Passage 1 My Stethoscope As I dug through the drawers of a forgotten cabinet, I found my old slide rule. Forty-five years ago, this instrument had been critical to my daily life and dangled from my belt for at least 2 years. It saw steady, daily use,and with it, I was able to do complex calculations effortlessly. I immediately tried to use it, and to my chagrin, I found I could not. Even after searching online for operating instructions, I found it all but impossible Directly under this archeological stratum that had preserved the slide rule was my old, broken stethoscope-an original Leatham chest piece with the aluminum little bell broken off. as i reverently took the remnant of the instrument out of the drawer, I remembered the process that had led to choosing this stethoscope over all the others auscultation of the heart was very important for medical students. We admired the residents and attending physician who could hear sounds that were simply not heard by us, and we rapidly learned which resident was really interested in auscultation by watching him position a patient when listening to the heart. We also quickly learned the hierarchy of auscultation Medical students tended to use only the diaphragm; senior residents knew how to use the bell; and cardiology attending physicians listened in both the left lateral decubitus and leaning-forward positions At first we learned that murmurs we couldn t hear were categorized according to 4 grades of intensity by the experts, but a new 6-grade system attributed to Dr Sam Levine became popular. The more secure residents ked about the grade 1 murmur, saying that only Dr. Levine and God could hear it-in that order. Endless arguments ensued on which make of stethoscope was the best. There were advocates for the Rieger-Bowles stethoscope. Others with equal fervor extolled the outstandin characteristics of the Sprague-Rappaport model, and the real experts claimed the superiority of the massive three-headed Tycos model. The newly popular Littman stethoscope wasn t even considered by any of us because none of the senior staff used it My problem was not merely failing to hear the murmurs but also in ach to cardiac auscultation I spent hours readi about murmurs, and the eureka moment eventually came when I found Dr Aubrey Leatham's article about cardiac murmurs in Lancet. Suddenly, it came to me-the reason i did not hear some of the murmurs was that lacked the correct instrument. I learned about the Leatham chest piece(as the stethoscope was called) from one of my tutors, and he told me that I tional instrument from canada. i donated a unit of blood twice for $25 each and took the bold step and ordered the seethe
Passage 1 My Stethoscope As I dug through the drawers of a forgotten cabinet, I found my old slide rule. Forty-five years ago, this instrument had been critical to my daily life and dangled from my belt for at least 2 years. It saw steady, daily use, and with it, I was able to do complex calculations effortlessly. I immediately tried to use it, and to my chagrin, I found I could not. Even after searching online for operating instructions, I found it all but impossible. Directly under this archeological stratum that had preserved the slide rule was my old, broken stethoscope—an original Leatham chest piece with the aluminum little bell broken off. As I reverently took the remnant of the instrument out of the drawer, I remembered the process that had led to choosing this stethoscope over all the others. Auscultation of the heart was very important for medical students. We admired the residents and attending physician who could hear sounds that were simply not heard by us, and we rapidly learned which resident was really interested in auscultation by watching him position a patient when listening to the heart. We also quickly learned the hierarchy of auscultation: Medical students tended to use only the diaphragm; senior residents knew how to use the bell; and cardiology attending physicians listened in both the left lateral decubitus and leaning-forward positions. At first we learned that murmurs we couldn’t hear were categorized according to 4 grades of intensity by the experts, but a new 6-grade system attributed to Dr. Sam Levine became popular. The more secure residents joked about the grade 1 murmur, saying that only Dr. Levine and God could hear it—in that order. Endless arguments ensued on which make of stethoscope was the best. There were advocates for the Rieger–Bowles stethoscope. Others with equal fervor extolled the outstanding characteristics of the Sprague–Rappaport model, and the real experts claimed the superiority of the massive three-headed Tycos model. The newly popular Littman stethoscope wasn’t even considered by any of us because none of the senior staff used it. My problem was not merely failing to hear the murmurs but also in lacking to find an approach to cardiac auscultation. I spent hours reading about murmurs, and the eureka moment eventually came when I found Dr. Aubrey Leatham’s article about cardiac murmurs in Lancet. Suddenly, it came to me—the reason I did not hear some of the murmurs was that I lacked the correct instrument. I learned about the Leatham chest piece (as the stethoscope was called) from one of my tutors, and he told me that I could order this exceptional instrument from Canada. I donated a unit of blood twice for $25 each and took the bold step and ordered the stethoscope
