥胖Weight loss 消瘦3 Cardiovascular Problems 心 血管问题 30Aortic Regurgitation 主动脉瓣反流Aortic Stenosis 主动脉瓣狭窄Arterial Insufficiency 动脉供血不足Asymptomatic Systolic Murmur 无症状的收缩期杂音Atrial Fibrillation 心房颤动Bacterial Endocarditis 细菌性心内膜炎Car
3、diovascular Rehabilitation 心血管疾病康复Chest Pain 胸痛Congestive Heart Failure 充血性心力衰竭Deep Vein Thrombophlebitis 深静脉血栓Exercise 锻炼Hypercholesterolemia 高胆固醇血症Hypertension 高血压Leg Edema 下肢水肿Mitral Regurgitation 二尖瓣返流Rheumatic Fever 风湿热Stable Angina 稳定型心绞痛Stress Testing 应激试验Superficial Thrombophlebitis 血栓性浅静脉炎S
4、yncope 晕厥Valvular Heart Disease 心脏瓣膜疾病Varicose Veins 静脉曲张Venous Insufficiency 静脉机能不全Ventricular Irritability 心室激惹状态4 Respiratory Problems 呼吸问题 34Asthma 哮喘Bronchitis and Pneumonia 气管炎和肺炎Chronic Cough 慢性咳嗽Chronic Dyspnea 慢性呼吸困难Chronic Obstructive Pulmonary Disease 慢性阻塞性肺疾患Clubbing 杵状指Common Cold 普通感冒H
5、emoptysis 咯血Interstitial Lung Disease 间质性肺病Occupational and Environment Respiatory Disease 职业和环境性肺疾病Pleural Effusions 胸腔积液Sarcoidosis 结节病Sleep Apnea 睡眠呼吸暂停Smoking Cessation 戒烟Solitary Pulmonary Nodule 孤立性肺结节Tuberculosis 肺结核5 Gastrointestinal Problems 胃肠道问题 36Abdominal Pain 腹痛Anorectal Complaints 肛门直
6、肠不适Cirrhosis and Chronic Liver Failure 肝硬化和慢性肝衰竭Constipation 便秘Diarrhea 腹泻Diverticular Disease 憩室病Dysphagia 吞咽困难External Hernia 外疝Gallstones 胆结石Gastrointestinal Bleeding 胃肠道出血Heartburn and Reflux 烧心和反流Inflammatory Bowel Disease 炎性肠病Irritable Bowel Syndrome 肠应激综合征Jaundice 黄疸Nausea and Vomiting 恶心和呕吐N
7、onulcer Dyspepsia 无溃疡性消化不良Pancreatitis 胰腺炎2Peptic Ulcer Disease 消化性溃疡病Serum Transaminase(Aminotransferase)Elevation 血清转氨酶升高Viral Hepatitis 病毒性肝炎6 Hematologic Problems 血液系统问题 39Anticoagulant Therapy 抗凝治疗Anemia 贫血Bleeding Problems 出血问题Erythrocytosis 红细胞增多Sickle Cell Disease 镰状细胞(贫血) 病7 Oncologic Probl
8、ems 肿瘤学问题 40Bladder Cancer 膀胱癌Breast Cancer 乳腺癌Cancer(General)癌症( 总论)Cervical Cancer 子宫颈癌Colorectal Cancer 结肠直肠癌Endometrial Cancer 子宫内膜癌Esophageal Cancer 食管癌Gastric Cancer 胃癌Hodgkins Disease 霍奇金病Lung Cancer 肺癌Non-Hodgkina Lymphoma 非霍奇金淋巴瘤Oral Cancer 口腔癌Ovarian Cancer 卵巢癌Pancreatic Cancer 胰腺癌Renal Ce
9、ll Carcinoma(Hypernephroma)肾细胞癌(肾上腺样瘤)Skin Cancer 皮肤癌Testicular Cancer 睾丸癌Thyroid Nodules and Thyroid Cancer 甲状腺结节和甲状腺癌Tumor of Unknown Origin 起源不明的肿瘤Vaginal Cancer 阴道癌Vulvar Cancer 外阴癌8 Endocrinologic Problems 内分泌学问题Diabetes Insipidus 尿崩症Diabetes Mellitus 糖尿病Galactorrhea and Hyperprolactinemia 乳头溢液
10、高催乳素血症Glucocorticoid Therapy 糖皮质激素治疗Gynecomastia 男子女性型乳房Hirsutism 多毛症Hypercalcemia 高钙血症Hyperthyroidism 甲状腺机能亢进Hypoglycemia 低血糖Hypothyroidism 甲状腺机能减退9 Gynecologic Problems 妇产科学问题Breast Masses and Nipple Discharge 乳房肿块和乳头溢液Fertility Control 节育Infertility 不育症Menopause 绝经Menstrual or Pelvic Pain 月经或痛经Se
11、condary Amenorrhea 继发性闭经Unplanned Pregnancy 计划外妊娠Vaginal Bleeding 阴道出血Vaginal Discharge 阴道分泌物Vulvar Pruritus 外阴搔痒10 Genitourinary Problems 泌尿生殖器问题Benign Prostatic Hyperplasia 良性前列腺增生Chlamydial Infection 衣原体感染Gonorrhea 淋病Hematuria 血尿Incontinence and Lower Urinary Tract Dysfunction 尿失禁和下尿路功能不全Nephroli
