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BURNS AND PLASTIC BURNS Infections in burn patients 1. Introduction Infection remains the leading cause of death among patients hospitalized for burns. The risk of burn wound infection is directly correlated to the extent of the burn and is related to impaired resistance resulting from disrupt ion of the skin’s mechanical integrity and generalized immune suppression. Bacterial burn wound infections and mortality from burn wound infection decrease with rapid burn debridement and wound closure and the use of effective topical and systemic antimicrobial chemotherapies. Overall mortality rates from burn wound infection remain high. Though advances in local burn therapies, including the judicious use of antimicrobials, has reduced infectious complications from large burns, secondary opportunistic Infections always complicate and alter the course of the illness. This is prevalent especially in patients sustaining larger burns (>40% total body surface area [TBSA] and in children less than 4 years of age. An analysis of the common isolates from the burn wound and blood cultures and their sensitivity patterns would help to formulate an institutional drug policy for the patients admitted to the Burn Unit. 2. Material and methods This is a retrospective analysis of isolates and their sensitivity patterns from the culture of wound swabs of patients admitted to the Burns unit of Kanchi Kamakoti Childs Trust Hospital, Chennai from December 1998 to December 2004. A total of 535 samples were processed during this period. Wound swabs were taken from the burn wounds and cultured. Blood cultures were also sent simultaneously. The isolates were identified and their antibiotic sensitivity determined using Kirby–Bauer disc diffusion technique. If an isolate is resistant to any one of the cephalosporins (cefotaxime, ceftazidime) confirmatory tests for an ESBL enzyme is performed by demonstrating increased susceptibility to cefotaxime and ceftazidime in the presence 1 of clavulanic acid as clavulanic acid inhibits ESBL enzymes and lowers the MIC of cephalosporins. 3. Results A total of 535 samples were studied during these 6 years. Single isolates were seen in 84% and multiple isolates in 9%. Forty samples were reported to be sterile (7%). The commonest isolate was Pseudomonas species in 41% followed by Staphylococcus aureus (37%), Escherechia coli (10%), Klebsiella (10%) and anaerobes in (2%). Gramnegative bacilli especially Pseudomonas were found to be highly sensitive to carbapenams followed by amino-glycosides and quinolones. The isolates from the burn wound and blood culture were found to be the same in our institution. E. coli and Klebsiella were usually found to be ESBL producers and the rates were 37%. 4. Discussion In the present study solitary isolates were more common than multiple isolates. This is in contrast to other studies were multiple isolates were more common. However, the observation by Kaushik et al. was similar to ours. In their study, Kaushik et al. found Pseudomonas as the most common isolate which was similar to the observation made in our study. Antibiotic sensitivity patterns served as a useful guideline for choosing the appropriate antibiotic. When we analyzed the sensitivity patterns of our isolates we found that Pseudomonas which was the commonest isolate was most sensitive to carbapenams followed by aminoglycosides and quinolones. Quinoloneswere found to be most suitable against Pseudomonas followed by aminoglycosides in the study done by Kaushik et al. Grampositive cocci were found to be highly sensitive to cloxacillin, amoxycillin clavulanic acid and Vancomycin. The extended spectrum beta lactamase (ESBL) rates of Gram-negative bacilli were 37%. ESBL are likely to give false susceptibility to third generation cephalosporins thereby misleading the clinicians about the choice of antibiotic. Therefore, it is essential to screen for ESBL in Gram-negative isolates especially E. coli and Klebsiella. Methicillin resistant Staphylococcus aureus (MRSA) rates were 2 insignificant. While there was no mention about ESBL rates in the studies done by Kaushik et al. and Revathy et al. the observation made by Taylor et al. was similar to our study. To conclude solitary isolates were more common with Pseudomonas and Staphylococcus forming the main organisms. The antibiotic sensitivity patterns and periodic surveillance of ESBL and MRSA rates were useful in choosing the appropriate antibiotic against the isolated organisms. PLASTIC Impact of Complications on Patient Satisfaction in Breast Reconstruction Background: The development of a complication after surgery can be difficult for both patient and surgeon. With a growing body of literature evaluating patient satisfaction after breast reconstruction, few studies directly focus on the impact of surgical complications on satisfaction. This study analyzed the effect of complications on general and aesthetic satisfaction after breast reconstruction. Methods: All women at an academic institution undergoing breast reconstruction between 1999 and 2006 were identified. Patient demographics and history of complications were collected. A questionnaire adapted from the Michigan Breast Reconstruction Outcomes Survey was administered examining general and aesthetic satisfaction. Patients with complications were compared with patients with no complications. Results: Overall, 716 women underwent 932 reconstructions; 233 patients had a complication. Patient demographics and response rate were similar between the two groups (overall response rate 75.4 percent). Development of a complication correlated with increased odds of aesthetic dissatisfaction. Other predictors of dissatisfaction were older age, reconstruction with an implant, and a longer time interval between reconstruction and survey, while autologous reconstruction was a predictor of 3 satisfaction. Among patients with a complication, implant reconstruction and mastectomy for prophylaxis were significant predictors of dissatisfaction. Conclusions: Aesthetic satisfaction after breast reconstruction is lower in patients developing a complication, older patients, and those receiving an implant reconstruction. Furthermore, patients with a prophylactic mastectomy are more likely than those with a therapeutic mastectomy to be dissatisfied when