[醫學][內科]WashingtonManual_33ed_1-1

[醫學][內科]WashingtonManual_33ed_1-1

書名：WashingtonManual_33ed

閱讀理由：

1.   不管以後要走什麼科，內科都是最基本的

2.   未來PGY、家人生病、開業轉診必備

3.   和同梯醫官張育睿約定：當兵這年(2013-07-06止)念完Washington Manual (懲罰未定)

4.   外科系也需要內科backup，不然會被clerk在背後酸…Clerk好可怕

5.   自我提升：我希望對病情診斷能夠更加精準，處置瞬間浮現，入院就看見病程/出院計畫

 

 履約開始

I. Patient Care in Internal Medicine

i.  General Care of the Hospitalized Patient

A.  General Principles

        1. Hospital orders：時間/日期/簽名/電話http://metaplasia.blogspot.tw/

        2. ADC VANDALISM

              (1) Admitting service, location and physician responsible for the pt

              (2) Diagnosis

              (3) Condition of the Pt

              (4) Vital signs with frequency http://metaplasia.blogspot.tw/

              (5) Activity limitations

              (6) Nursing instructions (e.g. Foley catheter to gravity drainage, Wd care, Daily weights)

              (7) Diet (NPO連藥都不能吃) http://metaplasia.blogspot.tw/

              (8) Allergy (food and drug) http://metaplasia.blogspot.tw/

              (9) Laboratory tests & radiographic studies

         (10) IV fluids (composition and rate)

         (11) Sedatives, analgestics and other PRN medications

         (12) Medications (dose, frequency, route, indication. +/- State “first dose now”)

        3. 時常review order http://metaplasia.blogspot.tw/

        4. Discharge入院就該準備，全人照護 (還有心力的話orz)

ii.  Prophylactic Measures

A.  Venous Thromboembolism (VTE)

        1. Risk factors：advanced age, previous VTE, trauma, prolonged immobility (major surgery, stroke, paralysis), obesity, heart failure, malignancy, pregnancy, Inflammatory Bowel Dz, coagulation factor deficiency

        2. Prevention

              (1) 能走盡量走(ambulate several times a day) http://metaplasia.blogspot.tw/

              (2) Prophylactic dosing：acutely ill + severe resp. dz / CHF或者躺床+其他risk factor者

                   a. UFH (5000U SC q8h or q12h)或

                  b. LMWH (enoxaparin 40mg SC or 4000U SC qd；dalteparin 5000U SC qd)或

                   c. fondaparinux 2.5mg SC qd 三擇一

              (3) 預防用藥不適合用Aspirin

              (4) 有risk factor但是抗凝劑也不能用的pt 用intermittent pneumotic compression 或graded compression stokings http://metaplasia.blogspot.tw/

              (5) 治療看17章

B.  Pressure Ulcers

        1. Epidemiology：通常在住院首2周出現，快一點2~6hr就有。會增加Mortality喔

        2. Prevention：http://metaplasia.blogspot.tw/

              (1) Risk factor assessment：immobility, limited activity, incontinence, impaired nutritional status, impaired circulation, △MS

              (2) Skin care：每天視診骨頭突起處，減少濕氣(incontinence, perspiration汗, Wd drainage)

              (3) Nutritional supplement：

              (4) Intervention著重減壓：frequent repositioning(至少2小時翻一次，輪椅wheelchair-bound每小時一次)、pillow枕頭/foam wedges泡棉、床頭不要搖太高、lifting devices(移動用吊床)、降壓pressure-reducing devices(foam, dynamic air mattresses氣墊床)、減壓pressure-relieving devices(low-air-loss低氣體流失, air-fluidized beds氣體流體床)

        3. Diagnosis：PE http://metaplasia.blogspot.tw/

              (1) Suspected deep tissue injury：intact skin but color change or s/s(+)

              (2) Stage I[81] ：表皮完整深色紅斑

              (3) Stage II：shallow ulcer

              (4) Stage III：fat(+)

              (5) Stage IV：bone/tendon/muscle(+)