12、thiasis 肾结石Prostatitis 前列腺炎Proteinuria 蛋白尿Renal Failure 肾衰Scrotal Pain,Masses,and Swelling 阴囊痛、肿块和肿胀Sexually Transmitted Diseases 性传播疾病Syphilis 梅毒Urethritis in Men 男性尿道炎Urinar Tract Infection 尿路感染11 Musculoskeletal Problems 肌肉与骨骼问题 42Asymptomatic Hyperuricemia 无症状性高尿酸血症Back Pain 背痛Elbow,Wrist,and Ha
13、nd Pain 肘,腕和手痛Fibromyalgia 纤维肌痛Foot and Ankle Pain 脚和踝痛Giant Cell Arteritis 巨细胞性动脉炎Gout 痛风Hip Pain 髋痛Knee Pain 膝痛Lyme Disease 莱姆病Monoarticular Arthritis 单关节的关节炎Muscle Cramps 肌肉痛性痉挛Neck Pain 颈痛Osteoarthritis 骨关节炎Pagets Disease 佩吉特病Polyarticular Complaints 多关节的问题3Polymyalgia Rheumatica 风湿性多发性肌痛Raynaud
14、s Phenomenon 雷诺现象Rheumatoid Arthritis 类风湿性关节炎Shoulder Pain 肩痛12 Neurologic Problems 神经病学问题Bells Palsy 面瘫Dementia 痴呆Dizziness 头晕Focal Neurologic Complaints 局部神经的主诉Headache 头痛Multiple Sclerosis 多发性硬化Parkinsons Disease 震颤麻痹Seizures 癫痫发作Transient Ischemic Attack and Asymptomatic Carotid Bruit 短暂性缺血发作和无症
15、状性颈动脉杂音Tremor 震颤Trigeminal Neuralgia(Tic Douloureux) 三叉神经痛13 Dermatologic Problems 皮肤病学问题 47Acne 痤疮Aphthous Stomatitis 溃疡性口炎Bites(Animal and Human)咬伤(动物和人)Cellulitis 蜂窝织炎Corns and calluses 鸡眼和胼胝Dermatitis(Atopic or Contact) 皮炎( 过敏或接触性)Dermatitis(Seborrheic) 皮炎(脂溢性)Dry Skin 干性皮肤Excessive Sweating 出汗过
16、多Fungal Infections 霉菌感染Hair Loss 脱发Herpes Simplex 单纯疱疹Herpes Zoster 带状疱疹Intertrigo and Intertriginous Dermatoses 间擦疹和擦烂性皮肤病Minor Burns 轻度烧伤Pigmentation Disturbances 色素沉着障碍Pruritus 搔痒症Psoriasis 银屑病Purpura 紫癜Pyoderma 脓皮病Rosacea and Other Acneiform Dermatoses 酒渣鼻和其它痤疮样的皮肤病Scabies and Pediculosis 疥疮和虱病S
17、kin Ulceration 皮肤溃疡Urticaria and Angioedema 荨麻疹和血管性水肿Warts 疣14 Ophthalmologic Problems 眼科学问题Age-Related Macular Degeneration 与年龄相关的黄斑退行性改变Cataracts 白内障Contact Lenses 接触镜Diabetic Retinopathy 糖尿病性视网膜病Dry Eyes 干眼Excessive Tearing 多泪Exophthalmos 眼球突出Eye Pain 目痛Glaucoma 青光眼Impaired Vision 视觉损伤Red Eye 红眼R
18、efractive Surgery 屈光手术Visual Disturbances 视觉障碍15 Ear,Nose,and Throat Problems 耳鼻喉问题 48Epistaxis 鼻衄Facial Pain and Swelling 面痛和肿胀Halitosis 口臭Hearing Loss 听力损失Hiccups 呃逆Hoarseness 声嘶Nasal Congestion and Discharge 鼻充血和分泌物Otitis 耳炎Pharyngitis 咽炎Sinusitis 鼻窦炎Smell Disturbances 嗅觉障碍Snoring 打鼾Taste Disturb
19、ances 味觉障碍Temporomandibular Joint Dysfunction 颞下颌关节功能障碍Tinnitus 耳鸣16 Psychiatric and Behavioral Problems 精神病学和行为问题Alcohol Abuse 酗酒Angry Patient 生气的病人Anxiety 焦虑Depression 抑郁Eating Disorders 进食障碍疾患Insomnia 失眠Nonmalignant Pain 非恶性的痛Sexual Dysfunction 性功能障碍Somatization Disorders 躯体化障碍Substance Abuse 精神性
20、药物滥用17 Allied Fields 相关领域Adolescents 青春期Alternative Therapies 替代疗法41 Principles of Primary Care 基本医疗原则Practice of Primary Care 基本医疗的实践Management 处理Organize PCP practice to provide coordinated, comprehensive, and personal care, available on first contact and continuous basis. Tasks of primary care in
21、clude 组织初级保健医生行医以提供协调的、全面的、个体化的保健服务，具有首诊的可及性和以连续性为基础的服务。初级保健的任务包括：1. Medical Dx and Rx 医学诊断和治疗2. Psychological Dx and Rx 心理学诊断和治疗3. Personal support of patients of all backgrounds, in all stages of illness 为各种背景处于各阶段疾病的病人提供个体化支持4. Communication of information about Dx, Rx, prevention, and prognosis
