醫(yī)學專題藥歷的類型及其書寫E

1、藥歷的類型及其書寫王 卓第二軍醫(yī)大學附屬長海醫(yī)院藥學部中國人民解放軍全軍臨床藥學中心2021/7/20 星期二1病歷：醫(yī)院記錄病人病史、診斷和處理方法的檔案。藥歷：是由臨床藥師記錄的關(guān)于發(fā)現(xiàn)、分析、觀察和解決病人藥物相關(guān)問題的技術(shù)檔案。2021/7/20 星期二2藥歷及其作用是臨床藥師的必備文書資料?？梢允古R床藥師和其他醫(yī)務(wù)人員能夠了解患者的藥物相關(guān)信息。用于法律程序、教育、研究以及質(zhì)量保證評價。是臨床藥師進行規(guī)范化藥學服務(wù)的具體體現(xiàn)。2021/7/20 星期二3藥歷的存在形式醫(yī)療病歷中的藥歷記錄 藥師單獨記錄的藥歷 電子藥歷 2021/7/20 星期二4二、藥歷的記錄模式1以藥物治療為主的藥

2、歷。2以用藥指導為目的的藥歷。3以問題為線索的藥歷。4以藥物不良反應(yīng)為線索的藥歷。5以治療藥物監(jiān)測為目的的藥歷。2021/7/20 星期二5三、藥歷的記錄形式敘述式表格式圖表式手冊式2021/7/20 星期二62021/7/20 星期二72021/7/20 星期二82021/7/20 星期二92021/7/20 星期二102021/7/20 星期二11中國臨床藥理學與治療學，2000；5（2）：166-1682021/7/20 星期二12中國臨床藥理學與治療學，2000；5（2）：166-1682021/7/20 星期二132021/7/20 星期二142021/7/20 星期二152021/

3、7/20 星期二162021/7/20 星期二17三、ASHP對藥歷記錄的規(guī)定美國醫(yī)療機構(gòu)藥師協(xié)會（ASHP）2003年2月新修訂的“ASHP Guidelines on Documenting Pharmaceutical Care in Patient Medical Records”明確指出：藥師為保證用藥的安全有效而進行的影響病人預后結(jié)果的專業(yè)活動必須書面記載于病人的病歷 (PMR，patient medical record)。作為醫(yī)學保健隊伍整體的一員，臨床藥師的文書記錄是病人連貫性監(jiān)護的關(guān)鍵，也可以同時展示出藥師服務(wù)的責任和價值。2021/7/20 星期二18基本要求必須以長期慣

4、用的形式記錄在案。便于所有保健者密切聯(lián)系和通力協(xié)作的形式，而不應(yīng)該在交流和進行專業(yè)判斷上制造壁壘。盡管緊急情況下電話和口頭的交流必須在緊急情況處理之后盡快記錄于病歷。其他不太緊急和常規(guī)的建議最好也應(yīng)盡快記錄在案。2021/7/20 星期二19病歷中藥師記錄的主要內(nèi)容：病人入院前的主要用藥史，包括藥物過敏史及其具體表現(xiàn)；在病人藥物治療中藥師向其他醫(yī)務(wù)工作者提供的有關(guān)用藥選擇及處置方面的口頭或書面會診服務(wù)；醫(yī)生口述的直接來源于藥師的醫(yī)囑；就用藥醫(yī)囑進行的說明解釋；有關(guān)用藥劑量、給藥頻率、藥物劑型或給藥途徑方面的調(diào)整；病人已用藥品（包括試驗用藥）；授權(quán)監(jiān)測的已出現(xiàn)或潛在的藥物相關(guān)問題；藥物治療監(jiān)測所

5、見；所提供的藥物相關(guān)的病人教育和相關(guān)咨詢。2021/7/20 星期二20病人藥物治療方案的適當性（包括給藥途徑和方法）；病人藥物治療方案中的重復用藥；已開藥物醫(yī)囑的病人依從程度；已出現(xiàn)的或潛在的藥物-藥物、藥物-食物、藥物-實驗室檢查值及藥物-疾病間的相互作用；臨床及藥動學實驗數(shù)據(jù)相關(guān)的用藥方案問題；已出現(xiàn)和潛在的藥物中毒及藥物不良事件；藥物治療相關(guān)的體征及臨床癥狀；藥物治療監(jiān)測所見2021/7/20 星期二21藥師的文書記錄應(yīng)符合已建立以下標準：易懂、清楚、不含裁判性語言、完整、為病歷所需要（相對于其他形式的交流）、有適當?shù)臉藴誓Ｊ娇刹捎萌鏢OAP（subjective, objective

