2007年10月26日 星期五

跆拳黑帶新招式--TKD new Black Belt form




  


A Proposal for a new form of Tae-Kwon-Do


 


四十四歲時,為了健身,到一家韓國人六段教練 Mr. Hong S. Kim 的跆拳道場,和小孩們一起,從ABC開始練習。不怕酸痛,每週去數次,結果越練越起勁,到七年後需要做膝蓋關節鏡手術,也不畏縮,持續練習。因為我個子不大、腿不長、踢不高,兩人對打時自然想出手腳並用、聲東擊西的打法,以便應付身材高大的對手。練到三段的時候,將其整合設計成為一套新的招式,呈給教練。以後聽繼承道館的教練 Mr. Jim Hansen 告訴我說,他還繼續教這招式給黑帶初段的學生,說:"You have left a legacy!"。


 


 


Name of the Form:       "New Dawn" (Shin-Shiaw  新曉)


 


Proposed by :                 Clement C. S. Hsu, MD


                                        Third degree black belt


 


School:                           Hong Sup Kim Tae-Kwon-Do


                                        Arlington Heights , IL , USA


                                        Tel: 708-398-1560


 


Date:                               October, 1993


 


Special feature of this “New Dawn”:  This is a black belt form designed for those with shorter body height or shorter legs to improve their free fighting skills by using combinations of hands and legs.


 


Forty-four steps




 


          North


               l


West <--  --> East


               l


         South


 


Step 0:   Stand straight, face North, left hand hold right fist at the mid abdomen. (Ready stance B)


 


Step 1:   Face East in left back stance (body face North, right foot to the East), with fist fighting position.


 


Step 2:   Shift the left foot to the right foot, stand straight, face East; both fists at the left lateral side of the chest.


 


Step 3:   Give side-snap-back kick with the right leg to the opponent’s groin (to the East).


 


Step 4:   Without moving the left foot, return to the same left back-stance position as in step 1)


 


Step 5:   Shift the left foot to the right foot with both fists at the left lateral side of the chest. (Same as step 2)


 


Step 6:   Move right leg one full step to the East with the knee bent while throwing a right back-fist towards the East at the opponent’s nose.


 


Step 7:   Immediately step left foot to the East and stand in left front-stance while throwing a left middle punch.


 


Step 8:   Using the left foot as the pivot, lift right leg and turn the body 270 degrees clockwise to face the body North, and stand in horseback-riding-stance, while stumping the right foot onto the opponent’s foot and throwing a spinning right back-fist to the opponent’s face at the same time;’ face look towards East and move left arm to the left waist position.


 


Step 9:   Twist the right fist down to free from the opponent’s grab, face the body to the East, shift the right foot half step to the South to stand in the right front-stance and throw a left high-punch. (Move simultaneously)


 


Step 10:  Face the body North, the face look towards West, shift the right foot towards the left foot and stand straight; both fist at the right lateral side of the chest.


 


Step 11:  Step left foot to the West, face look to the West and stand in right back-stance, with both fists in fighting position. (The opposite direction of the step 1).


 


Step 12:  Shift the right foot to the left foot and stand straight; both fists at the right lateral side of the chest (as in step 10).


 


Step 13:  Give side-snap-back kick with left leg to the West at the opponent’s groin.


 


Step 14:  Without moving the right foot, return to the same right back-stance position (as in step 11).


 


Step 15:  Shift the right foot to the left foot with both fists moving to the right lateral side of the chest, and stand straight (as in step 12).


 


Step 16:  Move left leg one full step to the left with the knee bent while throwing a left back-fist to the West at the opponent’s nose.


 


Step 17:  Immediately step right foot to the West, stand in the right front-stance while throwing a right middle-punch.


 


Step 18:  Using the right foot as the pivot, lift the left leg, the body face North in the horseback-riding-stance, while stumping the left foot onto the opponent’s foot and throwing a spinning left back-fist to the opponent’s face at the same time; face look towards the West and move the right arm to the right waist position.


 


Step 19:  Twist the right wrist down to free from the opponent’s grab, face the body to the West, shift the left foot half step to the South to assume the left front-stance, and throw a right high-punch. (Move simultaneously).


 


Step 20:  Stand straight, body face the West, the face look towards the North; both fists at the left lateral side of the chest.


 


Step 21;  Step right foot to the North, face look to the North, and change to the left back-stance with double knife hands.


 


Step 22:  Give a left front snap-back kick, and…


 


Step 23:  Turn body to the East, assume the horseback-riding-stance, face look towards the North and throw a left lateral knife hand to the North.


 


Step 24:  Jump half a step back while turning the body to face the West, assume the left back-stance with a right hand blocking down.


 


Step 25:  Sink body down, jump sideways towards the North and jab the right knife hand to the opponent’s mid section.


 


Step 26:  Immediately throw a left high punch to the opponent’s nose.


 


Step 27:  Instantaneously following the left high punch, give a left round-house kick to the opponent’s solar plexus.


 


Step 28:  Assume the right back0stance, body face the East, face look


towards the North, with double knife hands.


 


Step 30:  Give a right side-snap-back kick and step a half step to the South.


 


Step 31:  Turn the body around counter clockwise 180 degrees, and then give a left side-snap-back kick to the South.


 


Step 32:  Assume the right back-stance, body face the West, face look towards the South, with double knife hands.


 


Step 33:  Give a right front snap-back kick and…


 


Step 34:  Turn body to the East, assume a horseback-riding-stance, face look towards South and throw a right lateral knife hand to the South.


 


Step 35:  Jump half a step back while turning the body to face the East, stand in right back-stance with a left knife hand blocking down.


 


Step 36:  Sink body down,, jump sideways towards South and jab the left knife hand to the opponent’s mid section.


 


Step 37:  Immediately throw a right high punch to the opponent’s nose.


 


Step 38:  Instantaneously following the right high punch, give a right round-house kick to the opponent’s solar plexus.


 


Step 39:  Assume the left back-stance, body face the West, face look towards the South with double knife hands.


 


Step 40:  Quickly look to the North, shift the left foot to the right foot, stand straight and use both hands to grab the arm of the opponent from the north and pull.


 


Step 41:  Give a left side-snap-back kick and step a half step towards the North.


 


Step 42:  Turn the body counter clockwise 180 degrees, and then give a right side-snap-back kick to the North.


 


Step 43: Assume a final left back-stance, looking towards the North.


