醫(yī)學英語(住院醫(yī)師規(guī)范化培訓)

PAGEPAGE80PrimaryCareMedicineRecommendations目錄PrinciplesofPrimaryCare基本醫(yī)療原則 4 4RespiratoryProblems呼吸問題 34PracticeofPrimaryeDiagnosticTess

醫(yī)療的實踐

Asthma哮喘BronchitisandPneumona管炎和肺炎HealthMaintenanceandRoleofScreening保健和篩查RiskandsTreatmentOptionsImmunization免疫接種SystemicProblems全身性問題 22

ChronicCough慢性咳嗽ChronicDyspnea慢性呼吸困難ChronicObstructivePulmonary疾患Clubbing杵狀指CommonCold普通感冒ChronicFever

性疲勞

Hemoptysis咯血InterstitialLungDies性肺病HIV-1InfectionVandyWeight消瘦CardiovascularProblems心血管問題 30AorticRegurgitation脈瓣反流Aortic動脈瓣狹窄ArterialAsymptomaticSystolicMurmur無癥狀的收縮期雜音Atrial顫動BacterialsCardiovascularChest胸痛CongestiveHearteDeepVeinThrombophlebits靜脈血栓鍛煉Hypercholesterolema膽固醇血癥Hypertension高血壓

業(yè)和環(huán)境性肺疾病PleuralsSleepApneaSmoking戒煙SolitaryPulmonaryTuberculosi肺結核GastrointestinalProblems胃腸道問題 36AbdominalPain腹痛AnorectalComplains門直腸不適CirrhosiandChronicLiverFailur衰竭n腹瀉DiverticulareDysphagia吞咽困難ExternalHerna疝GallstonesLegEdema下肢水腫MitralnRheumaticFeve

瓣返流

Gastrointestinal道出血Heartburnand心和反流InflammatoryBowelStable

定型心絞痛

IrritableBowel應激綜合征Stress激試驗SuperficialThrombophleb性淺靜脈炎

Jaundice黃疸NauseaandgSyncope暈厥ValvularHeart

瓣膜疾病

Nonulcer腺炎

潰瘍性消化不良VaricosesVenous脈機能不全VentricularIrritability

PepticUlcerDises化性潰瘍病SerumTransaminase(Aminotransferase)Eleva轉氨酶升高ViralHepatii毒性肝炎HematologicProblems血液系統(tǒng)問題 39AnticoagulantAnemia

FertilityInfertilt育癥MenopauseMenstrualorPelvicnBleeding

血問題

SecondaryAmenorrhea繼發(fā)性閉經Erythrocytoss細胞增多

UnplannedPregnanc計劃外妊娠SickleCellDiseas

VaginalgOncologicProblems腫瘤學問題 40Bladderr胱癌BreastrCervicalr宮頸癌Colorectal腸EndometrialrEsophagealrr

VaginalDischare道分泌物Vulvar陰搔癢10GenitourinaryProblemsProstaticChlamydial原體感染Gonorrhea淋病IncontinenceandLowerUrinaryTract失禁和下尿路功能不全Hodgkin’sDiseasLung肺癌

奇金病

結石列腺炎Non-Hodgkin’aLymphoma非霍奇金淋巴瘤OralCance口腔癌OvarianCance卵巢癌PancreaticRenalCellCarcinoma(Hypernephroa腺樣瘤)Skin皮膚癌Testicular

aRenaleScrotalPain,Masses,andSexuallyTransmitted播疾病Syphili梅毒Urethritisin性尿道炎UrinarTractInfec11MusculoskeletalProblems肌肉與骨骼問題 42ThyroidNodulesandThyroid狀腺癌

腺結節(jié)和甲

AsymptomaticBack背痛

癥狀性高尿酸血癥TumorofUnknownOrigiVaginalrVulvarCance外陰癌 EndocrinologicProblemsDiabetes崩癥Diabetes尿病Galactorrheaand素血癥GlucocorticoidGynecomastia男子女性型乳房多毛癥Hypercalcemia高鈣血癥

Elbow,Wrist,andHandFibromyalgi纖維肌痛FootandAnkle和踝痛GiantCellGoutHipPain髖痛KneePain膝痛LymeDisease萊姆病MonoarticularArthrtsMuscleCramps肌肉痛性痙攣Neck頸痛Hyperthyroidis甲狀腺機能亢進

Diseas

吉特病Hypoglycemia低血糖Hypothyroidism甲狀腺機能減退GynecologicProblemsandNipplee

PolyarticularsPolymyalgiaaRaynaud’sPhenomenon雷諾現象Rheumatoid風濕性關節(jié)炎溢液 Shouldern痛12NeurologicProblemsBel’sPals面癱Dementia癡呆頭暈FocalNeurologicComplaitHeadacheMultipleScleroi發(fā)性硬化