complications arise. These relationships are important, as measures to improve quality and decrease complications can directly improve patient satisfaction. Patient Selection A retrospective review was performed of all patients undergoing postmastectomy breast reconstruction at Beth Israel Deaconess Medical Center from January of 1999 to December of 2006. Procedures were performed by seven different surgeons over this time frame. Patients who had reconstruction of partial mastectomy, salvage mastectomy, and congenital breast defects were excluded. There were 716 women who underwent 932 breast reconstructions. During the 23.3 months of mean follow-up time, 233 patients (287 reconstructions) developed complications requiring additional surgical management (complication group), and 483 patients (645 reconstructions) did not develop any significant complications (no complication group). Nine patients (six responders) with bilateral reconstructions known to have a different type of reconstruction for each breast (e.g., autologous and implant/expander) were excluded in the satisfaction analysis. Data on patient demographics and complications were gathered retrospectively from the online medical records, office charts, and inpatient medical records. Assessment of Complications The onset of complications in the study population was assessed using an extensive retrospective analysis of the patients’ online medical records, office charts, and inpatient hospital records. The complications included in this analysis were those requiring additional surgical management. Complications included infection, hematoma, seroma, mastectomy skin flap loss, abdominal hernia or bulge, total and 4 partial flap loss, open wound, fat necrosis, capsular contracture, implant rupture, extrusion, malposition, and rippling. Patients with bilateral breast reconstructions were considered to have a complication if one or both breasts had developed a complication. 5 From Townsend: Sabiston Textbook of Surgery, 18th ed. 2007 Copyright © 2007 Saunders, An Imprint of Elsevier SAFER SURGICAL SYSTEMS (1) Surgical services represent JCSs amenable to improved effectiveness, improved efficiency, and improved safety with focused management practices and professional leadership. Improving surgical safety, particularly operating room safety, will require surgeons to assume their responsibility to lead the surgical JCS. Many surgeons currently lead efforts to improve surgical safety. The following paragraphs describe some of these efforts and delineate additional opportunities to prevent adverse events, errors, and accidents. Team Development Systems include people working with artifacts to accomplish goals: teams. Consequently, addressing systems of care begins with an examination of the people in the system forming the team. In surgical care the team includes surgeons, anesthesiologists, anesthetists, nurses, allied health personnel, and administrators. To work effectively in surgical teams the people require competency, proficiency, continued learning, and skill development. Competency refers to the cognitive skills and knowledge required to practice a profession. Proficiency is the ability to execute a task at a consistently optimum level and outcome. Learning is the acquisition of new knowledge. Maintaining surgical competency and proficiency requires a long-term, perhaps endless process that begins with the selection of trainees. Because some individuals learn and acquire skill faster than others do, the training process should possess continual, objective, standardized assessments of cognition and technical skills. These processes should then continue beyond the training period into continuing 6 professional practice to provide continuing assessment of established surgeons for revalidation and recertification. Practicing surgical professionals of all disciplines require opportunities for continuing acquisition of new knowledge and new technical skills. Because of the rapidly increasing volume of new knowledge and new technology, learning and development of new skills assume increasing importance for maintaining patient safety.[24] Surgical professionals need reliable performance assessment in the form of regularly provided outcome data such as morbidity rates, mortality rates, cure rates, and patient postoperative quality-of-life assessments. In addition, some system for analyzing and evaluating anonymous incident, error, and accident reports could promote safety in surgical practice. The U.S. Congress enacted laws permitting collection of such data without risk of legal discovery. The Agency for Healthcare Research and Quality is developing federal regulations to permit health care organizations to form patient safety organizations for the purpose of examining data on medical errors and accidents. Surgeons have a special responsibility to promote safety by providing leadership to surgical teams. Surgeon leaders must have sufficient experience and surgical volume to sustain a high level of proficiency. A surgeon leader who understands the system will implement good team management and promote optimal performance of all involved professionals by focusing on the interests of the patient. Leadership requires the physical presence of the surgeon in the operating room. A safety-oriented surgical system would include measures to identify impaired members of the team, including surgeons, anesthesiologists, anesthetists, nurses, allied health professionals, and administrators. These problems occur infrequently but can pose threats to patient safety when they occur. Our profession has not addressed this matter as well in the past as it must in the future. Team leaders should develop processes for recognizing impaired members. Impairments include substance abuse, mental illness, and physical 7 illness. In addition, recognition and correction of declining competency and proficiency should promote safety. Teams should also recognize and correct behavioral problems causing disruption in the workplace. Professionals who cannot work effectively with others or who are abusive to others, including personnel and patients, must undergo rehabilitation. Institutional or team leaders should identify problem staff members early and take corrective action in a timely manner. A system of professional accountability must be objective, based on data; it must be fair and apply to everyone in the system; and it must respond with prompt and effective treatment with the goal of enabling all to continue professional practice.