怎样成为好医生.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,文档仅供参考，不能作为科学依据，请勿模仿；如有不当之处，请联系网站或本人删除。,What makes a good doctor什么是好医生,“,The doctor should have a kind disposition,great patience,meticulous freedom from prejudice,an understanding of human nature resulting from an abundant knowledge of the world,adroitness in conversation and a special love of his calling”,G Greisinger 1840,Big 3 attributes-caring,responsibility,knowledge,“,医生应该有良好的气质，极大的耐心，谨慎地不带成见，通过丰富的阅历理解人的属性，机智灵敏地与别人交谈，对病人充满爱心,”,G Greisinger 1840,3,个重点：,关怀,责任,知识,12条指导原则,好医生应该有自己的指导原则。我认为，作为这个崇高和伟大的职业群体的一员，我们应该努力地让病人、同行和社会把我们看成一流的专业人员,。,Develop rapport&good communication skills,建立尊重和良好沟通机能,Big 2:,listening,best name,Others:friendly greeting,respect and courtesy,well briefed,non-judgemental,2,个要点,:,倾听,称呼名字,其他,:,友好地招呼病人,尊重和有礼貌,言简意赅,不带偏见,3 golden communication rules沟通的三个黄金法则,Listen倾听,Call patient by preferred name用病人的名字称呼病人,Appropriate touch采用适当的方式触摸病人,History-some guiding rules病史：一些基本规则,The provisional diagnosis should come from the history,Believe the patient,Always believe a worried parent,See patient alone if possible,Ask the patient what they consider is their real problem,Three incorrect strikes and its out!,初步的临时诊断应该从病史中发现,要相信病人,要永远相信患儿父母,如果可能，最好单独看病人,询问病人，问他认为真正的问题,是什么,2.Ask the right questions 询问正确的问题,Why have you come to see me today?,Do you have any particular concerns about your health?,Tell me about things at home?,Tell me about things at work?,What do you think deep down is the cause of your problem?,Is there anything that I havent asked you and that it would be best if you told me?,Is there anything in your life that you would like to change?,你今天是什么原因来找我？,你具体担心自己哪方面的健康问题？,告诉我你在家里的情况？,告诉我你在工作单位的情况？,你认为你的病的深层次原因是什么？,有没有我没有问到，但你想告诉我的事情？,你是不是想过改变一下自己的生活？,3.Be astute and observant 机敏并善于观察,The art of physiognomy(Addison)-the art of reading both physical and emotional problems from the face and body language,“Watson you see everything but observe nothing”,Sherlock Holmes,相面术 通过表情和身体语言阅读躯体和心理问题的艺术,“,华生医生,，,你看到了全部，但什么也没观察到,”,福尔摩斯,History:general symptoms(often overlooked-”red flags”)常见症状（通常忽略，红色警戒事件）,Tiredness/malaise fatigue劳累，不适，疲劳,Fever/sweats发热，出汗,Weight change体重变化,Unusual lumps or bumps 异常肿瘤或肿块,Pain or discomfort anywhere疼痛，或周身不适,Unusual bleeding异常出血,Ask:“is there anything else you should tell me about?”,询问：还有没有你应该告诉我的其他事情？,The skill of accurate diagnosis at point of first contact初次接诊的准确诊断技术,Questions to ask oneself,问自己几个问题,1 What is the probability diagnosis?可能的诊断是什么？,2.What serious disease must not be missed不能忽视的严重疾病是什么？,3.What conditions are often missed-pitfalls?通常会存在什么陷阱？,4.Could the patient have a masquerade?