DiabeticDry干眼ExcessiveTearing淚ExophthalmosEye目痛Glaucoma青光眼ImpairednParkinsn

sDiseas

顫麻痹

RedEye紅眼Seizures癲癇發(fā)作TransienIschemiAttackandAsymptomatic短暫性缺血發(fā)作和無癥狀性頸動脈雜音Tremor震顫TrigeminalNeuralgia(TicDoulouru)神經痛13DermatologicProblems皮膚病學問題 47Acne痤瘡Aphthous瘍性口炎Bites(AnimalandHuma窩織炎CornsandorContDry干性皮膚ExcessivegFungal菌感染Hair脫發(fā)HerpesSimplex單純皰疹

Refractive光手術Visual覺障礙15Ear,Nose,andThroatProblems耳鼻喉問題 s衄FacialPainandgsHearingLosHiccups呃逆聲嘶NasalCongestionandesssSmellDisturbancs打鼾TasteTemporomandibularHerpes

狀皰疹

Tinnitu耳鳴IntertrigoandIntertriginouss性皮膚病MinorBurns輕度燒傷

16PsychiatricandBehavioralProblems精神病學和行為問題AlcoholAbuse酗酒PigmentationDisturbance

沉著障礙

Angrytss紫癜Pyoderma

Anxiety焦慮Depression抑郁EatingDisorde失眠RosaceaandOtherAcneiform

鼻和其

Nonmalignant

惡性的痛它痤瘡樣的皮膚病ScabiesandsSkinUlceratin膚潰瘍UrticariaandWarts疣14OphthalmologicProblems眼科學問題

SexualnSubstanceAbus精神性藥物濫用17AlliedFields青春期AlternativesAge-RelatedMacular退行性改變

齡相關的黃斑CataractsContactsPracticeofPrimaryCare基本醫(yī)療的實踐Management處理OrganizePCP practicetoprovidecomprehensive,andfirstcontactandofprimarycareMedicalDxandx學診斷和治療

attributioitPCP'sclinicalorscientificofandmodelssothatpatienfeelillnescanbeunderstooandcontrolled,regardlessofits探出他們對該疾病的信念。通過初級保健醫(yī)生的對疾病的臨床或科學解釋來鞏固或更正病人的固有信念，如提供標記，名稱，模型，這使病人感到不論對疾病的專業(yè)治療如何疾病是可以被理解和控制的。Togainpatients'fullcooperationinRx,itislearnaboutpatient'sviewsofRxandanyBymakingclinicecisioa"sharedrocessPCPfosterspartnershipthatenhancescomplianceandoutcomes.canbeunderstandingsymptomsandinfashioningrealisticstrategiesforpreventionPsychologicalDx

學診斷和治療

程來制定臨床Personalsupportofpatientsofallbackgroundsnal級保健醫(yī)生可以培養(yǎng)醫(yī)患關系以增強順從性illnes供個體化支持

各種背景處于各階段疾病的病人提

和預后。注意病人的社交網絡對了解癥狀和形成切合實際的預CommunicationofinformationaboutDx,prevention,andprognssMaintenanceofpatientswith病患者

防和治療策略至關重要。DiagnosticTests診斷性試驗Preventionofdisabilityanddiseasethroughdetection,education,behavioralchange,ande測，教育，改變行為和預防性治療來預防殘疾和疾病

Management 處理Diagnostictestshaveseveraluses:診斷性試驗有幾種PCP'srecognitionofandresponsetopatients'emoinlreactiontoillnescriticeterminanofqualitofprimarycare.EquallyimportantisaddressinpatienexpectationandrequestsPatients'majorandcomplyingwithRx,andindetermininghealthoutcomes.Requestsareconcretehelpingactionandbehaviorthatareidentifiypatients.makeefficientandmore

TomakeDxinpatientknowntoe做出診斷使其知道生病了Toknowndiseas為患者提供預后信息使其了解疾病Toidentifypersonwithsubclinicaldiseaseoratsubsequentdevelopmentof出患有?臨床疾病或存在將來發(fā)展為疾病的風險的人TomonitorongoingR測正在進行的治療IneachcaseobjectiveisnotsimplytoclassifyorbuttoreduceM&Mandincreasesatisfactionandsensewell-being度和舒適感。DxprocesisinherentluncertaincertainanbeanyparticularWhenpatientsconfrontseriousillness,elicitpresent,astestresultsarebeinginteraboutthatillness.Confirmationorcorrectiosofnbothitprobabilifbeingpresenbeforetestinandthevalidifinformatioprovidebytest thadiseasbeingpresenand(1-p)/pisoddsagainst

斷的過程本身固有不確定性;這種不確定性

thatdisease.疾病的概率也可以使用疾病的預試驗優(yōu)可以用概率來表達。正如試驗結果所做的解釋那樣， 勢比和似然比加以校正。若p是疾病的概率與(1-當前任何特定疾病的概率，同時取決于試驗前的概率

pp/(

-p1-p)和試驗結果所提供信息的可靠性。Sensitivisprobabilihatesresulwilbepositivewhenpersontested

/。Pretesoddsofdiseaultipliypositivlikelihoodratioproducesposttestoddsofdiseaseafterpositivesensitivetestcanruleoutdiseaseifis感性是指當被試驗的病人實際上已患該疾病時測試結果為陽性的概率。如果結果是陰性，高敏感試驗可以排除該疾病。