6、, assessment, and plan）或TITRS(title, introduction, text, recommendation, and signature)，以及如何與藥師聯(lián)絡(luò)（如電話或傳呼機號碼）。2021/7/20 星期二22保護病人隱私保證所進行的交流簡明、準確還應(yīng)考慮到當?shù)氐募奥?lián)邦的相關(guān)指導原則、法規(guī)。應(yīng)使用非裁判性的語言，要特別注意避免使用帶有責備（如差錯、失誤、不幸、疏忽等）或不符合標準（如有害的、無效、不當、不宜、錯誤、不足、缺乏、問題及不滿意）等暗示的文字。事實應(yīng)記錄得準確、清晰、客觀，應(yīng)能夠反應(yīng)整個醫(yī)療小組所建立的治療目標。2021/7/20 星期二23正式

7、受邀的會診可包括直接的建議和相應(yīng)的意見。但是非正式受邀的會診、臨床印象、發(fā)現(xiàn)、意見或建議通常應(yīng)記錄得更為靈活（subtly），應(yīng)使用非直接的建議，允許對方拒絕建議而不致承擔責任。例如，若使用“可考慮”類的詞匯，則可以有機會根據(jù)病情采納或不采納所提建議。2021/7/20 星期二24四、藥歷記錄的格式與要求1病歷式藥歷：一般資料既往用藥史現(xiàn)用藥史建議藥物治療計劃藥程錄出院小結(jié)統(tǒng)計分析項目2021/7/20 星期二25一般資料內(nèi)容基本與病歷相同，例如姓名、性別、年齡、職業(yè)等一般項目，但作為藥歷，必須包括有正確的身高及體重，因這二項與今后藥物建議方案、劑量選擇緊密相關(guān)。2021/7/20 星期二26

8、既往用藥史應(yīng)在既往病史基礎(chǔ)上加以擴充和延伸，應(yīng)著重記載藥物過敏史、藥物不良事件以及既往病史所記述疾病的藥物選擇及療效分析。2021/7/20 星期二27現(xiàn)用藥史首先必須對現(xiàn)病史加以描述，在此基礎(chǔ)上同步描述在現(xiàn)病史中各個階段及各種癥狀及體征所選用藥物治療，以及藥物治療響應(yīng)，包括療效及不良事件。2021/7/20 星期二28建議藥物治療計劃本內(nèi)容為藥歷最重要組成部分，臨床藥師在作出建議前必須充分了解現(xiàn)診斷及臨床上各項實驗室檢查結(jié)果，特別是與用藥相關(guān)一些主要臟器功能狀態(tài)，然后提出完整治療計劃，包括建議使用藥物、劑量、給藥途徑，并需提出可能存在的藥物相互作用，預見可能會發(fā)生不良反應(yīng)，且盡可能需有定量監(jiān)

9、測指標。2021/7/20 星期二29藥程錄與病歷中的病程錄相同步，且需與病程錄中出現(xiàn)癥狀與體征描述相結(jié)合，逐日記載病員用藥后療效、不良事件及一些新出現(xiàn)癥狀與所用藥物相關(guān)性，及時地更新藥物治療，確保在整個藥療過程中安全、有效、經(jīng)濟。2021/7/20 星期二30出院小結(jié)對整個藥物治療過程回顧性分析與總結(jié)。必須評述整個住院期藥療全貌，從中找出一些普遍規(guī)律，為病員出院后維持與鞏固治療提出建設(shè)性意見，且供藥師在臨床群體實踐中積累經(jīng)驗。2021/7/20 星期二31統(tǒng)計分析項目以藥物利用分析為目的的統(tǒng)計分析項目，可以對某病例某次住院期間的藥物利用情況進行不同角度的分析統(tǒng)計，如：以疾病為中心進行統(tǒng)計分析

10、、以藥物為中心進行統(tǒng)計分析、以費用為中心進行統(tǒng)計分析、以相類似作用藥物為中心比較利用情況等。2021/7/20 星期二32SOAP模式S（Subjective）：患者的主訴病癥和病史、過敏史、藥物不良反應(yīng)史、既往用藥情況（包括藥和家庭自用藥物）、家族病史、個人習慣、是否吸毒。O（Objective）：對患者檢查的客觀記錄 ，包括生命體征、生化指標、血藥濃度、影像學檢查結(jié)果、血和痰培養(yǎng)結(jié)果，檢查和治療費用等。這些檢查將有助于明確診斷和治療決策。2021/7/20 星期二33A（Assessment）：醫(yī)師的臨床診斷。P（Plan）：治療方案，包括用法用量、服藥時間、發(fā)藥數(shù)量和用藥指導，應(yīng)對患者繼