22、交流有关诊断、治疗、预防和预后的各种信息5. Maintenance of patients with chronic illness 维护慢性病患者6. Prevention of disability and disease through detection, education, behavioral change, and preventive Rx 通过检测，教育，改变行为和预防性治疗来预防残疾和疾病PCPs recognition of and response to patients emotional reactions to illness is critical dete
23、rminant of quality of primary care. Equally important is eliciting and addressing patient expectations and requests. Patients expectations often play major part in their seeking care and complying with Rx, and in determining health outcomes. Requests are specific and concrete helping actions and beh
24、aviors that are identified by patients. Attention to requests can make practice more efficient and more effective.初级保健医生对患者对于疾病的情绪反应的认同和响应是决定基本医疗质量好坏至关重要的因素。同样重要的是探出和处理病人的期望和需求。在患者寻求保健时和对治疗的顺从性上，患者的期望往往发挥主要作用，并决定了其健康的预后。需求就是患者所认为的特殊和具体的帮助活动和行为。对患者需求的关注可以使行医更有效率和效果。When patients confront serious illn
25、ess, elicit their beliefs about that illness. Confirmation or corrections of patients attributions with PCPs clinical or scientific explanations of illness provide labels, names, and models so that patient feels illness can be understood and controlled, regardless of its technical Rx.当患者面对严重疾患时，探出他们
26、对该疾病的信念。通过初级保健医生的对疾病的临床或科学解释来巩固或更正病人的固有信念，如提供标记，名称，模型，这使病人感到不论对疾病的专业治疗如何疾病是可以被理解和控制的。To gain patients full cooperation in Rx, it is important to learn about patients views of Rx and any self-treatment. By making clinical decision a “shared process, PCP fosters partnership that enhances compliance an
27、d outcomes.Attention to patients social network can be critical to understanding symptoms and in fashioning realistic strategies for prevention and Rx.为在治疗中获得病人的充分合作，重要的是要学会用患者的眼光看待治疗和任何自我治疗。通过一个“共同参与过程来制定临床决策，初级保健医生可以培养医患关系以增强顺从性和预后。 注意病人的社交网络对了解症状和形成切合实际的预防和治疗策略至关重要。Diagnostic Tests 诊断性试验Managemen
28、t 处理Diagnostic tests have several uses: 诊断性试验有几种用途：1. To make Dx in patient known to be sick 给患者做出诊断使其知道生病了2. To provide prognostic information for patient with known disease 为患者提供预后信息使其了解疾病3. To identify person with subclinical disease or at risk for subsequent development of disease 鉴别出患有亚临床疾病或存在将
29、来发展为疾病的风险的人4. To monitor ongoing Rx 监测正在进行的治疗In each case objective is not simply to classify or “label,“ but to reduce M uncertainty can be expressed by probabilities. Probability of any particular 5disease being present, as test results are being interpreted, depends on both its probability of bei
30、ng present before testing and the validity of information provided by test results. 诊断的过程本身固有不确定性;这种不确定性可以用概率来表达。正如试验结果所做的解释那样，当前任何特定疾病的概率，同时取决于试验前的概率和试验结果所提供信息的可靠性。Sensitivity is probability that test result will be positive when person tested actually has disease. Perfectly sensitive test can rule