乘以陽性似然比得到試驗后疾病的優(yōu)勢比。Positivlikelihoatiisprobabilif(orgivenpresenceofSpecificityisprobabilitythattestresultwillbyprobabilityofthatresultgivenabwhenpersonnothavedisease.rulein時測試結果為陰性的概率。如果結果是陽性的，高特異性試驗可以診斷該疾病。Whentesresulreknown,probabilitsdiseasoritabsenceinlighofthesresulremostn

ofPositivelikelihoodratioisthereforeratioof1elikelihooratiisratioffalse-negatiate(i.e.,1-sensitivity)tospecificity.PretestoddsPCPsandpatients.Predictivevaluepositiveisprynegativlikelihoatiproduceposttestofdiseaswithpositivtest(Probabilihadiseasis

oddsof

性似然比absentdespitepositivetestcanbethoughtofasprobabiliffalsalarm.Predictialuenegativisprobabilifnodiseasewithanegativtest(Thecanbethoughtofasoftheseprobabilitedeterminebyprobabilifdiseasebeforetestwasorderedandspecificityof

1檢測結果之后試驗前疾病的優(yōu)勢比乘以陰性似然比得到試驗后疾病的優(yōu)勢比。Publishedtestprovideoptimisticquestion.PCPscanavoidbeingmisleadbypayingattentiotocommonproblemsinstudydesign,gunrealistxpectatioboutpredictialuebecauseofhigherdiseaseprevalenceinstudypopulationthan的概率。(結果為陰性時而疾病又存在的概率能被認為

預測值的不切實際的期望，因為出現了研率和試驗的敏感性和特異性所決定。

究人群比實際有更高的患病率;unrealisticestimatesofsensitivityandspecificityImportanceofpretestprobabilityofdiseaseininvrlapintesbeingevaluateandtest(sedtosuch definepresenceofpatients)fordeterminingpredictivevaluesoftessotn因為出現了正在評估中的測試和用于界定notfullyappreciatedandmayleadtotclinicalperformance

unrealiststimateofsensitivenpopulatiowithdiseaseinstudyhasmoresevereandmoredetectablediseasethanthoseinProbabilitiesofdiseasecanalsoberevisedusingtoddsofdiseaseandlikelihoodratios.Ifpisprosstimateofspecificihenpopulationdisease,ratioofpto(1-p),orp/(1-p)isstudyistoowellandmorefreeofbeconfusedwithquestion todetectdiseaseduringthanthosein

被研究的未患病人群比在實

asymptomaticperiod在無癥狀期檢測疾病的試驗足際中更健康，可能與正研究中的疾病相混淆，會出現對疾病特異性不切實際的估計;

夠敏感Sufficientpecifitoprovideacceptablpredictiveunrealisticestimatesofclinicalvalueoftestwhenlupositiv試驗有足夠特異性能提供可接受的陽notmuchnewprovidedbycomparedwithprovidedbyothertest

性預測值Acceptabletopatins可接受Characteristicsofpopulation

的特征的試驗與其他試驗相比提供了多少新的信息時，會出現對實驗的臨床應用價值不切實際的估計。Sensitivtestorlesstringeriteror

Sufficientighdiseasprevalenc高withsubsequentdiagnosticresultinglowfalse-negativerateshouldbefavoredtsandnecessarx后的診斷性試驗和必要的forconditionexistsandcostoflostopportunitisgreatHighspecificirmorecriterordiseasandresultiowfalse-posittearemostimportantwhenpositiveresultdoesnot

治療有可接受的順應性CONDITIONS THAT WARRANT EVALUATIONINALLPATIENTSOFAPPROPRIATEAGEAND GENDER 所有年齡和性別適當的患者都要significantlyinfluenceRxoroutcomeandmaybe周期性評估的情況：forpatient.某疾病在有條件時能被有效治療而失去要求更嚴格。

HTN:seenia:seeHypercholesterolma高膽固醇血癥章節(jié)Smoking:seeSmokingCessato煙：見戒煙章節(jié)Coloncancer:seeColorectal腸癌章節(jié)Breastcancer:seeBreastrCervicalcancer:seevCance宮頸癌：見子宮頸癌章節(jié)HealthMaintenanceandRoleofScreening

Alcoholism:seeAlcohol

：見酒精濫用章節(jié)保健和篩查Differential別診斷CRITERIAFORSCREENING 篩選標Characteristicsofthe特征

CONDITIONS THAT WARRANT PERIODICEVALUATION INSELECTED PATIENTS被選定的部Rubella易感性Riskfactorsanticipatregnancyandriskgroupmembership;occupation(healthcareworker);Significanteffectonqualityor

life

見;免疫接種章節(jié)量和壽命有重大影響Prevalencesufficientlyhighto病率導致可觀的花費

HIVnRiskandriskmembership;bloodtransfusio1978-1985;seeHIV-1AcceptableRxavaila

受的有效治療

險因素：預期懷孕和風險組成員;1978-1985AsymptomaticperioduringwhichdetectioandRx HIV-1感染章節(jié)significanduceM&M 在無癥狀期間進行檢測和

