醫(yī)、技學(xué)院(華盛頓醫(yī)療手冊(cè)培訓(xùn)-課程總論)課件

1、The Washingtong Manual of Medical Therapeutics Patient Care in Internal MedicineJianan Wang MD PhD FACCSecond Affiliated Hospital Zhejiang University School Of MedicineGeneral Care of the Hospitalized PatientGENERAL PRINCIPLESIndividualization based on Evidence MedicineCareful Explanation( benefits,

2、 risks and alternative)Basic measures minimizing risksUse of standardized abbreviations and dose designationsExcellent communication between physicians and other caregiversInstitution of appropriate prophylactic precautionsPrevention of nosocomial infections, including attention to hygiene and disco

3、ntinuation of unnecessary cathetersMedicine reconciliation at all transfers of careHospital OrdersAdmission Order following ADC VANDALISM Admitting service, location, and physician responsible for the patientDiagnosesCondition of the patientVital signs with frequencyActivity limitationsNursing instr

4、uctions (e.g., Foley catheter to gravity drainage, wound care, daily weights)Diet. Remember that “npo” may preclude oral medications unless specifiedAllergies, sensitivities, and previous drug reactionsLaboratory tests and radiographic studiesIV fluids, including composition and rateSedatives, analg

5、esics, and other PRN medicationsMedications, including dose, frequency, route, and indication. State “First dose now” when appropriate Prophylactic MeasuresVenous Thromboembolism ProphylaxisMost preventable cause of death in Hosp.Drugs for prevention of DVT Heparine LMWH 10a antagonist: fondaparinux

6、, rivaroxaban (拜瑞妥） Mechanical prophylaxis with intermittent pneumatic compression or graded compression stockings Aspirin is not indicatied 外科病人靜脈血栓危險(xiǎn)分層ACCP 共識(shí)會(huì)議對(duì)外科手術(shù)病人靜脈血栓的危險(xiǎn)分層 低 危： 年齡 40 歲 小手術(shù) 無其他危險(xiǎn)因素 中 危： 年齡 40 歲 大手術(shù) 無其他危險(xiǎn)因素 高 危： 年齡 40 歲 大手術(shù) 合并一個(gè)其他危險(xiǎn)因素 （MIs 或 VTE 過去史 腫瘤 高凝狀態(tài)） 極高危： 年齡 40歲 大或小手術(shù) 合

7、并多個(gè)其他危險(xiǎn)因素 （VTE 或 IS 過去史 腫瘤 高凝狀態(tài)） 全髖或全膝關(guān)節(jié)置換術(shù) 髖部骨折 嚴(yán)重創(chuàng)傷 脊柱損傷1023LowriskIncreasedrisk0123 Class of predisposing risk Dehydration Polycythaemia or thrombocytosis Varicosis VTE in family HRT Obesity Thrombophilia History of VTE Active malignancy or 3 risks from category 1 2 risks from category 2 No basic

8、 risk Age 65 years Pregnancy Oral contraception Nephrotic syndrome Myeloproliferative syndrome 2 risks from category 10123 Ischaemic stroke with paralysis Acute decompensation of COPD with ventilation Myocardial infarction Heart failure (NYHA Class III and IV) Acute decompensation of COPD without ve

9、ntilation Sepsis Infection/acute inflammatory disease: bed-rest Infection/acute inflammatory disease: non-strict bed-rest Central venous lines or port system No acute risk0123Individualized Risk Classification of DVT for Internal Patients Lutz L, et al. Med Welt, 2002, 53: 231 - 234COPD: chronic obs

10、tructive pulmonary disease HRT: hormone replacement therapyNYHA: New York Heart AssociationClass of exposing riskPressure UlcerFall precautionSeizureRestraintDiagnostic Testingoxygenation statuschest radiography electrocardiogram (ECG) Spiral computed tomography (CT) VQ scans Initial therapy Suspici

