《怎样成为好医生课件.ppt》由会员分享，可在线阅读，更多相关《怎样成为好医生课件.ppt（51页珍藏版）》请在三一办公上搜索。
1、怎样成为好医生What makes a good doctor,怎样成为优秀的全科医生”,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
2、 of his calling” G Greisinger 1840Big 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
3、重和良好沟通机能,Big 2: listening best nameOthers: 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
4、些基本规则,The provisional diagnosis should come from the historyBelieve the patientAlways believe a worried parentSee patient alone if possibleAsk the patient what they consider is their real problemThree 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 th
5、e 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
6、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 proble
7、ms 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 l
8、umps 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.
9、 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 oathTh
10、e 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?Wha
11、t 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
12、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,PallorCyanosisAltered conscious state Cold extremitiesTachypnoeaTachycardiaFever- temperature 38 CPoor capillary refi
13、ll 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,DepressionDiabetesDrugs iatrogenic self abuse and OTCAnaemiaThyroid & other endocrineSpinal dysfunctionUrinary 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 (re
14、d faces)典型的陷阱,Abscess (hidden)AllergiesChronic fatigue syndromeCoeliac disease Domestic abuse inc.childrenDrugsHerpes zosterFaecal impactionForeign bodiesGiardiasisHaemochromatosis,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 (unsusp
15、ected)Menopause syndromeMigraine (atypical variants)Pagets diseasePregnancySarcoidosisSeizure disordersTourettes 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 agendaTicket of entryMasked depressionUnderlying anxiety/fear
16、sConflicts-at homeConflicts-at workBullyingSexual 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 l
17、umps 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
18、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
19、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 issuesKeep up to date Avoid using drugs if there is an alternative- consider complementary strategiesBe good at treating nitty gritty problems eg dandruff
20、, halitosis, cramps, warts, tinea, eczema, stress, mouth ulcers, anxiety, lumbago, pruritus ani and vulvaePromote 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
21、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 satis
22、fying 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 in
23、teresting and rewarding responsibilityBe 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
24、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
25、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 waterLacerations ion scalpClearing the snotty noseGetting the mouth open-pinch testInstilling nose drops-over nares-cover mouthCutting plaster-use tongue depressorAbdominal palpationFirm round foreign body in nose,创可贴，石膏，
26、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 horizonNightmares: anti-epileptics phenytoin; epilumHiccups: breakfast question; 20 ml spirit in teaspoon sugar; breath hold + iceErectile dysfunction: Viagra etc; con
27、sider ischaemic heart diseasePremature ejaculation: SSRI eg Prozac dailyPremenstrual 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 inn
28、ervationKnee pain-think hipBeware 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
29、子滑囊炎,Common in females 45-50 yearsPain on outside hip-? referred as far as footPain lying on hip at nightLimpRx 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
30、底筋膜炎的治疗,Orthotic aids eg Rose insoleHydrotherapy-hot and cold water 30 seconds each alternate 15 timesTherapeutic foot massageExercisesNSAIDS-3 weeksInjection 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
31、litigationAge range 5-15 (early teens)85% salvageable within 6 hoursMost lost with delays on investigationRefer immediately to surgeon/centreTeenage 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,S
32、plinter 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, needleMissing a ruptured tendonExposed joint capsule in wrist: watch fist punchBites-human
33、, cats, dogsHigh pressure guns-oil and paintStab wounds: nerves, tendonsCut finger or toeTourniquet left on fingerBeware jumping from height onto feet-fractures, concussBeware painful elbow in childBeware 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
34、，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
35、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 modi
36、fication-alcohol, smoking etcManage associated conditions eg diabetesMedication-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
37、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, exerciseOral monotherapy-metformin (choice 1) or sulfonylureaCombination oral therapy metformin + sulfonylurea (? Gliptin)Add a glitazone or other agentAdd insulin-isophane
38、 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 dipstickMicro-culture (clean catch)High fluid intake-? wait 3 day and see ruleAntibiotics-trimethoprim or cephalexinAlkaliniser especially severe dy
39、suriaRepeat MCU 1 to 2 weeks after AB courseConsider 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12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 penicillinFever 38 CTender cervical lymphadenopathyTonsillar exudateNo
40、 coughOthers: 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325岁人群A组-溶血性链球菌,Otitis media- children儿童中耳炎,Possible clinical indicators for antibioticsSick child with feverVomitingRed-yellow bulgi
41、ng ear drumLoss of drum landmarksPersist 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 humidityParacetamol suspension in high dosageDecongestants only if nasal congestionAntibioti
42、cs as indicated eg amoxycillin 40 mg/kg/d in 3 divided doses for 7 daysFollow 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 rulesAcute coronary states- 60-90 minutes to coronary unitStroke- cerebral infarct- 3-4 hours to stroke unitFemoral artery 4 hours 4 hours=limb salvage6 hours=amputationTorsion 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,