Endocarditis

炎易感性治療能大大減少患病率和死亡率Rxinasymptomaticphase

Riskfactors:valvularheartdisease;seeBacterialEndocarditisresultthandoesRxdelayeduntilsymptoms癥狀階段治療比延遲到出現癥狀時治療能夠獲得更

Rheumaticfever

的易感性好的治療效果 Riskfactors:rheumaticfeverHx;seeRheumaticCharacteristicst特性 危險因素：風濕熱病見風濕熱章節(jié)TB(PPDreactivitRiskfactorccupationaexposureseeOccupationallungeRiskfactorccupationxposureseeOccupational

aRiskfactorspregnancykidneystonesseeTractLowerurinarytract路癌癥andEnvironmentalRespiratory因素：職 Riskfactors:occupationalexposuretoaromaticSusceptibilitytoB型肝炎病毒易感性Riskfactorale;(healthcareworker);seeViral

(e.gyestuffeathetanningrubber)seeBladderCancerTesticularcane丸癌性同性戀接觸職業(yè)衛(wèi)生保健工作者見病毒性肝 Riskfactors:cryptorchidism;seeScrotalPain,炎章節(jié)Anemia貧血

andSwelling;TesticularCneRiskfactors:pregnancy;see

質疏松癥性貧血章節(jié)Sicklecell細胞的特性

RiskseeOsteoporosis險Riskfactors:African-Americanofinge險因素：生育年齡的非洲裔美國人 Riskage,TIAHx;seeTransientGeneticcounselingmustbeacceptable;seeAttackandAsymptomaticCarotidtDisease遺傳咨詢必須是可被接受的;見鐮狀細胞病章節(jié)ThyroidrRiskfactoradiatifheadandneck;seeNodulesandThyroidCancer危險因素：頭部和頸部受過輻射;見甲狀腺結節(jié)和甲狀腺癌章節(jié)Diabetes糖尿病

素：老年，短暫性腦缺血發(fā)作病史;見短暫性腦缺血發(fā)作和無癥狀性頸動脈雜音章節(jié)SkinrRiskfactoraiskinsunexposurefamilyHx;SkinGlaucoma青光眼Riskfactors:familyHx;advancedage;seeGlaucomaRiskfactors:pregnancy;familyHxofDM;obesity;ofgestationiabetesseeDiabeteMellitu危險因 Oralcancr腔癌見糖尿病章節(jié)Endometrialcancr宮內膜癌

Riskfactors:alcohol;tobacco;see素：酒精，煙草，見口腔癌章節(jié)Decreasedg

ncerRiskfactorsexogenousestrogensseeCancerVaginalrRiskfactornuterodiethylstilbesosuresee

Riskage;excessivenoise;HearingLosVaginal癌章節(jié)Syphili梅毒

RiskandPrognosis風險和預后Riskfactors:malehomosexual;pregnancy;otherSTDs;seeSyphilsChlamydialgenitourinaryn染

Management 處理Doctor-patieialogueaboutfutureimplicationofillnerrisfactoareoftemomentousrFewtasksofprimarycarearemoreimportant.Riskfactors:otherSTDs;womenofchildbearingaboutuncertainfuturemust beseeChlamydialn育齡婦女;見衣原體感染章節(jié)

communicatedwithclarity,compassion,andappreciatioforuniquenesofeachpatienteeds疾病或危險因素的醫(yī)患對話往往對患者非常重要。很少有其他初級衛(wèi)生保健的工作比這更重要。在對未來不確定信息進行溝通時必須明確，有同情心，并個體化。

來的，他們往往有別于在初級保健站中所見到的患者群。Communicatingriskandprognosiscanbedifficult.ImportantsourceofconfusionisPatientsvarysignificantlyindesireforandabsoluterisk.EffectofriskfactorsisfuturePCPshouldelicndhonoreAlsothattheyshouldbepreparetoexprestheipreferenceforhavingornothavingothercliniciansinvolvedinToavoidbeingmisledandmustunderstandbiasesthatcanbesuboptimalmethodsareusedtohelppredictfuueSomeproblemsarespecifitocase-contrtudiethat

expresseasrelatiiskorriskratioandeffectofinterventioreusuallyexpressedaslow,cangiveanunrealistiewofpotentiaharmsandwayofriskfactoistocitrisattributaborisfactoorreductionattributabletoanintervention.Attributablisdifferenetweenincidencamongexposedpeopleandincidenceamongthosewhoarenotcompareratesof"exposure"toriskfactorsamongwithdiseaseoroutcomeandthosewithoutsameeoroutcome.Theseratesareusedtoproduceanapproachtosummarizingthiskindofiswhichoutcomewithrisfactocomparedto

citnumberofpatiennewouldneedtotreato一種來總結這類的數orderforoddsratiotobeaccurateestimateofediseaseoroutcomeinquestionmuste病例對照研究是特異的，即在哪些有疾病或結果與沒有同樣的疾病或結果之間對危險因素的暴露率相比較。這些比率可用來產生一個優(yōu)勢比，這是估計在伴與不伴隨風險因素相比較時疾病和后果的相對風險。為了使優(yōu)勢比能對相對危險度準確估計，疾病或后果必須是罕見的。Accuracyofretrospectiase-contromethodorofretrospectiohorstudies