 


Step 44:  Return to step 0. (Ready stance B)


 


2007年10月25日 星期四

Mediterranean cruise—2000












Travelogue—Mediterranean cruise— 2000


 


這篇2000年地中海遊記和相片檔原來已從我的電腦不慎遺失,但上週玉麗從過去列印的文章中再發現,趕緊打入電腦儲存。自己讀完,發覺我都早已忘卻當時旅遊時的詳情,其實連寫過這一篇的事實也忘了,再度覺得一個人的記憶力不可靠。從小就有寫日記的習慣,雖然是斷斷續續的,還是會對我的退休生活有增添彩色的作用。


 


For us, I and Yui-li, the exciting Mediterranean cruise started when we left Dallas for Rome on 2000/9/14 . This was our first cruise ever.


 


The first day when we arrived at Rome airport around noon on 9/15, we were picked up by a bus and sent directly to the cruise ship with other guests. Most of them came with us on the same airplane, and majority are in their 70 -80’ s. We did not have a chance to see any scenery in Rome even though Rome was mentioned as one of the places that we would visit in the cruise brochure.


 


The ship was twin-hulled, relatively small, 20,000 ton, with three floors for guest rooms. Despite its size, it only rocked a little when sailing at night. The number of guests was also petite, 350 maximum, with 230 crew members from 30 different countries. There was a group of guests, about 120 in all, recruited by NY area WOR TV food critic, Arthur Schwartz. Some of them are much younger.


 


Everyday during the day, we had either a half or a full day tour of different Mediterranean cities we visited, sailed at night, and had a 6-course dinner in a rather classy atmosphere, with a comedy or song-and-dance shows following the dinner, in a lounge. There was a small casino, but nobody seemed interested in it. We ate breakfast and lunch daily, in contrast to our no-breakfast-light-lunch pre-cruise routine, and, sure enough, we gained weight rapidly. And you know what we were trying to do desperately after the cruise.


 


I took about 70 photos with the digital camera almost everyday and stored them into my laptop at night. This kind of camera allows you to have as many pictures as you like, as long as you prepare extra sets of batteries and the batteries are recharged diligently. Also, you can view the photos right away without the hassle of having to wait for films to be developed by the photo shops. The best part of it is the ease in its filing and storage. [The worst part is that the whole file could be lost permanently if not saved in another hard drive, as happened in my case later!!]


 


The stateroom, or the cabin, was rather spacey, with floor-to-ceiling window that face the sea, and shower and bathtub in the washroom. The room was made up by a stewardess a couple of times a day as in any 5-star hotel, with supplement of fresh fruits. Four small, about 250 mL each, complementary bottles of liqueur were also in the room. We did not open them, but took them home when the cruise was over!



The cruise started by sailing to Sorrento that evening. There, we took the tour of the lost city, Pompeii . The city was built 5-6 centuries BC with a population as many as 20,000 people. It was destroyed by the Mt. Vesuvius volcanic eruption in 79 BC, and unearthed in the 17th. century. With plethora of wines and women, Pompeii was considered a sin city and was not supposed to be remembered or mentioned in earlier times. That was probably the reason for this delay in its discovery. There were public bathhouses, and sauna for the rich. They were separated into those for men and women.



The highlight of the tour was a house for the oldest profession of mankind, prostitution, with various postures for pleasure painted on the wall. The reason for these pictures to be painted like a menu for the restaurant was, scholars speculated, that this city was visited by sailors from different countries at that time. They would be attracted to these houses, yet, they might not be proficient in the language of this great metropolis. These sailors could then point to the menu on the wall to request certain form or forms of services.


 


The question came up in my mind was that, were there sexual gratification by mouth during this period of time. There were none in the several paintings discovered on the wall. The excavation is still continuing after 3 hundred years. For a cosmopolitan port city of 20,000, one bordello might not be adequate. It was most regrettable that, amidst the fascination I was overcome with, I did not think of taking pictures of these menus.


 


The scenery along the seashore highway was breathtaking. Because my digital camera had a major deficiency of requiring 15-60 seconds between each photo to recharge the battery, I could not take more of those wonderful sights. There was a black tie or dark suit dinner that evening. I brought only one dark suit. My tuxedo was made more than 10 kg ago, and I do not need tuxedo in Taiwan . I also forgot to bring the nice jacket I bought in LA for these occasions.


 


The next day was a 2-hour tour of Port Cervo. But the sea was so rough, that after I got onto the tender and while waiting for other guests to come aboard, I became so nauseous from the rocky boat that I had to get off quickly. We just enjoyed sunbathing on the ship deck and the view from the sea, which was just as pleasant.



The several miles of sea coast from Portofino to St. Margherita to St. Paolo that we saw from a tour boat on the following day was one of the most beautiful landscape on earth. Green hills and mountains right by the sea, with many elegant houses scattered and hidden among trees! No wonder many rich people, like Frank Sinatra and Lisa Minnellli bought houses there. One regrettable discovery in this visit was that the statues or other decorations we saw on all the buildings of these towns are just paintings by art students from the area. That was quite disappointing. I felt like being cheated by their tourist bureau.


 


At the city of Livorno the next day, the ship docked on the port. Some went to the Tower of Pisa . We chose to visit Florence one-hour drive away. The city was ruled by the art-loving family of Medici form 14th to 17th century, and attracted geniuses like Michaelangelo, Leonardo da Vinci, Dante, Galileo, and the like during the Renaissance. (I believe that the geniuses are produced in crops because of the societal influence. Geniuses, or potential geniuses, have always been around, only that the majority never had the opportunity to grow, to exhibit, or be recognized. That was probably the reason that there were so many poets during the Tang and Song Dynasties but few in other periods of time in the Chinese history.)


 


This tour of Florence was a near ten-hour feast treated by the cruise ship free of charge. However, we could only see small part of this town, which is so rich in culture and history. The old, narrow, stone-covered streets, European-style houses and buildings, roadside café with flower pots surrounding it, statues in city squares, the history of Renaissance, and the world-famous paintings and sculptures! The whole town is filled with the artistic and romantic flavors.


The city was swarmed by tourists, because there was another huge cruise ship visiting. September is the nicest season for tours in the Mediterranean areas because the weather is so mild. To enter a museum, if you have to wait in line, it might take two hours. Because of the previous arrangement between the tour agencies and the museums, we did not have to wait, we walked straight into the Academy of Art . In this Academy, some of the most famous works of Michaelangelo, statues of David and Prisoners, are kept. One thing noteworthy was that in these museums, which contain numerous priceless artifacts, the entrance is no larger than that of an ordinary residential door.


 


For the next two days we visited Cannes and Monte Carlo . I started to feel numb and unmoved by the picturesque scenery or the ornaments and decorations in churches or the Palace of Monaco . After seeing paintings and sculptures by those historical personalities, like Michaelangelo’s David, those in the Palace appear, unfortunately, like rather rough imitations even though they were works of famous artists centuries ago.



