manish mehta

身為醫師，最重要的就是治療病人。現今醫師重視的不只是疾病本身，更包含病人心理及家屬層面的照護。本書是結合實證處理原則和多功能性的「實地」指引手冊。內容包含各種情節的危機處理、針對住院主治醫師常遇到的治療處置，提供圖解說明指引、住院病人常見診斷還有實證處理原則，並提供具體的小秘訣和建議以避免住院主治醫師過勞。本書可提供疾病處理到倫理議題的解決方法參考，讓住院主治醫師在執業處理原則方面能快速查詢，幫助醫師即時處理病人需求，在病人的照護上更臻完善。

序言(Preface)

駐院科醫師是現代醫療中相對較新的名詞。隨著這個領域的發展，選擇走進入此科的內科醫師其培養訓練也日漸重要。本書正是闡述這樣的需求。美國的內科住院醫師訓練計畫，乃是努力培訓畢業生具備處理住院病人和門診病人的綜合能力。然而，因為工作管理和流程上的差異，使得傳統內科醫師仍與急症住院照護醫師或駐院科醫師有所區隔。這也是這本書想要闡述的重要概念。此外，在急性住院病人醫療中可能會出現重症照護和處置部分的問題，此書可作為快速的參考查詢。我們希望這本書讓醫師可以即時處理病人的需求，提供過去忙碌的家庭醫生不太可能做到的服務。
期望讀者從這本手冊得到幫助且於閱讀中獲得樂趣。我們重視您的意見，並希望您能協助我們改進以利後續版本的發行。
 