病人是不是戴着面具？,5.Is the patient trying to tell me something?这个病人是不是想要告诉我什么？,4.Develop optimal ethical&professional standards 遵循道德和职业规范,Hippocratic oath,The Declaration of Geneva,希波克拉底誓言,日内瓦宣言,-,Cardinal,医生的美德,最首要的,-,prudence,justice,，,courage,temperance,谨慎，判断，勇气，克制,Key-generosity 大度宽容,-compassion 同情怜悯,-tolerance 宽容宽恕,-gentleness 温情和善,-politeness 礼貌客气,-humour 诙谐幽默,5.Have a fail-safe diagnostic strategy,第五条：采用“保险”的诊断策略,What is the probable diagnosis?,What must not be missed?,What are the pitfalls?Have I learned from past mistakes?,Is the patient trying to tell me something?Hidden agenda/ticket of entry,What tests should I order?,可能的初步诊断是什么？,一定不能忽略哪些严重疾病？,会不会有陷阱？我从以往的错误中学到什么？,我应该让病人做什么检查？,Classic minefield problems conditions prone to error典型的容易发生诊治错误的问题,Acute abdominal pain急性腹痛,Acute chest pain急性胸痛,Breast lumps乳房肿块,Headache头痛,Cough咳嗽,Childrens disorders especially infections儿童问题，特别是感染,Endocrine disorders内分泌问题,Signs-red flags迹象,红色预警情况,Pallor,Cyanosis,Altered conscious state,Cold extremities,Tachypnoea,Tachycardia,Fever-temperature 38 C,Poor capillary refill 2 secs,面色苍白,紫绀,神志状态变化,肢体末端温度低,呼吸急促,心跳过速,发烧体温,38C,微血管回复充盈差,2 secs,The 7 first line masquerades七种最常见的戴化装面具的疾病,Depression,Diabetes,Drugs,iatrogenic,self abuse and OTC,Anaemia,Thyroid&other endocrine,Spinal dysfunction,Urinary infection,抑郁症,糖尿病,药物问题,因医生引起的,自己药物滥用,或非处方药,贫血,甲状腺病或其他内分泌疾病,脊柱功能损伤,尿路感染,Classic pitfalls(red faces)典型的陷阱,Abscess(hidden),Allergies,Chronic fatigue syndrome,Coeliac disease,Domestic abuse inc.children,Drugs,Herpes zoster,Faecal impaction,Foreign bodies,Giardiasis,Haemochromatosis,脓肿暗疮,各种过敏,慢性疲劳综合症,腹腔疾病,家庭暴力，包括虐待儿童,药物滥用,带状疱疹,大便干燥,异物,贾第鞭毛虫病,血色素沉着症,Classic pitfalls(red faces),cont,典型的陷阱（续）,Malnutrition(unsuspected),Menopause syndrome,Migraine(atypical variants),Pagets disease,Pregnancy,Sarcoidosis,Seizure disorders,Tourettes syndrome,营养不良（未曾发现）,绝经期综合症,偏头疼（非典型性）,佩吉特病（湿疹样皮损）,怀孕,皮肤结节病,癫痫发作,多发性抽动症,Is the patient trying to tell me something?病人是不是想告诉我什么？,Hidden agenda,Ticket of entry,Masked depression,Underlying anxiety/fears,Conflicts-at home,Conflicts-at work,Bullying,Sexual issues inc STIs,?Munchausens,藏在心里的目的,要张,门票,隐藏的抑郁,潜在的焦虑,或恐惧,在工作场所和别人有矛盾,被人欺负,与性有关的问题,，,包括性传播疾病,6.Develop your own guidelines 制作你自己的指南,For diagnosis and management of,common symptoms,e.g.,headache,back pain,acute chest pain,rash,acute,abdominal pain,breast lumps,sick febrile child,common conditions,eg angina,diabetes,hypertension,cardiac,failure,asthma,epilepsy,诊治常见症状，如头疼，背痛，急性胸痛，皮疹，急性腹痛，乳房肿块，小儿发热,诊治常见疾病，如心绞痛，糖尿病，高血压，心衰，哮喘，癫痫,教科书上的指南是有用的，不过好医生会制定出适合自己的指导原则。医生可以列出诊断和治疗常见症状的“自我指南”，比如头疼、背疼、出疹、胸痛的诊治方法，并且把这些症状与相关的疾病联系起来，如糖尿病、心绞痛、哮喘等。善于归纳出自己的指南，实际上是医生能更好地理解这些常见症状和疾病。