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第一次準備病例報告就上手,
如何準備病例報告?
How to Prepare A Case Report Presentation
2015/3/12 (四) 17:10~19:10 @台北醫學大學
新光吳火獅紀念醫院 劉人瑋/張婷雅藥師新光吳...
} 檔案在這裡
檔案下載
2
http://goo.gl/ue1QDy
請加入
粉絲團喔~
3
} [幫助一] 馬上就會用到,實習一定會有病例報告 (case
report),今天的課就是要告訴你如何準備
} [幫助二] 從教室走向病房,教室只有學生、病房只有病
人,如何快速掌握病情? 彙整病人的問題,甚至提出解決
方案?
} [幫助三]...
臨床藥師在幹嗎?
5
護理人員
社工師
營養師
住院醫師
主治醫師
臨床藥師
路人甲
} “Pharmacotherapy Casebook: A Patient-
Focused Approach, 8th Edition (2011)”
} [特色]:
- 由美國將近100個機構,超過190位藥師撰寫
之臨床病例
- 配合教...
} 哪裡可以取得?
- [書籍] 合記書局 售價1,125元 (ISBN 9780-0717-46267)
- [網路] Access Pharmacy
(http://accesspharmacy.com/caseToc.aspx)
教材
7
} [主訴 Chief Complaint]:
- "This is the worst pain I have ever felt in my life.“
主訴一定是以病人的口吻描述,通常描述的症狀/病徵,或就
診原因
} [最近病史 HP...
} [最近病史 HPI]:
to his jaw and is accompanied by nausea and
diaphoresis. The pain first started approximately 6
hours ago af...
} [過去病史 PMH]:
- HTN
- Type 2 DM
- Dyslipidemia
- CAD with PCI with a bare metal stent 10 years ago
過去病史最好包括疾病、嚴重度/分期、曾經接受的...
} [家族史 FH]:
- Father died from heart failure at age 75 and mother
is alive at age 88 with HTN and type 2 DM.
家族史並非族譜,僅需描述與...
} [家族史 FH]: 家族樹 (family tree) 通常沒什麼幫助!
請記錄與「健康」有關的事項,其他的…就…
病例報告 - FH
12
冠狀動脈血管疾病掛了!
I
II
III
Coronary artery disease
Traf...
} [用藥史 Meds]:
- Aspirin 81 mg po daily
- Metoprolol tartrate 25 mg po BID
- Simvastatin 40 mg po QHS
- Metformin 500 mg po...
} [系統總覽 ROS]:
- Positive for some baseline CP on exertion for the
past 3~4 weeks, now with CP at rest
} [理學檢查 PE]:
- Gen: ...
} [理學檢查 PE]:
- Lungs: Few dependent inspiratory crackles; bi-
basilar rales; no wheezes
- CV: Normal S1 and S2, no MRG
- A...
理學檢查是同學們最不熟悉的部份,試著去了解每項理學檢
查結果代表的意義,及這項檢查想要偵測的是什麼? 例如:
- Lungs: Few dependent inspiratory crackles; bi-
basilar rales; no ...
} [實驗室檢驗 LAB]:
- Na 134 mEq/L Ca 9.8 mg/dL K 4.4 mEq/L Mg 2.0
mg/dL Cl 102 mEq/L PO4 2.4 mg/dL
- Hgb 14.0 g/dL Hct 44% WBC...
實驗室檢驗值的重點在於判讀,而非高低,因此,應該避免
沒有頭腦的大盤趨勢圖 或 會計報表,而著重於某項 (或某
些) 檢驗值的異常 (或正常) 所代表的意義,例如:
- Troponin I 8.6 ng/ml (0~0.50 ng/ml) [...
} [心電圖 ECG]:
- ECG taken on arrival in the ED showing ST-segment
elevation in leads II, III, and aVF.
病例報告 - Others
19
} [評估 Assessment]:
- Acute inferior STEMI
書中並非使用「診斷 (diagnosis)」一字,而是使用「評估
(assessment)」,避免僅列出病名,而非整體評估
} [問題 Questions]:
...
