Chapter 1 Patient-Physician Interaction 第一章 医患沟通
The patient-physician interaction proceeds through many phas of clinical reasoning and decision making. 医患沟通在临床诊断和治疗决策的许多阶段中进行着。The interaction begins with an elucidation of complaints or concerns, followed by inquiries or evaluation to address the concerns in increasingly preci ways.这种沟通开始于病人诉说或所关注问题，然后通过询问、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 cours 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，进行诊断性化验，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，并与病人及家属反复磋商以形成治疗方案Physicians increasingly can call on a growing literature of evidence-bad medicine to guide the process so that benefit is maximized, while respecting individual variations among different patients.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，但要考虑到不同病人中个体差异是存在的。
姽婳词 The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine越来越多的可用于指导临床诊断与治疗的随机试验资料不应变成“烹调书”医学。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着重于特征性病人的求证过程。Substantial clinical judgment is required to determine whether the evidence and guidelines apply to individual patients and to recognize the occasional. 实际的临床判断需要确定这些现象和思路能否应用于某个病人个体，并能找出例外。战伤救护Even more judgment is required in the many situations in which evidence is abnt or inconclusive.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 physician’s responsibility to emphasize when prenting alternative options to the patient. 桎梏是什么意思病人还会根据自己的倾向调节着临床症状，但医生有责任通过选择性问题搞清事实。蜗牛歌曲周杰伦The adherence of a patient to a specific regimen is likely to be enhanced if the patient a
lso understands the rationale and evidence behind the recommended option.假如病人也懂得医生问题的基本原理和表现，有特殊生活方式病人的固执容易被强化。
To care 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 patient’s social situation, family issues,疏懒 financial concerns, and preferences for different types of care 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 the issues, the science of medicine cannot be applied appropriately, and even the most knowledgeable physician fails to achieve appropriate outcomes. 假如医生没有正确理解和定位这个问题，医学就不可能恰当地应用于临床，甚至一个知识最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 reliability.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 u 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 options but must advi 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 open 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能考虑的治疗选择，是极及关键的。
The physician does not exist in a vacuum but rather as part of a complicated and e
购房定金合同
xtensive system of medical care and pubic health.医生不是生存在真空中的，而是复杂而庞大的医疗和公共健康体系中的一部分。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 dia.王子简笔画在未发达时代，甚至当今在一些发展中国家，基本卫生、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措施。In developed countries, the adoption of healthy lifestyles, including better diet and appropriate exerci, are cornorstones to reducing the epidemics of obesity, coronary dia, and diabetes.而在发达国家中，健康的生活方式包括合理饮食和适当锻炼，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 u of tobacco, illicit drugs, and 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。
Chapter 5 Clinical Preventive Services 第五章 临床预防服务
Clinical preventive rvices include counling, immunization, screening tests, and reduction of the susceptibility to dia 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、筛查以及通过治疗性的生活习惯改变和药物治疗来减少易感性。Preventive rvice often are classified as primary, condary, 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 directed toward preventing dia or injury before it develops, whereas condary prevention deals with early detection and treatment to impede the progress of overt dia.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的早期发现和早期治疗，以防止临床疾病的进一步发展。In contrast, tertiary prevention refers to rehabilitative activities after the ont of dia to minimize complications and disability.对比之下，三级预防是指疾病发生后的康复治疗，以减少并发症和病残。Becau of considerable overlap, distinguishing among the phas 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 condary prevention of hypertensive c
ardiovascular dia but primary prevention of heart failure and stroke. 发现和治疗高血压可以认为是对高血压性心血管疾病的二级预防，但也可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 dia, to avoiding premature death and disability.长期一贯地减少易感因素可能是防止疾病、避免早死早残最好的预防。The sooner the prevention, the more likely unnecessary 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 themlves.安逸的近义词越来越多的重点已经集中到对危险因素本身的预防。The term primordial prevention has been introduced for this concept.术语---根源预防（病因预防）已经引进了这个概念。