Manish Mehta, MD
Arun Mathews, MD

Chapter 1　駐院科醫師醫學的發展                                                                    1
Chapter 2　為你的第一天做好準備                                                                    3
■資訊收集...................................................................................... 4
■急症照護醫師的衣著及背後道理.............................................. 6
■應帶物品...................................................................................... 7
Chapter 3　編碼及計費                                                                                        9
■一般ICD-9-CM(國際疾病分類)編碼......................................... 10
■駐院科醫師計費代碼................................................................ 12
　□入院計費代碼........................................................................ 12
　□後續追蹤照護計費代碼........................................................ 13
　□出院計費代碼........................................................................ 13
Chapter 4　各種疾病                                                                                          15
■心血管疾病................................................................................ 16
　□胸痛........................................................................................ 16
　□ST段上升的心肌梗塞............................................................ 18
　□不穩定性心絞痛／非ST段上升心肌梗塞............................ 21
　□心房顫動................................................................................ 23
　□心室上心搏過速.................................................................... 25
　□心室性心搏過速.................................................................... 27
　□鬱血性心臟衰竭.................................................................... 29
　□心搏過緩................................................................................ 32
　□竇性心搏過緩／心臟傳導阻斷............................................ 32
　□高血壓危象............................................................................ 33
■心電圖複習................................................................................ 35
　□步驟一.................................................................................... 35
　□步驟二.................................................................................... 35
　□步驟三.................................................................................... 36
　□步驟四.................................................................................... 36
　□步驟五.................................................................................... 37
　□步驟六.................................................................................... 39
　□步驟七.................................................................................... 41
　□高血鉀.................................................................................... 43
■肺部疾病.................................................................................... 44
　□氣喘........................................................................................ 44
　□慢性阻塞性肺部疾病............................................................ 46
　□肺栓塞.................................................................................... 48
　□社區型肺炎............................................................................ 50
■胃腸疾病.................................................................................... 52
　□腸胃道出血............................................................................ 52
　□急性胰臟炎............................................................................ 54
　□腸阻塞.................................................................................... 57
■腎臟疾病.................................................................................... 60
　□急性腎衰竭............................................................................ 60
　□高血鉀.................................................................................... 64
　□低血鉀.................................................................................... 66
　□高血鈉.................................................................................... 68
　□低血鈉.................................................................................... 71
■神經疾病.................................................................................... 74
　□短暫性腦缺血發作................................................................ 74
　□急性中風................................................................................ 77
　□一般處置................................................................................ 81
　□腦膜炎.................................................................................... 83
　□癲癇發作................................................................................ 88
　□意識狀態改變........................................................................ 91
■血液疾病.................................................................................... 92
　□貧血........................................................................................ 92
　□深層靜脈栓塞........................................................................ 96
　□INR上升的治療...................................................................... 98
■內分泌疾病................................................................................ 99
　□糖尿病酮酸血症.................................................................... 99
　□低血糖症.............................................................................. 102
　□抗利尿激素不當分泌症候群.............................................. 105
■感染性疾病.............................................................................. 108
　□蜂窩性組織炎...................................................................... 108
　□壓瘡...................................................................................... 110
Chapter 5 加護病房照護                                                                                  113
■成人呼吸窘迫症候群.............................................................. 114
■休克.......................................................................................... 118
　□低血容性休克...................................................................... 118
　□分佈性休克.......................................................................... 118
　□心因性休克.......................................................................... 119
　□阻塞性休克.......................................................................... 120
　□臨床評估.............................................................................. 120
　□治療...................................................................................... 121
■呼吸輔助.................................................................................. 124
　□非侵入性呼吸輔助.............................................................. 124
　□機械式呼吸輔助.................................................................. 125
■常用的醫學方程式.................................................................. 130
Chapter 6 治療處置                                                                                          131
■中央靜脈導管置放.................................................................. 132
■股靜脈套管插入術.................................................................. 134
■內頸靜脈套管插入術.............................................................. 135
■鎖骨下靜脈套管插入術.......................................................... 136
■氣管內管插管.......................................................................... 138
■腹腔穿刺術.............................................................................. 143
■脊髓穿刺.................................................................................. 146
■關節穿刺術.............................................................................. 148
■肘關節穿刺術.......................................................................... 150
■胸腔穿刺術.............................................................................. 152
■動脈血氣體分析(橈動脈穿刺)................................................ 154
■動脈導管置放.......................................................................... 157
Chapter 7 術前評估                                                                                          161
■ACC／AHA術前心臟風險因子評估...................................... 162
■ACP術前心臟風險因子評估................................................... 163
Chapter 8 工作步調及同理心                                                                          165
　□同理心..................................................................................... 168
　□工作步調和效率：駐院科醫師該怎麼做............................. 169
Chapter 9 醫院醫學的倫理議題                                                                      171
　□不予急救醫囑......................................................................... 172
　□治療的撤除............................................................................. 174
　□知情同意書............................................................................. 176
　□決定的能力............................................................................. 178
　□保密和健康保險可攜性及責任法案（HIPAA）規定......... 180
　□無效治療和不合理的病人要求............................................. 183
　□困難病人................................................................................. 185
　□疼痛控制和緩和醫療............................................................. 187
　□預立醫療指示......................................................................... 189
　□倫理諮詢................................................................................. 191
Chapter 10 駐院科醫師的危機處理                                                  193
　□駐院科醫師的角色與醫療使用............................................. 194
　□身為內科醫師，要了解你的極限......................................... 194
　□交班的藝術............................................................................. 194
　□交班出錯：真實案例............................................................. 195
　□交班出錯：分析..................................................................... 196
　□交班的規範：六個基本原則................................................. 197
　□駐院科醫師開立出院............................................................. 199
　□駐院科醫師開立入院............................................................. 200
　□急診與駐院科醫師：收集資訊的掙扎................................. 201
　□急診與駐院科醫師：基本的處理方式................................. 201
　□結論：要小心行事................................................................. 202
附錄 A 縮寫................................................................................................... 203
附錄 B 書寫範本........................................................................................... 205
■入院記錄(病史和理學檢查)範本................................................. 206
■出院病摘範本................................................................................ 207
參考書目.......................................................................................................... 209
索引.................................................................................................................. 311