藥物相關問題
} 什麼是藥物相關問題 (drug-related problem)?
- 藥物相關問題分類:
國際上藥物相關問題分類眾多,包括ASHP、PCNE等 (Ann
Pharmacother. 2004; 38: 859-67. PMI...
} [問題 Questions]:
- Problem identification
- Which findings in this patient's case history are
consistent with acute STEMI...
怎麼寫「SOAP」?
} 病歷閱讀/SOAP繕寫
- S-O-A-P是一種「思考」,不是一種「表格」
常見錯誤: 寫 (抄) 的跟醫師一樣 (把診斷當作評估)、沒有問
題為導向 (不知道自己在寫什麼)
醫師版 藥師版
S (主觀) 病患主觀描述...
} [參考答案 Answers]:
- Symptoms: A substernal, crushing, and pressure-
like chest pain that radiates to his jaw and is
accomp...
} [參考答案 Answers]:
- Modifiable risk factors of this patient:
- Lifestyle: Smoking
- Medical: Hyperlipidemia, type II DM, H...
} [問題 Questions]:
- Desired Outcome
- What is the immediate goal of therapy in this patient?
- How can this goal be achiev...
} [參考答案 Answers]:
- The short-term goals of treatment for the ACS are:
- Early restoration of blood flow to the infarct-re...
怎麼寫「SOAP」?
} Medical problem: chest pain, not relieved by rest.
S:
O:
A: ST-segment elevated myocardial infarction (STEMI)...
} [問題 Questions]:
- Therapeutic Alternatives
- What nonpharmacologic therapeutic alternative can
also achieve the immediat...
} [問題 Questions]:
- Therapeutic Alternatives
- What is the role of adjunctive anticoagulant therapy
during PCI, and how sh...
} [參考答案 Answers]:
- Monitor parameters of parenteral anticoagulants:
- Efficacy:
- Safety: S&S of bleeding (e.g. uncontrol...
} [問題 Questions]:
- Therapeutic Alternatives
- What is the role of adjunctive antiplatelet therapy
before, during, and aft...
} [參考答案 Answers]:
- Clopidogrel 75 mg orally once daily recommended in
addition to aspirin in patients with STEMI whether ...
} [問題 Questions]:
- Therapeutic Alternatives
- What are other important goals of therapy in this
patient?
} [參考答案 Answers]...
} [問題 Questions]:
- Therapeutic Alternatives
- Based on the history and presentation, what initial
drug therapy is indicat...
} [參考答案 Answers]:
- Nitroglycerin 10 mcg/min IVF for persistent
discomfort due to ischemia, control of high blood
pressure...
} [問題 Questions]:
- Outcome Evaluation
- How should the recommended therapy be
monitored for efficacy and adverse effects?...
} [參考答案 Answers]:
- Adverse effects:
病例問題 – 病例內容
38
Drug Adverse effects Monitoring
Aspirin Dyspepsia,
bleeding, gastritis...
} [參考答案 Answers]:
病例問題 – 病例內容
39
Drug Adverse effects Monitoring
Enoxaparin Bleeding, heparin-
induced
thrombocytopenia
(H...
} [參考答案 Answers]:
病例問題 – 病例內容
40
Drug Adverse effects Monitoring
Captopril Hypotension,
cough, hyper-
kalemia,
prerenal
az...
} [療程 Clinical Course]:
病例導讀 – 病例內容
41
2/18 15:40 2/21 9:002/18 14:40
ED PCI Echocardio-
graphy
Dx of
STEMI
2/18 8:00
Brea...
} [問題 Questions]:
- Patient Education
- Based on his hospital course, which discharge
medications would be most appropriat...
} [參考答案 Answers]:
- To prevention LV remodeling following MI
- ACEIs, beta-blockers, and selective aldosterone
receptor an...