特别是，医生要能够谨慎地对医疗保险机构确定的那些疾病进行诊治，因为这些疾病的处理不当，可能导致医疗赔偿或诉讼。,有六种症状：胸部肿块、急性胸痛、急性腹痛、小儿发烧、严重头疼、急性呼吸困难。,7 Develop supportive networks 建立支持网络,Know your consultants/hospitals,附近的专家和医院,Colleagues Phone,其他全科医生及电话,Social workers phone,社会工作者及电话,Religious/counsellors phone,宗教人士及电话,Allied health team phone,辅助医疗团队及电话,CAT team,危重病人评估小组,Psychiatric services,精神病学服务,Internet,互联网,8.Know essential therapeutics 掌握基本的治疗技术,Know your key drugs by heart and the prescribing issues,Keep up to date,Avoid using drugs if there is an alternative-consider complementary strategies,Be good at treating nitty gritty problems eg dandruff,halitosis,cramps,warts,tinea,eczema,stress,mouth ulcers,anxiety,lumbago,pruritus ani and vulvae,Promote patient education handouts extensively,牢记主要的药品，及其处方注意事项,掌握最新的用药情况,如果可以考虑用其他的替代方法，则不要用药,善于治疗小毛病，如掉头皮屑，口臭，抽筋，疣子，皮癣，湿疹，紧张，口腔溃疡，焦虑，腰肌劳损，肛门搔痒，外阴搔痒,给病人健康促进资料,掌握基本的治疗方法,好医生应该非常熟悉经常使用的药品，并为病人准备好这些药品的说明书。医生还要掌握不断出现的新药，在可能的情况下替换原来的旧药。这一点对于治疗精神疾病的药物来说特别有用，如抗抑郁药和抗精神病药。,对于每天可能遇到的那些“实际问题”，医生也要有好的治疗方案，如头皮屑、口臭、口腔溃疡、脚癣、肉疣、抽筋、湿疹、瘙痒，等等。如果采用改变生活方式、自然疗法、补充维生素就能够解决问题的，就尽量避免使用复杂的药物治疗。,给病人准备好健康教育资料。,9.Develop basic procedural skills 掌握基本的操作技术,Advantages,continuing skills improvement,more interesting and satisfying work,cost effective for your patients,好处,持续地改进操作技术,，,可以让医生对工作更有兴趣，对工作更满意,有助于提高诊治病人的成本效益,病人非常敬佩医生的地方，是他们能驾轻就熟地使用那些“家伙”，如听诊器、检耳器、检眼镜、直肠镜等诊断辅助器械。,病人还非常钦佩医生能灵巧处理常见疾病，如耳道清洗、创伤缝合、切除原发肿块、拔除异物、颈部和腰部理疗、肌肉骨骼系统系统疾病的注射治疗等。,10.Be prepared for emergencies 准备好应对紧急情况,Managing emergency conditions is a huge but interesting and rewarding responsibility,Be prepared-plan,equip,practice,对紧急情况的诊治需要大量的工作，不过从中可以学到很多知识和经验，而且也体现的医生的责任所在,要准备好 计划，设备，服务,准备好基本的急救措施,很多病人病得很严重，他们有可能就倒在医生面前。好医生应该准备好基本的急救措施，能操作基本的急救设备，对病人的突发情况给与快速的反应。医生应该具备如下能力：,掌握心肺复苏技术，抢救心脏骤停的病人,针对过敏性反应的急救措施,针对呼吸窘迫的急救技术，如哮喘、急性肺水肿、哮吼,急性心肌炎或心肌梗死的急救,肾和胆绞痛的处理,惊厥的处理,第十一条：掌握特定服务的专门技能,针对需要特定服务的人群，医生要制定和遵守明确和符合伦理的原则。这些特定人群包括：,年老体弱者，比如家庭诊疗技术,社会弱势群体,先天发育和智力障碍群体,绝症患者，比如提供姑息关怀,各种伤害的受害者,土著人（少数民族）,难民,第十二条：了解自己，了解自己的局限性,医生要知道自己知识和技能的局限，要准备好请教别人，寻求别人的帮助。记住这个“棒球规则”：三振出局（事不过三，即不能总犯同样错误）。医生要能从工作中找到乐趣，喜欢自己的工作。医生拥有与病人交往的神圣特权，因此也应该从中得到最大的收益。,“好医生就是善待病人”,人民日报短文,每个医生在心里都有自己的“好医生”标准，你的标准是什么呢？,Practice tips全科医学服务要诀,Tips in children给儿童提供服务的要诀,Removing plaster-soak in water,Lacerations ion scalp,Clearing the snotty nose,Getting the mouth open-pinch test,Instilling nose drops-over nares-cover mouth,Cutting plaster-use tongue depressor,Abdominal palpation,Firm round foreign body in nose,创可贴，石膏，胶布：在水里揭,头皮内创伤处理,清理鼻涕,让儿童张口（捏鼻）,滴鼻液：在鼻孔上，捂嘴,切石膏,：,使用压舌板,腹部触诊方法,在鼻子上固定,Nitty gritty tips小毛病的服务要诀,Seasickness:plug one ear;ginger;look to the horizon,Nightmares:anti-epileptics phenytoin;epilum,Hiccups:breakfast question;20 