[25] Surgeons, anesthesiologists, nurses, and allied health professionals recognize the importance of teamwork in the operating room. For many operations, pathologists play a crucial role in safe, effective surgery and smooth conduct of surgical procedures. A high-performance operating room requires good communication among all surgical team members because breakdowns in communication can lead to errors, adverse events, and accidents compromising patient safety. Medical team training can improve communication in the operating room. Operating room teams can use crew resource management (CRM) principles to enhance communication and patient safety. CRM principles include didactic instruction, interactive participation, role-playing, training films, and clinical vignettes. Awad and coworkers investigated CRM quantitatively and concluded, “Medical team training using CRM principles can improve communication in the operating room, ensuring a safer environment that leads to decreased adverse events.”[26(p773)] Gap Protection Cook and colleagues introduced the useful concept of gaps and recognized that gaps provide opportunities for errors and accidents.[27] Gaps, or discontinuities, may produce loss of information, loss of momentum, or interruptions in delivery 8 of care. Fortunately, gaps rarely lead to failure or produce errors because nurses, technicians, clerks, or physicians anticipate, identify, and bridge most gaps. Organizational boundaries, changes in authority or responsibility, different roles of professionals, and divisions of labor produce gaps. For example, shift changes, patient transfer to different units within a hospital, patient transfer between hospitals, discharge to a rehabilitation facility, and discharge home produce gaps in care. Gaps can occur within the activities of a single practitioner, for example, when a nurse divides attention between two or more patients. Organizational change or the introduction of new technology can cause new gaps or disrupt bridges spanning established gaps. System complexity creates gaps in care, and information can be lost. Every transition in care constitutes a gap. The increasing fragmentation of medical care produces more gaps. Structured handoff routines and checklists can decrease information loss at gaps. A dozen or more gaps or handoffs can occur between evaluation in the clinic, surgical admission unit, operating room, recovery room, ICU, and surgical ward and discharge from the hospital. Each gap requires a handoff. Handoff routines can include reading back orders and instructions, face-to-face review of clinical information, or handoff information technology resources. Checklists and standardized orders can also minimize loss of information at handoffs. Checklists can simplify preoperative planning, operating room scheduling, admission scheduling, night-before instructions, preoperative details (briefing), and postoperative care (Fig. 11-3). A system can apply standardization to admission and preoperative orders, postoperative orders, transition orders, discharge orders, and discharge instructions. Guidelines, clinical pathways, protocols, and algorithms can also facilitate bridging of gaps. All these gap transition artifacts prompt routine, necessary action at system gaps, can be customized for individual patients, and are effective, inexpensive, low-tech, and efficient.[27] 9 Figure 11-3 Checklists such as this one can maximize effective communication at gaps and during handoffs along the continuum of surgical care. (Courtesy of the Department of Surgery, University of California, San Francisco.) The Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the American College of Surgeons (ACS), and the Veterans Administration Health System (VAHS) recommend processes for preoperative review to promote safety and eliminate errors in patient and surgical site identification, as well as other important considerations.[28–30] The ACS, JCAHO, and VAHS endorse a preoperative briefing or time-out before every surgical procedure. Box 11-4 shows the JCAHO recommendations for its time-out procedure. This guide stipulates essential topics for preoperative discussion by all members of the surgical team and a checklist to verify that all personnel, all necessary equipment, and all necessary processes have been accomplished or are in place before making the incision or beginning the procedure. Development of a preoperative briefing guide and the related checklists can begin with the patient's first encounter with the surgical team. This first encounter can initiate an iterative process that produces a checklist for review by members of the surgical team on the preoperative evening in elective cases. The preoperative time-out in the operating room will then verify all items on the list. After the operation, members of the surgical team will bridge the gap between the operating room and the recovery room or the ICU. Box 11-4 JCAHO Time-Out Immediately Before Starting a Procedure Must be conducted in the location where the procedure will be performed, just before starting the procedure. It must involve the entire operative team, use 10 active communication, be briefly documented, such as in a checklist (the organization should determine the type and amount of documentation), and must, at the least, include the following: ▪ Correct patient identity ▪ Correct site and side ▪ Agreement on the procedure to be performed ▪ Correct patient position ▪ Availability of correct implants and any special equipment or special requirements The organization should have processes and systems in place for reconciling differences in staff responses during the time-out Adapted from the Joint Commission on Accreditation of Healthcare Organizations. Universal Protocol, 2006. Available http://jointcommission.org?PatientSafety/UniversalProtocol at . Retrieved October 27, 2006. Improvements in Information Technology Federal and state governments and all health industry stakeholders assign high priority to the application of information technology for increasing the safety and quality of health care. With the leadership of the Department of Health and Human Services, 13 government agencies, professional organizations, private foundations, providers, and vendors formed an organization, the National Health Information Infrastructure (NHII), to promote the development and implementation of information technology systems and programs to support the development of a national health care system. Box 11-5 lists the goals and 11 objectives of a national health information technology system. This task will require unprecedented leadership from government, industry, and the health professions. In addition, the project faces substantial financial challenges. As it develops over time, a national health information infrastructure will undoubtedly improve the quality and safety of health care.