              (6) Unstagable：base of the ulcer is covered by slough腐肉 and/or eschar

        4. Tx：http://metaplasia.blogspot.tw/

              (1) Initial interventions：pressure-relieving devices, occlusive dressings, pain control, saline沖洗, topical agents促進傷口癒合(DuoDERM, SSD, bacitracin zinc, Neosporin, Polysporin)，避免延緩癒合的藥物(antiseptic agents殺菌劑, such as Dakin solution, hydrogen peroxide雙氧水; wet to dry gause濕紗)

              (2) Adequate nutrition：protein(1.25~1.5g/kg/d), Vit. C (500mg PO qd), zinc sulfate (220mg PO qd)

              (3) Clean pressure ulcers持續有滲出液或2~4週仍未癒合→使用兩週局部抗生素(SSD, double antibiotics)

              (4) Other adjunctive therapies：不癒合可以考慮electrical stimulation, radiant heat, negative pressure therapy, surgical intervention

C.  Other precautions

        1. Fall precautions：以前摔過或high risk(dementia, syncope, orthostatic hypotension)→應在病歷上註明http://metaplasia.blogspot.tw/

        2. Seizure precautions：以前抽過或有risk，準備襯墊(padded bed)和oral airway在bedside

        3. Restraint orders約束：自傷之虞或危險行為干擾治療，每24hr評估一次

iii.  Acute Inpatient Care

A. 住院病人complaint多，評估包括Hx, S/S, PE, Drug Hx等(就全套啦)，必要就送檢查

B.  Chest Pain ─排除急症[82] 

        1. Hx：尤其是心血管病史、cardiac & PTE risk factors

        2. PE發作當下做最好：Vital signs (+bil. BP), 心胸腹PE, trauma, rash(帶狀泡疹), 能否重現疼痛

        3. Exam：SpO2, CXR, ECG, Serial cardiac enzymes, Spiral CT, VQ scan

        4. Tx：http://metaplasia.blogspot.tw/

              (1) Cardiac ischemia：Morphine sulfate (1~2mg IV), O2, NTG(0.4mg SL), Aspirin, 詳見第三章

              (2) GI：Maalox + Diphenhydramine (30 mL of each in a 1:1 mix)

              (3) Costochondritis or other Musculoskeletal pain：NSAID

              (4) Prompt empiric anticoagulation：懷疑MI 或PTE，在等檢查結果時就可以先上

C.  Dyspnea

        1. 常見心肺因素(CHF, cardiac ischemia, bronchospasm, PTE, infxn, mucus plugging, aspiration)，須迅速謹慎的評估

        2. Hx：尤其是Cardiac & Pulmonary http://metaplasia.blogspot.tw/

        3. PE：Vital sign & 心肺檢查，記得和之前的結果做比較

        4. Exam：ABG比SpO2準, CXR, 其他檢查根據 Hx/PE finding

        5. Tx：根據檢查及你的impression

D.  Acute Hypertensive Episodes

        1. Etiology：最常見原發性高血壓沒控制，住院就人品爆發

        2. 加重因子：Volume overload(給太多水), pain (未適當止痛)

        3. Ddx：Withdrawal syndromes (e.g. alcohol, cocaine), rebound HTN (突然停藥像clonidine, α-blocker)治療見Ch4 http://metaplasia.blogspot.tw/

        4. Tx：考慮baseline BP, S/S (chest pain 或SOB), 日常用藥  (就醬！？)

E.  Fever

        1. A valuable marker of disease activity (這病人也瞭)

        2. Hx：首重Chronology時序性和相關的S/S, medications, potential exposures, social & travel Hx http://metaplasia.blogspot.tw/

        3. PE：體溫前後量同一處(口溫/肛溫)，inpatient注意rash, new murmur, abnormal fluid accumulation, IV line, indwelling devices (NG / foley). Neutropenic fever 注意skin/oral/perineal area mucosal integrity. 治療見Ch19