ml spirit in teaspoon sugar;breath hold+ice,Erectile dysfunction:Viagra etc;consider ischaemic heart disease,Premature ejaculation:SSRI eg Prozac daily,Premenstrual tension:SSRI 10 days before M,晕车晕船,:,塞住一只耳朵，生姜，眼看前方,做恶梦,:,抗癫痫药，,苯妥英，丙戊酸钠,呃逆，打嗝,:,早餐问题,;20 ml,酒加一小勺糖,;,屏住呼吸冰,勃起困难,:,伟哥,;,考虑是否患冠心病,早泻,:,选择性,5-,羟色胺再吸收抑制剂,SSRI,，,如,百忧解,，,每天,1,次,经前期紧张,:,月经来前,10,天吃,SSRI,Pain in the knee trap奇怪的膝盖疼,Hip joint-L3 innervation,Knee pain-think hip,Beware children with slipped upper femoral epiphysis,髋关节,L3,神经支配,膝盖疼要想到臀部问题,儿童要注意是否上股骨端脱臼,Tennis elbow网球肘 肌腱炎,Muscle strengthening exercises best for tendonitis肌肉强度练习，对肌腱炎有好处,For medial epicondylitis(tennis elbow)-extensors of wrist医学上的肱骨上髁炎（网球肘）-腕伸展肌,Trochanteric bursalgia大转子滑囊炎,Common in females 45-50 years,Pain on outside hip-?referred as far as foot,Pain lying on hip at night,Limp,Rx Physio&exercises,Massage,Trial NSAIDs,Injection local anaesthetic,and corticosteroid,45-50,岁以上妇女常见,髋外侧疼,可能波及到脚,夜间髋部疼痛,走路跛行,处方,理疗和锻炼,按摩,非类固醇抗炎药,局部麻醉剂注射,以及,皮质类固醇,Treatment of Plantar fasciitis,足底筋膜炎的治疗,Orthotic aids eg Rose insole,Hydrotherapy-hot and cold water 30 seconds each alternate 15 times,Therapeutic foot massage,Exercises,NSAIDS-3 weeks,Injection under tibial nerve block,矫正器，如罗斯鞋垫,水疗,冷热水每,30,秒交替一次，共做,30,次,治疗性足按摩,锻炼,非类固醇抗炎药,3,周,注射,胫骨神经封闭,Torsion of testicle“a time bomb”睾丸扭转 定时炸弹,Common cause of litigation,Age range 5-15(early teens),85%salvageable within 6 hours,Most lost with delays on investigation,Refer immediately to surgeon/centre,Teenage boys maybe diagnosed,as appendicitis,常见的诉讼原因,年龄范围,5-15,岁,(,青少年早期,),85%,的病例可以在,6,个小时内得以挽救,大多数不可挽回的病例,耽误在检查上,立刻转诊到外科或医学中心,年轻男孩可能被误诊为阑尾炎,Removal of foreign bodies清除异物,Splinter under nail扎在指甲里的碎片,Fish hook钓鱼钩,Splinter in skin扎在皮肤里的碎片,Pulled elbow in children儿童的牵引肘,Reduce by supination,用反掌姿势复位,Simple trauma traps and tips小外伤的陷阱和要诀,Missing a foreign body:glass,gravel,splinters,needle,Missing a ruptured tendon,Exposed joint capsule in wrist:watch fist punch,Bites-human,cats,dogs,High pressure guns-oil and paint,Stab wounds:nerves,tendons,Cut finger or toe,Tourniquet left on finger,Beware jumping from height onto feet-fractures,concuss,Beware painful elbow in child,Beware scaphoid fracture after fall on outstretched hand,没找到扎在身体里的异物：玻璃，沙砾，碎片，针,没找到断裂的肌腱,腕关节囊暴露：拳击,咬伤,人，猫，狗,高压枪,油或油漆,暴露伤,:,神经，肌腱,切手指或脚趾,止血带留在手指上,当心从高处跳下,骨折，脑震荡,当心儿童的肘痛,当心舟骨骨折,摔倒后手触地,Neck dysfunction-muscle energy therapy颈部功能失常 肌能治疗,A simple safe treatment简单安全的治疗,Back pain treatment背痛的治疗,Mobilisation&manipulation搬运和操作,Exercises练习,Management-lifestyle advice-NEAT疾病管理对生活方式的建议,N,=Nutrition,:,optimal diet,low fat,合理营养,：优化饮食结构，低脂饮食，维生素，矿物质，多喝水,E,=Exercise,:,physical activity,加强锻炼,：让身体活动起来,A,=Avoid