USMLE 第一步复习/临床决策
临床决策是一个涵盖生物统计学和流行病学的广泛主题领域。还包括对病人访谈、体格检查和建立鉴别诊断的方法。
病人访谈，或病史，包括
- 主诉 (CC)
- 现病史 (HPI)
- 用药史
- 过敏史
- 既往史 (PMH)
- 既往手术史 (PSH)
- 社会史
- 家族史
- 系统回顾 (ROS)
系统地询问现病史和探究症状
- Onset of pain (what was the patient doing when the pain started?)
- Palliative or Provocative factors for the pain
- Quality of pain (burning, stabbing, aching, etc.)
- Radiation (up to jaw, down left arm, etc.)
- Severity of pain (usually 1 - 10 scale)
- Timing of pain (eg: after meals, in the morning, how long it lasts, etc.)
类似地
- Site of pain
- Onset of pain
- Character of pain (dull, sharp, aching, stabbing, tearing etc.)
- Radiation of pain (eg. central abdominal pain radiating to Right Iliac Fossa)
- Associated factors (eg. nausea/vomiting)
- Timing of pain/duration
- Exacerbating/alleviating factors
- Severity of pain (usually 1 - 10 scale)
或者
- Aggravatiing and Alleviating factors
- Severity
- Character, quality
- Location
- Associated symptoms
- Setting
- Timing
(ASCLAST means let the patient talk first, then ask him/her specific questions.)
to make a differential diagnosis for a problem use the word VINDICATE V vascular I inflamation / Infection N Neoplasm D Degenerative I Intoxication C collagen disease / congenital disease A autoimmune disease T Trauma E endocrine
病人访谈很少能指向单一诊断；相反，通常会有一系列潜在诊断，称为鉴别诊断。系统性地思考鉴别诊断可以确保考虑所有可能性。记忆辅助词VITAMIN C 常用于完成此任务
- Vascular
- Infectious
- Traumatic
- Autoimmune
- Metabolic
- Idiopathic/iatrogenic
- Neoplastic
- Congenital
当病人入院时，必须开出一些医嘱。记忆辅助词DAVE WILMINGTON 有助于系统性地完成此任务
- Diet
- Activity
- Vital signs (how often)
- Excrement (test urine / stool)
- Weight (how often to monitor)
- Input/output (eg, "strict ins/outs")
- Labs (what, how often)
- Meds (which, route, interval)
- I V fluids (what and at what rate)
- Nursing care (e.g. position, wound care, up in chair, ostomy care etc)
- General care (e.g. Physical Therapy, Respiratory Therapy etc)
- Tests (X-ray, EKG, EEG etc)
- Observe for reaction, seizure, neuro exams
- Notify parameters (e.g. Temp > 100 / respiration changes)
记忆辅助词ADC VAAN DIML 也常被使用
- Admit (23 hours, full admit, service of attending,...)
- Diagnosis
- Condition ("Stable", "Guarded", etc.)
- Vitals (post-op, routine, q 1 hour, etc.)
- Allergies
- Activities (Strict bed rest, fall precautions, ad lib, bathroom privileges, etc.)
- Nursing (Strict I&O's, Daily weights, Call P.R.N. whatever, etc.)
- Diet (NPO, Regular, Clears - advance diet as tolerated, 2000 cal ADA, renal, etc.)
- IV fluids (D5 1/2 NS c 20 KCL at 110 ml/hr, LR @ 100 ml/hr, etc.)
- Meds (scheduled and PRN's)
- Labs and x-ray (CBC in AM, PCXR in PACU, etc.)