Preparation for Patient Rounds
It's 8: 30 AM, time to begin patient rounds. Today we'll make patient rounds with the pulmonary team. In room 1107, we find 65yr. old Mr. Smith who was admitted yesterday afternoon. The pulmonary team includes the attending physician, senior pulmonary fellow, junior resident, and 3 medical students. The admitting junior resident who admitted the patient the previous day begins the case presentation. Mr. Smith presents with a sore throat, productive cough and shortness of breath; he's been febrile for 5 days; his illness failed to respond to IV Annkacin given during his hospitalization at a small local hospital so he was transferred to our hospital with the diagnosis of pneumonia. His family brought his medical records including a Chest X- ray and lab reports performed in the local hospital, but the junior resident left them in his on-call sleeping room. One of the medical students quickly retrieves the nursing chart from the nursing station. Review of the vitals is noteworthy for a progressive increasing pulse and respiratory rate during the night. The junior resident now briefly reexamines the patient, lung auscultation, and then the pharynx. After completing the physical exam, he notes the patient has "crackles" in the right lung base and purulent pharyngeal exudate. No results of yesterday's Chest X-ray, CBC, and ABG were provided. An ABG or pulse oximetry forgotten. Further examination notes bilateral diffuse crackles, BP 90/60,pulse 120, resp.32/min. He orders a stat ABG and Chest X- ray and while waiting we request the nurse check the patient's O2 saturation using pulse oximetry and discover the O2 saturation is only 80%. Urgent arrangements are made to transfer the patient to ICU.
查房準備早晨8點30分，開始查房。今天，我們和呼吸內科的醫生一起查房。1107號病房患者是史密斯先生，65歲，昨天下午入院。查房小組由7人組成，包括呼吸內科的主治醫生、專科住院醫生、住院醫生和3名醫學生。先由昨天受治患者並完成病歷的住院醫生報告病情。史密斯先生表現為咽痛、咳嗽多痰、氣促，發燒已有5天，在當地一家小醫院住院時靜脈用丁胺卡那針劑治療無效，以肺炎轉入我院治療。患者家屬將病歷及胸透片、化驗單等資料交給了一位住院醫生，並被遣忘在值班室。一個醫學生迅速地到護理站將記錄拿了過來。檢查提示，昨晚患者的心率和呼吸頻率均顯著增快。住院醫生迅速複查了這名患者，先是肺部聽診，然後檢查患者咽喉部。體格檢查完畢後，他注意到患者右肺底有溼羅音，咽喉部有膿性分泌物。未提供昨天患者的胸片、血細胞和血氣分析的結果。漏查血氣分析。然後，主診醫生迅速地檢查了一下患者，注意到患者雙側肺底有溼羅音，血壓90／60毫米汞柱（mmHg），心率120次／分，呼吸20次／分。他迅速開出血氣分析和胸透片的檢查醫囑。我們一邊等待結果，一邊讓護士查一下血氧飽和度，結果血氧飽和度（SaO2）僅為86%。患者被迅速轉移到重症監護室。
A subsequent ABG shows pH 7.50, PC O2 30rnnff/g and P O2 46mm Hg. Within 1 hr. of ICU admission, the patient requires intubation and mechanical ventilation.
血氣分析報告提示pH為7.50，二氧化碳分壓（PC O2 ）為30毫米汞柱，氧分壓（P O2 ）為46毫米汞柱。轉入重症監護室1小時後，患者接受氣管插管、機械通氣。
Adequate preparation for patient rounds is essential for efficient, quality patient care. Poor preparation not only prolongs patient rounds, but worse it may delay “timely” decisions concerning the patient treatment, and even delay recovery and discharge. Ultimately it may compromise the quality of medical care and ominously even result in premature death!
查房前的充分準備對向患者提供高效和高質量的診治非常重要！準備工作不充分不僅延誤了整個查房的時間，更重要的是，它延誤了對患者病情的及時處理，甚至會延誤患者的恢復和出院。最終會降低醫療服務的質量，甚至可能導致患者因喪失搶救時機而早死。
Adequate preparation for patient rounds should first include knowledge of the patient's current condition, which may be obtained by a brief “pre-round” chart review, including the nursing record and a bedside evaluation as well. This should be followed by collecting current lab, X-ray, and pathology reports to be available for review during rounds. Although the written reports may not be available on the chart, often a preliminary report may be obtained either by phone or from a computer monitor on the ward. These results may then be discussed with other team members during patient rounds, which will facilitate earlier diagnosis and treatment.
查房準備首先是要了解患者目前的狀況，這些信息可以通過查房前的病歷回顧，包括護理記錄和床邊評估等獲得。接著是收集患者現有的實驗室、X線和病理報告以備查房時使用。有時查房前可能拿不到正式報告，但可以通過電話或病區的計算機先得到初步報告。這些結果可以在查房時供查房小組討論，這將有利於疾病的早期診斷和治療
“Tools” are extremely necessary to perform a proper physical exam. No physician should ever begin rounds without a stethoscope and penlight in his coat pocket. Although he may not always carry a tongue blade, chopsticks or a teaspoon could be substituted for the oropharyngeal exam. Inspection of the oral mucosa may faciltate diagnosis of such diseases as pharyngitis, tonsillitis, mucositis, oral candidiasis or oral ulcerations, each of which may present clues to such diseases as SLE, HIV infection, herpes simplex, leukemia, megaloblastic anemia, or Behcet's disease.