In Cannes , there was a perfume factory, Fragonaud, in an outskirt village, Grasse. However, in this factory, we just saw idle machines, sales persons but no workers. The perfume must be made in other places. Once inside the perfume factory, or it should be called a shop with atmosphere of an factory to attract customers, every woman tourist looked so excited and got busy buying boxed of perfumes. It is amazing how much women spend on perfumes and cosmetics!


 


The guide’s introductions surprised me that it takes 700 kg of flowers and three months of work to make one liter of perfume. We smelled several perfume samples and they do smell different, some like flowers of various kinds, some smelled like cakes, and some like fruits. The strange thing was that they did not show us mountains of flowers or green houses, which should be another spectacle. At least some pictures would help us understand the amount of flowers needed and the work it takes to make perfumes.


 


We then went to a Medieval town, St. Paul de Vance, which is located on top of a hill and said to be the most visited town in France , 20,000 tourists a day. The houses, shops, an old fountain in a small town square, and narrow street covered with stones! They were just like those seen in movies of old European towns. Despite all those tourists, I could still feel centuries of European history permeating throughout this village. But we ran so short of time as we did in all other cities. We had only 20-40 minutes of free time at each city. It was important to stick to our schedule, otherwise the ship would sail without us. We also became wet from a rather heavy rain at St. Paul de Vance by the end of the day. However, I did not feel that I missed much by not having enough time to ourselves. The streets, shops, and restaurants all started to look similar by then. Nothing appeared appetizing for us to buy. I could not find any bola tie (called loop tie in Japan ), which I thought must be very commonly used in Europe .




We were supposed to anchor off Monaco the next day. But due to the rough sea, we had to anchor in the port of Villefranche (meaning free of taxes) miles away. We had to get on the tour bus and rode for 40 some minutes through a very scenic highway: blue seas and skies, azure bay with white sailboats anchored in it, and hilly green shorelines sprinkled with orange-colored roofs with yellow walls of the houses along the way. We passed by Nice and arrived at Monaco . Monaco has been an independent country for 700 years, now under the protection of France . It is divided into the old town on the hill by the shore where the Palace is located, and the Monte Carlo where casinos operate. A Prince Carlo built a luxurious casino there, and Monte Carlo became a gathering place for playboys and tourists. They became mesmerized and happily gave away their money in large or small amounts in just a matter of minutes. It is stupefying to watch how casino collects money from each bet. No wonder the residents in Monaco do not have to pay taxes.


 


We paid extra $7 for the entrance to the largest casino that was seen in the movie, “Casino Royale”, which is located next to the famous Hotel de Paris. We had already paid $50 for this “discovery of Monaco ” tour and that should have included the entrance fee. However, people who visited casino lose this amount of money in a matter of seconds that the casino probably thought these guests would never mind a mere $7.


 


On board the ship there was a small gift shop, which opened only at certain hours. I bought a polo sport shirt (that means “no pocket”) with a Radisson Diamond logo. It costs me $50, about 3 times I could have paid in Taiwan . And, surprise! We found that it was made in Taiwan !


 


At the formal dinner the first night, photographers took portraits of us, and pictures with the captain who was only 37 years old. (He said, “ I came here in place of my father who is not on the ship now…. I will try to run the ship so that it will not sail any lower than the current level.”) For these photos they charged $25 or $10. We still bought them. Luxury tour desensitized our senses of value of merchandise, not that the company of the captain is not worth that much.


 


On 9-22, the cruise ship docked at the last stop, Nice. We cleared out the room by 8 AM, got on the bus and were sent to the airport. We left around noon, reached JFK Airport and transferred to another flight, arrived at DFW airport by 8 PM the same day. The time in Rome and France is 5 hours ahead of Dallas .


 


It was our first cruise and the first trip to the Mediterranean cities. The trip was nothing short of memorable. It was really nice that we went with classmate Chan Teh-sheng and his wife, Lillian. They were both so considerate to prepare pen and papers to write down what we were talking about for Yui-li who is hearing impaired, when we were dining together.



I was particularly happy to have taken so many photos, which could be viewed anytime I wanted to by turning on my laptop. This was certainly going to help my memory. I also took pictures of other people whom we got acquainted with. I sent them the pictures by e-mail later. [Unfortunately, after I finished writing this travelogue, sometime during transfers of the content of my old laptops to the new ones, this particular photo file, that contained more than 400 cruise pictures, was lost!! I could salvage only about 30 back into my current file from those I sent out to friends and to Yui-li.]


 


On the last day of the cruise, I took pictures of the workers for meal services on the ship, and several of them came to me at the last dinner with a cake, saying “Isn’t it your birthday today?” and sang a Happy Birthday for me. My birthday is in October. I was certainly very pleased with this unexpected personal touch. This was probably the kind of ambience they wanted to show their guests on this rather expensive luxury cruise. This Mediterranean cruise is surely going to be the most unforgettable journey of my life.


 


I am attaching photo series (3): [These photos are included in my photo file: “2000 Mediterranean cruise” in my blog.]


1)      Gate to Paradise in front to the St. Mary’s Cathedral in Florence . Each frame of carvings on the door represents a story in the Bible, which I do not know very well.



2)      The Old Bridge in Florence that, I believe, Su Suu-Min was referring to.



3)      Dante Alighieri’s statue in a city square in Florence . He is the father of poems in the Renaissance era/



4)      This plain appearing door is the entrance to the Academy of Art that contains world’s art treasures.



5)      The Prisoner, sculptured by Michaelangelo, in the Academy. It is also called Slaves, because part of the body is still locked in the stone.



6)      Beautiful indigo bay along the French Riviera.



 


 


2007年10月23日 星期二

Phthirus pubis (陰蝨;crab louse;pubic louse)

Phthirus pubis (陰蝨;crab lousepubic louse)


l        很多節肢動物(arthropods)為長期或短期寄生在人體皮膚上的體外寄生虫(ectoparasite)。有五個綱(class)Hexopoda(六足綱)Arachnida(蜘蛛綱)Diplopoda (millipedes毫足虫)Chilopoda (唇足虫綱;centipedes)、及Crustacea(甲殼綱)


l        Class Hexopoda之下,order() Anoplura (蝨目;suckling louse)有兩個genera()PediculusPhthirus(兩者皆譯為蝨屬)是人體寄生虫。Pediculus灰白、無翅、扁平、長型(2-4 mm)Phthirus則短而寬,似螃蟹。卵(nits)緊附於髮毛,7-10天後幼虫(nymph)出現,24小時內餵食以生存,2-3週後成虫,交配,雌虫20-30天內產250-300個卵,然後死亡。