In a short while. it arrived and was instantly the subject of much discussion among my classmates. Very quickly I became a zealous promoter of the chest piece, and I particularly enjoyed showing off the little bell" piece that worked well for children. We spent countless hours taking our patients to the quiet room, where the triple insulation allowed us maximum concentration for the cardiac sounds. Ever so slowly, I started to hear the murmurs others described, and I attributed this improvement to he wonderful new instrument in my pocket The stethoscope lasted through my housestaff training and as a young attending physician in general medicine. In the ICU, I demonstrated to the students and residents the proper way to listen to the various anticipated murmurs and extra heart sounds. Over the next 30 years(and two replacement Leatham chest pieces), I continued my habit of careful auscultation on rounds while my team stood at the bedside, shifting their weight from one foot to the other, urging me to stop expounding on all the sounds when they already had the echocardiography results in the chart During that time, I had to admit that the lengthy and careful auscultation seldom led to new findings rheumatic heart disease was pretty well gone from North America, and all of the congenital heart lesions had been fixed long before the patients became adults. There was still aortic stenosis and the description of the slow-rising pulse with an anacrotic notch, but by the time the patient arrived on the floor, there was already an echocardiogram telling us the gradient across the valve and the valve area. Many of my colleagues asked me why I jumped through all hose auscultatory hoops when echocardiography was so much more accurate Eventually, I was forced to admit that i really had not added anythin new through auscultating the hearts of our new admissions. Even third heart sounds failed to excite the students because the ejection fraction had been documented by an echocardiogram by the time we saw and evaluated patients with congestive heart failure. The last time I had made a significant cardiac diagnosis was some years ago when I saw an intubated and ventilated patient with hemoptysis in the ICU, and I recognized the straightening of the left heart border with the very large left atrium on the admission chest radiograph and diagnosed tight mitral stenosis Yet, I will not readily abandon the process of auscultation. I still listen to the lungs, even after I have seen the chest radiograph, and listen to the heart, even knowing the ejection fraction. Despite recognizing that my auscultation fails to add to the care of the patient, I persist. Touching the patient during the physical examination with my stethoscope helps to establish a connection with the patient, helps to gain their trust, and adds a bit to the often-impersonal greetings our patients receive. This impression however is not evidence-based
In a short while, it arrived and was instantly the subject of much discussion among my classmates. Very quickly I became a zealous promoter of the “chest piece,” and I particularly enjoyed showing off the “little bell” piece that worked well for children. We spent countless hours taking our patients to the “quiet room,” where the triple insulation allowed us maximum concentration for the cardiac sounds. Ever so slowly, I started to hear the murmurs others described, and I attributed this improvement to the wonderful new instrument in my pocket. The stethoscope lasted through my housestaff training0 and as a young attending physician in general medicine. In the ICU, I demonstrated to the students and residents the proper way to listen to the various anticipated murmurs and extra heart sounds. Over the next 30 years (and two replacement Leatham chest pieces), I continued my habit of careful auscultation on rounds while my team stood at the bedside, shifting their weight from one foot to the other, urging me to stop expounding on all the sounds when they already had the echocardiography results in the chart. During that time, I had to admit that the lengthy and careful auscultation seldom led to new findings. Rheumatic heart disease was pretty well gone from North America, and all of the congenital heart lesions had been fixed long before the patients became adults. There was still aortic stenosis and the description of the slow-rising pulse with an anacrotic notch, but by the time the patient arrived on the floor, there was already an echocardiogram telling us the gradient across the valve and the valve area. Many of my colleagues asked me why I jumped through all those auscultatory hoops when echocardiography was so much more accurate. Eventually, I was forced to admit that I really had not added anything new through auscultating the hearts of our new admissions. Even third heart sounds failed to excite the students because the ejection fraction had been documented by an echocardiogram by the time we saw and evaluated patients with congestive heart failure. The last time I had made a significant cardiac diagnosis was some years ago when I saw an intubated and ventilated patient with hemoptysis in the ICU, and I recognized the straightening of the left heart border with the very large left atrium on the admission chest radiograph and diagnosed tight mitral stenosis. Yet, I will not readily abandon the process of auscultation. I still listen to the lungs, even after I have seen the chest radiograph, and listen to the heart, even knowing the ejection fraction. Despite recognizing that my auscultation fails to add to the care of the patient, I persist. Touching the patient during the physical examination with my stethoscope helps to establish a connection with the patient, helps to gain their trust, and adds a bit to the often-impersonal greetings our patients receive. This impression, however, is not evidence-based
