狠狠撸

狠狠撸Share a Scribd company logo

第一次準备病例报告就上手

?
?
人瑋 劉
人瑋 劉

The document provides guidance on how to prepare a case report presentation. It discusses including key elements like the chief complaint, history of present illness, past medical history, family history, social history, medications, allergies, review of systems, physical exam, lab results, ECG findings, assessment, and questions. It emphasizes focusing on clinically relevant information and interpreting exam and lab findings rather than just reporting values. The document also discusses using a "SOAP" format for case discussions with a pharmacist perspective rather than just copying the physician's notes.

1 of 49
Downloaded 264 times
第一次準备病例报告就上手， 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
} 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] 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
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
} 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 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
} [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
} [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
} [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
} [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～
} [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
} [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」
} [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
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
} [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
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
} [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]: - Problem identification - Outcome evaluation - Desired outcome - Patient education - Therapeutic alternatives - Optimal plan 病例報告 - A & Q 20 Note
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
} [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
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
} [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
} [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
} [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
} [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
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
} [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
} [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
} [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
} [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」
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} [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
} 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？」
} 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
} 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

More Related Content

第一次準备病例报告就上手

  • 1. 第一次準备病例报告就上手， 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
  • 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
  • 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. } 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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. 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. } [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. 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. } [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. } [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. 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. } [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. 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. } [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. } [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. } [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. } [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. 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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } [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. } 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. } 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. } 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