者在群體患者中的人數。患者的人數在單個患者將有一個預期效應。ProportioofpeoplewithparticulaconditiowhoofthecaseSomeindicationofdurationofsurvivalmaybeincludebydescribingsurvivalatpointintimeafterDxsurvivalrate).Simplerateshaveadvantageofbeingtorememberandcommunicate.However,valuabledistributiofofscrutinybeappliedtoHxofcaseseventsovertime,issummarizedbysinglera病例對照方法或回顧性隊列研究的精確度需要對病例 Morecompletepictureofprognosisiscapturedin組與對照組病史同樣程度的細致檢查。

死率是在特定條件下最終死于這種疾PerhapsmostforPCPsto病的人口比例。一些持續(xù)生存的指標可用治療之后某studiesofprognosishasbeentermedreferralroccurfrequentsresuloffacthapatiennmany 率有易于記憶和交流的優(yōu)勢。然而隨著時間的推移分publishedreportshavebeendescribedbecausethey不確定性事件，通過單一的比率來總結預后會丟beenacademictheyarethoseseenin

失有價值的信息數據。通過生存曲線可獲得對預后更完整的描述。Sometimes,proportionofpeoplewhoexperiencerathethanproportiowhoareevent-fresplotteonverticxisSuchcumulativincidenccurvesconveysameinformatioorecompletepicturpresentebysurvivalcurve,includinglow

isolateeffectofexperimentaRx時，對特定患者的治療效果仍不確定，這反映了用臨incidenceofrecurrenceinnearterm,maybemore中使用的方法去衡量經驗治療的無關的后果。topatieneopleresponddifferentosameriskA1%riskforstrokeduring5-or10-yrperiodmaybethreateniosomebutinconsequentioothersThiscanbeexplainedbyveryrealcompetingrisksthat

PCPmustbeconcernedbothaboutinternalidiftrialastestofeffectivenessorefficacyofintervenspecifiopulatioundercontrollircumstanceandaboutitsexternalvalidity:theextenttowhichapplicabletodifferentpatientsseenntice.性即測試對于受控情況下的特殊人群進行干涉的效果或效力，和外部真實性：試驗結果應用范圍，能適用于在實際中遇到的不同患者。這兩點初級保健醫(yī)師都必須關心。differentpeoplefacebecauseofothermedicalofrelativescarcityofrandomized-controltriortheenvironmentinwhichtheylive.Similarly,oftenrelyonquasi-experimentalclinicaltrpeoplehaveorpresentornearfutureanddistantfuture.Puttingbeusedinsideforsomepossiblegoodsensetosomebutlittle

observationastudietopatiencare.patiencharacteristongalternatixgroupsmaysensetoothers.Again,competingrisksexplaintoerroneousconclusionsaboutRxiveness.thesedifferencs5101是種威脅而對其他人卻無關緊要。由于其他醫(yī)療條件或居住環(huán)境的不同，這可以用不同的人所面對的非常實際的競爭風險來解釋。同樣，不同的人在權衡選擇當前與不久的將來和遙遠的未來時有不同的態(tài)度。為了未來可能的受益現在忍受副作用或不便，這對有些人非常有意義但對其他人卻沒有意義ChoosingTreatmentOptions治療的選擇Management處理Randomized-controclinicriarovidbesevidenceregardinRxeffectiveneenmultipltrialhavebeenmostcomprehensiveissuesUnfortunatelandomized-controstudiesarerelativearformanycommonillnessndtheiRx.隨機對照臨床試驗為治療效應提供了最佳證據。當多個試驗已經完成，對這些試驗進行概述，或進行薈萃分析，能提供對該事件最全面的理解。不幸的是，許多常見疾病和其治療的隨機對照研究比較少見。

于隨機對照試驗相對缺少，初級保健醫(yī)師必須經常依賴準經驗性的臨床試驗或沒有對照的臨床觀察研究。然而把臨床觀察研究的結論應用于病人保健時應十分謹慎。替代治療組中病人特征方面的差異可能會導致對于治療效果的錯誤結論。Thereisampleevidencepatients'expectatioegardineffectivenefRxhasprofoundRxoutcome.Itisnotatallunusualforshamsurgicalprocedurestoreportanimprovementinsymptoms.TherearealsoexamplesofwhichhavecomplyfaithfullywithprescribedregimendobetterpatientwhodonotThese"complianceffectccurregardlefwhetherregimenincludeactivagentor的期望對治療結果有著深刻的影響。這并不罕見于接受無活性藥物(安慰劑)或假手術操作治療的病人報告其癥狀有改善。也有一些研究例子中，對處方治療忠實順應的高期望患者比相反的病人效果好。不論是否有活性藥物或真實的操作療法，這些“順應效應”都會發(fā)生。EvenifprobabilitifoutcomescontingentonalternativeRxchoicescanbeestimatedprecisely,stillmuchworktobedonetoensurewiseRxchoiceEvenwhenrandomizedtrialsareperformed,uncertaipnatryticularpatient.DifferentpatientshavedifferentremainsabouteffectivenefRxforspecifipatients,