} [參考答案 Answers]:
- Aspirin 100 mg PO QD indefinitely
- Clopidogrel 100 mg PO QD at least 1 month
- Carvedilol 12.5 mg PO ...
} [療程 Clinical Course]:
- Six months later, he states that he is really trying to
exercise more and eat better. He has bee...
} [療程 Clinical Course]:
- Labs reveal the following:
- TC 135 mg/dL TG 89 mg/dL HDL 39 mg/dL
LDL 78 mg/dL
- CK 450 IU/L
- ...
} 內文:
- 字型大小: 10人以上「24」以上為佳
- 字型挑選: 勿使用太細、太扭曲的字體
- 內文呈現: 條列式,勿長篇大論
- 內容數量: 30分鐘約30~35張、50分鐘約40~45張、60分
鐘不要超過50張
} 圖表:
- 大小...
} 上台前:
- 放鬆活動: 全身放鬆一下!走走動動會比坐在原地緊張好
- 內容提示: 在投影片中放內容提示比寫稿子死背好
} 演講時:
- 肢體眼神: 肢體 (手為主) 活動較能聚焦,眼神與聽眾要能
接觸 (別只看著螢幕或某個奇怪的地方)
-...
} 提供準備病例報告同學建議:
- 至少花時間練習1~2個病例
- 第1個通常只拿50分,但第2個可以進步到75分
建議參考教科書,並配合最新治療指引
- 從定義、症狀、診斷、治療到預後 [別只看治療]
想要贏在起跑點,只有早點起跑
「從準備報...
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第一次準備病例報告就上手

為準備病例報告頭痛嗎?針對藥學系學生的第一次準備就上手喔~

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第一次準備病例報告就上手

  1. 1. 第一次準備病例報告就上手, 如何準備病例報告? How to Prepare A Case Report Presentation 2015/3/12 (四) 17:10~19:10 @台北醫學大學 新光吳火獅紀念醫院 劉人瑋/張婷雅藥師新光吳火獅紀念醫院 劉人瑋藥師
  2. 2. } 檔案在這裡 檔案下載 2 http://goo.gl/ue1QDy
  3. 3. 請加入 粉絲團喔~ 3
  4. 4. } [幫助一] 馬上就會用到,實習一定會有病例報告 (case report),今天的課就是要告訴你如何準備 } [幫助二] 從教室走向病房,教室只有學生、病房只有病 人,如何快速掌握病情? 彙整病人的問題,甚至提出解決 方案? } [幫助三] 什麼是「DTP」? 怎麼寫「SOAP」? 如果你不 知道,一定要看後續報導 這堂課對你有什麼幫助? 4
  5. 5. 臨床藥師在幹嗎? 5 護理人員 社工師 營養師 住院醫師 主治醫師 臨床藥師 路人甲
  6. 6. } “Pharmacotherapy Casebook: A Patient- Focused Approach, 8th Edition (2011)” } [特色]: - 由美國將近100個機構,超過190位藥師撰寫 之臨床病例 - 配合教科書章節擬訂,每個病例都有清楚的學習目標、參 考章節/文獻 } [意義]: - 可學到道地且精準的病例繕寫 - 提供初學者快速上手的一本書 教材 6
  7. 7. } 哪裡可以取得? - [書籍] 合記書局 售價1,125元 (ISBN 9780-0717-46267) - [網路] Access Pharmacy (http://accesspharmacy.com/caseToc.aspx) 教材 7
  8. 8. } [主訴 Chief Complaint]: - "This is the worst pain I have ever felt in my life.“ 主訴一定是以病人的口吻描述,通常描述的症狀/病徵,或就 診原因 } [最近病史 HPI]: - Gary Roberts is a 68-year-old man admitted to the ED complaining of chest pressure/pain lasting 20~30 minutes occurring at rest. He describes the pain as substernal, crushing, and pressurelike that radiates 病例報告 - CC & HPI 8 Note
  9. 9. } [最近病史 HPI]: to his jaw and is accompanied by nausea and diaphoresis. The pain first started approximately 6 hours ago after he ate breakfast and was unrelieved by antacids or SL NTG x 3. He also states he has been experiencing intermittent chest pain over the past 3~4 weeks with minimal exertion. 最近病史描述的是與本次就診有關的故事,會進一步描述主 訴,包括症狀、發生時間、相關處置等等 病例報告 - HPI 9 Note
  10. 10. } [過去病史 PMH]: - HTN - Type 2 DM - Dyslipidemia - CAD with PCI with a bare metal stent 10 years ago 過去病史最好包括疾病、嚴重度/分期、曾經接受的治療 及 治療反應 (是否達治療目標),例如: “Chronic kidney disease (Stage VI): eGFR 18 ml/min/ 1.73 m2 two weeks ago.” 病例報告 - PMH 10 Note
