The patient-physician interaction proceeds through many pases of clinical reasoning and decision making . The interaction begins with an elucidation of complaints or concerns , followed by inquiries or physical examination , ordering of diagnostic tests , integration of clinical findings with the test results , understanding of the risks and benefits of the possible courses of action , and careful consultation with the patient and family to develop future plans . Physicians increasingly can call on a growing literature of evidence-based medicine to guide the process so that benefit is maximized , while respecting individual variations among different patients.医患沟通贯穿于临床推论和临床决策的各个阶段.医患沟通始于主诉的阐述或关心的表达,并以越来越精确的方式,通过学问或评估得以继续,这一过程通常需要仔细的病史(采集)和体格检查,安排诊断性实验,并使实验结果与临床发现一体化,以及对可能所采取行动的风险和好处的理解，与病人及其家庭之间细致的商讨以产生将来的计划。
医生越来越（趋于）访问日益增多的循证医学文献去指导这个过程，以使取得最大的收益，同时对于不同的病人充分考虑个体的不同变化。
Chapter 8 第四段Fourth , cognitive impairment increases in prominence as people age. Cognitive impairment is a risk factor for a wide range of adverse outcomes ,including falls , immobilization , dependency , institutionalization , and mortality . Cognitive impairment complicates diagosis and requires additional care giving to ensure safety .Chapter 21 第六段A new device for visualizing the entire gastrointestinal mucosa consists of a small camera in an ingestable capsule that transmits images to receivers attached to the patient~s abdomen diagnostic yield of capsule enteroscopy is not yet clear,but this approach may potentially visualize segments of the small bowel that were previously inaccessible . No therapeutic maneuvers are possible with the device.An increased drive to ventilate may also cause dyspnea . Such stimuli include hypoxia , usually when arterial oxygen tensions are less than 60 mm Hg , and stimuli from inflamed lung parenchyma , as occur in bacterial pneumonia or alveolitis and that drive the respiratory centers of the brain . These stimuli often lower the resting carbon dioxide pressure (Pco2) to less than the normal level of 40mm Hg and cause dyspnea , especially on mild exertion.过度通气也可以导致呼吸困难。
兴奋呼吸中枢的刺激因素有动脉氧分压低于60mmHg时的低氧以及细菌性肺炎或肺泡炎时肺实质产生的炎性产物。
这些刺激因素常常使静息时的二氧化碳分压降至40mmHg的正常水平以下而导致呼吸困难，在轻微活动时更加明显。
Chapter 23 第三段After several years,most diabetic patients exhibit diffuse glomerulosclerosis,although a minority have pathognomonic Kimmelsteil-Wilson nodular lesions.Although pathologic changes continue to mount throughout the disease,glomerulosclerosis extensive enough to cause ESRD develops in a minority of patients;in these cases,overt albuminuria (>300mg/day) begins approximately 15 years after diagosis.Soon after,following a variable perod on the order of 3 to 5 years, the GFR begins a relentless decline(>=10ml/min/year),which is erentually reflected by an increase in serum creatinine. The appearance of massive proteinuria and often heralds progression to ESRD.Once the seratinine rises (reflecting an approximately 50% decline in GFR),ESRD develops in most patients within 10years.This course is highly variable,however,particularly in type 2 diabetics,who may exhibit moderate proteinuria for several years without a substantial deterioration of renal function.Asimple but useful method of monitoring progression to renal failure is to plot the reciprocal of the serum creatinine as a function of time.This technique allows better assessment of both therapeutic interventions and the time when renal replacement therapy will become necessary.几年以后，大多数糖尿病患者出现弥漫性肾小球硬化症，而少数患者出现特异性K-W结节损害。
尽管病变进展持续贯穿疾病始终，少数患者肾小球硬化广泛足以引起ESRD的发展，在这些情况下，糖尿病肾病诊断后15年患者开始出现明显的白蛋白尿（大于等于300mg/天）。
不久，大约3到5年的可逆期过后，肾小球滤过率开始不停下降（大于等于10ml/分钟/年），最终表现为血清肌酐的上升，在这种情况下，通常大量蛋白尿和肾病综合症开始出现，并宣告肾病已经进入到ＥＳＲＤ．一旦血清肌酐上升（反映肾小球滤过率大约降低５０％），大部分患者在１０年内发展成为ＥＳＲＤ．这个过程是极具可变性的，然而，尤其在２型糖尿病患者，他们可能表现为持续好几年的中等量蛋白尿而肾功能不恶化．一个简单但有用的监测肾功能衰竭进展的方法是绘制血清肌酐倒数Clinical and Pathologic EvaluationSince all patients with cancer of unknown primary site have advanced disease ,therapeutic nihilism has been common.contains subsets of patients with widely diverse prognoses ;some cancers are highly responsive to treatment,and some patients may have a substantial chance of achieving long-term survival with appropriate treatment.The initial clinical and pathologic evaluation should therefore focus on identifying a primary site when possible and on identifying patients for whom specific theatment is indicated.临床和病理评估．由于所有原发灶不明肿瘤患者都会到疾病晚期，姑息治疗就变得很普遍．然而，现在很显然的是这些特殊病人有很多不同的结局．有些癌症对治疗高度敏感，这使得有些病人通过适当治疗可能存活很长时间．因此最初的临床和病理评估应该集中于在可能的情况下识别原发灶以及识别那些需要特殊治疗的病人．Chapter 26 第二段In the management of the pregnant trauma patient,the critical point is that resuscitation of the fetus is accomplished by resuscitation of the mother.Therefore the initial evaluation and treatment of the pregnant injured patient is identical to that of the nonpregnant injured patient.Rapid assessment of the maternal airway,breathing,and circulation and ensuring an adequate airway avoids maternal and fetal hypoxia.In the later stages of pregnancy,as already described,uterine compression of the vena cava may result in hypotension from diminished venous return,so the pregnant trauma patient should be placed in left lateral decubitus position.If spinal cord injury is suspected the patient may be secured to a backboard with pregnancy has important implications in the trauma patient.Signs of blood loss such as tachycardia and hypotension may be delayed until the patient loses nearly 30% of her blood volume.As a result, the fetus may be experiencing hypoperfusion fluid resuscitation should be administered even in the pregnant patient who is normotensive.在处理孕期创伤病人时，关键点是胎儿的复苏能够通过母亲的复苏来实现．因此，孕期创伤病人最初的评估和治疗跟非孕期受伤病人是一样的．对孕妇气道、呼吸和循环的快速评估并确保足够的通气能够避免母婴低氧血症。