samealsocanalsowhichreflectsmethodsusedinclinicaltrialstosamelevelofriskorsametrade-offsovertime.Therightchoice,therefore,rnstravelioareainwhichinfluenzactivitybetweenPCPandwhatpossibleoutcomeswillmeanforthatpatient'squalityoflifeovere

amongpeoplefromworldinwhichtheriscurreninfluenzactivit流感活動區(qū)旅游的健康后果不同的患者有不同的反應。隨著時間的過 Previousanaphylacticreactiontothisvaccine,to去他們對相同的風險水平或相同的權衡選擇也能也有不同的看法。因此，正確的選擇，需要初級保健醫(yī)師和病人對于可預見的未來的生活質量來說可能的預后意味著什么進行認真的溝通。

itscomponents,orto任何組分、對雞蛋有過過敏反應。Moderateorsevereacuteilns計劃表GiveneveryyeaInImmunization免疫接種

isoptimaltimetoreceiveannualflushottomaximizbegivenanytimeduringinfluenzseason(typicalecember-March)oratManagement 處理

othertimeswhenriskofinfluenza

SUMMARYOFSUMMARYOFRECOMMENDATIONSFORROUTINEADULTIMMUNIZATIONS常規(guī)成人免疫Forwhomrecommended推薦接種的人

帶，10-11月是接受每年流感疫苗注射獲得最大保護的最佳時機，但疫苗可以在流感季節(jié)的任何時間給與(代表性的12-3月份)或當流感風險存在的任何時間。MaybegivenwithatseparateAdultsaged

齡>=65歲的成人

site.可以與任何其他疫苗同時給與但要在不同部Peopleaged6mos-65yrswithmedicalproblemssuch位。asheartdisease,lungdisease,diabetesnrenal dysfunction,hemoglobinopathies,and665

IM肌注PneumococcalForwhomrecommended和免疫抑制；生活在長期護理場所的人。

Peopleaged2-65whohavechronicillnessorotherPeopleaged>=6mosworkngorat-risk.與有風險的人一起工作生活的年齡大于6

chroniccardiacorpulmonarydiseaseschronilivediseasealcoholismDM,and月的人。

CSFleaks;andpersonslivinginspecialenvironmentsAllworkersandthosewhoprovidekey

orsocialsettings(includingAlaskanativesandcommunityservices

有的健康護理工作人員和那

AmericanIndianpopulations).Thoseathighestrisk些提供關鍵社區(qū)服務的人。

fatalpneumococcalinfectionarepersonswithanatomiHealthypregnantwomenwhowillbeinsecondorthfunctionaaspleni(includinsicklceldisease);trimesteuringinfluenzseason23Pregnantwomen whohaveunderlyingmedicalbefluregardlessofstateof

immunocompromisedpersons,includingthosewithHIVinfect,leukemia,lymphoma,Hodgkin'smultiplemyeloma,thosereceivingimmunosuppressive chemotherapy (including時期，需要在流感季節(jié)到來前接收疫苗接種的處于

corticosteroids);andthosewhohavereceivedan潛在醫(yī)學情況的孕婦。

orbonemarrow265Anyonewhowishestoreducelikelihoodofbecoming性病或其他風險因素，包括慢性心臟或肺疾病，慢influenza能性的人

何希望減少由于流感而生病可

性肝病，酗酒，糖尿病，CSF缺乏；生活在特殊環(huán)腫瘤、慢

員有家庭接觸或性伴侶；使用違法的注射用藥物；61Previousanaphylacticreactiontothisvaccine,toyitscomponents,orto

All

的青少年任何組分、對雞蛋有過過敏反應。Moderateorsevereacuteilns

Note:In1997,NIH ConsensusDevelopmentConference,apanelofnationalexperts,recommendedSchedule計劃表

thathepatits

giventoallpersonsRoutinelygivenas1-timedose;administerifprevectedwithC1997vaccinationHx1苗接種史不清楚時給與。

院共識發(fā)展會議，一個國內專家組建議所有感染丙型肝炎病毒的人給與乙型肝炎病毒性疫苗。One-timerevaccinationisrecommended5yrslateritorotePerformserologiscreeninforpeopleinfectionorrapidantibodyloss(e.g.renaldiseaseandfor

whohaveemigratedfromendemicareas.WhenHbsAg-positivepersonsarepeopleaged>65iffirstdosewasgivenbeforeagepropriatdiseasmanagement.Inadditionscreenand>=5yrshaveelapsedsincee. theirhouseholdmembersandintimatecontactsand,于處于致命性肺炎球菌感染最高風險的或快速抗體

foundsusceptiblaccinat

輯按：對流行區(qū)移民65歲以前給與>=565人。Maybegivenwithatseparate位。RouteofnIMorSQ肌注或皮下HepatitisBForwhomrecommended推薦接種的人

