我想要畫畫

intern life消磨人生
拿出本本我離小畫冊好遠好遠
好久好久沒有給你寫信
想更深刻地想念你
想為你寫字想到哭

james blunt的歌正在播
我曾寫過他的詞給你
我想要深刻的過生活
就算是激烈的放聲大哭開懷大笑
你說intern的生活會磨去我很多的純真
我感受到了

刺蝟的優雅

tough outside, soft inside
我的肚皮柔軟的白白的毛絨絨的

Fever

Etiology
1.infection
2.malignancy
3.autoimmune

History
1.associated symptoms
2.medications
3.potential exposure
4.travel hisotry

PE
就一般該做的都就要做，
inpatient要再特別注意這些
-注意皮膚有無rash
-有無new onset的murmur
-是否有abonomal fluid accumulation
-身上的intravascular lines
-其他indwelling device(Foley)
-在neutropenic病人，要再注意skin.oral.perineal area for mucosal integrity

Test
-CBC/DC
-liver function test
-Urinalysis
-U/C and B/C
-CXR
其他的culture(abnormal fluid.sputum.CSF.stool)視情況做！

Treatment
1.Antipyretics-減少病人的discomfort
Acetaminophen325-600mg PO or per rectum,q4H
Aspirin 325mg
但aspirin在adolescents with viral infection(URI.chickenpox)不要用，會有Reye's syndrome

2.Tepid water bath洗溫水澡澡(cooling blanket和ice pack並不建議用)

3.Empiric antibiotics should be considered in
-hemodynamically unstable(infection is primary concern)
-neutropenic
-asplenic

Pressure Ulcer

Pressure Ulcer也就是bedsore或decubitus ulcer
通常在住院時期前2週發生，在短短2-6小時之內就可能出現pressure ulcer，一旦發生就很難復原
所以最重要的就是預防啦！

Risk factor
1.immobility
2.limited activity
3.impaired nutritional status
4.impaired circulation
5.altered level of consciousness

預防包括兩部分
1.skin care:注意bony prominence的部分，減少皮膚曝露在潮溼的狀況下(如:失禁，流汗，傷口drainage)
2.relieving or redistributing pressure:最少2小時要翻一次身，坐輪椅的病人1小時就要改變姿勢一次
睡氣墊床

stage I - intact skin , nonblanchable erythema (只在epidermis)
stage II - extension through epidermis, shallow ulcer(吃到dermis未超出)
stage III - full thickness without extension through fascia(吃出dermis到subcutaneous)
stage IV - full thickness with destruction of underlying tissue(muscle.bone.tendon)

治療

-pressure relieving device
-occlusive dressing
-pain control
-normal saline for clean,
-use of topical agent promote wound healing
(silver sulfadiazine,bacitracin zinc,Neosporin,Polysporin)
-removal of necrotic debris
-注意:避免會妨礙傷口癒合的東西(antiseptic agents,如H2O2,Dakin solution)


-protein intake 1.25-1.5g/kg/day
-vitaimn C 500mg PO daily
-zinc sulate 220mg PO daily

如果經過2-4週治療後還一直有exudate或沒有癒合
可以考慮2 week trial of topical antibiotics(silver sulfadiazine, double antibiotics)


electircal stimulation,radiant heat,negative pressure therapy,surgical intervention

Venous thromboembolism prophylaxis

VTE 有75%的PE是發生在NON-SURGICAL patient身上，而且VTE是可預防的阿！

危險因子包括:
1.advanced age
2.previous VTE
3.trauma
4.prolong immobility(包含major surgery,stroke,paralysis)
5.obesity
6.heart failure
7.pregnancy
8.inflammatory bowel disease
9.coagulation factor deficiency

預防方式


1.with severe respiratory disease
2.with CHF
3.bedridden加上有其他的危險因子
這三類病人，應預防性給予
- low-dose unfractionated heparin(UFH),5000 units SC q8H
- LMWH (enoxaparin 40mg SC 或 4000units SC daily) OR (dalteparine 5000units SC daily)
如果病人是contraindication to antocoagulation prophylaxis應用
- intermittent pneumatic compression
- compression stockings


在postoperative病人依發生VTE的risk不同，分成三個group
1.Low risk(minor procedure,<40yr,no other risk factor)
- early mobilization is recommended

2.Moderate risk(nonmajor procedure and 40-60yr or other risk factor)
(major procedure and <40yr)
-LDUH 5000 units SC bid 或 LMWH < 3400 units per day

3.High risk(nonmajor procedure,>60yr,and other risk factor)
(major procedure,>40yr,and other risk factor)
-LDUH 5000 units SC tid 或 LMWH > 3400 units per day再併用mechanical methods
注意！！單純只用aspirin來預防DVT是不適合的哦！！

出自washington manual 32th, page2

羨慕

我也好想去澎湖
我還想要一個人去流浪

我覺得自己好糟阿

從北醫到台大
來到大廟真的覺得自己好不足

UGI bleeding

處理
1.NPO (只要NPO就該給IV fluid，一開始N/S 500-1000mL chanllenge，記得2條large cath.)
2.NG decompression
3.抽CBC/platelet + pT/pTT
4.Liver function 和 renal function
5.備血
6.安排PES

non-variceal
給high dose PPI (omeprazole 40mg bid po或 omeprazole 80mg iv stat)
不論是症狀改善或是對ulcer heal效果都比H2 antagonist(cimetidine等)好
variceal
1.給octreotide 50-100mcg iv stat, 之後25-50mcg/hr
2.vasoppresin 0.3units/min IV,之後每30分鐘加0.1unit直到達成hemostasis，
最大劑量為0.9units/min，但因有cardiac arrest和MI的complications所以不常用
搭配用nitroglycerin(SBP>100mmHg才可以用哦！) 10mcg/min IV,每10-15分鐘可以加10mcg，
到SBP掉到100mmHg，最大劑量為400mcg/min