[31] However, the health care industry should introduce new information technology with care and deliberation because such new technology could create tighter coupling in the system and produce unforeseen challenges in system control and unanticipated opportunities for error.[23] Box 11-5 Goals of the National Health Information Infrastructure ▪ National platform for standards ▪ Confidentiality ▪ Electronic medical records ▪ Computerized physician order entry ▪ Electronic prescriptions ▪ Quality improvement databases ▪ Repositories of best evidence ▪ Computer-assisted decision support ▪ Prompts and reminder systems From U.S. Department of Health and Human Services. National Health Information Infrastructure (NIIH 2002-2004), http://aspe.hhs.gov/sp/NHII/index.html 2006. Available . Retrieved October 27, 2006. 12 at Nonetheless, computerized physician order entry and computerized prescription writing already show promise for reducing medical errors. Information technology provides multiple opportunities for improving patient safety; for example, computerized rounding and sign-out systems have the potential to improve the continuity of care and facilitate the bridging of gaps. Van Eaton and associates, working in an academic medical center, developed a centralized, Web-based computerized rounding and sign-out system that securely stores information, automatically downloads patient data, and prints the data to rounding, sign-out, and progress note templates. Authorized users could access the system from any hospital workstation or from their own computers. The centralized computer allowed residents to organize patient lists, enter detailed sign-out information, and compile “to do” lists. Residents could add patient data to other team's lists when cross-covering or consulting. The system produced sign-out reports and rounding lists that included clinical data and laboratory values downloaded from the hospital clinical information systems. This team evaluated the system in a prospective randomized trial involving six general surgery services and eight internal medicine services. Helping residents cope with the limitations of the 80-hour work week motivated this project, which succeeded in this objective by decreasing rounding time. However, the system also enhanced patient care by decreasing the number of patients missed on resident rounds and improved the continuity of care. Although a teaching hospital developed this system, the method and the principles developed should work in any hospital.[32] 13 Pre-operative Assessment By Wang Xiang Department of Neurosurgery, West China Hospital Preoperative assessment aims to: o Reduce morbidity and mortality associated with surgery o Prevent unnecessary cancellations o Reduce hospital stay Aim of preoperative planning Inform patient of the proposed procedure Obtain informed consent for the procedure Assess pre-existing medical conditions Plan pre and postoperative management of these conditions Issues that should be discussed Time of admission and starving instructions Management of usual medication Any specific pre-operative preparation that may be required Transport to theatre Any specific anaesthetic issues Anticipated duration of surgery Likely recovery period Need for drains, catheters Likely discharge date Need for dressing change or specific postoperative care Follow up requirements Likely date of return to work or full activity 14 Important medical diseases that increase morbidity and mortality Ischaemic heart disease Congestive cardiac failure Hypertension Cardiac arrhythmias Chronic respiratory disease Diabetes mellitus Endocrine dysfunction Chronic renal failure Nephrotic syndrome Obstructive jaundice Advantages of pre-admission clinic Allows pre-operative optimisation of patients Reduces duration of hospital stay Reduces risk of unnecessary cancellations Guidelines minimise unnecessary preoperative investigations Elements of the Surgical Safety Checklist. Sign in Before induction of anesthesia, members of the team (at least the nurse and an anesthesia professional) orally confirm that: The patient has verified his or her identity, the surgical site and procedure, and consent The surgical site is marked or site marking is not applicable The pulse oximeter is on the patient and functioning All members of the team are aware of whether the patient has a known allergy The patient’s airway and risk of aspiration have been evaluated and appropriate equipment and assistance are available If there is a risk of blood loss of at least 500 ml (or 7 ml/kg of body weight, in children), appropriate access and fluids are available 15 Time out Before skin incision, the entire team (nurses, surgeons, anesthesia professionals, and any others participating in the care of the patient) orally: Confirms that all team members have been introduced by name and role Confirms the patient’s identity, surgical site, and procedure Reviews the anticipated critical events Surgeon reviews critical and unexpected steps, operative duration, and anticipated blood loss Anesthesia staff review concerns specific to the patient Nursing staff review confirmation of sterility, equipment availability, and other concerns Confirms that prophylactic antibiotics have been administered ≤60 min before incision is made or that antibiotics are not indicated Confirms that all essential imaging results for the correct patient are displayed in the operating room Sign out Before the patient leaves the operating room: Nurse reviews items aloud with the team Name of the procedure as recorded That the needle, sponge, and instrument counts are complete (or not applicable)That the specimen (if any) is correctly labeled, including with the patient’s name Whether there are any issues with equipment to be addressed The surgeon, nurse, and anesthesia professional review aloud the key concerns for the recovery and care of the patient 16 A Brief Introduction to Drug Instructions 说明书的表达方式包括: instructions, labels, fact sheet, package insert, directions, descriptions, 结构: leaflet 1. drug names 药品名称 2. description 性状 3. pharmacological actions 药理作用 4. indications 适应症 5. contraindications 禁忌症 6. dosage and administration 剂量和用法 7. adverse reactions 副作用 8. precautions 注意事项 9. package 包装 10. storage 储存方法 11. others 其他 1. Drug names 常见的药品名称: 商品名 (trade name or proprietary name); 注册名 (registered name); 通用名 (generic name); 化学名 (chemical name) 药品名称的翻译法可采用音译, 意译, 音意合译及谐音译意等方法. 