來的人進行血清學篩查。為被查出HbsAg陽性的人提供適當的疾病處理。另外，篩查他們的家庭成員和親密接觸者并對易感者行免疫接種。aitscomponents,orto何組分、對雞蛋有過過敏反應。Moderateorsevereacuteilns計劃表3dosesneededon0-,1-,6-mos第High-riskadults,includinghouseholdcontactsande1，6HbsAg-positivepersons;usersofillicit Alternatetimingoptionsforvaccinationinclude0,injectabledrugs;heterosexualswith>1sexpartnem;0,1,4mos.免疫接種的替換時間選擇包括第mos;menwhohavesexwithmen;peoplewithrecentl0y-，2-，4-月；第0-，1-，4-月。diagnosedSTDs;Theremustbe4wksbetweendoses1and2,and8wkspatienithrenadiseasthamayresulindialysis; betweendoses2and3.Overall,theremustbe>=4moscertainbloodproducts;healthcare betweendoses1and.第12workersandpublicsafetyworkerswhoareexposedo4238blood;clientsandstaffofdevelopmentallydisabled;inmatesoflong-term

總的來講在第1與第3針之間必須至少間隔>=4月。Scheduleforthosewhohavefallenbehind:ifseriesdelayedbetweendoses,donotstartseriesover.berecommended

Continuefromwhereyou

dependingonspecifileveofriskorHbsAg陽性人

劃的人：如果系列在兩針之間被延遲，沒必要從頭開始系列。繼續(xù)從拉了的那針開始。Maybegivenwithatseparate位。RouteofnIMOthercomments其他注釋Brandsmaybeusedinterchangeaby以互換

第1與第2針之間至少間隔6月。Ifdose2not1.dose21僅打第2針就可以了。Maybegivenwithatseparate位。RouteofnIMHepatitis

A型病毒性肝炎

Othercomments其他注釋Forwhomrecommended推薦接種的人 Brandsmaybeused牌子之間可PeoplewhotraveloutsideU.S.(exceptforwesternEurope,NewZealand,Australia,Canada,and

美國以外旅游的人(除了歐洲北部和西部，

新西蘭，澳大利?，加拿大和日本)Peoplewith

Forwhomrecommended推薦接種的人AlladolescentsandwithHCVinfection,peoplewithhepatitisBwhoprimaryserieshasbeencompleted,boosterdosechronicliverdisease,illicitdrugusers,menwhoarecommendedq10yrs.Makesurepatienthavesexwithmen,peoplewithclottinfactodisorders,

receivedprimaryseriesof

peoplewhoworkwithHAVinsettinthidoesnotrefetoroutinmedical

成后，推薦每10年加強1針。確保病人已經接受了3針基礎系列。andfoodprivate Boosterdoseasearlyas5yrslatermaybeneededfoemployersdeterminevaccinationtobemanagement,soconsultACIPrecommendations.慢性肝病的人，包括丙肝感染者，有伴有乙肝的慢性肝病的人，使用違法的注射用藥物，男性與男性性交，有凝血因子機能紊亂的人，在有甲肝病毒試

對于傷口處理的加強針，最早要在上一針5年以后，所以請查閱免疫實踐咨詢委員會的推薦。和衛(wèi)生當局或私營雇主決定疫苗注射是有成本效益 Previousanaphylacticreactiontothisvaccine,to時的健康食品加工人員。Note:Prevaccinationtestingislikelytobecost-effectrpersonsaged>40aswellas

itscomponents,orto任何組分、對雞蛋有過過敏反應。Moderateorsevereacuteilnsyoungerpersonsincertaingroupswithhighofnof40甲肝感染率組的年輕人一樣，在接種疫苗前進行檢測有成本效益。

IM肌注Measles,Mumps,RubellaForwhomrecommendedAdultsbornin1957orareaged>=18(includinthosebornoutsidU.S.)shouldPreviousanaphylacticreactiontothisvaccine,todoseofMMRifthereisnoserologicproofofitscomponents,orto任何組分、對雞蛋有過過敏反應。Moderateorsevereacuteilnsbenefitagainspotentiisk

immunityordosegivenonorfirsbirthday111957或以后出生的年齡大于18歲的成人(包括那些在美國以外出生的)應該接受至少1針MMR。定，所以請權衡利弊。 Adultsinhigh-riskgroups,suchashealthcare計劃表 studentsenteringcollegesandothereducational2doses.要2針。 institutionsafterhighschool,andinternationalMinimumintervalbetweendoses1and2ismos.shouldreceive22生保健工作人員，進入大學和其他高中以上教育機構的學生，和國際旅行者。Allwomenofchildbearigeandpremenopausaladultwomen)whodonothave

周后。Maybegivenwithatseparate位。acceptableevidenceofrubellaimmunityorvaccinaricellvaccineandMMR (orotherliveviral所有無可接受的風疹免疫力或疫苗接種證據的育齡 vaccinessuchasyellowfevervaccine)areneededimmune,butproofofimmunitymaybedesirablfor1957

arenotadministeredonsameday,spacethem>=4wksapart.如果水痘疫苗和MMR(或其他活病毒疫苗如黃熱病疫苗)都需要接種并沒有在同一天接種時，它們需要間隔4周。RouteofnSQ皮下VaricellaForwhomrecommended推薦接種的人Previousanaphylacticreactiontothisvaccineorlsceptibdultandadolescentakespecialofitscomponents.(Anaphylacticreactiontoeggstovaccinatesusceptiblepersonswhohaveclolongercontraindicationto

