医技学院（华盛顿医疗手册培训课程总论）

TheWashingtongManualofMedicalTherapeuticsPatientCareinInternalMedicine JiananWangMDPhDFACCSecondAffiliatedHospitalZhejiangUniversitySchoolOfMedicine GeneralCareoftheHospitalizedPatientGENERALPRINCIPLES IndividualizationbasedonEvidenceMedicineCarefulExplanation benefits risksandalternative BasicmeasuresminimizingrisksUseofstandardizedabbreviationsanddosedesignationsExcellentcommunicationbetweenphysiciansandothercaregiversInstitutionofappropriateprophylacticprecautionsPreventionofnosocomialinfections includingattentiontohygieneanddiscontinuationofunnecessarycathetersMedicinereconciliationatalltransfersofcare HospitalOrders AdmissionOrderfollowingADCVANDALISMAdmittingservice location andphysicianresponsibleforthepatientDiagnosesConditionofthepatientVitalsignswithfrequencyActivitylimitationsNursinginstructions e g Foleycathetertogravitydrainage woundcare dailyweights Diet Rememberthat npo mayprecludeoralmedicationsunlessspecifiedAllergies sensitivities andpreviousdrugreactionsLaboratorytestsandradiographicstudiesIVfluids includingcompositionandrateSedatives analgesics andotherPRNmedicationsMedications includingdose frequency route andindication State Firstdosenow whenappropriate ProphylacticMeasures VenousThromboembolismProphylaxisMostpreventablecauseofdeathinHosp DrugsforpreventionofDVTHeparineLMWH10aantagonist fondaparinux rivaroxaban 拜瑞妥 MechanicalprophylaxiswithintermittentpneumaticcompressionorgradedcompressionstockingsAspirinisnotindicatied 外科病人静脉血栓危险分层 ACCP共识会议对外科手术病人静脉血栓的危险分层低危 年龄 40岁小手术无其他危险因素中危 年龄 40岁大手术无其他危险因素高危 年龄 40岁大手术合并一个其他危险因素 MIs或VTE过去史肿瘤高凝状态 极高危 年龄 40岁大或小手术合并多个其他危险因素 VTE或IS过去史肿瘤高凝状态 全髋或全膝关节置换术髋部骨折严重创伤脊柱损伤 1 0 2 3 Lowrisk Increasedrisk 0 1 2 3 Classofpredisposingrisk DehydrationPolycythaemiaorthrombocytosisVaricosisVTEinfamilyHRTObesity ThrombophiliaHistoryofVTEActivemalignancyor 3risksfromcategory1 2risksfromcategory2 Nobasicrisk Age 65yearsPregnancyOralcontraceptionNephroticsyndromeMyeloproliferativesyndrome2risksfromcategory1 0 1 2 3 IschaemicstrokewithparalysisAcutedecompensationofCOPDwithventilationMyocardialinfarctionHeartfailure NYHAClassIIIandIV AcutedecompensationofCOPDwithoutventilationSepsisInfection acuteinflammatorydisease bed restInfection acuteinflammatorydisease non strictbed restCentralvenouslinesorportsystemNoacuterisk 0 1 2 3 IndividualizedRiskClassificationofDVTforInternalPatients LutzL etal MedWelt 2002 53 231 234COPD chronicobstructivepulmonarydiseaseHRT hormonereplacementtherapyNYHA NewYorkHeartAssociation Classofexposingrisk PressureUlcerFallprecautionSeizureRestraint Acutepatientcare ChestpainPulmonaryembolizationAorticdissectionAcuteCoronarySyndromeAcutecholecystitisAcutegastritis DiagnosticTesting oxygenationstatuschestradiographyelectrocardiogram ECG Spiralcomputedtomography CT VQscans Initialtherapy SuspiciousACSsupplementaloxygenAspirin Plavixnitroglycerin 0 4mgSLmorphinesulfate 1to2mgIV Dysnea CHFcardiacischemiaBronchospasmpulmonaryembolusLunginfectionmucuspluggingaspiration Fever DrugreactionMalignancyInfectionAutoimmunedisease Vasculitis SLEetc VTETissueinfarction AntipyreticmedicationsAspirin avoidedforadolescent Acetaminophen 325to650mgPOorperrectumq4h Hypothermic cooling blanketsIcepacksTepidwaterbathsEmpiricantibiotics hemodynamicallyunstablepatientsinwhominfectionisaprimaryconcernNeutropenicAsplenic Painmanagement AcetaminophenAspirinNSAIDsCyclooxygenase 2 COX 2 inhibitors celecoxib Meloxicam OpioidanalgesicsTramadol PERIOPERATIVEMEDICINEPreoperativeCardiacEvaluation Figure1 Cardiacevaluationalgorithmfornoncardiacsurgery Adaptedfromthe2007ACC