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Yami

Jingdong book

内科医师查房手册

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内科医师查房手册

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查房的过程也是各级医师学习的过程。在查房过程中,上级医师经常会向下级医师提问,很多初级医师、实习医师都“害怕”上级医师提问,也不知道上级医师会问些什么。本书临床病例为主线,采用问答形式模拟临床查房,精心收录相关的诊疗问题,力求使临床第一线的医师向上级医师学习本专业知识,学习通科知识,加强临床实践,增加临床经验,全面地熟悉全科知识,了解新的诊疗技术及研究进展;力求帮助低年资医师提高临床工作能力,开拓诊疗视野。
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《内科医师查房手册》结合病例,以临床需要为内容取舍标准,对内科疾病的主要知识点作了较为全面和深入的阐述,突出临床查房实践中的重点知识和逻辑思维,但又不仅是临床查房工作的简单再现,还广泛涉及内科疾病诊治的最新的研究进展和循证医学证据。本书图文并茂,设置问题目录便于读者查阅。
适合初上临床的轮转医师、临床型研究生、见习/实习医学生,也适合内科的主治医师和住院医师阅读、参考。
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姚定康,男,医学博士,副主任医师、副教授,硕士研究生导师。第二军医大学附属长征医院内科教研室副主任。现任中华医学会卫生学分会全国青年委员会会员,中华医学会卫生学分会临床与预防专业委员会委员,上海市肝病研究中心中青年专家委员会委员,上海市生物力学学会委员,国家自然科学基金同行评议专家,第二军医大学教学督导专家。担任《中华消化病与影像杂志(电子版)》编委,《中华临床医师杂志(电子版)》编委,《临床肝胆病杂志》优秀审稿专家。从事消化内科临床工作23年,尤其专长疑难肝病的诊治;长期承担长征医院肝硬化特色专病门诊,迄今已诊治2000余例次慢性肝病,其中包括500余例原发性胆汁性肝硬化病例,发表有关原发性胆汁性肝硬化的基础与临床研究文章40余篇,其中采用独特的中西医结合治疗方法取得较好效果,在国内有一定的影响,已经形成长征消化内科的特色之一。承担及参加国家及省部级科研课题10余项,其中近4年负责上海市重点科研项目2项,总经费40万,负责国家自然科学基金1项,经费30万。课题主要涉及肝病蛋白质组学、肿瘤蛋白质组学等内容,公开发表论文90余篇,核心期刊60篇(SCI录用 6篇,总影响因子18分),主编专著2部,参编著作6部,申请国家专利2项。负责长征临床医学院内科学、物理诊断学、临床流行病学、临床药物治疗学等课程的教学工作,其中物理诊断学被评为总后优秀课程;2007年获得总后优秀教师称号,2009年获得上海市育才奖,2011军队育才奖银奖,多次被评为校优秀教学工作者、优秀实习带教老师、校A级优秀教员等。负责2项卫生部及上海市教学课题研究,2项校重点教学研究课题,参加3项国家教育规划课题研究,获得上海市医学会科技成果二等奖1项(2007),上海市教学研究成果一等奖2项,国家教育成果二、三等奖各1项,全军优秀教学成果1项,校教学成果一等奖、三等奖各1项。

梅长林,男,医学博士,主任医师、教授,博士生导师。现任第二军医大学附属长征医院内科学教研室主任兼肾内科主任。梅长林教授长期从事慢性肾病、尿毒症、类风湿关节炎和系统性红斑狼疮的诊断和治疗,具有丰富的临床经验,尤对多囊肾病分子发病机制的研究及诊断治疗居国内领先水平,对尿毒症病人的血液透析及其并发症的处理也具有丰富经验。他与相关科室协作,采取内外科结合治疗肾病、尿毒症和多囊肾病获得满意疗效。所建血液透析中心成为上海领先,全国规模最大、收治病人最多的四大血透中心之一。他所领导的肾内科先后发展为全军肾病技术中心、肾病研究所。近10年来,获上海市医学科技一等奖1项,中华医学科技奖二等奖1项,上海市科技进步三等奖1项,军队科技进步二、三等奖6项,获国家自然科学基金重点项目“863”等重大基金项目8项,基金总额377万元。发表论文181篇,主、副编出版著作15部,参编著作11部。1993年被评为上海市第四届“银蛇奖”一等奖。首批入选上海市“百名跨世纪优秀学科带头人”培养计划。荣立二等功1次。2001年获国务院颁发的政府特殊津贴,2005年获中国医师奖。
Catalogue