1) 音译: 按英文药品名称的读音译成相同或相近的汉语. 如: Rulide 罗力得 Amoxicillin 阿莫西林 2) 意译: 按药品名称的含义译成相应的汉语. 如: Cholic Acid Techracyclin 胆酸 四环素 3) 音意合译: 药品名称中一部分用音译法, 一部分用意译法. 如: Medemycin Erythromycin 麦迪霉素 17 红霉素 4) 谐音译意: 以音译为原则,选择谐音的汉字,既表音,又表意. 如: Webilin Doriden 胃必灵 多睡丹 2. Descriptions (性状) Other names: chemical structure (化学结构); composition (成分); physical and chemical properties (理化性质) 1) 常用词组: be derived from (由...提取); be obtained (制得); contain (含有); be prepared from (由...制备); consist of (由...组成) ; have/possess (有) 2) 表示性质的词类: injection (注射剂); solution (溶液); tablets (片剂); liquid (液体); powder (粉末); solid (固体); stable (稳定的); unstable (不 稳定); 3. tasteless (无味的); soluble (可溶的); insoluble(不可溶的); odorless(无臭的); crystalline (结晶的); color (颜色) Pharmacological actions (药理作用) Other names include: clinical effects (临床效果); mechanism of action (作用机理); mode of action (作用方式); pharmacological properties (药理性质) 1) 常用词: 动词 absorb (吸收); act on / exert action on (作用于); produce (产生) result in(导致); maintain (维持); promote (促进); excrete (排泄); inhibit (抑制); demonstrate (显示); exhibit (显示); indicate (表明); show (表明); suggest (表明); accumulate (积蓄); prevent (预防); 形容词 average (平均的); mean (平均的); 18 minimum (最低的,最小的); maximum (最高的,最大的); be related to (与...有关的); be sensitive to be active against (对---有效); (对...敏感的); be effective against (对---有效); be resistant to (...有耐药性的) 名词 activity (活性); distribution (分布); excretion (排泄); mechanism (机理); half life (半衰期); tolerance (耐受性); toxicity (毒性); in vitro(体外); in vivo (体内), serum concentration (血清浓度); 4. Indications (适应症) 多为疾病名或致病菌的名称 diabetes (糖尿病); 如: plasm level (血浆浓度) hypertension (高血压); gram-positive (革兰氏阳性菌); streptococcus (链球菌); virus (病毒); gram-negative (革兰氏阴性菌); staphylococcus (葡萄球菌) 常用词组 be active agaist (对...有效); be administered in (适用于); be indicated in/ for (适用于); be in/ for the treatment of (用于治疗); be intended to (适用于); be used to/ for/ as (用于); be recommended for (推荐用于); be employed to (用于); be associated/ conbined with (与...联合使用) be compatible with(与...配伍使用); be concomitant with(与...共同使用), together with (与...共同使用); in conjunction with(与... 结合使用). 5. 禁忌症 (contraindications) 1) 特殊患者: in pregnancy (妊娠期); lactation (哺乳期); pregnant woman (孕妇); the first trimester of pregnancy (妊娠的头三个月) children under---years of age (...岁以下儿童); 19 2) 对---过敏: be allergic / hypersensitive to; present allergy/ hypersensitivity to; 患有---疾病者 patient with---- patient suffering from ----- 3) 常出现的疾病名: severe anemia (严重贫血); cardiac failure (心力衰竭); liver/ hepatic damage (肝损伤); impairment of kidney (肾损伤); cardiac (renal) insufficiency (心或肾功能不全); 6. Dosage and Administration (剂量和用法) Other names include: mode of application (用法); direction for use (用法); How to use (用法); posology (剂量学); dosage (用量); Route of administration (给药途径); 1) 表示剂量的术语: average dose (平均剂量); 量); divided dose (分次剂量); indicated dose (有效剂量); daily dose (日剂 initial/ beginning/ starting dose (首 次剂量); maintenance dose (维持剂量); fatal/ lethal dose (致死量); overdose (过 量); therapeutic dose (治疗剂量); maximum dose (最大剂量); usual/normal dose (常用剂量); single dose (单次剂量); minimum dose (最小剂量); standard dose (标准剂量); 2) 给药次数表示法: daily / per day / every day (每日); every---hours (每隔...小时); twice daily (每日两次); every other day (每隔一天); once a week (每周一次); divided into-----doses (分...次); in two or three divided doses (分为二或三次) 3) 给药对象: infants (婴儿,幼儿); newborns (新生儿); 20 baby (婴儿); children (儿童); adults (成年人); pregnant women (孕妇); debilitated patients (体弱患者); senile/elderly patients (老年 患者) 4) 给药方式: parenterally (肠道外给药); intraperitoneally (腹腔内给药); locally (局部给药); intravenously (静脉内给药); intramuscularly (肌内给药); intragluteally (臀肌内给药); orally=by mouth (OS) (口服给药); per rectum =pro recto (直肠给药) by the intravenous infusion/ perfusion (静脉输注); by aerosol (喷雾给药); by phleboclysis (静脉输液); by enema (灌肠); by the intranasal route (鼻内给药); by drip phleboclysis (点滴静脉输液); 5) 常用给药或用药的动词: 给药: give; indicate; use; 用药: take (服用) ; employ; administer inhale (吸入); swallow (吞服); spray (喷雾); inject (注射); apply to (涂于, 敷于) 7. 用于表示副作用的术语: Adverse / side/ unwanted reactions, side-effects, by-effects 1) 常见毒副作用: allergic/ hypersensitive/ anaphylactic reactions (过敏反应); local reactions (局部反应); systematic reactions (全身反应); skin reaction (皮肤反应); ); dizziness (眩晕); flush (潮红); thirst (口渴); 皮疹); 倦); coma (昏迷); nausea (恶心); fatigue (疲倦); anorexia (厌食 rash ( tiredness (疲 spasm (痉挛) 2) 表示停药的动词: abandon ; discontinue ; cease; suspend; terminate; withdraw. 21 stop; 3) 其他常见词汇: reversible (可逆的); irreversible (不可逆的); severe (严重的); mild (轻微的); temporary (暂时的); transient (短暂的); disappear (消失); give rise to (产生); lead to (导致); manifest (表明, 显示); result from (由...引起); result in (导致) 8. 注意事项: cautions; precautions; note; N.B.=nota bene 注意 常见的检查项目: blood count (血细胞记数); liver function (肝功); renal function (肾功); clotting time (凝血时间); blood picture or hemogram (血象); serum concentration (血清浓度); serum creatinine test (肌酸酐检查); creatinine clearance (清除率); urine routine (尿常规) 9. 