        4. Ddx：Infection, Drug, Malignancy, VTE, Vasculitis, tissue infarction, 或其他排除診斷

        5. Exam：blood culture/ Urine culture, CBC + differential, serum chemistries + liver function, U/A, CXR, culture of abnormal fluid collections, sputum, CSF, stool. Culture最好在上anti前收, 但是anti不要delay http://metaplasia.blogspot.tw/

        6. Tx：http://metaplasia.blogspot.tw/

              (1) Antipyretic drugs退燒藥減輕不適：Aspirin (325mg) 或 Acetaminophen (325~659 PO or Rect q4h) . Aspirin 用在青少年小心Reye syndrome賠到脫褲

              (2) Tepid water baths溫水拭浴：對高燒(hyperpyrexia)有效，33ed不建議用hypothermic (cooling) blanket 和 ice packs了 (因為會造成不舒服)

              (3) Empiric antibiotics：hemodynamically unstable Pt inwhom infxn is a primary concern、neutropenic 、asplenic.

              (4) Heat stroke and malignant hypothermia：見Ch24

F.  Pain  http://metaplasia.blogspot.tw/

        1. 記得用pain scales (雖然我每次問”如果1分最不痛，10分最痛，現在是幾分”的時候都會被病人白眼，之前其他R也沒在問的)

        2. Classification

              (1) Acute pain：temporary Tx暫時性治療

              (2) Chronic pain：nonnarcotic preparations非麻醉類製劑

              (3) Neuropathic pain：Anticonvulsants and antidepressants

              (4) Pain refractory to conventional Tx：nerve blocks, sympathectomy, relaxation Tx

        3. Medications：

              (1) Acetaminophen http://metaplasia.blogspot.tw/

                   a. Effects：antipyretics(＋), analgesic(＋), anti-inflammatory(－), antipletlet(－)

                  b. Preparation and dosage：325~1000mg q4~6h (max 4g/d), low dose in liver dz

                   c. Adverse effects：no gastric toxicity, but hepatic toxicity may be serious, acute overdose 10~15g can cause fatal hepatic necrosis

              (2) Aspirin

                   a. Effects：antipyretics(＋), analgesic(＋), anti-inflammatory(＋), antipletlet(＋)

                  b. Preparation and dosage：325~650mg PO q4h PRN (max 4g/d) for relief of pain, 腸膜錠(enteric coated tablets)和非乙醯化水楊酸(non-acetylated salicylates)較不傷胃 ; 肛門劑量300~600mg q3~4h 會黏膜刺激且有吸收差異

                   c. Adverse effects：Dose related (tinnitus, dizziness, hearing loss) ; Dyspepsia, GI bleeding, Hypersensitivity (bronchospasm, laryngeal edema, urticaria)不常見但在asthma和nasal polyp病人要注意(對aspirin有allergic or bronchospastic reaction 的病人禁給NSAID), 慢性過量小心interstitial nephritis and papillary necrosis, 另外在以下病人要注意: hepatic dz, renal dz, bleeding disorders, pregnancy, receiving anticoagulation Tx

                  d. Antiplatelet effects last up to 1 week after a single dose

              (3) NSAIDs

                   a. Effects：antipyretics(＋), analgesic(＋), anti-inflammatory(＋), antipletlet(－) 前三項因－cycloxygenase. 副作用和水楊酸類似

                  b. Adverse effects：blunt the cardioprotective effects of ASA. Renal / liver不好的人要小心使用

                   c. Ketorolac：analgesic, 15~30mg q8h IM or IV, 但parenteral(腸外) Tx不應超過五天. IM 給藥腎毒性比PO更顯著.