第一章 呼吸系统疾病
中年男性,反复咳嗽、咳痰十余年,加重伴发热、咯血1周--支气管扩张症
中年女性,反复发作性咳嗽、咳痰、胸闷二十余年,加重3天--支气管哮喘
青年男性,反复发热伴咳嗽、咳痰1周--肺炎
老年男性,反复咳嗽、咳痰30年,活动后气促10年,加重伴双下肢水肿半个月--慢性阻塞性肺疾病(COPD),肺源性心脏病(肺心病)
反复咳嗽、咳痰15年,加重伴呼吸困难1天--COPD急性加重期,Ⅱ型呼吸衰竭
青年男性,反复低热、盗汗2个月,咳嗽、咯血1个月--结核性胸膜炎
中年女性,咳嗽伴胸痛1个月,发热、胸闷4天--胸腔积液
老年男性,反复咳嗽、胸痛半年,加重伴消瘦、乏力1个月--非小细胞肺癌
第二章 循环系统疾病
老年男性,反复胸闷、气促5年余,加重伴双下肢水肿1个月--高血压性心脏病,慢性心功能不全
老年男性,反复心悸10年,加重伴头晕2周--病态窦房结综合征
老年女性,腹胀、乏力1周,心悸伴双下肢水肿1天--心房扑动和心房纤颤
中年女性,反复头晕1周--房室传导阻滞
中年男性,运动后心悸、胸闷、冷汗4个月余--室性心动过速
青年男性,发作性心悸、胸闷3年,再发6天--阵发性室上性心动过速
老年男性,剑突下疼痛伴大汗、呕吐3h--急性心肌梗死(AMI)
中年男性,发现血压增高10年--原发性高血压
老年女性,腹胀、食欲缺乏1年,黑粪3个月--限制型心肌病
青年女性,阵发性心悸、气短、反复上呼吸道感染2年--心房间隔缺损
青年女性,劳力性胸闷、气促20年,反复发热1年余--心脏瓣膜病,感染性心内膜炎
青年女性,发热伴持续性心前区疼痛2天--急性心包炎
老年男性,突发胸痛伴晕厥17h--急性主动脉夹层伴继发主动脉瓣撕裂
第三章 消化系统疾病
老年女性,反复胸痛1个月,加重伴反酸、烧心1周--反流性食管炎
青年男性,上腹痛、反酸2个月,黑粪1天--十二指肠溃疡
老年男性,上腹痛半年伴反复黑粪2个月--胃癌
中年女性,腹胀、尿少2周,伴发热1周--结核性腹膜炎
青年女性,反复黏液脓血便伴下腹痛2年--溃疡性结肠炎
中年女性,反复上腹部不适、嗳气2年,加重伴失眠半个月--功能性消化不良
中年女性,疲劳1年,肝功能异常半年--自身免疫性肝炎
中年男性,食欲缺乏、乏力2年,腹胀1个月,呕血、黑粪1天--乙型肝炎后肝硬化
中年男性,右上腹胀痛伴食欲减退1个月--原发性肝癌
中年男性,酒精性肝硬化十余年,睡眠障碍5天,意识行为异常3天--肝性脑病
中年男性,中上腹剧烈疼痛伴呕吐1天--急性胰腺炎
老年女性,反复右上腹痛1周,加重伴发热、尿黄1天--急性化脓性胆管炎
中年男性,反复上腹不适伴黑粪3周,呕血1天--上消化道出血
第四章 泌尿系统疾病
青年男性,血尿、水肿1个月,少尿半个月--急进性肾小球肾炎
老年男性,眼睑及双下肢水肿4个月--肾病综合征