包装:pack, package, supply, presentation, availability 1) 常用的包装单位: pack (包); bottle (瓶); tube (管); vial (玻璃小瓶), box (盒); ampoule =ampule (安瓿); 2) 常见剂型: injection (针剂); drops (滴剂); aerosal / spray/ inhaler (气雾剂) ointment (软膏), liniment (搽剂), suppositotories (栓剂) cream (乳膏), syrup (糖浆), granule (颗粒), ampoule (针剂); powder (粉剂); pill (丸剂); oral solution (口服液); degrees (糖衣丸); cream (乳膏); tablets (片剂); capsules (胶囊) sugar-coated tablets (糖衣 片); 10. storage (储存): keep in a cool and dry place (存于阴凉干燥处); 22 prevent moisture (防潮); away from light/ heat =protect from light/ heat (避光或热); away from children =out of the reach of children (勿让儿童接触) 11. others: validity (有效期); expiry (Exp.) date (失效期 shelf/ storage life (储存期限); stability (稳定性) ); Package Insert GENERIC NAME: NORFLOXACIN - ORAL (nor-FLOX-uh-sin) BRAND NAME(S): Noroxin (诺氟沙星) WARNING: This medication may rarely cause tendon damage (e.g., tendinitis, tendon rupture) during or after treatment. Your risk for tendon problems is greater if you are over 60 years of age, if you are taking corticosteroids (such as prednisone), or if you have had a kidney, heart or lung transplant. Stop exercising, rest, and seek immediate medical attention if you develop joint/muscle/tendon pain or swelling. USES: Norfloxacin is used to treat a variety of bacterial infections. This medication belongs to a class of drugs called quinolone antibiotics. It works by stopping the growth of bacteria.This antibiotic treats only bacterial infections. It will not work for virus infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness. HOW TO USE: Read the Medication Guide provided by your pharmacist before you start taking norfloxacin and each time you get a refill. If you have any questions, consult your doctor or pharmacist.Take this medication by mouth, usually twice a day, at least 1 hour before or 2 hours after a meal or dairy products (e.g., milk, yogurt). Take with a full glass of water (8 ounces or 240 milliliters). The dosage is based on your medical condition and response to treatment. Drink plenty of fluids while taking this medication unless your doctor tells you otherwise.Take this medication at least 2 hours before or 2 hours after taking any drugs that contain magnesium, aluminum, or calcium. Some examples include quinapril, certain forms of didanosine (chewable/dispersible buffered tablets or pediatric oral solution), vitamins/minerals, 23 and antacids. Follow the same instructions if you take calcium-enriched juice, bismuth subsalicylate, sucralfate, iron, and zinc. These medications/products bind with norfloxacin and prevent its full absorption. Antibiotics work best when the amount of medicine in your body is kept at a constant level. It is important not to miss a dose. To help you remember, take this medication at the same times every day.Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may allow bacteria to continue to grow, which may result in a return of the infection.Tell your doctor if your condition persists or worsens. SIDE EFFECTS: See also Warning section. Nausea, diarrhea, dizziness, lightheadedness, or headache may occur. If any of these effects persist or worsen, tell your doctor or pharmacist promptly. Seek immediate medical attention if any of these rare but very serious side effects occur: severe dizziness, fainting, fast/irregular heartbeat. Norfloxacin may rarely cause serious nerve problems that may be reversible if identified and treated early. Do not use anti-diarrhea products or narcotic pain medications if you have any of the following symptoms because these products may make them worse. Tell your doctor immediately if you develop: persistent diarrhea, abdominal or stomach pain/cramping, blood/mucus in your stool. Use of this medication for prolonged or repeated periods may result in oral thrush or a new vaginal yeast infection. Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge, or other new symptoms. A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any of the following symptoms of a serious allergic reaction: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088. PRECAUTIONS: Before taking norfloxacin, tell your doctor or pharmacist if you are allergic to it; or to other quinolone antibiotics such as ciprofloxacin, gemifloxacin, levofloxacin, moxifloxacin, or ofloxacin; or if you have any other allergies. Before using this medication, tell your doctor or pharmacist your medical history, especially of: certain metabolic disorder (G6PD deficiency), diabetes, heart problems (e.g., recent heart attack), joint/tendon problems (e.g., tendonitis, bursitis), kidney disease, certain muscle problem (myasthenia gravis), nervous system disorder (e.g., peripheral neuropathy), seizure disorder, conditions that increase your risk of seizures (e.g., brain/head injury, brain tumors, cerebral atherosclerosis). Norfloxacin may cause a 24 condition that affects the heart rhythm (QT prolongation). QT prolongation can infrequently result in serious (rarely fatal) fast/irregular heartbeat and other symptoms (such as severe dizziness, fainting) that require immediate medical attention. The risk of QT prolongation may be increased if you have certain medical conditions or are taking other drugs that may affect the heart rhythm (see also Drug Interactions section). Before using norfloxacin, tell your doctor or pharmacist if you have any of the following conditions: certain heart problems (heart failure, slow heartbeat, QT prolongation in the EKG), family history of certain heart problems (QT prolongation in the EKG, sudden cardiac death). Low levels of potassium or magnesium in the blood may also increase your risk of QT prolongation. This risk may increase if you use certain drugs (such as diuretics/"water pills") or if you have conditions such as severe sweating, diarrhea, or vomiting. This medication may rarely cause serious changes in blood sugar levels, especially if you have diabetes. Watch for symptoms of high blood sugar including increased thirst and urination. Also watch for symptoms of low blood sugar such as nervousness, shakiness, fast heartbeat, sweating, or hunger. Check your blood sugar regularly as directed by your doctor and report any changes. If you experience symptoms of low blood sugar, you may raise your blood sugar by using glucose tablets/gel or eating a quick source of sugar such as table sugar, honey, or candy, or drinking fruit juice or non-diet soda. Tell your doctor immediately about the reaction and the use of this product. To help prevent low blood sugar, eat meals on a regular schedule, and do not skip meals.This drug may make you dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic beverages.This medication may make you more sensitive to the sun. Avoid prolonged sun exposure, tanning booths, and sunlamps. Use a sunscreen and wear protective clothing when outdoors. Caution is advised when using this medication in children younger than 18 years because they may be at greater risk for joint/tendon problems. Kidney function declines as you grow older. This medication is removed by the