工具對檢查極其重要。任何一個醫生在開始查房時至少要有聽診器和筆式電筒，也許他不一定總帶著壓舌板，但可以設法用筷子或勺子等代替進行口咽部的檢查。檢查口腔粘膜有助於咽炎、扁桃體炎、粘膜炎、口腔白色念珠菌病或是口腔潰瘍的診斷，從而為系統性紅斑狼瘡（SLE）、艾滋病（AIDS）、單純皰疹、白血病、惡性貧血或Behcet病等疾病提供線索。
The obvious importance of a stethoscope for physical examination should need no explanation. Lung auscultation may detect rales, rhonchi or wheezes; valuable clues to such illnesses as pneumonia, asthma or congestive heart failure （CHF）. Decreased breath sounds may be noted with a pleural effusion, COPD, atelectasis and pneumothorax. The Cardiologist uses the stethoscope for cardiac auscultation; listening carefully to detect irregular rhythms, an S3 or S4 often noted in CHF and heart murmurs heard with stenotic valve lesions. Likewise, the stethoscope allows the examiner to detect mid systolic clicks in mitral valve prolapse and pericardial friction rubs.
很顯然，體格檢查時聽診器的作用非常重要。肺部聽診可以聽到溼羅音、幹羅音或哮鳴音，這對診斷肺炎、哮喘或充血性心力衰竭很有價值。呼吸音減低則可以在胸腔積液、慢性阻塞性肺病（COPD）、肺不張和氣胸時被發現。心臟科醫生使用聽診器進行心臟聽診，仔細傾聽來發現心律失常、心力衰竭時常出現的第三心音（S3）和第四心音（S4）以及狹窄性瓣膜病變時產生的心臟雜音。同樣聽診器有利於檢查者發現二尖瓣脫垂時收縮中期喀喇音和心包摩擦音。
Other useful tools for patient rounds include the following:
1. A small ruler to measure skins lesions, nodules and PPD skin test reactions;
2. A reflex hammer to assess DTR's during the neurologic exam;
3. A small pocketsize reference book that lists medications and their dosage. Alternatively, many physicians now purchase hand-held mini-computers such as the Palm Pilot that stores a veritable “wealth” of medical information accessed with a mere tap of the finger.
其他工具包括：
1. 一把小尺：用於測量皮膚損害和結節的大小及PPD皮試反應；
2. 一把叩診錘：用於神經系統檢查時評價DTR；
3. 一本袖珍藥物手冊：用於查閱藥物和藥物劑量。現在許多醫生擁有手提式微型計算機，如“掌上電腦”，手指輕輕一點就能查閱儲存的大量有價值的醫療信息。
During patient rounds the resident should bring the nursing record to the bedside where the team can readily review pertinent patient data such as vital signs, fluid volume intake and urine output during the previous 24 hrs. The current medication list and the nurse's notes that may report frequent changes in the patient's condition must also be reviewed. Often several medications may be discontinued or switched to the oral route.
查房時，住院醫生必須將護理記錄拿到床邊，這樣有利於查房小組很容易地瞭解患者有關的病情，如生命休徵、24小時液體攝入量和尿量。還應該審查目前藥物使用情況和記錄患者病情變化的護理記錄。有些藥物常常會被停掉或改為口服。
Finally, the physician's attire and clothing must bear a professional appearance. Usually white coats are the standard physician's attire. However, frequently physicians neglect to change their coat when it becomes “soiled” with blood, ink, urine or even fecal matter. This not only presents an unpleasant appearance to the patient, but also poses a risk of transmitting infection. An identification badge that identifies the physician's name and level of training （attending, fellow, resident） must be clearly visible to the patient. This is important not only to identify the physician, but also for security reasons.
最後需要強調的是，醫生的著裝必須符合職業的特點。白大褂是醫生的校準職業裝，但醫生常常忽略衣服所沾上的血跡、鋼筆水、小便甚至大便。穿著這樣的衣服工作不僅使病人感到醫生外觀不雅，而且有傳播疾病的危險。必須佩帶標明醫生姓名和等級（如主治醫生、專科住院醫生和普科住院醫生）的身份牌，使患者能夠一目瞭然。這對識別醫生身份和安全考慮都很重要。
In summary, adequate preparation for patient rounds is essential for efficient, organized and productive patient care. It not only facilitates efficient care, but also will engender patient confidence and trust in the physician team. Furthermore, poor preparation for patient rounds often leads to the omission of pertinent patient information and thus compromises the quality and safety of patient care.
總之，查房前準備充分對實施有效、有序和富有成果的病人護理是至關重要的。它不僅有助於促進醫療工作，而且會增強患者對於醫務人員的信任。相反，查房準備不足導致患者信息的遺漏，損害患者的治療及安全。
閱讀更多 精衛之心 的文章