病變:


l        對虫唾液的過敏而引起的強烈搔癢感為主要症狀。抓傷可能受感染。


l        Pediculus humanus var.corporis (Pediculus corporis體蝨)引起pediculosis corporis成虫虫卵主要在衣服縫隙,虫卵存活一個月。可以傳播Rickettsia prowazekii (epidemic typhus)Rochalimaea quintana (trench fever)、及Borrelia recurrentis (relapsing fever)Pediculus humanus var. capitis (Pediculus capitis頭蝨)引起pediculosis capitis虫及卵在後頭部及顳部毛髮及鬍鬚根部。兩者都由身體、衣、帽、梳子接觸傳染。人擠、個人衛生差有關。


l        Phthirus pubis之分佈主要在陰毛,但腋毛、眉毛、睫毛、體毛、頭髮都可能有。毛髮根部可見虫及卵附著。睫毛可能有痂殼(crusting)。體、腿、上臂皮膚可能有虫咬後由其anticoagulant引起的青灰斑,約不到1 cm大小,稱為maculae cerulae (blue spot,青斑)。經性交等密切接觸傳染。


治療:


l        頭蝨及陰蝨可用1% lindane or gamma benzene hexachloride shampoo (Kwell。塗抹體表,24小時後洗淨,一週後重複一次)pyrethrin liquid with piperonyl butoxide (RIDA-200 pyrinate liquid)permethrin creme rinse (Nix)0.5% malathion lotion (Prioderm。塗抹體表5分鐘後揉搓起泡,再以溫水洗淨,一週後重複)


l        台灣常用20% sulfur (mesulfen mesulphenthiantholumScabolAntigal MitigalScaphen,塗敷體表,一日數次,連續數日)crotamiton 10% cream (EuraxCrolaxGaviscon。塗抹體表徹底揉搓,每日晚間一次,不可碰到眼睛,有傷口處可能會吸收,危險。)benzyl benzoate lotion (25%BBL,塗抹體表後24小時後洗淨,每晚或隔晚一次,共三次)


l        懷孕婦女及嬰兒用sulfur


l        體蝨要處理衣服,用熱洗、烘乾、熨燙,或以1% malathion powder or 10% DDT powder噴灑。


l        眼皮要用凡士林塗抹一天兩次,共八天;或1% yellow oxide of mercury塗抹,一天四次,兩週。


l        搔癢用antihistamin口服,或steroid cream塗抹。


l       抓傷感染要用dicloxacillincephalexin等抗生素。


 (採自2002年許清曉著『傳染病防治手冊』,最有用的中英文索引Index佔全書三分之一,可在藝軒圖書公司購得。以上是有關此病原的基本常識。最新資料還是要從網路或圖書館醫學雜誌取得。)


2007年10月19日 星期五

「假使我是你,、、」Dr. Arnold S. Relman對「告知病人,如何選擇」的建議



「假使我是你,、、、」


Dr. Arnold S. Relman對「告知病人,如何選擇」的建議



                  [醫療品質雜誌 2008;2(2):110-111]



許清曉 醫師


2007-10


醫療機構診治病人時,應向病人、或其代理人、配偶、親屬或關係人告知其病情、治療方針、處置、用藥、預後情形及可能之不良反應(醫療法第八十一條)。同樣的,對於手術或侵入性診斷或治療,醫方都有告知病方的義務(醫療法第六十三及第六十四條)。中華醫學會在 1997年5月20日發佈「病人權利十大聲明」,明確的指出病人對於醫方提供的診斷及治療方式有同意及選擇的權利。


 


經過醫療品質策進會近幾年來強調病人權益的努力,醫院及醫師幾乎完全都會給病方詳細的診治方式的說明,並留下記錄,否則醫院評鑑不會通過。主治醫師平常會向病人說明診治方式的優點及缺點、或其他可以選擇的方式,以供病方選擇。


 


病人不一定是醫學專家,而診治方式的選擇項目來自主治醫師的推薦。可是病人如何決定呢?各種選擇的項目、及其優、缺點都擺在眼前,是不是病方就有能力作最適當的、可以使他心安的決擇呢?我們如果站在各種知識教育水準的病人立場,就知道答案是:不盡然。固然有些病方有對醫療熟悉的親友,會提供意見,可是大多數病人只能選擇「聽來似乎較合宜」的診治方式,或依照醫師的既定計畫方式遵行,可是心裡不免有不安的感覺,『是不是我做了正確的選擇?醫師有沒有考慮到我的這些痼疾?將來有沒有可能發生對我特別不方便的合併症?』筆者就曾經聽過一位在醫院工作的同仁,向我抱怨過,「醫師就是要我選,可是我哪知道哪一種方式的治療對我才適當!」


 


筆者1967年在波士頓市立醫院任第二年內科住院醫師的時候,當時的內科主任 Dr. Arnold S. Relman對於「如何告知病人,教病人如何選擇」,給我們如下的指示:


 


主治醫師給病人說明診治方式的優、缺點、及其他選擇之後,還要替病人著想,告訴病人說,「假使我是你的話,我會做這個選擇,因為考慮這些診治方式的優(缺)點、你的過去病史、家族史、家庭狀況、現在的體能、、、,做這一個選擇將來對你最有好處,會有哪些好處」。


 


Dr. Arnold Relman可說是當代一言九鼎,美國最受尊敬的醫界人物。他於1946年自哥倫比亞大學醫學院畢業之後,在波士頓大學醫學院任職,到1967年繼 Dr. Franz J.Ingelfinger(消化學、New England Journal of Medicine主編)昇任內科主任。之後,轉任University of Pennsylvania School of Medicine的內科主任。他早先研究腎臟病、電解質。1974年和 Ingelfinger及Maxwell Finland (微生物、感染科)兩位當時醫界巨人合編有名的兩部「Controversy in Internal Medicine」。以後逐漸轉入醫學倫理、經濟學、社會學等問題。1962-1967任 Journal of Clinical Investigation之主編,1977-1991任NEJM 之主編。之後續任 Editor-in-Chief Emeritus of NEJM。1991任哈佛大學醫學院 Professor Emeritus of Medicine and Social Medicine。他得了最少八家醫學院的榮譽學位,曾在加拿大國會演說。近二十年來一直嚴拒沒有科學證據的「另類醫學」(alternative medicine),反對論件計酬的醫師給薪方式(他主張應該以醫師所花的時間給薪,以免弊病)及醫療行為商業化等問題。


 


他平時態度嚴肅,不假言笑,很注意住院醫師的服裝言行,絕對遵守病人安全第一的原則,嚴謹的維護醫界的尊嚴。


 


他為什麼有一天,在他主持的每週一次的內科住院醫師會議,給我們這個「如何告知病人,教病人如何選擇」的指示,筆者已經忘了。可是他四十年前這句話,給我很深的印象,到現在還可以感受他說話時嚴肅肯定的神情。他的「告知病人」的作法,也可以看出他處處替病人著想的態度。


 


自然,醫師不能因為某種診療可以增加他正在研究的案例數,而給予病人有利於自己研究的指示(這是最不合醫學倫理的行為之一);也不能裝做為了要客觀、不影響病患的決定,而一點也不給適當的建議,讓病患困惑不知如何決定。醫師如果感覺有利益衝突的時候,應該將此病人轉手讓給其他醫師處理。如果不能轉手,也可以,關鍵是要能夠「站在病人的立場」,建議做出對病患最有益處的抉擇,不該做的診治就不能做!