  11. 11. } [家族史 FH]: - Father died from heart failure at age 75 and mother is alive at age 88 with HTN and type 2 DM. 家族史並非族譜,僅需描述與疾病相關之家族成員狀況即 可,以直系血親為主 (感染性疾病除外) } [社交史 SH]: - (+) Tobacco x 20 years but quit when he received his BMS 10 years ago; drinks beer usually on weekends; denies illicit drug use. 病例報告 - FH 11 Note 社交史描述的重點是生活型態
  12. 12. } [家族史 FH]: 家族樹 (family tree) 通常沒什麼幫助! 請記錄與「健康」有關的事項,其他的…就… 病例報告 - FH 12 冠狀動脈血管疾病掛了! I II III Coronary artery disease Traffic accident 男的 女的 Note 車禍也掛了~
  13. 13. } [用藥史 Meds]: - Aspirin 81 mg po daily - Metoprolol tartrate 25 mg po BID - Simvastatin 40 mg po QHS - Metformin 500 mg po BID - SL NTG PRN CP } [過敏史 All]: NKDA (no know drug allergy) 用藥史/過敏史必須詳盡,用藥史最好包括遵醫囑性,過敏史 最好包括症狀甚至是再暴露反應,這些都是連續性照護重點 病例報告 - 用藥史 13 用藥史應包括藥名、劑量、頻次、用法 Note
  14. 14. } [系統總覽 ROS]: - Positive for some baseline CP on exertion for the past 3~4 weeks, now with CP at rest } [理學檢查 PE]: - Gen: WDWN man, A & O x 3, still with ongoing chest pain, somewhat anxious - VS: BP 145/92, P 89, RR 18, T 37.1; Wt 95 kg, Ht 170 cm - HEENT: PERRLA, EOMI, fundi benign; TMs intact - Neck: No bruits; mild JVD; no thyromegaly 病例報告 - ROS & PE 14 系統總覽描述的是醫療人員對病人的「印象」
  15. 15. } [理學檢查 PE]: - Lungs: Few dependent inspiratory crackles; bi- basilar rales; no wheezes - CV: Normal S1 and S2, no MRG - Abd: Soft, nontender; liver span 10~12 cm; no bruits - Genit/Rect: Deferred - MS/Ext: Normal ROM; muscle strength on right 5/5 UE/LE; on left 4/5 UE/LE; pulses 2+; no femoral bruits or peripheral edema - Neuro: CNs II–XII intact; DTRs decreased on left; negative Babinski's sign 病例報告 - PE 15
  16. 16. 理學檢查是同學們最不熟悉的部份,試著去了解每項理學檢 查結果代表的意義,及這項檢查想要偵測的是什麼? 例如: - Lungs: Few dependent inspiratory crackles; bi- basilar rales; no wheezes 代表聽診時,病人吸氣時出現雜音,兩側肺底部有囉音,但 沒有哮喘音 [解析] 醫師藉由聽診得知病人可能有肺水腫 (pulmonary edema) 的問題,因此將安排胸部X光 或 心臟超音波檢查 病例報告 - PE 16 Note
  17. 17. } [實驗室檢驗 LAB]: - Na 134 mEq/L Ca 9.8 mg/dL K 4.4 mEq/L Mg 2.0 mg/dL Cl 102 mEq/L PO4 2.4 mg/dL - Hgb 14.0 g/dL Hct 44% WBC 5.0 x 103/mm3 Plt 268 x 103/mm3 - PT 12.5 sec aPTT 32.4 sec INR 1.0 - T. chol 159 mg/dL Trig 92 mg/dL LDL 105 mg/dL HDL 36 mg/dL - AST 22 U/L ALT 30 U/L BUN 15 mg/dL SCr 1.0 mg/dL Alk Phos 75 U/L HbA1c 7.6% Glu 140 mg/dL Troponin I 8.6 ng/mL 病例報告 - LAB 17
  18. 18. 實驗室檢驗值的重點在於判讀,而非高低,因此,應該避免 沒有頭腦的大盤趨勢圖 或 會計報表,而著重於某項 (或某 些) 檢驗值的異常 (或正常) 所代表的意義,例如: - Troponin I 8.6 ng/ml (0~0.50 ng/ml) [異常] [解析] Troponin是心肌受損時釋放出來的蛋白質,作為心肌 梗塞診斷與預後指標 - PT 12.5 sec aPTT 32.4 sec INR 1.0 [正常] [解析] 凝血功能將影響治療策略,決定是否使用抗凝血藥物 病例報告 - LAB 18 Note