Vocabulary chagrin n.懊恼,懊丧 bell n.听诊器的钟面 hierarchy n.等级制度,层次 diaphragm n.听诊器的膜面;膈肌 decubitus n.卧姿 murmur n.心脏杂音 ensue vl.接着发生 make n.牌子,类型 eureka in.我知道了!我找到了!我想出了! insulation n.隔音 housestaff n.住院医生 anacrotic a.升线一波(脉)的 notch n.切迹 gradient n.阶差 auscultatory a.听诊的 hoop n.经受磨炼 intubateνt.插管,插入喉管 ventilate vt.通风,通气 hemoptysis n.咯血 radiograph n.射线照片,X光照片 Reading Comprehension Directions: There are four suggested answers to each of the following questions. Choose the best one according to the passage you have just read. 1. The author mentions the slide rule in the first paragraph to A. show how his mathematic capability has declined over time B. introduce the Leatham stethoscope which was just as old D. recall his old happy times in medical practice 2. It can be inferred that medical students admire the residents and attending physician because A. the latter were able to position the patient properly B. the latter were in possession of the best stethoscope C. the latter were on the top of the hierarchy of auscultation D. the latter taught the former how to use both the diaphragm and the bel 3. Which of the following is true about murmurs of heart? A. Grade 1 is less intense than grade B. There are only 4 grades of intensity. C. Littman categorized them into 6 grades D. The rieger-Bowles stethoscope is the most sensitive in detecting them
Vocabulary chagrin n. 懊恼，懊丧 bell n. 听诊器的钟面 hierarchy n. 等级制度，层次 diaphragm n. 听诊器的膜面；膈肌 decubitus n. 卧姿 murmur n. 心脏杂音 ensue vi. 接着发生 make n. 牌子，类型 eureka int. 我知道了！我找到了！我想出了！ insulation n. 隔音 housestaff n. 住院医生 anacrotic a. 升线一波（脉）的 notch n. 切迹 gradient n. 阶差 auscultatory a. 听诊的 hoop n. 经受磨炼 intubate vt. 插管，插入喉管 ventilate vt. 通风，通气 hemoptysis n. 咯血 radiograph n. 射线照片，X 光照片 Reading Comprehension Directions: There are four suggested answers to each of the following questions. Choose the best one according to the passage you have just read. 1. The author mentions the slide rule in the first paragraph to __________. A. show how his mathematic capability has declined over time B. introduce the Leatham stethoscope which was just as old C. demonstrate how technology has evolved over time D. recall his old happy times in medical practice 2. It can be inferred that medical students admire the residents and attending physician because____________. A. the latter were able to position the patient properly B. the latter were in possession of the best stethoscope C. the latter were on the top of the hierarchy of auscultation D. the latter taught the former how to use both the diaphragm and the bell 3. Which of the following is true about murmurs of heart? A. Grade 1 is less intense than grade 2. B. There are only 4 grades of intensity. C. Littman categorized them into 6 grades. D. The Rieger–Bowles stethoscope is the most sensitive in detecting them
4. By reading Dr. Aubrey Leatham's article in Lancet, the author suddenly understood that he couldn t hear the murmurs because A. he was not bold enough B. he didnt have the right tool C. he was not intelligent enough D. he was not adequately trained 5. The author mentioned echocardiography to A. justify that stethoscope has not been made obsolete B. illustrate his insistence on the process of auscultation C. remind his students of the potential problems of relying on hi-tech D. argue for reconsidering stethoscope as an essential tool for diagnosis 6. The author insists on jumping through auscultatory loops because he believe that It A. remains one of the most important diagnostic tools for cardiac diseases B. has become outdated because of the availability of new technology C. serves the purpose of more than a mechanical physical examination D. is still well appreciated by today's medical students and residents
4. By reading Dr. Aubrey Leatham’s article in Lancet, the author suddenly understood that he couldn’t hear the murmurs because ____________. A. he was not bold enough B. he didn’t have the right tool C. he was not intelligent enough D. he was not adequately trained 5. The author mentioned echocardiography to _________. A. justify that stethoscope has not been made obsolete B. illustrate his insistence on the process of auscultation C. remind his students of the potential problems of relying on hi-tech D. argue for reconsidering stethoscope as an essential tool for diagnosis 6. The author insists on jumping through auscultatory loops because he believe that it _________. A. remains one of the most important diagnostic tools for cardiac diseases B. has become outdated because of the availability of new technology C. serves the purpose of more than a mechanical physical examination D. is still well appreciated by today’s medical students and residents