對這個疫苗、

contactwithpersonsathighriskforserious對它的任何組分有過過敏反應。(對雞蛋的過敏反應不再被認為是MMR的禁忌癥。)Pregnancyorpossibilifpregnancywithin33

complication(e.g.healtcareworkersandfamilycontactsofimmunocompromised persons)andareathighexposure(e.geacherofyoungchildreayeHIVpositivityisnotacontraindicationtoMMRexcreepstidentsandstaffininstitutionsaelttingssuchasforthosewhoareseverelyimmunocompromsd. collegesandcorrectionalinstitutionilitary病病毒陽性不是用MMR 的禁忌癥除非那些嚴重免 personnel,adolescentsandadultslivingwithchildre疫妥協的人。Immunocompromisecausedbycancer,leukemia,

nonpregnantwomen ofchildbearingage,andinternationravelehodonothaveelymphoma,andimmunosuppressivedrugRx,includingimmunity).所有易感的成人和青少年。要特別努力high-dosesteroidsor淋巴瘤和免疫抑制劑治療，包括高劑量類固醇或放療治療導致的免疫妥協。Ifbloodimmunehavebeenadministeredduringpast11mos,consultACIPrecommendationsregardingtimetowait

去給那些與會有嚴重并發(fā)癥高風險人群接觸的易感

過去11個月里接受過血制品或免疫

接種。球蛋白治療，查閱免疫實踐咨詢委員會的關于疫苗接種前等待的時間的推薦。Moderateorsevereacuteilns.重急性疾病Note:MMRisnotcontraindicatedifPPDtestdonerecently.PPDshouldbedelayedfor4-6MMR hasbeen注意：如果最近做過PPD試驗，麻腮風疫苗不是禁忌癥。如果接種過MMR 么PPD試驗需推后4~6周。Schedule計劃表1or2dosesneedd1或2針。

Note:Assumeimmunityinpeoplewithreliabxofchickenpox(e.g.,self-reportorparentalreportofForadultwithoureliabx,serologitestinmaybemostadultswithnegativeortainHxofvaricellaareimnaIfdose2isrecommended,giveitnosoonerthan4anaphylacticreactiontothisvaccineorto1.如果推薦打第2針，至少在第1針的4 ofits前對這個疫苗對它的任何組分有過過敏反應。 于年>=18歲的人不常規(guī)推薦。Pregnancyorpregnancywithin1mo Note:AdultslivingintheU.S.whoneverreceived3mos).妊娠或可能在1 completedprimaryseriesofpoliovaccineneednot個月內懷生產商推薦為3個月。Immunocompromisecausedbymalignanciesandprimaryoracquiredcellularimmunodeficiency,Note:Forthoseonhigh-doseimmunosuppressive Rx, consult ACIPrecommendationsregardingdelaytime.由于惡性腫瘤，和原發(fā)或獲得性細胞免疫缺陷，包括艾滋病病毒感染或艾滋病患者。注意對那些使用高劑量免疫抑制劑治療的人，查閱免疫實踐咨詢委員會的關于

exposuretowild-typevirusisreceive1boosterdoseiftravelingtopolio-endemicra延遲時間的推薦。

RefertoACIPrecommendations

免疫實IfbloodproductsorIGhavebeenadministeredpast5mos,recommendationsregarding 計劃表timetowaitbefore

5個月里接受

RefertoACIPrecommendationsregardingunique過血制品或免疫球蛋白治療，查閱免疫實踐咨詢委員會的關于疫苗接種前等待的時間的推薦。ModerateorsevereacuteilnsNote:Manufacturerrecommendsavoidedfor6wksvaricella

situatioshedulesanddosinginformatio疫實踐咨詢委員會的關于特殊情況，時間表，和劑量信息的推薦。MaybegivenwithatseparatevaccinebecauseoftheoreticalriskofReye'se.6周內使用水楊酸鹽。Schedule計劃表doses2Dose2isgiven4-8wksafterds.針4-8周

RouteofnGiveIMor肌注或皮下LymeDisease萊姆(氏)病Forwhomrecommended推薦接種的人Considerforpersonsaged15-70whoreside,work,or后給與第2針。 playinareasofhighormoderateriskandwhoengageMaybegivenwithatseparate位。IfvaricellvaccineandMMR (orotherliveviral

inresultinfrequentorprolongedexposuretotick-infested15-70歲的人，其在高或中危地區(qū)居住、工作或游玩，和其所從事的活動導致頻繁或遷延暴露與蜱感染的棲vaccinessuchasyellowfevervaccine)areneeded地。arenotadministeredonsameday,spacethem>=4withHxofpreviousuncomplicatedLyme如果水痘疫苗和MMR(或其他活病毒疫苗如 diseasewhoareatcontinuedhighriskforLymedisea黃熱病疫