  19. 19. } [心電圖 ECG]: - ECG taken on arrival in the ED showing ST-segment elevation in leads II, III, and aVF. 病例報告 - Others 19
  20. 20. } [評估 Assessment]: - Acute inferior STEMI 書中並非使用「診斷 (diagnosis)」一字,而是使用「評估 (assessment)」,避免僅列出病名,而非整體評估 } [問題 Questions]: - Problem identification - Outcome evaluation - Desired outcome - Patient education - Therapeutic alternatives - Optimal plan 病例報告 - A & Q 20 Note
  21. 21. 藥物相關問題 } 什麼是藥物相關問題 (drug-related problem)? - 藥物相關問題分類: 國際上藥物相關問題分類眾多,包括ASHP、PCNE等 (Ann Pharmacother. 2004; 38: 859-67. PMID 15054145) 給藥後給藥前 未治療之適應症 應監測 (治療前) 無適應症治療 劑量、療程、用法不當 應監測 (治療後) 藥物、疾病交互作用 效果不佳、重複處方 有衛教需求 Note 21
  22. 22. } [問題 Questions]: - Problem identification - Which findings in this patient's case history are consistent with acute STEMI? - What risk factors for the development of coronary artery disease are present in this patient? 這些問題多著重於讓同學們練習擷取並整理相關資訊,並進 一步抽絲剝繭列出危險因子;最好能根據症狀 (symptom)/ 病徵 (sign) 等線索排列;症狀通常是主觀的,而病徵通常是 客觀的 病例問題 – 病例內容 22 練習將病例資訊與疾病相呼應 判斷與疾病有關之危險因子Note
  23. 23. 怎麼寫「SOAP」? } 病歷閱讀/SOAP繕寫 - S-O-A-P是一種「思考」,不是一種「表格」 常見錯誤: 寫 (抄) 的跟醫師一樣 (把診斷當作評估)、沒有問 題為導向 (不知道自己在寫什麼) 醫師版 藥師版 S (主觀) 病患主觀描述、外觀/症狀 同 O (客觀) 病患病史、檢查結果,實驗 室與相關檢查 同,更著重用藥史 A (評估) 診斷或臆測疾病 評估藥物相關問題 P (計畫) 治療或診斷 (疾病) 計畫 治療或診斷 (藥物不良 反應) 計畫 我跟你寫得不太一樣喔!! Note 23
  24. 24. } [參考答案 Answers]: - Symptoms: A substernal, crushing, and pressure- like chest pain that radiates to his jaw and is accompanied by nausea and diaphoresis occurring at rest - Signs: High troponin I level, abnormal ECG findings (ST-segment elevation in inferior leads, and right bundle branches block) 建議可參考疾病診斷標準作答,參考資料包括教科書與疾病 診斷/治療指引 (不要只抄 !!) 病例問題 – 病例內容 24 Note 就是「SOAP」中的S&O
  25. 25. } [參考答案 Answers]: - Modifiable risk factors of this patient: - Lifestyle: Smoking - Medical: Hyperlipidemia, type II DM, HTN and Hx of CAD - Risk factors cannot be modified: - Age - Family Hx of CHD 一個重要待常被忽略掉的危險因子是「藥物」,藥師們應試 著篩選是否有藥物可能誘發或導致該疾病的可能性 病例問題 – 病例內容 25 Note 應包括可改變與不可改變的危險因子
  26. 26. } [問題 Questions]: - Desired Outcome - What is the immediate goal of therapy in this patient? - How can this goal be achieved using pharmacotherapy? 應避免空洞的目標: 治癒病人 (cure the patient)、緩解症 狀 (relieve the symptoms) 等 或過度窄化的目標: 醣化血色素 (HbA1c) <7%、血壓 (SBP/DBP) <135/80 mmHg 病例問題 – 病例內容 26 練習列出目前治療目標 針對該目標建議藥物治療 Note
  27. 27. } [參考答案 Answers]: - The short-term goals of treatment for the ACS are: - Early restoration of blood flow to the infarct-related artery to prevent infarct expansion - Prevention of death and other MI complications - Prevention of coronary artery re-occlusion with re- infarction - Relief of ischemic chest discomfort - Resolution of ST-segment and T-wave changes on ECG 病例問題 – 病例內容 27