11、續(xù)觀察的項目。藥師根據(jù)這些信息可以進行藥物治療安全性和合理性的考察，評估藥物藥物、藥物疾病間的相互作用，判斷患者服藥的依從性。2021/7/20 星期二34PH-MD-ROME模式藥歷P（Patient Intruduction，病人簡介）簡要介紹病人因出現(xiàn)何種情況、為何入院尋求醫(yī)療服務(wù)。記錄日期、病人姓名、年齡（或出生年月）、民族、身高、體重、入院日期、性別、主訴（chief complaint）或病人現(xiàn)況描述。2021/7/20 星期二35H（Health Problem，健康問題）包括醫(yī)療診斷、精神病學診斷、病人主訴、異常實驗室檢查結(jié)果、異常的癥狀或體征、社會或經(jīng)濟狀況、心理狀況、生理缺

12、陷。有時還包括藥師所進行的查體或問診獲得的病史。應(yīng)注明病人自述的藥物過敏史，對病人自己不詳，而藥師查知的過敏史應(yīng)在確認后特別注明。在“健康問題”項下不討論藥物治療。既往與目前的藥物治療情況將記錄在“治療藥物”項下，如果必要時則在“藥學診斷”項下進行討論。2021/7/20 星期二36M（Medications，治療藥物）模塊分為兩部分：當前藥物清單和已用藥物清單?，F(xiàn)用藥品清單可以用來篩查藥物相互作用、重復治療、多重用藥、是否過敏以及劑量是否適當。藥師應(yīng)不僅確定其過去用藥方案中的劑量詳情，更應(yīng)考察該方案效果如何、是否發(fā)生不良事件以及為何后來停用了該方案等細節(jié)。2021/7/20 星期二37D (

13、Pharmaceutical diagnosis ，藥學診斷)定義（Culbertson et al）：“用來鑒定病人特定的藥物相關(guān)問題的、以問題為中心的認識過程。”敘述有關(guān)的藥物相關(guān)問題及其分析、鑒別。每一個診斷都應(yīng)提供足夠的證據(jù)支持，并且應(yīng)用藥物治療原則來解決該問題。藥學診斷與藥物治療選擇間的關(guān)系。要使用、調(diào)整和停用某種藥物，都應(yīng)該討論其效益和風險。2021/7/20 星期二38藥學診斷處方問題劑量不足劑量過大療程過長療程不足給藥的具體時間表不當給藥劑型或給藥途徑不當經(jīng)濟學不當醫(yī)療保險問題難辨認藥物醫(yī)囑缺項或不詳不易得藥品2021/7/20 星期二39藥物治療評價相關(guān)問題未處置問題是否有必

14、要使用預防性用藥、繼續(xù)用藥或長期維持用藥治療反應(yīng)不佳適應(yīng)證不明確或有疑問替代藥物的選擇重復治療藥動學評價2021/7/20 星期二40藥物治療的不良反應(yīng)問題藥物不良反應(yīng)或不良事件潛在的禁忌證潛在的不良藥物-飲食相互作用潛在的不良藥物-藥物相互作用潛在的不良藥物-實驗室檢查相互作用2021/7/20 星期二41監(jiān)測相關(guān)問題臨床情況不完善臨床檢查數(shù)據(jù)不完善臨床檢查數(shù)據(jù)過多尚需進一步觀察2021/7/20 星期二42病人相關(guān)因素依從性差用藥過度用藥精神依賴用藥身體依賴（停藥后可能出現(xiàn)撤藥反應(yīng)）藥品儲存不當病人教育問題病人教育不足特殊教育問題2021/7/20 星期二43R（Recommended O