kidneys. Therefore, older adults may be more sensitive to its side effects (e.g., blood sugar or tendon problems), especially if they are also taking corticosteroids (e.g., prednisone, hydrocortisone). During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor. It is not known whether this drug passes into breast milk. Therefore, breastfeeding is not recommended while taking this drug. Consult your doctor before breast-feeding. DRUG INTERACTIONS: See also the How to Use section.Your doctor or pharmacist may already be aware of any possible drug interactions and may be 25 monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with them first. This drug should not be used with the following medication because very serious interactions may occur: strontium.If you are currently using the medication listed above, tell your doctor or pharmacist before starting norfloxacin. Many drugs besides norfloxacin may affect the heart rhythm (QT prolongation), including amiodarone, dofetilide, procainamide, quinidine, sotalol, certain macrolide antibiotics (e.g., erythromycin, clarithromycin), and certain antipsychotic medications (e.g., pimozide, thioridazine, ziprasidone), among others. Therefore, before using norfloxacin, report all medications you are currently using to your doctor or pharmacist.Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: live bacterial vaccines (e.g., typhoid, BCG), "blood thinners" (e.g., warfarin), corticosteroids (e.g., prednisone, hydrocortisone), cyclosporine, drugs removed from your body by certain liver enzymes (such as clozapine, duloxetine, ropinirole, tacrine, tizanidine), drugs for diabetes (e.g., glyburide, insulin), nonsteroidal anti-inflammatory drugs (NSAIDs such as ibuprofen, naproxen), probenecid, urinary alkalinizers (e.g., potassium/sodium citrate). Also report the use of drugs that might increase seizure risk when combined with this medication such as isoniazid (INH), phenothiazines (e.g., chlorpromazine), theophylline, or tricyclic antidepressants (e.g., amitriptyline), among others. Consult your doctor or pharmacist for details.Avoid drinking large amounts of beverages containing caffeine (coffee, tea, colas), eating large amounts of chocolate, or taking over-the-counter products that contain caffeine. This drug may increase and/or prolong the effects of caffeine.This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. NOTES: Do not share this medication with others.This medication has been prescribed for your current condition only. Do not use it later for another infection unless told to do so by your doctor. A different medication may be necessary in that case. Laboratory and/or medical tests (e.g., kidney function, complete blood count, blood glucose) may be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details. 26 MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. STORAGE: Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets. Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product. 27 Case History The main contents of a complete case history • 一般项目 general/statistical/biographical data • 主诉 • 现病史 Present illness (P.I.) • 既往史 Past History (P.H.) • 个人史 Personal History (Per. H.)/Social History • 家族史 Family History (F.H.) • 系统回顾 System Review, Review of Systems • 体格检查 Physical Examination • 实验室检查 Laboratory Data • 初步诊断(印象) Impression(Imp.)/Diagnosis Chief Complaints (C.C.) 1. General Data • Full name • Sex / Gender • Age • Date of Birth(DOB) • Race/Color • Religious • Occupation • Address • Marital Status: • Reliability: • Supplier/Complainter/Source of History • Date of Record 2. Chief Complaints Common Symptoms Black tarry stools nausea constipation vomiting orthopnea dyspnea 28 Cough with yellow sputum tachypnea hemoptysis hematemesis melena anorexia emaciated dyspepsia Dizziness/vertigo Blurred vision Jaundice/Icterus cyanosis palpitation restlessness 表示症状持续时间的几种方式 1)症状+since+症状开始的时间点 sore throat since yesterday 2)症状+for+时间段 sore throat for two days 3)症状+时间段+in duration cough with yellow sputum two years in duration 4)症状+of+时间段(名词所有格)+duration night sweat of two week’s duration 3. Present Illness • Onset: explosive, gradual, abrupt attack/sudden onset/began all of a sudden • Location: in the left lumbar region, in the right upper quadrant of, in the … side of • Nature/feature: afebrile, constinuous, persistant, paroxysmal, acute, chronic, spastic, palpable, • Severity: bearable, unbearable, mild, moderate, medium-degree, severe, asymptomatic, indistinct • Frequency: recurrent, variable, relapsing, intermittent, occurred sporadically, frequent, transient • Relation: 伴发 be accompanied by/be associated with 29 并发 erupt simultaneously 合并症 complication 继发症 sequel 接着发生 follow 诱发 induced have relation to/with…/be related to… 与……有关 • Development: persist 持续 be more severe/worsen have a relapse/recur improve 改善 be relieved 缓解 aggravate 加剧 subside 减轻 disappear 消失 heal 恶化 复发 愈合 (fully)recover 痊愈 remained the same/was unchanged • 无变化 Diagnoses and treatment had…previous hospitalizations was treated by the local physician was referred to the hospital was admitted for work-up was treated symptomatically • The present status Stools: constipation, undigested stools, formed stools, loose stools, keep one’s bowels open Urination: cloudy urine, oliguria, urinary incontinence, retention of urine, hematuria, milky urine Appetite: have a good/poor appetite, excessive appetite, lose one’s appetite, capricious appetite Sleep: have a good/poor sleep, insomnia, somnolence, paroxysmal sleep Mental:in low/poor/great/high/royal spirits, lose one’s spirits, very energetic, full of vigour, exhsusted/worn out, be down in spirits, depressed Strength and weight: Feel quite strong again, A strong constitution / delicate constitution; Lose weight / Gain weight; In poor health 30 A 4. Past History Main contents • Previous state of health: He had excellent health until the present illness began. She was in good/poor health in the past. He was apparent healthy most of his life. • Previous illnesses • Vaccination and infectious diseases • Allergy to drugs or other substances Tuberculosis, hepatitis, pneumonia, cholecystectomy, appendectomy, splenectomy, nephrectomy 5. Personal History Main contents • Life style and habit • Occupation and working condition • Travelling • Marriage and child-bearing • Menstruation 6. Family History • Record the health status of the patient’s family, usually immediate family. But if necessary, F.H. also includes the health status of the patient’s extended family. 