 


不過,我們除了不違背醫學倫理,還可以反省一下,以我們目前不完整的病史詢問(history taking),以目前對病患及病患家屬背景非常簡單的瞭解,是否能夠替病患做任何「假使我是你的話、、、」之類的建議?我們是否有足夠的訊息,可以站在病人的立場,建議病人做出可以安心接受的抉擇?這個質疑也是很多資深醫師非常關心目前詢問病史不夠詳細的原因。


 


「告知病人」是重要的醫病溝通程序。在醫病關係中,坦誠、沒有誤會的徹底溝通是避免醫療糾紛的最理想手段。醫師要練出以平易的言語說明病情、說服病人或家屬的能力。對病情以及病患個人及家庭背景的徹底瞭解、對病人的親切關心及誠意,是這種說服力的根源。


 


筆者除了在此和讀者分享 Dr.. Relman的建議之外,還要提醒主治醫師們,假使病人是德高望重、滿腹學問的醫師,也最好將他當作一般病患,給他完整的說明。不能假設「他應該知道吧!」,而省去該有的解釋及建議。因為醫師不一定完全熟悉他將接受的醫療的優、缺點。而且醫師自己生病時,常常會失去方寸,沒有做正確的判斷及處理。讓他自己決定,會有偏見及誤差。同樣的理由,醫師不宜處理自己或自己家人的疾病。


 


 


 


2007年10月12日 星期五

Fish poisoning (魚及海鮮中毒)

[我一直想登刊這一篇給喜歡吃海鮮的讀者作為基本常識]


Fish poisoning (魚及海鮮中毒)


n        河豚(puffer-fish)之內臟、卵巢、皮膚有耐熱、非蛋白質的神經毒素(tetrodotoxin),食用後數小時致兩三天內發毒性(puffer-fish poisoning):頭昏、感覺異常(paresthesia)、消化道症狀、運動失調(ataxia)、麻痺,數小時內死亡。死亡率高達60%Porcupine fishnewtsalamandersunfish等都有此毒。日本吃河豚生魚,如廚師未受特別訓練會有中毒案件。


n        蝦貝(mussel)體內有海中矽藻(marine diatomNitschia pungens所含有之神經傳導物質domoic acid。食用後15分鐘到38小時內發生毒性腦病變稱為amnesic shellfish poisoning (健忘性蝦貝中毒)。強烈頭痛、噁心、嘔吐、腹絞痛、瀉痢,1/4有急性遺忘,更甚者會痙攣、昏迷。神經病變可持續數年。


n        蝦貝體內有藻類Gymnodinium breve(形成紅潮之藻類)之耐熱神經毒素。食用後數分鐘到數小時內出現中毒現象(neurotoxic shellfish poisoning;神經毒性蝦貝中毒)。冷熱覺顛倒(temperature reversal)、感覺異常、噁心、嘔吐、瀉痢、運動失調等症狀。一般會自癒。美國Florida州海邊可見到。


n        雙殼軟體動物類(bivalve mollusk)如牡蠣、蛤子、文蛤等可含有數種海藻(Gonyaulax catanellaGonyaulax tamarensisPyronidium bahamensei)分泌的耐熱毒素。食用後數分鐘到數小時內出現中毒現象(paralytic shellfish poisoningPSP;麻痺性蝦貝中毒),嘴邊四肢的感覺異常、可有消化道症狀,數天內恢復。但嚴重者運動失調、不能出聲、不能吞嚥、肌肉麻痺、呼吸停止,數小時內死亡。藻類常在北緯30度以北、南緯30度以南之海域,也可以形成紅潮。毒素可用mouse bioassay


n        有四百多種海礁魚類(reef fish)可在體內有Gambierdiscus toxicus及其他藻類釋出之毒素(ciguatoxin)。食用後數1-24小時內出現中毒現象(ciguatera fish poisoning “cigua”為西班牙文毒螺之意)。先有噁心、嘔吐、腹絞痛、腹瀉,低血壓、心跳緩慢,再一兩天後出現下肢痛及無力,又可能有冷熱覺顛倒、牙痛。大部份病人數週內恢復,但數個月或數年內可復發。嚴重者神經症狀出現後一天內昏迷、呼吸停止。可以mannitol 1 gm/kg, 20% 溶液,45分鐘內靜脈點滴完,對嚴重病患有很好的效果。在澳洲、南太平洋、西印度群島、美國Florida州等地區常見。


n       鯖魚、鮪魚、鰹魚、飛魚(屬鯖魚類;scombroid fish)、海豚、或鮭魚等魚類體內有多量的histidine,經魚體內的細菌分解(decarboxylation)成為histamine (組織銨)Histamine之量多過20 mg/100 gm魚肉時食用後會數小時內出現histamine之作用(histamine poisoningscombroid fish poisoning):嘴邊感覺異常、面紅漲、噁心、嘔吐、頭痛、心悸、流汗、頭昏、發疹。十二小時內恢復,無後遺症。捕魚後冷凍或以放射線(g-irradiation)處理就可預防。其他含有多量histidine之食物都可能發生。


(採自2002年許清曉著『傳染病防治手冊』,最有用的中英文索引Index佔全書三分之一,可在藝軒圖書公司購得。以上是有關此病原的基本常識。最新資料還是要從網路或圖書館醫學雜誌取得。)


病毒的分類

n        病毒主要分為DNA virusesRNA viruses


 


1.        DNA viruses分為以下六科﹕



l        Hepadnaviridae (DNA病毒科﹐例如hepatitis B)


l        Parvoviridae (小病毒科﹐例如human parvovirus B-19)


l        Papovaviridae (乳突腫瘤病毒科﹐例如JC virus)


l        Adenoviridae (腺病毒科﹐例如human adenoviruses)


l        Herpesviridae (皰疹病毒科﹐例如herpes simplex virus)


l        Poxviridae (痘病毒科﹐例如vaccinia)



 


