（精）14-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 必威体育精装版更新的药物界面： 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 patient’s 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 FINISH WRITING ORDERS FOR TRANSFER TO THE INTENSIVE CARE UNIT ON YOUR NEW PATIENT WITH DIABETIC KETOACIDOSIS 7:30 PM:你写完了将新接收的糖尿病酮症酸中毒的患者转到重症监护室的医嘱 8:00 PM: YOU AND YOUR SENIOR ARE FINISHING IN THE EMERGENCY ROOM WHEN YOU ARE PAGED TO A DELIVERY 8:00 PM: 你和