查房準(zhǔn)備patient rounds

Preparation for Patient Rounds

查房準(zhǔn)備

It’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.

早晨8點(diǎn)30分，開(kāi)始查房。今天，我們和呼吸內(nèi)科的醫(yī)生一起查房。1107號(hào)病房患者是史密斯先生，65歲，昨天下午入院。查房小組由7人組成，包括呼吸內(nèi)科的主治醫(yī)生、�？谱≡横t(yī)生、住院醫(yī)生和3名醫(yī)學(xué)生。先由昨天受治患者并完成病歷的住院醫(yī)生報(bào)告病情。史密斯先生表現(xiàn)為咽痛、咳嗽多痰、氣促，發(fā)燒已有5天，在當(dāng)?shù)匾患倚♂t(yī)院住院時(shí)靜脈用丁胺卡那針劑治療無(wú)效，以肺炎轉(zhuǎn)入我院治療�；颊呒覍賹⒉�歷及胸透片、化驗(yàn)單等資料交給了一位住院醫(yī)生，并被遣忘在值班室。一個(gè)醫(yī)學(xué)生迅速地到護(hù)理站將記錄拿了過(guò)來(lái)。檢查提示，昨晚患者的心率和呼吸頻率均顯著增快。住院醫(yī)生迅速?gòu)?fù)查了這名患者，先是肺部聽(tīng)診，然后檢查患者咽喉部。體格檢查完畢后，他注意到患者右肺底有濕羅音，咽喉部有膿性分泌物。未提供昨天患者的胸片、血細(xì)胞和血?dú)夥治龅慕Y(jié)果。漏查血?dú)夥治觥Ｈ缓�，主診醫(yī)生迅速地檢查了一下患者，注意到患者雙側(cè)肺底有濕羅音，血壓90／60毫米汞柱(mmHg)，心率120次／分，呼吸20次／分。他迅速開(kāi)出血?dú)夥治龊托赝钙�的檢查醫(yī)囑。我們一邊等待結(jié)果，一邊讓護(hù)士查一下血氧飽和度，結(jié)果血氧飽和度(SaO2)僅為86％�；颊弑谎杆俎D(zhuǎn)移到重癥監(jiān)護(hù)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?dú)夥治鰣?bào)告提示pH為7.50，二氧化碳分壓(PC O2 )為30毫米汞柱，氧分壓(P O2 )為46毫米汞柱。轉(zhuǎn)入重癥監(jiān)護(hù)室1小時(shí)后，患者接受氣管插管、機(jī)械通氣。

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!

查房前的充分準(zhǔn)備對(duì)向患者提供高效和高質(zhì)量的診治非常重要！準(zhǔn)備工作不充分不僅延誤了整個(gè)查房的時(shí)間，更重要的是，它延誤了對(duì)患者病情的及時(shí)處理，甚至?xí)�延誤患者的恢復(fù)和出院。最終會(huì)降低醫(yī)療服務(wù)的質(zhì)量，甚至可能導(dǎo)致患者因喪失搶救時(shí)機(jī)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.醫(yī).學(xué)全.在.線m.52667788.cn

查房準(zhǔn)備首先是要了解患者目前的狀況，這些信息可以通過(guò)查房前的病歷回顧，包括護(hù)理記錄和床邊評(píng)估等獲得。接著是收集患者現(xiàn)有的實(shí)驗(yàn)室、X線和病理報(bào)告以備查房時(shí)使用。有時(shí)查房前可能拿不到正式報(bào)告，但可以通過(guò)電話或病區(qū)的計(jì)算機(jī)先得到初步報(bào)告。這些結(jié)果可以在查房時(shí)供查房小組討論，這將有利于疾病的早期診斷和治療。

“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.

工具對(duì)檢查極其重要。任何一個(gè)醫(yī)生在開(kāi)始查房時(shí)至少要有聽(tīng)診器和筆式電筒，也許他不一定總帶著壓舌板，但可以設(shè)法用筷子或勺子等代替進(jìn)行口咽部的檢查。檢查口腔粘膜有助于咽炎、扁桃體炎、粘膜炎、口腔白色念珠菌病或是口腔潰瘍的診斷，從而為系統(tǒng)性紅斑狼瘡(SLE)、艾滋病(AIDS)、單純皰疹、白血病、惡性貧血或Behcet病等疾病提供線索。

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.

很顯然，體格檢查時(shí)聽(tīng)診器的作用非常重要。肺部聽(tīng)診可以聽(tīng)到濕羅音、干羅音或哮鳴音，這對(duì)診斷肺炎、哮喘或充血性心力衰竭很有價(jià)值。呼吸音減低則可以在胸腔積液、慢性阻塞性肺病(COPD)、肺不張和氣胸時(shí)被發(fā)現(xiàn)。心臟科醫(yī)生使用聽(tīng)診器進(jìn)行心臟聽(tīng)診，仔細(xì)傾聽(tīng)來(lái)發(fā)現(xiàn)心律失常、心力衰竭時(shí)常出現(xiàn)的第三心音(S3)和第四心音(S4)以及狹窄性瓣膜病變時(shí)產(chǎn)生的心臟雜音。同樣聽(tīng)診器有利于檢查者發(fā)現(xiàn)二尖瓣脫垂時(shí)收縮中期喀喇音和心包摩擦音。醫(yī)學(xué) 全在.線提供

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.

其他工具包括：

1. 一把小尺：用于測(cè)量皮膚損害和結(jié)節(jié)的大小及PPD皮試反應(yīng)；
2. 一把叩診錘：用于神經(jīng)系統(tǒng)檢查時(shí)評(píng)價(jià)DTR；
3. 一本袖珍藥物手冊(cè)：用于查閱藥物和藥物劑量。現(xiàn)在許多醫(yī)生擁有手提式微型計(jì)算機(jī)，如“掌上電腦”，手指輕輕一點(diǎn)就能查閱儲(chǔ)存的大量有價(jià)值的醫(yī)療信息。

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.

查房時(shí)，住院醫(yī)生必須將護(hù)理記錄拿到床邊，這樣有利于查房小組很容易地了解患者有關(guān)的病情，如生命休征、24小時(shí)液體攝入量和尿量。還應(yīng)該審查目前藥物使用情況和記錄患者病情變化的護(hù)理記錄。有些藥物常常會(huì)被停掉或改為口服。

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.

最后需要強(qiáng)調(diào)的是，醫(yī)生的著裝必須符合職業(yè)的特點(diǎn)。白大褂是醫(yī)生的校準(zhǔn)職業(yè)裝，但醫(yī)生常常忽略衣服所沾上的血跡、鋼筆水、小便甚至大便。穿著這樣的衣服工作不僅使病人感到醫(yī)生外觀不雅，而且有傳播疾病的危險(xiǎn)。必須佩帶標(biāo)明醫(yī)生姓名和等級(jí)(如主治醫(yī)生、�？谱≡横t(yī)生和普科住院醫(yī)生)的身份牌，使患者能夠一目了然。這對(duì)識(shí)別醫(yī)生身份和安全考慮都很重要。

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.

總之，查房前準(zhǔn)備充分對(duì)實(shí)施有效、有序和富有成果的病人護(hù)理是至關(guān)重要的。它不僅有助于促進(jìn)醫(yī)療工作，而且會(huì)增強(qiáng)患者對(duì)于醫(yī)務(wù)人員的信任。相反，查房準(zhǔn)備不足導(dǎo)致患者信息的遺漏，損害患者的治療及安全。