2.        RNA viruses分為以下十三科﹕



l        Picornaviridae (小病毒科﹐例如poliovirus)


l        Caliciviridae (杯狀病毒科﹐例如Norwalk virus)


l        Togaviridae (套膜病毒科﹐例如rubella virus)


l        Flaviviridae (黃病毒科﹐例如yellow fever virus)


l        Coronaviridae (冠狀病毒科﹐例如coronaviruses)


l        Rhabdoviridae (桿狀病毒科﹐例如rabies virus)


l        Filoviridae (線狀病毒科﹐例如Marburg virus)


l        Paramyxoviridae (副黏液病毒科﹐例如measles virus)


l        Orthomyxoviridae (正黏液病毒科﹐例如influenza virus)


l        Bunyaviridae (本洋病毒科﹐例如California encephalitis virus)


l        Arenaviridae (砂狀病毒科﹐例如lymphocytic choriomeningitis virus)


l        Reoviridae (呼吸道腸道病毒科﹐例如rotavirus)


l        Retroviridae (反轉錄病毒科﹐例如HIV-1)


l        Astroviridae (星狀病毒科﹐例如Marine County virus)



 


n        病毒又可以其他特徵再分類﹐包括﹕病毒的形狀與大小﹑對物理及化學藥劑之敏感性﹑複製的方式﹑所含有之酵素(polymerase)﹑免疫學特性﹑傳染途徑﹑是否有包涵體(inclusion body)﹑對宿主細胞的親和性﹑所引起的病徵等。對臨床醫師較有用的特徵為傳染途徑及所引起的病徵


 


n        病毒依病徵分類如下﹕



一、經血流全身性感染﹐可能有皮膚疹者包括﹕vacciniameaslesrubellachickenpoxyellow feverdengueenteroviruses﹑及其他。


二、神經系統感染﹕poliomyelitisaseptic meningitis (poliovirusescoxsackieviruses﹑及echoviruses)﹑rabiesarthropod-borne encephalitideslymphocytic choriomeningitisherpes simplexmeningoencephalomyelitis of mumpsmeaslesvaccinia﹑及”slow” virus infections


三、呼吸道感染﹕influenzaparainfluenzarespiratory syncytial viral pneumoniabronchiolitisadenovirus pharyngitis﹑和common cold


四、皮膚及黏膜感染﹕herpes simplex type 1 and 2molluscum contagiosumwartsherpanginaherpes zoster﹑及其他。


五、眼睛感染﹕adenovirus conjunctivitisherpes keratoconjunctivitisepidemic hemorrhagic keratoconjunctivitis (enterovirus 70)


六、肝臟感染﹕hepatitis ABCetcyellow fever﹑及新生兒之enterovirusesherpesvirusesrubella virus


七、唾液腺感染﹕mumpscytomegalovirus


八、消化道感染﹕rotavirusNorwalk virusenteric adenoviruses


九、性病病原﹕herpes simplex virushepatitis B virus papilloma virusesmolluscum contagiosum virusesretroviruses (HIVs)cytomegaloviruses



(採自2002年許清曉著『傳染病防治手冊』,最有用的中英文索引Index佔全書三分之一,可在藝軒圖書公司購得。以上是有關此病原的基本常識。最新資料還是要從網路或圖書館醫學雜誌取得。)


急性出血性結膜炎 的病原

[這一段是摘自腸病毒Enteroviruses一項,已在本「感染症病原」一章中介紹]


[著者曾在急診室十餘公尺外遠遠地看到一紅眼症病患。雖然沒有直接碰觸,第二天我也得了結膜炎。顯然和其他醫護人員或病患間接的接觸,導致我的感染,其他人員並沒有明顯被感染的現象。個人的免疫狀況也很重要。]


急性出血性結膜炎 (acute hemorrhagic conjuctivitisAHC)1969年初次被發現。由enterovirus 70(更常出血)coxsackievirus A24引起,傳染性極高,顯然是經手指接觸及fomite傳染。潛伏期約一天,兩三天內開始好轉。(Adenovirus引起之epidemic keratoconjunctivitis or EKC之潛伏期5-7天,數天內惡化,2-3週後才痊癒)。少數20歲以上者在感染5-60天後得polio似的運動神經麻疹。可自conjunctival sac分離病毒(90%)


2007年10月5日 星期五

病程記錄書寫的改進意見

[上接: 病歷寫作 (]


病程記錄書寫的改進意見


200710


許清曉 醫師


[醫療品質雜誌 2008;3 (May): p.100-105]


醫療品質策進會於2003年制訂新制醫院評鑑規範,規定病歷記載的內容好壞為「必需項目」,只這一項不及格,醫院評鑑就不通過。之後,主要由醫療品質協會大力的策劃之下,全國大大小小的研習會、醫院內的討論會,不知舉辦了多少場次,病歷書寫的內容確實也有一部分改善,或者在改進中。不過本人發覺一些重要的問題還是存在,而且不理想的住院病歷上病程紀錄(Progress Note)開始根深蒂固地成為大部分醫院病歷的制式書寫方式。早先由各位醫院評鑑委員們發覺到的、從病歷內容不易看出「病情演變及主治醫師的評估」的問題,似乎又重生復活。我們推動「病歷書寫改善」四年,原先希望能夠將病歷內容提升到:簡單、明瞭、完整、「一目了然」的目標。可是以目前的記載方式,這目標並沒有達成。因此本人再追加改善建議。


 


以下的討論及建議是本人一兩年來在受到一些醫院邀請,去上課、演講,或評鑑的時候,察看住院病患病歷而得來的感受。本人看到的問題並不一定代表台灣全體醫院或醫師的病歷書寫樣式,但總是意味著一些可憂心的傾向。主要問題是「病程記錄內容不完整」;有些部分則是明顯的「錯誤」。


 


第一點先說明觀念的「錯誤」。很多病歷中的病程記錄用SOAPsubjective, objective, assessment/analysis, plan),其中A的意思是「評估、分析」,而不是「診斷」。這個錯誤是以前就有的。可是到現在,這種誤解還是持續的存在。為何主治醫師不能糾正住院醫師或糾正負責為他們書寫病歷的專科護理師的錯誤觀念,很難理解。A在住院記錄(Admission Note)是分析鑑別診斷(differential diagnosis);但是在病程記錄中是「分析住院診治後的病況」,是能夠看出主治醫師的能力及醫療品質的重要部分。病人接受醫師治療,醫師一定要分析治療成效。每天再重述住院時的診斷是荒謬的錯誤。


 


這個誤解,在改用POMR (Problem-Oriented Medical Record)之後有些病歷已有些改變,就是Problem list的項目標題就是疾病名稱或是主要症狀,因此已代替A,其下有S(主觀症狀)、O(客觀的檢查結果)、及P(以後的診治計畫),而症狀及檢驗結果改善與否的描寫常分散到SO之後,但主治醫師對病況評估的分析(例如:什麼處置改善了病情),仍然缺如。


