禁忌药值班时常会想开但绝对不能开!.docVIP

禁忌藥 ( 值班時常會想開,但絕對不能開! ) 再痛都不可給Keto(或其它NSAID)! 內科住院病人多為腎功能不好(大多都很老)或高潰瘍risk(有潰瘍病史或high stress),給了易AKI/GI bleeding 打嗝不可給Baclofen! 除非確認病人沒腎功能異常,否則會造成病人永遠昏睡不醒! (既使有在HD也會發生) 口服降血糖藥 (所有OHA, 但Novonorm除外. 建議打RI或Novorapid最安全有效) 除非是病人本來就巳經長期在吃,否則腎功能不好者容易變成嚴重低血糖(Amaryl/Nonin) N/S, NaHCO3, 3% Saline不可使用在〔最近曾Na = 120〕,一定要在CR的指導下才可開 既使是N/S,也容易因Na上昇太快而osmotic demyelination (因為常在急診就巳補過一堆N/S) Survival tips Vital signs, vital signs, vital signs: T, P, R, BP, SpO2, Consciousness 病人大於學習, 義務大於權利, 如果病人是你媽媽你會怎麼做? R1一定會被罵, 也一定會犯錯, 也一定會有病人mortality. R1要越多critical的case, complaint很多的家屬, 值班很累接很多病人, 才會進步的快. 不要怕, 每個人都被罵過, 盡力了就好. 一定要到bedside看病人 = relieve symptoms = diagnostic workups = definite treatment 換course交班要交: 兩個人一起把 1) order單看一遍 2) 最近lab看一遍 3) 最近CXR看一遍 4) 主治醫師何時查房 5) 病房有哪些活動 6) 哪些data要追 開藥先算estimated Ccr然後查如何調劑量 Diet ~30kcal/kg; eg 60kg - 1750-1800kcal/day COPD: high fat diet; Dialysis: dialysis diet; CRF not under dialysis: low protein diet Persistent diarrhea: elemental diet; Gout: low purine diet; DM: DM diet CHF: low sodium diet, 限水1000ml/day, eg. NG: 1750kcal/1133ml/day 限鹽: 2g salt起跳 Dialysis: dialysis diet CRF not under dialysis: low protein diet Persistent diarrhea: elemental diet Gout: low purine diet IVF 無糖: N/S, H/S 500ml; Lactate ringer 500ml: 有K 4meq, Na約為N/S的85%, 有Ca 有糖: D10W, D5W, D2.5W 500ml Taita No.5 500ml 有K 10meq, Na 約為N/S的 1/4, sugar濃度同D10W, 有Mg! * 含Ca, Mg的東東不可以跟Jusonin (NaHCO3, 現稱Rolican)混在一起, 會結晶 * 只能泡Cryptococcus antigen, TB PCR (自費), amylase (chylothorax), cell block(病理單) 2. 腹水六管: key routine, albumin, gram stain, bacterial culture, (Gram stain 和bacterial culture共一管), AFS+ TB culture, fungus culture, cytology *其他: Cryptococcus antigen, TB PCR (自費), cell block(病理單) *SBP: PMN=250 or WBC=500 and PMN=50% 3. CSF 9管: key routine, Indian ink (routine和Indian ink共一管), TP, glucose, gram stain, bacterial culture, (Gram stain 和bacterial culture共一管), AFS+ TB culture, fungus culture, cryptococcus antigen(fungus culture和cryptococcus antigen起來), cytology, virus isolation, 兩管冰冰