1美国全科住院医师的一天.ppt

Personal Digital Assistant 个人数字助理 (PDA) ? Data base meta-analysis: Up-to-date 数据库 meta 分析：更新 ? Internet 网络 ? Books: dictionaries, texts 书籍：字典，课本 ? Tools: OB wheel, algorithms 工具：产科轮表；流程图 ? Most updated drug interface: epocrates 最新更新的药物界面： epocrates ? Diagnosis 诊断 ? Therapy 治疗 ? Symtoms 症状 ? Labs 实验室检查 ? Med Calculations 医学计算 ? Tables 表格 Use of Electronic Medical Records (EMR), initiated in the U.S. by Family Medicine Physicians 使用由家庭医生引入美 国的医学电子档案 Air panels to use within patient rooms for all documentation 在病房里可 以无线连接所有文件 ? 5:00 PM: FINISHED WITH CLINIC, YOU RETURN TO THE HOSPITAL FOR CALL 5:00 PM: 完成诊所工作，回到医院值班 ? 5:30 PM: YOU RETURN TO THE HOSPITAL AND CHECK OUT WITH YOUR COLLEAGUES 5:30 PM: 你回到医院跟同事接班 ? 6:00PM : YOU ARE PAGED TO SEE TWO PATIENTS IN THE EMERGENCY ROOM 6:00PM : 你被叫去看两个急诊室里的病人 Admissions 收入院 ? Throughout the day 贯穿整天 ? Emergency Room physician stabilizes patient and transfers patient to the family medicine team 急诊医生稳定病情后就将病人 转给全科医生团队 ? Residents review ER events and patients work -up 住院医生回 顾急诊情况和病人的检查结果 ? Call for old records 调出以往的记录 ? Full work-up: History and Physical 整体情况：病史和查体 ? Intern sees patient first, unless critical (senior resident would go with intern then) 若非紧急情况，实习医生先看病人（若紧急则高 年级住院医生一起去） History Physical 病史和查体 ? Chief Complaint 主诉 ? History of Present Illness 现病史 ? Past Medical / Surgical History 既往医疗 / 手术史 ? Allergies / Medications 过敏史 / 用药史 ? Review of Systems 系统回顾 ? Social History: 社会史 ? Tobacco/alcohol/drugs 烟 / 酒 / 药物 ? Family situation 家庭史 ? Sexual history 性生活史 ? Spiritual history 精神病史 History Physical 病史和查体 ? Vital Signs 生命体征 ? Physical Exam 体格检查 ? Labs 实验室检查 ? Studies 研究 ? Assessment 病情评估 ? Plan 诊疗计划 ? Discuss with senior, fine tune plan 与高年级住院医生 讨论，调整诊疗计划 ? Intern and senior discuss with attending physician 实习医生和高年级住院医生与主诊医师讨论 ? 7:30 PM : YOU F