15、rders，推薦醫(yī)囑）提出解決問題的辦法。每條建議都應(yīng)與上述藥學診斷的編號對應(yīng)。更深一步的分析討論或綜合等敘述性內(nèi)容都應(yīng)在上述“health problem”或“pharmaceutical diagnosis”項目下完善。藥物治療的建議應(yīng)書寫得盡可能簡明，使用處方常用的縮略語，列出具體的藥品、劑型、劑量、給藥途徑、劑量計劃以及療程等。2021/7/20 星期二44O（Desired Outcome，理想結(jié)果）設(shè)定特定的治療目標或終點。應(yīng)針對具體的監(jiān)測指標提出哪些指標變化、哪些不便，提出治療應(yīng)達到的適當結(jié)果，并保證在此過程中病人不會遭受任何明顯的藥物不良反應(yīng)。如果結(jié)果不能達到此預定目標，則必須

16、重新對其評估，并設(shè)定新的目標。2021/7/20 星期二45M（Monitoring，監(jiān)測）監(jiān)測所涉及的參數(shù)指標包括實驗室檢查、臨床測定已經(jīng)根據(jù)病人保健問題和藥學診斷現(xiàn)狀所反饋的情況預期的一些觀察指標。每一種監(jiān)測指標應(yīng)列出其相應(yīng)的監(jiān)測時間、監(jiān)測頻率，必要時應(yīng)注明特殊的監(jiān)測者。2021/7/20 星期二46E（Patient Counseling and Education，病人咨詢和教育）列出藥師應(yīng)提供給針對特定病人的重要的信息、建議、訓練以及鼓勵。如果出現(xiàn)“依從性不好”等情況時，則本項目下應(yīng)包括對糾正該問題的具體指導。應(yīng)具體記載對病人進行咨詢教育的具體時間、方式、效果以及進行該工作的藥師。2

17、021/7/20 星期二47五、藥歷舉例SOAP擴展模式CHIEF COMPLAINTK.H. is a 52-year-old man who comes to the clinic today with complaints of shortness of breath and increased sputum production.HISTORY OF PRESENT ILLNESSHe reports that a rash began yesterday.He also complains of feeling depressed, lacking energy, waking up

18、 early in the morning and not being able to go back to sleep, a decreased appetite, and a general lack of interest in everything, including his job and his family for the last 6 weeks. Although he has several medical problems, he has been doing well prior to this episode.2021/7/20 星期二48PAST MEDICAL

19、HISTORYChronic bronchitis secondary to smoking. Increasing SOB over last two years.Patient injured his right leg in a fall seven months ago. Deep vein thrombosis in the calf developed a week later.SOCIAL HISTORYK.H. has a stable and happy marriage; he has two sons in college, both doing well. K.H. c

20、ontinues to smoke 1 pack per day; he has 50 pack-year history. K.H. tried marijuana once with his son but did not like it.2021/7/20 星期二49MEDICATION HISTORYTheodur 600 mg bid for 2 yearsTerbutaline inhaler 4 puffs qid and pm for 2 yearsVibramycin 100 mg qd for bronchitis x 10 daysWarfarin 3 mg qd, st

21、arted 7 months agoAcetaminophen prn headacheALLERGIESNone known2021/7/20 星期二50PHYSICAL EXAMINATIONGEN: Middle aged man, in severe distressVS: BP 120/80, HR 100 reg, T 37.6, RR 32, Wt 80 kg, Ht 57HEENT: NormalCOR: Normal S1 and S2; no S3, S4 or murmursCHEST: Numerous rales, rhonchi, and wheezesABD: N

22、o organomegalyGU: WNLRECT: WNLEXT: NL DTRs, maculopapular rash on trunk and thighsNEURO: Oriented x 3, WNL2021/7/20 星期二51 RESULTS OF LABORATORY TESTSNa 140 Hct 55 Alb 4 K 4.0 Hgb 17.5 TBili .8 Cl 101 WBC 8.1Glu 95 Uric acid 7.4 HCO3 28 Plts 305kCa 8.8 BUN 37 Cr 1.2 P04 2.6AST 40 ALT 35 Mg 2.0 PT 25

23、(INR = 3)WBC differential: Neutrophils 4.8, bands 0, lymphs 3.0, monos .5, eos .12ABGs: pH 7.37, P02 55, PCO2 49PFTs: pre-bronchodilator FEV1 = 2000 mL (50% of FVC), post-bronchodilator FEV1 = 2600 mL (65% of FVC)Gram stain of sputum sample was unsuitable due to numerous squamous epithelial cellsUri

24、nalysis: WNLChest x-ray: Clear, no signs of pneumonia2021/7/20 星期二52PHARMACY-RELATED PROBLEM LIST1. Chronic bronchitis in an acute exacerbation2. Drug allergy3. Depression4. Deep Vein ThrombosisPROBLEM 1. CHRONIC BRONCHITIS EXACERBATIONS: K.H. complains of SOB and increased sputum production.O: K.H.