  28. 28. 怎麼寫「SOAP」? } Medical problem: chest pain, not relieved by rest. S: O: A: ST-segment elevated myocardial infarction (STEMI), additional therapy needed. P: 藥師版「SOAP」的重點是指出「藥物相關問題」,且之後 的計畫應該根據這個問題擬定目標與對策 28 這個是診斷 (diagnosis) 這是藥物相關問題 (drug-related problem) Note
  29. 29. } [問題 Questions]: - Therapeutic Alternatives - What nonpharmacologic therapeutic alternative can also achieve the immediate goal in this patient? } [參考答案 Answers]: - Initial therapy: oxygen (all patients for first 6 hours, and then as needed to maintain SaO2 >90%) - Immediate primary PCI: balloon angioplasty or placement of a bare-metal or drug-eluting intra- coronary stent) 病例問題 – 病例內容 29
  30. 30. } [問題 Questions]: - Therapeutic Alternatives - What is the role of adjunctive anticoagulant therapy during PCI, and how should these therapies be monitored? } [參考答案 Answers]: - Parenteral anticoagulants should be used to patients undergoing PCI (ACCF/AHA Class I, Level C) - Consider using enoxaparin at time of PCI in patients who have not received prior antithrombin therapy (ACCF/AHA Class IIb, Level B) 病例問題 – 病例內容 30
  31. 31. } [參考答案 Answers]: - Monitor parameters of parenteral anticoagulants: - Efficacy: - Safety: S&S of bleeding (e.g. uncontrolled bleeding from injection sites, hemoglobin drop of unknown cause) 病例問題 – 病例內容 31 Anticoagulant Parameters Unfractioned heparin (UFH) aPTT Low-molecule weight heparin (LMWH) Anti-Xa Fondaparinux Anti-Xa Bivalirudin aPTT or ACT除了療效更應該有安全性指標
  32. 32. } [問題 Questions]: - Therapeutic Alternatives - What is the role of adjunctive antiplatelet therapy before, during, and after PCI, and how should these therapies be monitored? } [參考答案 Answers]: - Aspirin 162-325 mg should be given (chewed) on first day of STEMI and continued indefinitely at 75- 162 mg once daily unless “true aspirin allergy” (ACC/AHA Class I, Level A) 病例問題 – 病例內容 32 藥物治療建議常遺漏「療程」
  33. 33. } [參考答案 Answers]: - Clopidogrel 75 mg orally once daily recommended in addition to aspirin in patients with STEMI whether or not they have reperfusion therapy (including fibrinolytic therapy) (ACC/AHA Class I, Level A), duration at least 14 days and up to 1 year - Alternatives to clopidogrel include: - Prasugrel (Effient) in patients having PCI (ACCF/AHA Class I, Level B) - Ticagrelor (Brilinta) 180 mg then 90 mg twice daily (ACCF/AHA Class I, Level B) 病例問題 – 病例內容 33