中年男性,尿中泡沫增多3个月,双下肢水肿2个月--IgA肾病
青年女性,颜面部红斑4个月,双下肢水肿2个月--狼疮肾炎
青年男性,双下肢皮肤紫癜伴关节痛3周,尿检异常5天--过敏性紫癜肾炎
中年男性,口干、多饮、多尿8年,双下肢水肿6个月--糖尿病肾病
中年女性,乏力、食欲缺乏3个月,夜尿增多1个月--慢性间质性肾炎
老年女性,尿频、尿急、右侧腰痛,伴发热2天--急性肾盂肾炎
中年女性,乏力、食欲缺乏1个月余,血肌酐升高1周--急性肾损伤
中年男性,尿检异常3年,咽痛、恶心、乏力1周--慢性肾衰竭
第五章 血液系统疾病
青年女性,皮肤瘀点、瘀斑、牙龈出血1个月,加重伴乏力7天--再生障碍性贫血
中年女性,发热、咽痛1周,咳嗽5天--抗甲状腺药物致粒细胞缺乏
老年女性,面色苍白、乏力2个月余,加重1周--骨髓增生异常综合征
青年男性,头晕、乏力、面色苍白1个月,牙龈出血5天,发热伴咳嗽2天--急性白血病
中年男性,淋巴结肿大,发热伴乏力、消瘦2个月--弥漫大B细胞淋巴瘤
老年男性,腰背痛5个月余,头晕、乏力伴泡沫尿3个月余腰痛加重1周--多发性骨髓瘤
青年男性,发热伴鼻出血14天--急性早幼粒细胞白血病合并弥散性血管内凝血
青年女性,反复皮肤瘀斑、牙龈出血1个月--特发性血小板减少性紫癜
第六章 内分泌系统和营养代谢性疾病
中年女性,闭经、溢乳、视力减退1年余--垂体瘤
青年男性,发现睾丸小、体毛稀少7年余--性腺分化异常
中年男性,心悸、乏力1年余,双眼畏光、流泪1年余--甲状腺功能亢进症(甲亢)
青年女性,月经紊乱3年余,心悸、胸闷半年,加重1周--甲状腺功能减退症(甲减)
中年女性,反复发热3个月--亚急性甲状腺炎
中年女性,体检发现颈部肿块2年--甲状腺结节
青年女性,肥胖、闭经伴腰背部疼痛4年--库欣综合征
中年女性,反复头晕1年,双下肢乏力、夜尿增多3个月--原发性醛固酮增多症(原醛症)
中年男性,反复阵发性头痛、心悸1个月--嗜铬细胞瘤
老年男性,发现血糖升高28年,四肢麻木、疼痛8年--糖尿病
中年女性,全身持续不适、酸痛、乏力3个月--甲状旁腺功能亢进症(甲旁亢)
第七章 风湿性疾病
中年女性,全身多关节肿痛、变形15年,加重3个月--类风湿关节炎
中年女性,反复颜面部水肿6年,面部蝶形红斑2年,发热2个月--系统性红斑狼疮
青年男性,反复腰背部疼痛半年,加重伴左髋关节疼痛1个月--强直性脊柱炎
中年女性,反复口干、眼干、乏力3年--干燥综合征
中年女性,全身多关节肿痛6个月,发热十余天--原发性血管炎
老年女性,颜面部红斑、肌肉痛2个月余,伴吞咽困难1个月--皮肌炎
中年女性,双手雷诺现象2年,伴多关节疼痛、面部麻木感1年--系统性硬化症
中年男性,反复发作性右侧第一跖趾关节红、肿、热、痛伴活动受限4年,再发1天--痛风