31、 out disease if result is negative. 敏感性是指当被试验的病人实际上已患该疾病时测试结果为阳性的概率。如果结果是阴性，高敏感试验可以排除该疾病。Specificity is probability that test result will be negative when person tested actually does not have disease. Perfectly specific test can rule in disease if result is positive.特异性是指当被试验者实际上并没有该疾病时测试结果为阴性的概率。如果
32、结果是阳性的，高特异性试验可以诊断该疾病。When test results are known, probabilities of disease or its absence in light of these results are most relevant to PCPs and patients. Predictive value positive is probability of disease with positive test. (Probability that disease is absent despite positive test can be thought
33、 of as probability of false alarm.) Predictive value negative is probability of no disease with a negative test. (The probability that disease is present despite negative test can be thought of as probability of false reassurance.) All of these probabilities are determined by probability of disease
34、before test was ordered and sensitivity and specificity of test.当测试结果已知时，根据该结果所得出的某疾病存在或没有的概率是初级保健医生和病人所最关心的。阳性预测值是检测呈阳性时得某病的概率。(结果为阳性时而疾病又不存在的概率能被认为是假阳性的概率。)阴性预测值是检测呈阴性时没有某病的概率。(结果为阴性时而疾病又存在的概率能被认为是假阴性的概率。)所有这些概率是由试验前疾病的概率和试验的敏感性和特异性所决定。Importance of pretest probability of disease in individual pat
35、ient (or prevalence of disease in population of such patients) for determining predictive values of test is often not fully appreciated and may lead to disappointment in clinical performance of test.用在个别病人中预试验的疾病概率(或在某类病人中某疾病的患病率 )来决定某测试的预测值的重要性往往没有得到充分的重视，并可能由此导致对该测试在临床上应用效果的失望。 Probabilities of di
36、sease can also be revised using pretest odds of disease and likelihood ratios. If p is probability of disease, ratio of p to (1 - p), or p/(1 - p) is odds favoring that disease being present and (1 - p)/p is odds against that disease. 疾病的概率也可以使用疾病的预试验优势比和似然比加以校正。若 p 是疾病的概率，p 与( 1 - p )的比，或 p / ( 1 -
37、 p)是目前这种疾病的优势性，( 1 -p) / p 是这种疾病反优势性。Pretest odds of disease multiplied by positive likelihood ratio produces posttest odds of disease after positive test result. 在得到阳性检测结果之后,试验前疾病的优势比乘以阳性似然比得到试验后疾病的优势比。Positive likelihood ratio is probability of positive result (or result within specified range) gi
38、ven presence of disease divided by probability of that result given absence of disease. 阳性似然比是题示阳性结果的概率( 或结果在特定范围内)除以没有患该疾病的概率。Positive likelihood ratio is therefore ratio of sensitivity to false-positive rate (i.e., 1 - specificity).因此阳性似然比是敏感性比上假阳性率(即 1 -特异性)。Negative likelihood ratio is ratio of
39、false-negative rate (i.e., 1 - sensitivity) to specificity. Pretest odds of disease multiplied by negative likelihood ratio produces posttest odds of disease after a negative test result. 阴性似然比是假阴性率(即 1 -敏感性)与特异性的比。在得到阴性检测结果之后试验前疾病的优势比乘以阴性似然比得到试验后疾病的优势比。Published test evaluations often provide optim
40、istic estimates of information provided by test in question. PCPs can avoid being mislead by paying attention to common problems in study design, including 已公布的实验评价往往对正被讨论质疑的实验提供乐观的估计。初级保健医师们通过关注在研究设计中的共同问题可避免被误导，其中包括：unrealistic expectations about predictive values because of higher disease prevale