  34. 34. } [問題 Questions]: - Therapeutic Alternatives - What are other important goals of therapy in this patient? } [參考答案 Answers]: - The long-term goals following MI are to - Control modifiable CHD risk factors - Prevent the development of systolic HF - Prevent recurrent MI and stroke - Prevent death, including sudden cardiac death 病例問題 – 病例內容 34
  35. 35. } [問題 Questions]: - Therapeutic Alternatives - Based on the history and presentation, what initial drug therapy is indicated in this patient? } [參考答案 Answers]: - The initial drug therapy of this patient would be: - Aspirin 300 mg ST followed by 100 mg PO QD - Clopidogrel 300 mg ST followed by 100 mg PO QD - Enoxparin 1 mg/kg (a maximum dose of 100 mg is recommended for the first 2 doses) SQ Q12H 病例問題 – 病例內容 35
  36. 36. } [參考答案 Answers]: - Nitroglycerin 10 mcg/min IVF for persistent discomfort due to ischemia, control of high blood pressure, or treatment of pulmonary edema - Carvedilol 12.5 mg PO BID - Captopril 6.25 mg PO TID - Atorvastatin 10 mg PO QD - Metformin 500 mg PO BID (resume after PCI) 藥物治療應有詳盡的藥名、劑量、途徑、頻次,有特定使用 方式則說明 病例問題 – 病例內容 36 Note
  37. 37. } [問題 Questions]: - Outcome Evaluation - How should the recommended therapy be monitored for efficacy and adverse effects? } [參考答案 Answers]: - Efficacy: - Relief of ischemic discomfort - Return of ECG changes to baseline - Absence or resolution of HF signs 病例問題 – 病例內容 37
  38. 38. } [參考答案 Answers]: - Adverse effects: 病例問題 – 病例內容 38 Drug Adverse effects Monitoring Aspirin Dyspepsia, bleeding, gastritis Clinical signs of bleeding, gastrointestinal upset; baseline CBC and platelet count; CBC platelet count Q6M Clopidogrel Bleeding, diarrhea, rash, TTP (rare) Same as aspirin IV Nitrates Hypotension, flushing, headache, tachycardia BP and HR Q2H 針對每一種藥物列出追蹤指標 有追蹤頻率將會更好
  39. 39. } [參考答案 Answers]: 病例問題 – 病例內容 39 Drug Adverse effects Monitoring Enoxaparin Bleeding, heparin- induced thrombocytopenia (HIT) Clinical signs of bleeding; baseline SCr, aPTT, INR, CBC and platelet count; daily CBC, daily CBC and SCr Carvedilol Hypotension, bradycardia, heart block, broncho- spasm, acute heart failure, fatigue BP, HR, and clinical signs of heart failure every shift during oral administration during hospitalization, then BP and HR Q6M following hospital discharge
  40. 40. } [參考答案 Answers]: 病例問題 – 病例內容 40 Drug Adverse effects Monitoring Captopril Hypotension, cough, hyper- kalemia, prerenal azotemia, acute renal failure, angioedema BP Q2H x 3 for first dose, then every shift during oral administration during hospitalization, then once Q6M following hospital discharge; baseline SCr and K; daily SCr and K while hospitalized Atorvastatin GI upset, myopathy, hepatotoxicity LFT at baseline, at 6 wks, and after titration to highest dose, then annually thereafter; counsel patient on myalgia