Book Abstract

什么是结核性脓胸?如何治疗?
答:(1)结核性脓胸是由于结核分枝杆菌或干酪样物质进人胸腔引起的胸膜腔特异性化脓性疾病,脓液常为淡黄色、稀薄、含有干酪样物质,普通涂片及培养无致病菌生长,脓液中找到结核杆菌则可确诊。
(2)结核性脓胸的治疗原则为消除脓腔与控制胸膜感染。应明确有无继发感染或支气管胸膜瘘。控制继发感染时青霉素注射液为治疗首选药物。
①单纯性结核性脓胸:除全身抗结核治疗外,应反复胸腔抽脓、冲洗和局部注射抗结核药物。每周抽脓2—3次,每次用2%碳酸氢钠或O.9%氯化钠(生理盐水)冲洗脓腔,在脓腔内注入对氨基水杨酸钠、异烟肼或链霉素。脓液可逐渐减少、变稀,肺脏张开,脓腔逐渐缩小至消失。
②结核性脓胸伴继发感染:除抽脓、冲洗、局部抗结核治疗外,应加用抗菌药物作周身和局部治疗。青霉素肌内注射、胸腔内注射或用其他抗生素治疗。继发感染控制后,按单纯性结核性脓胸治疗。
③支气管胸膜瘘:是严重的并发症。除继发感染外,可能发生结核病灶的支气管播散。先予胸腔引流,情况好转后手术治疗。
④慢性结核性脓胸:慢性脓胸长期存在化脓性炎症,胸膜增厚,显著纤维化和脓性肉芽组织增生,肺不张,严重影响肺功能。伴支气管胸膜瘘者,病灶可发生支气管播散。外科手术治疗可消灭脓腔,使肺复张。术前须了解两肺有无活动性结核,以及健侧肺功能情况。若肺部病灶有手术切除指征,伴有支气管狭窄,估计肺不能复张者,在切除脓腔的同时,应做肺叶或全肺胸膜切除,加胸廓改形术。若肺部病灶已无活动性,只做脓胸残腔切除;若有支气管胸膜瘘,同时做瘘管修补术。主任医师总结
(1)正常人胸膜腔内有3—15ml液体,在呼吸运动时起润滑作用,但胸膜腔中的积液量并非固定不变。即使是正常人,每24h亦有500-1000ml的液体形成与吸收。胸膜腔内液体自毛细血管的静脉端再吸收,其余的液体由淋巴系统回收至血液,滤过与吸收处于动态平衡。若由于全身或局部病变破坏了此种动态平衡,致使胸膜腔内液体形成过快或吸收过缓,临床产生胸腔积液。其病因有很多,发病机制总结为以下几占:①胸膜毛细血管内静水压增高;②胸膜毛细血管通透性增加;③胸膜毛细血管内胶体渗透压降低;④壁层胸膜淋巴引流障碍;⑤损伤所致胸腔内出血。
(2)针对不同病因,临床上将胸腔积液分为渗出液、漏出液两大类。目前最常用的诊断标准是标准。近年来随着内科胸腔镜技术的开展,很多不明原因的胸腔积液患者可以得到及时正确的诊断,尤其是对于肿瘤、结核或其他肉芽肿性病变的患者。
(3)胸腔积液为胸部全身疾病的一部分,病因治疗尤为重要。漏出液常在纠正病因后可吸收。渗出性胸膜炎的常见病因为结核病、恶性肿瘤和肺炎。该患者为结核性胸膜炎,此类患者多数经抗结核药物治疗效果满意,少量胸液一般不必抽液或仅做诊断性穿刺,胸腔穿刺不仅有助于诊断,且可解除肺脏、心脏。血管受压,改善呼吸,防止纤维蛋白沉着与胸膜增厚,使肺功能免受损伤。糖皮质激素可减少机体的变态反应及炎症反应,改善毒性症状,加速胸腔积液吸收,减少胸膜粘连或胸膜增厚等后遗症。但亦有一定不良反应或导致结核播散,故应慎重掌握适应证。此类患者经规范抗结核治疗,预后较好,服药期间定期复查肝肾功能及血常规,停药后定期复查胸部X线片。
……
Introduction

为了培养和提高年轻内科医师的逻辑思维能力,并规范查房,我们组织第二军医大学长征医院内科资深教员编写了《内科医师查房手册》。
《内科医师查房手册》分为七章,涵盖呼吸系统、循环系统、消化系统、泌尿系统、血液系统、内分泌系统等的常见疾病病例,以临床病例为主线,采用问答形式模拟临床查房,收录相关的诊疗问题,力求使临床第一线的医师增加临床经验,全面地熟悉全科知识,了解新的诊疗技术及研究进展;力求帮助低年资医师提高临床工作能力,开拓诊疗视野。本书描述的重点,在作出正确诊断和鉴别诊断上,在治疗方案的选择上;在内科医师查房时应解决和掌握的疑点、难点和重点上;力求动态地反映查房全过程。
本书系统全面,重点突出,逻辑性强,力求反映出当代医学的新理论、新概念、新技术,同时又兼顾知识面的广度及临床实用性,不仅可以作为临床医师规范查房参考,也适用于临床见习和实习生、住院医师规范化培训以及基层医师使用,对了解和掌握临床思维方法、提高临床思维能力具有很好的指导意义。
由于本书编写人员较多,文风各异,我们在要求基本格式一致情况下尽量保留作者编写风格,因此各章节有不同特点;也难免有差错,不当之处,希望读者批评指正。
编者
2014年8月

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