25、 has a decreased FEV1, rales, rhonchi, wheezes, an increased respiratory rate, pulse, Hct and Hgb, and arterial blood gases that show an increased PCO2 and a decreased oxygen. K.H. has a 50 pack-year smoking history.2021/7/20 星期二53A: K.H. has a symptomatic exacerbation of his chronic bronchitis that

26、 requires treatment. Smoking is the most likely etiology of the chronic bronchitis, while a viral upper respiratory tract infection is probably the cause of the acute exacerbation since K.H. shows no signs of systemic bacterial infection. He has a normal WBC, he is afebrile, and his chest x-ray is c

27、lear. The use of antibiotics in this situation is controversial, although recent evidence suggests a benefit. Pre-bronchodilator and post-bronchodilator FEV1 show reversible airway obstruction. The theophylline level is within the therapeutic range and there is no need to increase the dose.2021/7/20

28、 星期二54P: Give methylprednisolone 40-125 mg iv stat and continue q6h for 72 hours. Give aerosolized metaproterenol 4 puffs stat and 1 puff q 5 minutes until relief or appearance of side effects. Continue oral theophylline. Begin oxygen 2 liters/minute via nasal prongs. Begin ampicillin 500 mg po qid.

29、Monitor SOB, sputum production, FEV1, ABGs, chest auscultation, theophylline level, nausea, vomiting, pulse, blood glucose, serum potassium, blood pressure, and tremor. The goal is to decrease morbidity and mortality associated with chronic bronchitis.Assess K.H.s ability to use his inhaler correctl

30、y and correct any problems. Provide a spacer if necessary. Explain the likely side effects of theophylline, steroids, and ampicillin.K.H. should discontinue smoking; refer him to a smoking cessation clinic.2021/7/20 星期二55PROBLEM 2. DRUG ALLERGYS: K.H. complains of a rash that began yesterday, but do

31、es not complain of itching.O: K.H. has maculopapular rash on trunk and thighs, his eos is 1.2.A: K.H. has developed a rash due to the doxycycline started 9 days ago. The usual drug rash is maculopapular and commonly occurs after 7-10 days of therapy. Avoid antihistamines unless K.H. is itching, beca

32、use they are sedating and have anticholinergic effects.P: Discontinue Vibramycin. A veeno baths for a soothing effect may be needed. Label K.H. allergic to doxycycline.Monitor for resolution of the rash.Educate patient that he has an allergy to doxycycline and possibly other tetracyclines.2021/7/20

33、星期二56PROBLEM 3. DEPRESSIONS: K.H. complains of feeling depressed, lacking energy, waking up early in the morning and not being able to go back to sleep, a decreased appetite, and a general lack of interest in everything, including his job and his family for the last 6 weeks.O: None.A: K.H. has had h

34、is current complaints for more than a month. While he does not appear to be suicidal at this point, he needs treatment. Fluoxetine is as effective, has less side effects, and, when all costs are taken into account, is no more expensive to use than older tricyclic antidepressants such as imipramine a

35、nd desipramine.2021/7/20 星期二57P: Begin fluoxetine 20 mg qd q am or at noon. Continue therapy for 6 months.Monitor changes in appetite, sleep pattern, interest in life, mood, quality of life, and suicidal thoughts. Physiologic signs and symptoms should improve in 1 week, while mood will take 2-4 week

36、s to respond. Also monitor for headaches, anxiety, insomnia, nausea, somnolence, dizziness or anticholinergic side effects.Advise patient to take fluoxetine in the morning or at noon to help prevent insomnia. Antacids may help with nausea. This drug may cause drowsiness or dizziness, so caution is a

37、dvised when driving or operating machinery. It will take several weeks for this drug to work or side effects to develop.2021/7/20 星期二58PROBLEM 4. DEEP VEIN THROMBOSISS: No complaintsO: The measurements of INR have shown wide swings over the last seven months. Presently the INR has stabilized around

38、3.0 for the last two months.A: Since the patient had only one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatmentP: Discontinue warfarin2021/7/20 星期二59PH-MD-ROME模式藥歷PATIENT INTRODUCTIONDate 2/24/97K.H. is a 52-year-old, 80 kg, 57” m