11、ous ACSsupplemental oxygenAspirin +Plavix nitroglycerin, 0.4 mg SL morphine sulfate, 1 to 2 mg IVDysneaCHFcardiac ischemiaBronchospasmpulmonary embolusLung infectionmucus plugging aspiration Antipyretic medicationsAspirin(avoided for adolescent)Acetaminophen(325 to 650 mg PO or per rectum q4h). Hypo

12、thermic (cooling) blankets Ice packs Tepid water bathsEmpiric antibiotics: hemodynamically unstable patients in whom infection is a primary concern Neutropenic Asplenic Pain managementAcetaminophenAspirinNSAIDsCyclooxygenase-2 (COX-2) inhibitors(celecoxib. Meloxicam )Opioid analgesicsTramadolPeriope

13、rative Anticoagulation and Antithrombotic ManagementPreoperative Specific SituationHypertensionPacemakers and Implantable Cardioverter Defibrillators (ICDs)Pulmonary Disease and Preoperative Pulmonary EvaluationAnemia and Transfusion Issues in Surgeryfinite and costly resourcebloodborne infectionstr

14、ansfusion-related acute lung injury (TRALI)transfusion reactionsimmunosuppressive effects.Diabetes Glucose well-controlled but prevention of hypoglycemia Adrenal Insufficiency and Corticosteroid ManagementChronic Renal Insufficiency and End-Stage Renal DiseasePreparation for patient roundsKnowledge

15、of the patients current condition Nursing record beside evaluation current lab reports X-ray reports pathology reportsA professional appearance Clean a identification badgeOrganization of the teamAn attending physicianA senior residentTwo 1st year residentsTwo medical studentsGeneral objectives for

16、both medical students and residentsBe altruistic, compassionate, and empathetic in caring for patientsUnderstand the scientific basis of medicine and be able to apply it to the practice of medicineBe highly skilled in providing appropriate care to patients based on the best available evidenceBe able

17、 to collaborate with other health care professionalsInteraction with Patient and FamilyShowing your respect and empathy a professional appearance nonverbal skills and behavior Explaining their illness and treatment plan use simple language that the family can understandPatient educationCollect patie

18、nt historyPatient history:IdentificationChief complaintHPI:(history of present illness)PMHx :(past medical history)MedicationsROS :review of systemsSocial HxPhysical ExamImpression/diagnosisTreatment planTaking medical historySelf-introduction state the reason for the visit ask the patients permissi

19、onEnsure patient comfort during the interviewBecome “ a good listener ”Patient Physical ExamFour major modalities : Inspection PalpationPercussionAuscultationTeach the eye to see, the finger to feel, and the ear to hear -Sir William OslerPatient Physical ExamMedical technology can never render the p

20、hysical exam Washing your hands in front of the patientEnsuring patient comfort and privacyHonest, open communication with the patient regarding abnormal physical findingsMedical record review The rules that the physician should follow when recording the history and physical: record all pertinent da

21、ta avoid extraneous data use common terms avoid nonstandard abbreviations be objective use diagrams or pictures when indicated Detailed daily medical recordFollow the SOAP format: S : subjective O: objective A: assessment P: Plan Operative or procedure notesDate and timeProcedure doneIndicationsPati

22、ent consentLab testAnesthesiaDescription of procedureDischarge summaryPatients name and medical record numberDate of admissionDate of dischargeAdmitting diagnosisDischarge diagnosisName of attending physician or team responsible for patientSurgical or other procedures performedDiagnostic tests perfo

23、rmedBrief history , pertinent physical exam and lab dataHospital coursePatients condition at dischargeDischarge plan including follow-up appointmentDischarge medicationsProblem list including all active and past problemPatient educationFunction: communicate about the diagnostic significance of the p

24、roblems recommend appropriate diagnostic procedures and treatment enhance coping ability by understanding the social and psychosocial consequences of the disease and treatmentPatient case presentationThe most important part : the impression or suspected diagnosis including the differential diagnosis

25、Not use a “symptom” as the diagnosisNot neglect the patientNo teaching without a patient for a text, and the best teaching is that taught by the patient himself -William OslerPatient RapportMust always consider the patients emotional needsMust consider the patient has a right to know everything about their conditionThe