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时间:2015-08-13 20:24点击:
Preparation for Patient RoundsIt's 8: 30 AM, time to begin patient rounds. Today we'll make patient rounds with the pulmonary team. In room 1107, we find 65yr. old Mr. Smith who was admitted yesterday afternoon. The pulmonary team includes the attending physician, senior pulmonary fellow, junior resident, and 3 medical students. The admitting junior resident who admitted the patient the previous day begins the case presentation. Mr. Smith presents with a sore throat, productive cough and shortness of breath; he's been febrile for 5 days; his illness failed to respond to IV Annkacin given during his hospitalization at a small local hospital so he was transferred to our hospital with the diagnosis of pneumonia. His family brought his medical records including a Chest X- ray and lab reports performed in the local hospital, but the junior resident left them in his on-call sleeping room. One of the medical students quickly retrieves the nursing chart from the nursing station. Review of the vitals is noteworthy for a progressive increasing pulse and respiratory rate during the night. The junior resident now briefly reexamines the patient, lung auscultation, and then the pharynx. After completing the physical exam, he notes the patient has "crackles" in the right lung base and purulent pharyngeal exudate. No results of yesterday's Chest X-ray, CBC, and ABG were provided. An ABG or pulse oximetry forgotten. Further examination notes bilateral diffuse crackles, BP 90/60,pulse 120, resp.32/min. He orders a stat ABG and Chest X- ray and while waiting we request the nurse check the patient's O2 saturation using pulse oximetry and discover the O2 saturation is only 80%. Urgent arrangements are made to transfer the patient to ICU, 查房准备早晨8点30分,开始查房。今天,我们和呼吸内科的医生一起查房。1107号病房患者是史密斯先生,65岁,昨天下午入院。查房小组由7人组成,包括呼吸内科的主治医生、专科住院医生、住院医生和3名医学生。先由昨天受治患者并完成病历的住院医生报告病情。史密斯先生表现为咽痛、咳嗽多痰、气促,发烧已有5天,在当地一家小医院住院时静脉用丁胺卡那针剂治疗无效,以肺炎转入我院治疗。患者家属将病历及胸透片、化验单等资料交给了一位住院医生,并被遣忘在值班室。一个医学生迅速地到护理站将记录拿了过来。检查提示,昨晚患者的心率和呼吸频率均显著增快。住院医生迅速复查了这名患者,先是肺部听诊,然后检查患者咽喉部。体格检查完毕后,他注意到患者右肺底有湿罗音,咽喉部有脓性分泌物。未提供昨天患者的胸片、血细胞和血气分析的结果。漏查血气分析。然后,主诊医生迅速地检查了一下患者,注意到患者双侧肺底有湿罗音,血压90/60毫米汞柱(mmHg),心率120次/分,呼吸20次/分。他迅速开出血气分析和胸透片的检查医嘱。我们一边等待结果,一边让护士查一下血氧饱和度,结果血氧饱和度(SaO2)仅为86%。患者被迅速转移到重症监护室。
A subsequent ABG shows pH 7.50, PC O2 30rnnff/g and P O2 46mm Hg. Within 1 hr. of ICU admission, the patient requires intubation and mechanical ventilation. 血气分析报告提示pH为7.50,二氧化碳分压(PC O2 )为30毫米汞柱,氧分压(P O2 )为46毫米汞柱。转入重症监护室1小时后,患者接受气管插管、机械通气。
Adequate preparation for patient rounds is essential for efficient, quality patient care. Poor preparation not only prolongs patient rounds, but worse it may delay “timely” decisions concerning the patient treatment, and even delay recovery and discharge. Ultimately it may compromise the quality of medical care and ominously even result in premature death! 查房前的充分准备对向患者提供高效和高质量的诊治非常重要!准备工作不充分不仅延误了整个查房的时间,更重要的是,它延误了对患者病情的及时处理,甚至会延误患者的恢复和出院。最终会降低医疗服务的质量,甚至可能导致患者因丧失抢救时机而早死。
Adequate preparation for patient rounds should first include knowledge of the patient's current condition, which may be obtained by a brief “pre-round” chart review, including the nursing record and a bedside evaluation as well. This should be followed by collecting current lab, X-ray, and pathology reports to be available for review during rounds. Although the written reports may not be available on the chart, often a preliminary report may be obtained either by phone or from a computer monitor on the ward. These results may then be discussed with other team members during patient rounds, which will facilitate earlier diagnosis and treatment. 查房准备首先是要了解患者目前的状况,这些信息可以通过查房前的病历回顾,包括护理记录和床边评估等获得。接着是收集患者现有的实验室、X线和病理报告以备查房时使用。有时查房前可能拿不到正式报告,但可以通过电话或病区的计算机先得到初步报告。这些结果可以在查房时供查房小组讨论,这将有利于疾病的早期诊断和治疗