 


第二點:本人認為目前住院病歷的病程記錄,經過各種研討會之後,雖然是已經改用POMR方式,將病人的每一種主要診斷或病狀依其嚴重性依次列項討論,可以馬上看出病人有多少問題或疾病。但是每一項目之下使用SOAP方式記載。SOAP原來是適用於病人新住院時之紀錄(Admission Note)、或是尚未開始治療者(例如急診病患)、或是治療方式較為單純者的病程紀錄(例如Occupational Therapy Note)。


 


SOAP作為已開始治療的病程記錄,是不適當的,因為它忽略了「治療過程」的描述!病人的治療方式是病程記錄的主要內容。治療用藥或方式,以及它所導致的病情改善,不能要求讀者再翻閱醫囑及檢驗結果、自己去瞭解。記載完善的TPR表上雖然可以大致看出治療用的主要藥物或方式,但在每天的紀錄上還是一定要每天記載:「迄今是如何處理疾病或症狀」。病歷是要讓所有需要照顧這位病患的醫療人員而寫的,不是只為熟悉治療過程的主治醫師自己看的。因此,治療過程複雜的病患病歷,尤其對於轉入加護病房者,以SOAP記載病程而忽略治療方式的記載,是不完整的紀錄,讓其他醫療人員、甚至主治醫師自己,也難以從病歷瞭解治療過程。


 


自從1964Weed開始主張用SOAP以來,從網路可以查閱的多位作者雖然繼續描述SOAP作為Admission Note, Progress Note的制式寫法,但是幾乎全部忽略了治療過程是如何加入內容。(不過有些作者是直接就說出SOAP紀錄並不等同於病程記錄。)沒有治療經過的病歷記載,不容易讓會診醫師徹底的瞭解病情,更難提供正確完善的會診意見。


 


那麼,到現在為止,會診醫師是如何瞭解病況的呢?原來是靠主治醫師、住院醫師、或其專科護理師來到身邊,給會診醫師親自說明診治經過!難道病歷還要用錄音帶補助?晚上值班醫師常常被叫起來看其他醫師的病人,真不知已經危害到多少病患的安全,為此發生過多少的醫療糾紛!。


 


第三點:描述一個故事,一定要考慮是否可以讓讀者看得懂,因此要寫的簡單易懂。書寫一段議論性文章,讓人最容易閱讀的寫法,就是第一句就寫出這一段的主旨,然後馬上切入讀者想要知道的論點。


 


住院後每天病程記錄的描述,應該先將病人的各種臨床問題,依照其嚴重度排列,分項討論(Problem-oriented recording)。在每一項下面,第一句應該寫出這是哪一種病症(Diagnosis confirmed?),住院三或四或五天後的今天,診斷工作已經進行到什麼地步,用什麼方法確定是什麼疾病了;下一步再寫,住院後迄今為止,已用何種方式處理症狀或疾病(Management thus far);然後再寫:根據主治醫師判斷,治療的結果是如何,並列舉各種症狀及檢驗結果來佐證主治醫師的判斷(Assessment or Analysis, based on S/O);最後再說明以後的計畫如何(Plan)。本人相信這是陳述這種住院病患的故事時,很自然的過濾訊息的次序。本人認為Progress Note內容雖然不一定要用DiMAP等標題顯示所描寫的是何事,不過有標題是可能會讓讀者覺得比較容易看,或將來電子病歷軟體設計上有其作用。


 


因此,本人建議病程記錄(Progress Note)改用DiMAP (可唸成DeeMap),而不要再用SOAP記載。有時這四種項目分開寫會很囉唆,那就將Di/MA/P合併寫也不妨。要記得的是:病歷內容要能夠「正確詳實的記載病人診治經過以及醫師的評估、意見」,書寫格式是次要的事。


 


舉例如下:


 


Problem 1. Sepsis, R/O pneumonia:



Bronchopneumonia confirmed by CXRs. Third day of cefuroxime 1.5 gm, q8h. WBC decreased from 15K 3 days ago to 10K today. Defervesced; less cough. Less rales. No more headache.



Clearly improving. To continue the same Rx. For the next 6-7 days.


 


上面這種平面的陳述方式,如果用DiMAP記載,則是如下列:


 


Problem 1. Sepsis, R/O pneumonia:



Di: Bronchopneumonia  confirmed by CXRs. 


M: Third day of cefuroxime 1.5 gm, q8h.


A: WBC decreased from 15K 3 days ago to 10K today. Defervesced; less cough. Less rales. No more headache. Clearly improving.


P: To continue the same Rx. For the next 6-7 days.



 


再一例:


 


Problem 1. High fever:



Still febrile up to 39.3°C last evening. WBC still around 10K. Bitemporal headache when febrile. All cultures: no growth.  Cause of the fever still unclear. Received 3 days of empiric Unasyn 1.5g, q6h, ceftazidime 2 gm, q8h, and  minocyclin 100 mg, bid. 


  Does not seem to be improving. May be viral infection or still be Rickettsial.  Will D/C the antibiotic and observe.  To check the report of influenza, parainfluenza virus antibodies.


  Renal function is worsening, will check for Hantavirus and Leptospira antibodies.  No jaundice.



 


以上的平述方式可以改用DiMAP記載如下:


 


Problem 1:


 



Di & M: High fever: Received 3 days of empiric Unasyn 1.5g, q6h,    ceftazidime 2 gm, q8h, and  minocyclin 100 mg, bid. 


Still febrile up to 39.3°C last evening. WBC still around 10K. Bitemporal


headache when febrile. All cultures: no growth.  Cause of the fever still


unclear.  


A: Does not seem to be improving. May be viral infection or still be Rickettsial. 


P: Will D/C the antibiotic and observe.  To check the report of influenza, parainfluenza virus antibodies.



     Problem 2:   Renal function is worsening, will check for Hantavirus and Leptospira antibodies.  No jaundice.


 


以下是第一個實例,及本人的評語。


 


 


#1. Acute appendicitis with rupture, post appendectomy on 96/7/15


        S: diarrhea, abdominal fullness, wound pain



  O: consciousness, alert; gas passage(+), bowel movement (+) with loose diarrhea.


  Mild lower abdominal distension; bowel sound hypoactive;


  Abdominal wound (filled with gauze): oozing yellowish-reddish discharge.