39、ale who comes to the clinic today with continued complaints of shortness of breath and increased sputum production.He reports that a rash began yesterday.He also complains of feeling depressed, lacking energy, waking up early in the morning and not being able to go back to sleep, a decreased appetit

40、e, and a general lack of interest in everything, including his job and his family for the last 6 weeks. Although he has several medical problems, he has been doing well prior to this episode.2021/7/20 星期二60HEALTH PROBLEMSChronic Bronchitis in an Acute ExacerbationSOB has been increasing over the las

41、t two years. The present respiratory rate is increased to 32. K.H. continues to smoke 1 pack per day. He has 50 pack-year history. Smoking is the most likely etiology of the chronic bronchitis. Numerous rales, rhonchi, and wheezes are heard on auscultation. Hct and Hgb are in the upper normal range

42、ruling out anemia as a cause for the SOB. Their elevation is probably secondary to hypoxia.Arterial blood gases indicate poor gas exchange, PCO2 is increased to 49 mm/Hg (normal 35-45), and PO2 is decreased to 55 mm/Hg (normal 80-100). An increased bicarbonate of 28 mEq/L (normal 20-26) shows compen

43、sation by the kidney resulting in a pH of 7.37, which is low-normal.WBC and differential are normal, temperature is normal, and chest x-ray is clear ruling out pneumonia. Gram stain of sputum sample was unsuitable due to numerous squamous epithelial cells A viral upper respiratory tract infection ma

44、y be the cause of the acute exacerbation.A pre-bronchodilator FEV1 = 2000 mL (50% of VC) indicates obstruction. However a post-bronchodilator FEV1 = 2600 mL (65% of VC) shows that this obstruction has a reversible component.2021/7/20 星期二61RashK.H. does not complain of itching. He has a maculopapular

45、 rash on trunk and thighs. His eosinophiles are in the normal range.DepressionThe five symptoms mentioned under patient introduction and their duration of over six weeks are consistent with a major depressive episode. However his breathing problem may be contributing to the mood disorder. The patien

46、t does not appear to be suicidal at this point.Deep Vein ThrombosisPatient injured his right leg in a fall seven months ago. Deep vein thrombosis in the calf developed a week later. The measurements of INR have shown wide swings over the last seven months. Presently the INR has stabilized around 3.0

47、 for the last two months.No known Allergies2021/7/20 星期二62MEDICATIONSPresent Medication ListTheodur 600 mg bid for 2 yearsTerbutaline inhaler 4 puffs qid and pm for 2 yearsVibramycin 100 mg qd for bronchitis x 10 daysWarfarin 3 mg qd, started seven months agoAcetaminophen prn HAPast Medication ListU

48、nknown2021/7/20 星期二63PHARMACEUTICAL DIAGNOSIS1. Suboptimal Response to BronchodilatorsD. G. has a symptomatic exacerbation of his chronic bronchitis that requires further treatment. The reversible airway obstruction would probably be amenable to additional bronchodilators. A theophylline level of 12

49、 mg/L is within the therapeutic range and pharmacokinetically consistent with his dosage. The use of antibiotics in this situation is controversial, although recent evidence suggests a benefit.2. Adverse Drug Reaction to DoxycyclineK.H. has developed a rash probably due to the doxycycline started 9

50、days ago. The usual drug rash is maculopapular and commonly occurs after 7-10 days of therapy. Avoid antihistamines unless K.H. is itching, because they are sedating and have anticholinergic effects.2021/7/20 星期二643. Untreated DepressionK.H. has had his current complaints for more than a month. Whil

51、e he does not appear to be suicidal at this point, he needs treatment. Fluoxetine is as effective, has less side effects, and, when all costs are taken into account, is no more expensive to use than older tricyclic antidepressants such as imipramine and desipramine.4. Excessive Duration of Warfarin

52、ProphylaxisSince the patient has only had one occurrence of deep vein thrombosis, warfarin therapy is usually discontinued after six months of prophylactic treatment2021/7/20 星期二65RECOMMENDED ORDERS1. Methylprednisolone 45 mg iv stat and continue q 6 h for 72 hours.Aerosolized metaproterenol 4 puffs

53、 stat and 1 puff q 5 minutes until relief or side effects, then two puffs every 4 hours while awake.Continue oral theophylline, 600 mg bid.Oxygen 2 liters/minute via nasal prongs.Ampicillin 500 mg po qid for seven days.2. Discontinue Vibramycin.Label K.H. allergic to doxyclycline.Aveeno baths for a soothing effect as needed.3. Fluoxetine 20