“Tools” are extremely necessary to perform a proper physical exam. No physician should ever begin rounds without a stethoscope and penlight in his coat pocket. Although he may not always carry a tongue blade, chopsticks or a teaspoon could be substituted for the oropharyngeal exam. Inspection of the oral mucosa may faciltate diagnosis of such diseases as pharyngitis, tonsillitis, mucositis, oral candidiasis or oral ulcerations, each of which may present clues to such diseases as SLE, HIV infection, herpes simplex, leukemia, megaloblastic anemia, or Behcet's disease. 工具对检查极其重要。任何一个医生在开始查房时至少要有听诊器和笔式电筒,也许他不一定总带着压舌板,但可以设法用筷子或勺子等代替进行口咽部的检查。检查口腔粘膜有助于咽炎、扁桃体炎、粘膜炎、口腔白色念珠菌病或是口腔溃疡的诊断,从而为系统性红斑狼疮(SLE)、艾滋病(AIDS)、单纯疱疹、白血病、恶性贫血或Behcet病等疾病提供线索。
The obvious importance of a stethoscope for physical examination should need no explanation. Lung auscultation may detect rales, rhonchi or wheezes; valuable clues to such illnesses as pneumonia, asthma or congestive heart failure (CHF). Decreased breath sounds may be noted with a pleural effusion, COPD, atelectasis and pneumothorax. The Cardiologist uses the stethoscope for cardiac auscultation; listening carefully to detect irregular rhythms, an S3 or S4 often noted in CHF and heart murmurs heard with stenotic valve lesions. Likewise, the stethoscope allows the examiner to detect mid systolic clicks in mitral valve prolapse and pericardial friction rubs. 很显然,体格检查时听诊器的作用非常重要。肺部听诊可以听到湿罗音、干罗音或哮鸣音,这对诊断肺炎、哮喘或充血性心力衰竭很有价值。呼吸音减低则可以在胸腔积液、慢性阻塞性肺病(COPD)、肺不张和气胸时被发现。心脏科医生使用听诊器进行心脏听诊,仔细倾听来发现心律失常、心力衰竭时常出现的第三心音(S3)和第四心音(S4)以及狭窄性瓣膜病变时产生的心脏杂音。同样听诊器有利于检查者发现二尖瓣脱垂时收缩中期喀喇音和心包摩擦音。
Other useful tools for patient rounds include the following:
1. A small ruler to measure skins lesions, nodules and PPD skin test reactions;
2. A reflex hammer to assess DTR's during the neurologic exam;
3.A small pocketsize reference book that lists medications and their dosage. Alternatively, many physicians now purchase hand-held mini-computers such as the Palm Pilot that stores a veritable “wealth” of medical information accessed with a mere tap of the finger.
1. 一把小尺:用于测量皮肤损害和结节的大小及PPD皮试反应;
2. 一把叩诊锤:用于神经系统检查时评价DTR;
3. 一本袖珍药物手册:用于查阅药物和药物剂量。现在许多医生拥有手提式微型计算机,如“掌上电脑”,手指轻轻一点就能查阅储存的大量有价值的医疗信息。
During patient rounds the resident should bring the nursing record to the bedside where the team can readily review pertinent patient data such as vital signs, fluid volume intake and urine output during the previous 24 hrs. The current medication list and the nurse's notes that may report frequent changes in the patient's condition must also be reviewed. Often several medications may be discontinued or switched to the oral route. 查房时,住院医生必须将护理记录拿到床边,这样有利于查房小组很容易地了解患者有关的病情,如生命休征、24小时液体摄入量和尿量。还应该审查目前药物使用情况和记录患者病情变化的护理记录。有些药物常常会被停掉或改为口服。
Finally, the physician's attire and clothing must bear a professional appearance. Usually white coats are the standard physician's attire. However, frequently physicians neglect to change their coat when it becomes “soiled” with blood, ink, urine or even fecal matter. This not only presents an unpleasant appearance to the patient, but also poses a risk of transmitting infection. An identification badge that identifies the physician's name and level of training (attending, fellow, resident) must be clearly visible to the patient. This is important not only to identify the physician, but also for security reasons. 最后需要强调的是,医生的着装必须符合职业的特点。白大褂是医生的校准职业装,但医生常常忽略衣服所沾上的血迹、钢笔水、小便甚至大便。穿着这样的衣服工作不仅使病人感到医生外观不雅,而且有传播疾病的危险。必须佩带标明医生姓名和等级(如主治医生、专科住院医生和普科住院医生)的身份牌,使患者能够一目了然。这对识别医生身份和安全考虑都很重要。
In summary, adequate preparation for patient rounds is essential for efficient, organized and productive patient care. It not only facilitates efficient care, but also will engender patient confidence and trust in the physician team. Furthermore, poor preparation for patient rounds often leads to the omission of pertinent patient information and thus compromises the quality and safety of patient care. 总之,查房前准备充分对实施有效、有序和富有成果的病人护理是至关重要的。它不仅有助于促进医疗工作,而且会增强患者对于医务人员的信任。相反,查房准备不足导致患者信息的遗漏,损害患者的治疗及安全。