toxins-cats,：,caffeine,alcohol,tobacco,sugar,salt,social drugs,远离毒物,：咖啡因，酒精，烟草，糖，毒品,T,=Tranquillity-,rest&recreation,stress management,yoga,meditation,good sleep,心态平静,：休息娱乐、减少压力，瑜伽，静坐,Hypertension高血压,Lifestyle modification-alcohol,smoking etc,Manage associated conditions eg diabetes,Medication-need 4-6 weeks trial,1.start with ACE/ARB or CCB or thiazide,2.ACE/ARB+CCB(best evidence)or thiazide,3.ACE/ARB+CCB+thiazide,改变生活方式 吸烟，饮酒等,管理好相关的疾病，如糖尿病,用药,需要,4-6,周的试验,先用血管紧张素转换酶抑制剂,ACE/,血管紧张素受体拮抗剂,ARB,或钙通道阻滞剂,CCB,或,噻嗪类,利尿剂,ACE/ARB+CCB(,证据显示效果最好,),或,噻嗪类,利尿剂,ACE/ARB+CCB+,噻嗪类,利尿剂,Diabetes mellitus-step up management糖尿病 建立管理计划,Lifestyle management-diet,exercise,Oral monotherapy-metformin(choice 1),or sulfonylurea,Combination oral therapy,metformin+sulfonylurea(?Gliptin),Add a glitazone or other agent,Add insulin-isophane or long acting,管理生活方式 饮食，锻炼,单药口服治疗,甲福明二甲双胍,(,首选,),或者,磺脲,联合口服治疗,甲福明二甲双胍,磺脲（,或,格列汀）,加,格列酮,加胰岛素 精蛋白胰岛素或长效胰岛素,Urinary tract infection(uncomplicated)尿路感染（无并发症）,Urine dipstick,Micro-culture(clean catch),High fluid intake-?wait 3 day and see rule,Antibiotics-trimethoprim or cephalexin,Alkaliniser especially severe dysuria,Repeat MCU 1 to 2 weeks after AB course,Consider further investigation,尿常规,显微培养,给大量液体？等,3,天看结果,抗生素,甲氧苄氨嘧啶,或,头孢氨苄,碱化剂，,特别是严重的排尿困难,1,2,周后重复膀胱造影检查，,after AB course,考虑进一步检查,Sore(streptococcal)throat咽痛（链球菌感染）,4 key features and indication for penicillin,Fever 38 C,Tender cervical lymphadenopathy,Tonsillar exudate,No cough,Others:those 3-25 years with presumptive GABHS from special communities with a high incidence of rheumatic fever,4个病症，需要用青霉素,发烧,38 C,颈部淋巴结肿大,扁桃体渗出液,不咳嗽,另外：特定的风湿热高发社区,3,25,岁人群,A,组,-,溶血性链球菌,Otitis media-children儿童中耳炎,Possible clinical indicators for antibiotics,Sick child with fever,Vomiting,Red-yellow bulging ear drum,Loss of drum landmarks,Persist fever and pain after 3 days of a conservative approach,可以使用抗生素的临床指标,儿童虚弱，发烧,呕吐,耳鼓蓬出,耳鼓边缘消失,保守治疗,3,天后持续发烧和疼痛,Otitis media in children-2儿童中耳炎2,Rest in warm room with adequate humidity,Paracetamol suspension in high dosage,Decongestants only if nasal congestion,Antibiotics as indicated eg,amoxycillin 40 mg/kg/d in 3 divided,doses for 7 days,Follow up including hearing in 10 days,休息房间保持温暖和适宜的湿度,大剂量,扑热息痛,输液,如果充血，给抗充血剂,抗生素,，,如,阿莫西林,40mg/kg/d,，,分每天,3,次,，,用,7,天,10,天内随访，包括耳检查,Think fast with infarction对血栓的快速考虑,Intervention time rules,Acute coronary states-60-90 minutes to coronary unit,Stroke-cerebral infarct-3-4 hours to stroke unit,Femoral artery 4 hours,4 hours=limb salvage6 hours=amputation,Torsion of testis 4-6 hours,干预时间的规则,急性冠心病：,60-90,分钟内送冠心病科,脑卒中，脑血管栓塞：,3-4,小时内送脑卒中科,股动脉,4,小时,4,小时,=,保肢,6,小时,=,截肢,睾丸扭转,4-6,小时,