  41. 41. } [療程 Clinical Course]: 病例導讀 – 病例內容 41 2/18 15:40 2/21 9:002/18 14:40 ED PCI Echocardio- graphy Dx of STEMI 2/18 8:00 Breakfast 2/18 14:00 Chest pain onset Discharged Post-PCI care 2/18 16:20 PCI Eptifabatide MONA, UFH, and metoprolol Clopidogrel
  42. 42. } [問題 Questions]: - Patient Education - Based on his hospital course, which discharge medications would be most appropriate for this patient? - What education should you provide to this patient? } [參考答案 Answers]: - For secondary prevention of myocardial infarction, those are this patient needed… 病例問題 – 病例內容 42
  43. 43. } [參考答案 Answers]: - To prevention LV remodeling following MI - ACEIs, beta-blockers, and selective aldosterone receptor antagonists have been shown to prevent it and reduce mortality of these patients 病例問題 – 病例內容 43
  44. 44. } [參考答案 Answers]: - Aspirin 100 mg PO QD indefinitely - Clopidogrel 100 mg PO QD at least 1 month - Carvedilol 12.5 mg PO BID - Lisinopril 20 mg PO QD - Atorvastatin 10 mg PO QD - Metformin 1 gm PO BID 短期 (緩解心肌缺血症狀) 與長期 (預防再次心肌梗塞) 藥物 治療目標不同,應針對目標而有不同治療策略 病例問題 – 病例內容 44 Note
  45. 45. } [療程 Clinical Course]: - Six months later, he states that he is really trying to exercise more and eat better. He has been taking all of his medications. - He states there are some pain in his calves and thighs, and he thinks at he has it is due to his walking exercise regimen he started 4 months ago. - It is bothering him enough that he has had to stop walking every day. 病例導讀 – 病例內容 45
  46. 46. } [療程 Clinical Course]: - Labs reveal the following: - TC 135 mg/dL TG 89 mg/dL HDL 39 mg/dL LDL 78 mg/dL - CK 450 IU/L - Vitals: BP 130/80 mmHg and P 65 bpm. } [後續問題 Follow-Up Question]: - What is the cause of this patient's myopathy and how should his regimen be modified taking into consideration his adverse effects and his goal LDL? 病例導讀 – 病例內容 46
  47. 47. } 內文: - 字型大小: 10人以上「24」以上為佳 - 字型挑選: 勿使用太細、太扭曲的字體 - 內文呈現: 條列式,勿長篇大論 - 內容數量: 30分鐘約30~35張、50分鐘約40~45張、60分 鐘不要超過50張 } 圖表: - 大小適中: 填半版以上至少需300x400大小 - 務必清晰: PDF檔向量擷圖最清晰 簡報製作 47 標題重點是「你想告訴聽眾什麼?」
  48. 48. } 上台前: - 放鬆活動: 全身放鬆一下!走走動動會比坐在原地緊張好 - 內容提示: 在投影片中放內容提示比寫稿子死背好 } 演講時: - 肢體眼神: 肢體 (手為主) 活動較能聚焦,眼神與聽眾要能 接觸 (別只看著螢幕或某個奇怪的地方) - 語調聲音: 輕重緩急、發音清楚 } 演講後: - 回答問題: 掌握記錄、點頭、重覆與回覆四項要點 - 解決問題: 擱置爭議、聲東擊西、反問聽眾 演講技巧 48
  49. 49. } 提供準備病例報告同學建議: - 至少花時間練習1~2個病例 - 第1個通常只拿50分,但第2個可以進步到75分 建議參考教科書,並配合最新治療指引 - 從定義、症狀、診斷、治療到預後 [別只看治療] 想要贏在起跑點,只有早點起跑 「從準備報告中學習」才是報告最大 的目的 結語 49 1 2 3

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