AHAguidelinesonperioperativeevaluationfornoncardiacsurgery Circulation2007 116 e418 PerioperativeAnticoagulationandAntithromboticManagement PreoperativeSpecificSituation HypertensionPacemakersandImplantableCardioverterDefibrillators ICDs PulmonaryDiseaseandPreoperativePulmonaryEvaluation AnemiaandTransfusionIssuesinSurgeryfiniteandcostlyresourcebloodborneinfectionstransfusion relatedacutelunginjury TRALI transfusionreactionsimmunosuppressiveeffects DiabetesGlucosewell controlledbutpreventionofhypoglycemiaAdrenalInsufficiencyandCorticosteroidManagementChronicRenalInsufficiencyandEnd StageRenalDisease PatientsRoundingandEvaluation Preparationforpatientrounds Knowledgeofthepatient scurrentcondition NursingrecordbesideevaluationcurrentlabreportsX rayreportspathologyreports Necessary tools StethoscopePenlightTonguebladeAsmallrulerAreflexhammerAsmallpocketsizereferencebookNursingrecordetc Aprofessionalappearance Cleanaidentificationbadge Organizationoftheteam Generalobjectivesforbothmedicalstudentsandresidents Bealtruistic compassionate andempatheticincaringforpatientsUnderstandthescientificbasisofmedicineandbeabletoapplyittothepracticeofmedicineBehighlyskilledinprovidingappropriatecaretopatientsbasedonthebestavailableevidenceBeabletocollaboratewithotherhealthcareprofessionals InteractionwithPatientandFamily ShowingyourrespectandempathyaprofessionalappearancenonverbalskillsandbehaviorExplainingtheirillnessandtreatmentplanusesimplelanguagethatthefamilycanunderstandPatienteducation Collectpatienthistory Patienthistory IdentificationChiefcomplaintHPI historyofpresentillness PMHx pastmedicalhistory MedicationsROS reviewofsystemsSocialHxPhysicalExamImpression diagnosisTreatmentplan Takingmedicalhistory Self introductionstatethereasonforthevisitaskthepatient spermissionEnsurepatientcomfortduringtheinterviewBecome agoodlistener PatientPhysicalExam Fourmajormodalities InspectionPalpationPercussionAuscultation Teachtheeyetosee thefingertofeel andtheeartohear SirWilliamOsler PatientPhysicalExam MedicaltechnologycanneverrenderthephysicalexamWashingyourhandsinfrontofthepatientEnsuringpatientcomfortandprivacyHonest opencommunicationwiththepatientregardingabnormalphysicalfindings Medicalrecordreview Therulesthatthephysicianshouldfollowwhenrecordingthehistoryandphysical recordallpertinentdataavoidextraneousdatausecommontermsavoidnonstandardabbreviationsbeobjectiveusediagramsorpictureswhenindicated Detaileddailymedicalrecord FollowtheSOAPformat S subjectiveO objectiveA assessmentP Plan Operativeorprocedurenotes DateandtimeProceduredoneIndicationsPatientconsentLabtestAnesthesiaDescriptionofprocedure Dischargesummary Patient snameandmedicalrecordnumberDateofadmissionDateofdischargeAdmittingdiagnosisDischargediagnosisNameofattendingphysicianorteamresponsibleforpatientSurgicalorotherproceduresperformedDiagnostictestsperformedBriefhistory pertinentphysicalexamandlabdataHospitalcoursePatient sconditionatdischargeDischargeplanincludingfollow upappointmentDischargemedicationsProblemlistincludingallactiveandpastproblem Patienteducation Function communicateaboutthediagnosticsignificanceoftheproblemsrecommendappropriatediagnosticproceduresandtreatmentenhancecopingabilitybyunderstandingthesocialandpsychosocialconsequencesofthediseaseandtreatment Patientcasepresentation Themostimportantpart theimpressionorsuspecteddiagnosisincludingthedifferentialdiagnosisNotusea symptom asthediagnosisNotneglectthepatient Noteachingwithoutapatientforatext andthebestteachingisthattaughtbythepatienthimself WilliamOsler PatientRapport Mustalwaysconsiderthepatient semotionalneedsMustconsiderthepatien