41、nce in study population than in practice; 对预测值的不切实际的期望，因为出现了研究人群比实际有更高的患病率;unrealistic estimates of sensitivity and specificity because of overlap in test being evaluated and test(s) used to define presence of disease; 对敏感性和特异性的不切实际的估计，因为出现了正在评估中的测试和用于界定存在疾病的测试有重叠;unrealistic estimates of sensitivit
42、y when population with disease in study has more severe and more easily detectable disease than those in practice; 当被研究的患病人群比在实际中患有更为严重和更容易探测的疾病时,会出现对疾病敏感性不切实际的估计;6unrealistic estimates of specificity when population without disease in study is too well and more free of disease that might be confuse
43、d with disease in question than those in practice; 当被研究的未患病人群比在实际中更健康，可能与正研究中的疾病相混淆，会出现对疾病特异性不切实际的估计;unrealistic estimates of clinical value of test when study authors do not consider how much new information is provided by test in question when compared with that provided by other tests.当研究者没有考虑到其所
44、研究的试验与其他试验相比提供了多少新的信息时，会出现对实验的临床应用价值不切实际的估计。Sensitive tests or less stringent criteria for disease and resulting low false-negative rate should be favored when effective Rx for condition exists and cost of lost opportunity is great. High specificity or more stringent criteria for disease and resulti
45、ng low false-positive rate are most important when positive result does not significantly influence Rx or outcome and may be burden for patient.当某疾病在有条件时能被有效治疗而失去时机的治疗成本巨大的情况下，应青睐高敏感性的试验，或放松对疾病的诊断标准低假阴性率的要求。当试验的阳性结果不显著影响某疾病的治疗或预后，而且还可能是患者的负担时，最重要的是应采用特异性高的试验，或对疾病的诊断标准和结果低假阳性率的要求更严格。Health Maintenanc
46、e and Role of Screening保健和筛查Differential Diagnosis 鉴别诊断CRITERIA FOR SCREENING 筛选标准Characteristics of the disease 疾病的特征Significant effect on quality or length of life 对生活质量和寿命有重大影响Prevalence sufficiently high to justify costs 相当高的患病率导致可观的花费Acceptable Rx available 可接受的有效治疗Asymptomatic period during wh
47、ich detection and Rx significantly reduce M occupation (health care worker); see Immunization 危险因素：预期怀孕和风险组成员 ; 职业(卫生保健工作者) ;见免疫接种章节HIV infection 艾滋病毒感染Risk factors: anticipated pregnancy and risk group membership; blood transfusion 1978-1985; see HIV-1 Infection 危险因素：预期怀孕和风险组成员; 1978-1985 年间输过血的人;见
48、 HIV-1 感染章节Endocarditis susceptibility 心内膜炎易感性Risk factors: valvular heart disease; see Bacterial Endocarditis危险因素：心脏瓣膜病;见细菌性心内膜炎章节7Rheumatic fever susceptibility 风湿热的易感性Risk factors: rheumatic fever Hx; see Rheumatic Fever危险因素：风湿热病史;见风湿热章节TB (PPD reactivity) 结核(结核菌素反应 )Risk factors: occupational ex
49、posure; see Tuberculosis危险因素：职业性暴露;见结核病章节Occupational lung disease 职业性肺部疾病Risk factors: occupational exposure; see Occupational and Environmental Respiratory Disease 危险因素：职业性暴露;见职业与环境呼吸系统疾病章节Susceptibility to HBV 乙型肝炎病毒易感性Risk factors: male homosexual; exposure; occupation (health care worker); see Viral Hepatitis 危险因素：男性同性恋;接触;职业(卫生保健工作者);见病毒性肝炎章节Anemia 贫血Risk factors: pregnancy; see Anemia 危险因素：妊娠; 见性贫血章节Sickle cell trait 镰状细胞的特性Risk factors: African-American of childbearing age 危险因素：生育年龄的非洲裔美国人Genetic counseling must be acceptable; see S