7. Physical Examination 这部分可使用简单语句表达,可以省略动词和冠词。 基本检查方法:inspection 视 palpation 触 percussion 叩 auscultation 听 Examination of general appearance(全身状态检查) 1) Temperature: oral/axillary/rectal temperature The temperature was …℃ when taken by mouth/orally/rectal/axillary. He measured/took/checked a temperature of …℃. 2) Pulse 31 Rapid pulse 脉频 Slow pulse 脉缓 Had a weak pulse 脉搏微弱 Pulse was thread-like. 脉弱如丝 No pulse palpable. 摸不到脉 radial/femoral/carotid artery pulsation intermittent pulse 间歇脉 pulse deficit 脉搏短绌 Corrigan pulse/water hammer pulse Pulsus alternans 交替脉 Pulsus paradoxus 奇脉 No palpable dorsalis pedis on the right. 桡动脉/股动脉/颈动脉搏动 水冲脉 右侧足背动脉未触及。 3) Respiration Tachypnea: rapid breathing Bradypnea: slow breathing Dyspnea: difficult breathing Apnea: no breathing Hyperpnea: hyperventilation Nasal alar breathing: 过度呼吸 鼻翼呼吸 Three depression sign: 三凹征 4) Blood pressure Sitting BP lying BP standing BP Check/take/measure BP BP rose/elevated 血压升高 Had some drop in BP BP remained stable BP was labile 测血压 血压下降 血压稳定 血压不稳定 5) Physical development and nutrition Habitus 体型 asthenic type 无力型 hypersthenic type sthenic type 超力型 正力型 32 Gigantism 巨人症 dwarfism Obese 侏儒症 肥胖 thin and frail cachectic 瘦弱 恶病质 Be of average build and nutritional level Well-nourished 发育营养一般 营养佳 Moderately nourished 营养中等 Mal-nourished, under-nourished, poorly nourished, dystrophy 营养不良 General conditions appears good 好/fair 尚可/normal 正常/poor 不良 6) Facial expression Alert and cooperative 神清合作 Looked/Appeared acutely/chronically ill Mitral face 二尖瓣面容 Sardonic face 苦笑面容 Moon face 满月面容 Masked face 面具面容 Critically face 病危面容 Dull appearance Agitated 7) Position 呈急/慢性病容 表情淡漠 表情激动 体位 Gait 步态 Active/passive/compulsive position 自动/被动/强迫体位 Supine/prone/lateral/upright position 仰卧位/俯卧位/侧卧位/直立位 Left lateral recumbent Orthopnea 端坐呼吸 Squatting 强迫蹲位 Opisthotonos 角弓反张位 Lordosis 脊柱前凸 kyphosis 脊柱后凸 scoliosis 脊柱侧弯 Propulsion 左侧卧位 慌张步态 shuffling gait/staggering gait scissor gait 剪刀步态 Steppage/footdrop gait swaying gait 蹒跚步态 跨阈步态 摇摆步态 33 waddling gait 鸭步 Hemiplegic gait 偏瘫步态 ataxic gait 共济失调步态 Skin Distribution of hair is normal 毛发分布正常 Hair and nails are normal 毛发指甲均正常 Baldness 秃发 Dyhydrated 脱水 Pitting edema 压陷性水肿 Inelastic 无弹性 Flabby skin 松弛的皮肤 Pigmentation 色素沉着 Localized depigmentation Petechia 出血点 Purpura 紫癜 ecchymosis 局部色素脱失 瘀斑 splinter hemorrhage 片状出血 hematoma 血肿 butterfly rash 蝶形斑 spider angioma 蜘蛛痣 nodule 结节 ulcer 溃疡 ulcer associated with exudate and crust formation scar 瘢痕 keloids 瘢痕疙瘩 溃疡伴渗出物及结痂 Lymph nodes Regional lymph node 局部淋巴结 Cervical lymph node 颈部淋巴结 Subaxillary lymph node 腋下淋巴结 Submaxillary lymph node 颌下淋巴结 Submental lymph node 颏下淋巴结 Supraclavicular lymph node Inguinal lymph node 锁骨上淋巴结 腹股沟淋巴结 Lymph nodes are enlarged and palpable Generalized lymphadenopathy 淋巴结肿大、可扪及 淋巴结普遍增大 34 Freely movable 可移动 Nontender/ no tender on pressure Hard and firm 无压痛 质硬 Without palpable evidence of superficial lymph nodes enlargement 浅表淋巴结未扪及 Head and Neck Head is normal in contour/shape/configuration and symmetrical. 头部外形正常及对称。 Microcephalia 小颅 large skull 巨颅 squared skull 方颅 Face somewhat bloated 面部轻度浮肿 Face covered with cold sweat 满面冷汗 Congestion of conjunctiva 结膜充血 Diplopia, double vision 复视 Jaundice in sclera 巩膜黄染 The pupils are round and equal, reactive to light and accommodation(PERRLA). 两侧瞳孔等大等圆,光反射、调节反射正常。 Color vision is abnormal Visual disturbance 色觉异常 视力障碍 Septum acutely deviated to the left 鼻 中隔极度左偏 No tenderness on/over nasal sinuses 鼻窦无压痛 Pharynx free of congestion 咽部无充血 Trachea on the midline/Trachea not deviated Trachea deviated to the right/left. 气管居中 气管偏右/偏左。 Jugular veins not distented 颈静脉不怒张 Thorax The chest is symmetrical. 胸廓对称。 thorax with an increase in anteroposterior diameter flat chest 扁平胸 barrel chest 桶装胸 funnel chest 漏斗胸 subcutaneous emphysema 胸廓前后径增加 皮下气肿 equal respiration movements bilaterally 两侧呼吸运动相等 Expiration is prolonged and inspiration is gasping. 35 呼吸延长,吸气困难 Normal vocal fremitus throughout both lungs. 两肺语颤正常 Vocal fremitus diminished/exaggerated/absent over …lobe … 侧语颤减弱/增强/消失 Both lungs were resonant to percussion. 两肺叩清 There was dullness to percussion on the … side. … The chest is clear to auscultation. Scattered rales 散在啰音 dry rales 干啰音 moist rales 湿啰音 fine rales 小水泡音 medium rales 中等啰音 coarse rales 大水泡音 crepitus 捻发音 wheezes 哮鸣音 sonorous rales 鼾音 drumlike resonance/tympany hyperresonance 胸部听诊无异常。 鼓音 过清音 audible pleural friction rub 胸膜摩擦音 massive pleural effusion 大量胸腔积液 heaves 侧叩浊 心前区隆起 apex/apical beat/impulse 心尖搏动 point of maximum impulse PMI 心尖搏动最强点 apex beat markedly accentuated 心尖搏动显著增强 ejection murmur 喷射期杂音 systolic murmur 收缩期杂音 diastolic murmur 舒张期杂音 constinuous murmur 连续性杂音 holosystolic 全收缩期 blowing 吹风样 rumbling 隆隆样 Abdomen Abdominal distention/The abdomen is protuberant. Abdominal retraction 腹部凹陷 scaphoid abdomen 舟状腹 rebound tenderness 反跳痛 fluid thrill 液波震颤 36 腹部膨隆 shifting dullness 移动性浊音 gurgling 气过水声 No masses present on palpation. bowel sounds 未触及包块 肠鸣音 Genitalia, Anus and Rectum phimosis 包茎 redundant prepuce 包皮过长 Testis had failed to descend and can not be palpated. normal distribution of the pubic hair marital outlet 已婚外阴 cystocele 膀胱膨出 阴毛正常分布 external genitalia was not examined rectal digital examination 睾丸未下降,未能扪及 外生殖器未查 直肠指检 Neurological Examination anosmia: loss of sense of smell 嗅觉丧失 olfactory hallucination 嗅幻觉 auditory hallucination 听幻觉 visual hallucination 视幻觉 paralysis 瘫痪 hemiplegia 偏瘫 paraplegia 截瘫 spastic paraparesis 痉挛性麻痹 muscle strength 肌力 muscular tone 肌张力 rigidity 强直性 cogwheel rigidity 齿轮强直 tremor 震颤 chorea 舞蹈样动作 athetosis 手足徐动 tetany 手足搐搦 ataxia 共济失调 finger-nose test 指鼻试验 heel-knee-tibia test 跟膝胫试验 alternate motion 轮替动作 anesthesia 感觉丧失 37 paresthesia 感觉异常 hyperesthesia 感觉过敏 superficial reflex 浅反射: corneal reflex 角膜反射, abdominal reflex 腹壁反射, cremasteric reflex 提睾反射, plantar reflex 跖反射 deep reflex 深反射: biceps reflex 肱二头肌反射, triceps reflex 肱三头肌反射, wrist jerk 桡骨骨膜反射, patellar reflex 膝腱反射, Achilles reflex 跟腱反射 pathological reflex 病理反射 ankle clonus 踝阵挛 patella clonus 髌阵挛 sign of meningeal irritation 脑膜刺激征: tonic neck 颈强直, Kernig’s sign 克氏征, Brudzinski’s sign 布氏征 reflex present/active 反射存在 reflex weak/hypoactive/decreased/depressed 反射减弱 reflex absent/disappeared areflexic 反射消失 reflex over-active/exaggerated hyperreflexic 反射亢进 reflex questionable 有无反射尚不肯定 38