              (4) COX-2 inhibitors  http://metaplasia.blogspot.tw/

                   a. Effects：作用於COX-2 (痛與發炎的媒介), 對胃黏膜和血小板凝集無顯著影響. 止痛方面和NSAID比較無顯著優勢.

                  b. Preparation and dosage：目前有Celecoxib,  Meloxicam(less selective for COX-2)

                   c. Adverse effects：慢性高劑量會增加MI死亡率; 對ASA或NSAID有allergy或bronchospastic reaction 的人禁用; Celecoxib禁用在對sulfonamides有allergic-type reaction的人身上

              (5) Opioid analgesics

                   a. Effects：藥理作用類似鴉片opium 和嗎啡morphine，適用於需要止痛不須退燒的病人

                  b. Preparation and dosage：(Table1)

 

                   c. Constant pain：around the clock + PRN (for breakthrough pain, 1/3 of the basal dose)，太常打PRN可以增加basal dose或縮短dosing interval。打到最高劑量無法止痛或副作用無法忍受→換藥(由同等止痛效果的1/2劑量開始)。盡量使用口服給藥，dysphagia, emesis, decreased GI absorption可以改打IV或SC. 連續靜脈給藥(Continuous IV administration)可以提供穩定血中濃度並快速調整劑量。盡量使用半衰期短的藥物(e.g. morphine), 未曾給過類嗎啡藥物的病人(Narcotic naïve patient)盡量從最低有效劑量開始. Patient-controlled analgesia (PCA)常用於術後或末期病人，優點有：加強止痛、減輕焦慮、減少麻醉藥物的總劑量。(Narcotic naïve patient不要設定basal rate, 易過量)

                  d. Selected drugs(各論)：

(a) Codeine：常與ASA和acetaminophen並用。以10~15mg PO q4~6h使用亦是有效的止咳藥

(b) Oxycodone & Propoxyphene：也常與ASA和acetaminophen並用口服。有三種複方錠劑：oxycodone + acetaminophen (5mg/325mg)、oxyodone+ASA (5mg/325mg)、proppoxyphene+acetaminophen (50mg/325mg or 100mg/650mg)

(c) morphine sulfate(嗎啡)：立即釋放型(Immediate-release, 5~30mg PO q2~8h)、持續型(sustained release, 15~120mg PO q12h)、直腸塞劑(rectal suppository)。無法吞可改用liquid form；產生tolerance時須加大劑量。Renal insufficiency病人要小心使用。

(d) Meperidine：和morphine比起來較不會biliary spasm, urinaty retension, constipation但是較易呼吸抑制(respiratory depression)且為心肌抑制劑(myocardial depressant)。禁止與MAOI併用或用於Renal failure病人(代謝物累積會導致CNS excitement or seizure)。重複給藥也容易造成seizure，不建議長期使用。併用hydroxyzine (25~100mg IM q4~6h)可以減少nausea並加強止痛效果。

(e) Methadone：口服超有效，且因T_1/2超長，可以抑制其他opioids造成的withdrawal symptoms.但是有一長必有一短，止痛期就挺短的。

(f) Hydromorphone：強效的嗎啡衍生物，2~4mg PO q4~6h ; 1~2mg IM/IV/SC q4~6h，也有直腸劑型(rectal suppository, 3mg)

(g) Fentanyl：經皮貼片(transdermal patch)藥力72hr，但是onset很久且fentanyl較常發生呼吸抑制

(h) Mixed agonist-antagonist agents混合性促效-拮抗劑：優點少副作用多，有butorphanol, nalbuphine, oxymorphone, pentazocine.

                   e. Precautions

(a) 禁忌(contraindication)：會掩蓋痛的型態妨礙診斷的時候(e.g. Head injury, Abdominal pain), opioid也會造成IICP

(b) 以下情形要謹慎使用(used with caution)：hypothyroidism, Addison disease, hypopituitarism, anemia, respiratory disease (e.g. COPD, asthma, kyphoscoliosis, severe obesity), severe malnutrition, debilitation (虛弱), chronic cor pulmonale.