Passage 2 The Changing Faces of Nursing: A Personal Story The definition of nursing has been dramatically revised and shaped in the past 25 years, being influenced by nursing theorists, new diseases, and new technology. Mom started her nursing career at a different time, which seems archaic by some standards nowadays. Gloves were used primarily for sterile procedures and wound dressings. Syringes were glass(and reusable!), and nursing theory was only then being revised and utilized. Patients were at the hospital until they were almost well, and there was time for back massages at night. My mother still believes in this holistic type of nursing- she has been a home health nurse for over twenty years, specializing in wound care. She still believes in giving time to her patients. Her uniforms are still starched, and though the cap is gone, she has the excitement and optimism that she had when she graduated, balanced with more realism. Because of the work of others behind the scenes"in nursing. she is able to continue to do what she believes for nure: ng theorists ideas and research provided much of the scientific basis for nursing as we know it today. For instance, in the 1970s and 1980s, Martha Rogers wrote several works, all of which explaining that nursing is an essential discipline, separate from others -namely, medicine and that it is a science with a unique body of knowledge. Gone is the thought that we are physicians handmaidens or only change bedpans throughout the day. Treating nursing as a discipline in and of itself elevates the profession and enables us to research and provide care for patients from a perspective different than that of any other discipline. Currently, it is widely accepted that nursing is an independent profession, though debate is still common regarding that status. A similar discussion occurred in the 1980s, when the courts did not routinely define nursing as an autonomous profession and often used medical doctors as experts in nursing care My mother graduated in a time when computers were not really for the average person she still has trouble urning on her pc-and were not generally used at the bedside. In fact, a study published in 1985 showed that a Medline search for articles took an average of 5-18 minutes by an experienced librarian. Now, I expect to find a Medline article in 5-18 seconds, depending on how fast I can type- no librarian required! Using the Medline search recently, I found journal articles from 1985 that reported the new drugs of the day. These ncluded glyburide and glipizide, medications that no diabetic patient is without today, and other medications such as nicotine resin complex (also known a Nicorette, Merrell Dow) and labetolol that are still used routinely. I must confess a certain fondness for these articles- I used to read my mothers nursing journals, and vividly remember the format of Nursing 83-88. Of course, at that age i was more interested in "Action Stat! and similar columns that
Passage 2 The Changing Faces of Nursing: A Personal Story The definition of nursing has been dramatically revised and shaped in the past 25 years, being influenced by nursing theorists, new diseases, and new technology. Mom started her nursing career at a different time, which seems archaic by some standards nowadays. Gloves were used primarily for sterile procedures and wound dressings. Syringes were glass (and reusable!), and nursing theory was only then being revised and utilized. Patients were at the hospital until they were almost well, and there was time for back massages at night. My mother still believes in this holistic type of nursing – she has been a home health nurse for over twenty years, specializing in wound care. She still believes in giving time to her patients. Her uniforms are still starched, and though the cap is gone, she has the excitement and optimism that she had when she graduated, balanced with more realism. Because of the work of others “behind the scenes” in nursing, she is able to continue to do what she believes in. Nursing theorists’ ideas and research provided much of the scientific basis for nursing as we know it today. For instance, in the 1970s and 1980s, Martha Rogers wrote several works, all of which explaining that nursing is an essential discipline, separate from others – namely, medicine – and that it is a science, with a unique body of knowledge. Gone is the thought that we are physicians’ handmaidens or only change bedpans throughout the day. Treating nursing as a discipline in and of itself elevates the profession and enables us to research and provide care for patients from a perspective different than that of any other discipline. Currently, it is widely accepted that nursing is an independent profession, though debate is still common regarding that status. A similar discussion occurred in the 1980s, when the courts did not routinely define nursing as an autonomous profession and often used medical doctors as “experts” in nursing care. My mother graduated in a time when computers were not really for the average person – she still has trouble turning on her PC—and were not generally used at the bedside. In fact, a study published in 1985 showed that a Medline search for articles took an average of 5-18 minutes by an experienced librarian. Now, I expect to find a Medline article in 5-18 seconds, depending on how fast I can type – no librarian required! Using the Medline search recently, I found journal articles from 1985 that reported the new drugs of the day. These included glyburide and glipizide, medications that no diabetic patient is without today, and other medications such as nicotine resin complex (also known as Nicorette, Merrell Dow) and labetolol that are still used routinely. I must confess a certain fondness for these articles – I used to read my mother’s nursing journals, and vividly remember the format of Nursing 83-88. Of course, at that age I was more interested in “ActionStat!” and similar columns that