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1、The increasing availability of randomized trials to guide the approach to diagnosis and therapy should not be equated with “cookbook” medicine. Evidence and the guidelines that are derived from it emphasize proven approaches for patients with specific characteristics. Substantial clinical judgment i
2、s required to determine whether the evidence and guidelines apply to individual patients and to recognize the occasional exceptions. Even more judgment is required in the many situations in which evidence is absent or inconclusive. Evidence also must be tempered by patients preferences, although it
3、is a physicians responsibility to emphasize when presenting alternative options to the patient. The adherence of a patient to a specific regimen is likely to be enhanced if the patient also understands the rationale and evidence behind the recommended option.但是，不断增多的可用于指导临床诊断与治疗的随机试验资料不应当作“烹调书”使用。因为
4、随机试验获得的现象和思路是侧重于求证具有某些特征病人而来的。实际的临床判断需要确定这些临床表现和诊断标准是否能应用于病人个体，并能找出例外。在许多情况下，临床表现缺乏或不典型，需要考虑更多的判断。虽然医生有责任要提出选择性问题让病人回答，但病人肯定会根据自己的倾向调节临床症状。假如病人懂得基本原理和表现，对医生提出的问题，有特殊生活方式病人的固执容易被强化。Even as physicians become increasingly aware of new discoveries, patients can obtain their own information from a variet
5、y of sources, some of which are of questionable reliability. The increasing use of alternative and complementary therapies is an example of patients frequent dissatisfaction with prescribed medical therapy. Physicians should keep an open mind regarding unproven options but must advise their patients
6、 carefully if such options may carry any degree of potential risks, including the risk that they may relied on to substitute for proven approaches. It is crucial for the physician to have an open dialogue with the patient and family regarding the full range of options that either may consider甚至，当医生越
7、来越容易知道新发现的同时，病人也能够通过各种资源得到他们的信息，当然，某些信息是不可靠的。替代疗法和辅助疗法的应用不断增加就是病人对常规疗法经常不满意的一个例子。医生对未证实的疗法应该保持开放的思想，但是，如果这些疗法具有任何程度的潜在风险，都必须细致地告知病人，包括可能需要用已证实的常规疗法去替代的风险。对医生来说，对病人及家属开诚布公地介绍所有可考虑的治疗选择，是非常重要的。A second way in which older adults differ from younger adults is the greater likelihood that their diseases p
8、resent with nonspecific symptoms and signs. Pneumonia and stroke may present with nonspecific changes in mentation as the primary symptom. Similarly, the frequency of silent myocardial infarction increases with increasing age, as does the proportion of patients who present with a change in mental st
9、atus, dizziness, or weakness rather than typical chest pain. As a result, the diagnostic evaluation of geriatric patients must consider a wider spectrum of diseases than generally would be considered in middle-aged adults.老年与青中年的第二个差异是更容易出现非典型的症状和体症。肺炎和中风时可出现非特异性意识变化作为主要的症状。同样地，隐匿性心肌梗塞发生频度随着年龄的增大而增加
10、，这些病人相应地频发精神状态改变、眩晕、虚弱而不是典型的胸痛症状。因此，老年病人的诊断应考虑更广泛的疾病谱，要超过通常对中年病人所考虑的范围。Finally, a serious and common outcome of chronic diseases of aging is physical disability, defined as having difficulty or being dependent on others for the conduct of essential or personally meaningful activities of life, from b
11、asic self-care (e.g., bathing or toileting) to tasks required to live independently (e.g., shopping, preparing meals, or paying bills) to a full range of activities considered to be productive and/or personally meaningful. Of older adults, 40% report difficulty with tasks requiring mobility, and dif
12、ficulty with mobility predicts the future development of difficulty in instrumental activities of daily living (IADL; household management tasks) and activities of daily living (ADL; basic self-care tasks). In persons age 65 and other, difficulty with IADL is reported by 20%, and difficulty with ADL
13、 is reported by 11%; for both, the prevalence increases with age.最后，老年人慢性病严重又常见的结果是身体能力不足，描述为个人最基本的或有意义的日常活动有困难或不得不依靠别人帮助指导，从基本的自理（如洗澡或如厕）到独立生活需要的各种任务（如购物、做饭、支付各种账单），到具有集体和或个人意义的所有活动。在老年人中， 40%对需要运动的任务有困难，运动困难提示将来开展日常工具锻炼（IADL；家庭护理项目）和目常锻炼（ADL；基本自理项目）的困难。大于65岁的老人或其它人，IADL困难报导为20%，ADL困难报导为11%；随年龄增加两个
14、都困难成为普遍现象。The initial approach to a patient with iron deficiency anemia depends on the presence of symptoms referable to either the upper or lower gastrointestinal tract. Regardless of the findings on the initial upper or lower endoscopic examination, all patients should have both upper and lower en
15、doscopy because the complementary endoscopic examination has a yield of 6% even if the first one was positive. For premenopausal women, a positive FOBT requires full evaluation, as does iron deficiency anemia. Barium radiographs of the upper and lower gastrointestinal tract have limited utility in t
16、he setting of occult bleeding because of their inability to biopsy or treat lesions that are identified.缺铁性贫血病人的早期检查方法要根据存在的症状是提示上消化道还是下消化道。无论首次上消化道或下消化道内窥镜检查会有何发现，所有病人两个检查都应该做，因为互补的内窥镜检查有6%的再发现，即使第一次检查是阳性的。对绝经前妇女，大便隐血试验阳性需要全面分析，缺铁性贫血也一样。隐匿性出血时，上、下消化道的钡剂造影应用有限，因为它们不能活检或治疗发现的病损。When endoscopic evaluation does not detect the cause of blood loss, radiographic procedures such as scinti