(c) 肝功能不良患者應做劑量調整

(d) 併用會加重opioid副作用的藥物：phenothiazines, antidepressants, benzodiazepines, alcohol

(e) 長期使用會產生耐受性(tolerance)與生理依賴性(physical dependence)

(f) physical dependence─withdrawal syndrome (anxiety, irritability, diaphoresis, tachycardia, GI distress, temperature instability). 只用藥2週突然停藥就可能發生；僅用藥3天給予opioid antagonist就可能發生戒斷。花幾天慢慢tapering可以將戒斷症狀減至最輕

                   f. Adverse and toxic effects：

(a) 雖然在同樣的止痛劑量下有些人比較能忍，但是副作用大同小異

(b) CNS：Sedation, euphoria, papillary constriction

(c) Respiratory depression：dose related, IV特別明顯

(d) CV：peripheral vasodilation & hypotension, IV特別明顯

(e) GI：constipation, N/V, 應與stool softeners & laxatives併用。斜躺姿勢(recumbent position)可緩和N/V s.e.；要止吐可以用benzodiazepines, dopamine antagonists (prochlorperazine, metoclopramide等), odansetron. Opioids在有Inflammatory bowel disease的病人會促成toxic megacolon

(f) Urinary retension：因造成bladder, ureter, urethral sphincter 肌張力上升

(g) Pruritus：最常見於spinal administration

                   g. Opioid overdose：

(a) Naloxone(哪裡爽？=opioid antagonist)意外或蓄意過量兩相宜，見Ch24。不過會有Hyper-or hypotension, irritability, anxiety, restlessness, tremulousness, N/V等副作用

              (6) Alternative medications：

                   a. Tramadol：似opioid但較不易成癮

(a) Preparation and dosages：急性疼痛50~100mg PO q4~6h；遇老人或肝腎不好宜減量

(b) Adverse effects：有中樞鎮靜效果，不宜與alcohol, sedatives, narcotic併用。Nausea, dizziness, constipation, headache也可能發生，雖然一般劑量下沒有Respiratory depression的案例發生過，但是過量就有可能了。禁止與MAOI併用。

                  b. Anticonvulsants (e.g. gabapentin, valproate) & TCA (e.g. amitriptyline)：PO治neuropathic pain

                   c. Topical anesthetics (e.g. lidocaine)：可局部止痛 (e.g. postherpetic neuralgia)

G.  △MS 12[83] 3

        1. Etiology：Infxn (e.g. pneumonia, UTI)是老人及患有神經學疾病者△MS最常見原因

        2. Hx：medication, underlying dementia, neurologic/psychiatric disorders, substance use

        3. PE：Vital signs, infxn focus, CV exam, NE+MS

        4. Exam：

              (1) Basic─Blood Sugar, electrolytes, Cr, CBC, U/A, SpO2, CXR

              (2) Other evaluation─Culture, CSF, toxicology screen, Thyroid, B₁₂ level, syphilis serology

              (3) Following─Head CT, ECG, EEG

        5. Medications：

              (1) Agitation & Psychosis：Acute management including antipsychotic, haloperidol, bemzodiazepine, lorazepam. 長期燥動及有精神病徵的病人可改用新一代antipsychotic (risperidone, olanzapine, quetiapine, clozapine, ziprasidone)較少EPS

                   a. Haloperidol：Agitation & Psychosis首選，initial dosage 0.5~5mg (0.25mg in elderly) PO and 2~10mg IM/IV. 可以每30~60分鐘重複給藥直到藥效發揮。通常10~20mg PO/IM就有鎮靜效果。IV infusion (1~40mg/hr)可以代替bolus injection。Haloperidol和其他相似效價(efficacy) 的antipsychitics比較，活性代謝物較少，較無anticholinergic, sedative hypotensive effects，但是EPS較嚴重。Low dose少見Hypotension, CV compromise, excessive sedation.

(a) QT Prolongation (略)

(b) Postural hypotension (略)

(c) Neuroleptic malignant syndrome (略)

                  b. Lorazepam：對於hepatic dysfunction, sedative, alcohol withdrawal造成的Agitation & Psychosis, 或是Patient對單一neuroleptics無效的時候有幫助。Initial dose 0.5~2.0mg IV

(a)  

              (2)  

H. Insomnia and Anxiety

◎動向→改為念實體書

        1. 打字實在太慢，實體書瀏覽可以到一天50頁(雖然過目即忘)，退而求其次改為畫重點了

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 [81]放stage

 [82]可加入口訣

 [83]Ddx口訣表格