  Right drain: small amount


  BP: 120/78; HR: 68/min; RR: 18/min; BT : 37.2 at 7 AM


P: To keep present management as follows:


  To start liquid diet, and supplement with iv fluid


  Wound CD with gauze filling, qd + prn


  Panadol 1#, tid, po, for pain


Antibiotic: Flumarin 1 vial, q8h, iv drip, (day 7) for infection control


  To try ambulation



#2. Cough with sputum


        S: cough and sputum decreased


      O: RR: 16-18/min, breathing sound mildly coarse; respiratory pattern smooth


      P: Medicon A 1 tab, tid, po


         To monitor respiratory status closely


 


上面一例是用SOAP方式書寫,仔細看,能猜測病況。但是內容相當的雜亂,讀者的腦筋內還得整理問題的次序,不容易馬上看懂病人目前的問題。而且還是看不出主治醫師的意見。Ruptured appendix經過手術清理後,感染的治療也應該是主要的問題了。年月日要用公元記載才不會被外國讀者誤會。


 


可以用DiMAP改寫如下:


 



Consciousness: alert; vital signs normal. (BP=120/76, PR=70, RR=18, Tmax=37.2 at 7 PM)



Problem #1: Ruptured appendix



D: Ruptured appendicitis complicated by localized peritonitis with early abscess formation (patient had had RLQ pain for 4 days p.t.a.), WBC=23k, CRP=123 on admission.


M: Operated on admission 7 days ago, abscess was cleaned and a drain inserted. Antibiotic, Flumarin (flumoxef) started, 1 gm, q8h, iv drip after a 2 gm loading dose given early during the surgery (23 y.o. man, Bw=85 Kg, 165 cm, Cr=0.8).


A: Wound discharge is more reddish, 25 mL today (300 mL the first day). Gauze changed, qid. 


Pus culture: E.coli, B. fragilis, enterococci (Resistant to flumoxef !!). However flumoxef appears effective thus far. Repeat WBC=12k and CRP=30 (4 days ago). Abdominal pain is less, BM(+) for two days, with loose stool x2/d. RLQ still mildly tender with hypoactive bowel sound.


Liquid diet started yesterday with iv fluid supplement.


P: To follow WBC, differential count, and CRP again today. If no further improvement in the infectious process as judged by the WBC and CRP, will consider switching antibiotic to piperacillin/tazobactam, 4.5 gm, q6h, iv drip, to cover enterococci and other Gram negatives.


To continue dressing change daily, qid.


To consider soft meal.


To start ambulation.


Panadol (acetaminophen) 1 tab (500 mg), tid, prn, po, for pain.



Problem #2



D/M: Cough with whitish sputum production for 5 days; lungs clear on auscultation. Given dextromethorphan 20 mg, tid for cough.


A/P: To encourage coughing and continue the dextromethorphan.


To watch respiratory status closely.


 



以上DM每天多半不變,但AP每天需注意確實評估分析。應該注意的是病況或檢驗數據不宜只寫下(靜態的)現狀,而要隨時和過去(記載時日)的結果比較,說明病況是較好了、或是較壞了、或是沒有變化。如此讀者才不必東翻西翻,自己判斷。


 


第二個實例如下:


096-8-12



S: Severe low back pain improved after CT-guided drainage


  Left lower leg weakness improved after CT-guided drainage


O: Fever noted after the CT-guided drainage, but has subsided now.


   Low back tenderness improved.


   Left lower limb weakness improved.


   Lab data: WBC 13,500; N/L: 78/16; Hb 12 gm; CRP: 90; ESR: 70


   Pig tail drainage: 80 mL at CT room; 30 mL yesterday (serosanguinous)


A: L2,3 infection (suspect tuberculous)


  Paraspinal abscess at the same area


P: To continue antibiotics (cefazolin 1 gm, q8h, + gentamicin 160 mg, qd, iv drip)


   To re-check WBC, CRP, ESR tomorrow.


   Pain relief with acetaminophen



 


上面第二實例的內容是相當充實。但是因為要符合SOAP書寫的硬性規定而閱讀時感覺次序顛倒。主治醫師對整體病況變化的評估也沒有。


 


如果用DiMAP記載,則如下:


 


Problem #1: L2,3 Spondylitis with paraspinal abscess



D: Admitted 3 days ago complaining of severe low back pain and left lower limb weakness.(可以不要寫這句) Suspect tuberculous spondylitis of L2,3; with paraspinal abscess confirmed with CT. 


     Lab data on admission: WBC 13,500; N/L: 78/16; Hb 12 gm; CRP:   90; ESR: 70.


M: CT-guided drainage was performed the second day of admission.


   Antibiotic coverage with cefazolin 1 gm, q8h, + gentamicin 160 mg, qd, iv drip, Day 3


A: Severe low back pain and left lower limb weakness improved after the CT-guided drainage.


Pig tail drainage: 80 mL at CT room; 30 mL yesterday (still serosanguinous)


       Fever spike noted after the procedure; has not recurred. Antibiotics may be effective. Gram stain: few Gram positive cocci; AFB stain: pending. Pus cultures for TB and bacteria: sent.


P: To follow WBC, CRP, ESR in AM


      To continue the same antibiotics for now.


      Acetaminophen 500 mg, tid, po, for pain



 


SOAP是住院記錄(Admission Note)的寫法,我們1960年代初,當學生的時候就被指導本質和SOAP完全相同的記載方式,SOAP並沒有提供更好的過濾病人訊息或更順暢的閱讀方式。可能將來電子病歷的軟體設計上,需要各個項目設個標題,因而有如此「SOAP」的發展。


 


但是本人認為以SOAP記錄病程(Progress Note)是缺乏治療方法描述而不完整的、同時也是次序顛倒難讀的方式,因此建議改用DiMAP。實地查閱各類醫院的病歷,更能體會SOAP的缺點。目前的方法有缺失、或有更好的記載方式,就應該盡早改正,以便溝通順暢、以免幾年後再度各地開研習會,勞民傷財。


醫院評鑑委員的責任非常地重大,影響更大。在評鑑最後的講評說一句:「為什麼沒有用DiMAP(或SOAP)?」這些醫院多半就趕緊完全遵旨照辦!不過現在每一家醫院評鑑的時間較長,有時間仔細查閱病歷內容,應該可以仔細看病程的描寫是否合理易懂,而不是只看有無DiMAP或其他類的標題。本人認為病歷內容能夠「簡單、明瞭、完整地描述病人治療的過程及醫師的診治意見」最重要,而不一定要遵從什麼制式的、有標題的寫法。「DiMAP」這些標題只是一個建議,因為它包含了治療的方式,而較為完善;讀來也比較順理成章。目前SOAP的寫法用來記載病程有缺失,應該捨棄不用。


 


不論哪一種Progress Note, Summary Note的寫法,沒有描寫病患處理方式及主治醫師的病情分析(Assessment/Analysis),不是完善的紀錄。