?????????(Intern/Clerk Orientation) - PowerPoint PPT Presentation

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Title:

?????????(Intern/Clerk Orientation)

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Title: PowerPoint Presentation Author: User Last modified by: JUMOMO Created Date: 1/18/2012 10:54:25 AM Document presentation format: – PowerPoint PPT presentation

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Title: ?????????(Intern/Clerk Orientation)


1
?????????(Intern/Clerk Orientation)
??? ?????CR Time ???1??16?615AM Place
??2??????
2
???????????!!

3
????
  • Meeting and Activity
  • ??????
  • ??????
  • Pre-op Order??
  • ??????
  • ???????
  • ????????????
  • ??????

4
Meeting and Activity
?? ?? Meeting Schedule ?? Note
??? 700800am ??????? ?1F
??? 700800am ????????--???? ?2F
??? 815915am ????????? 7G ????????????
5
Meeting and Activity
?? ?? Meeting Schedule ?? Note
??? 700800am Intern Clerk Instruction Course(????) 7G ????????????????Journal Meeting
??? 700800am Journal Meeting ?2F ????????????????Journal Meeting
??? 1301700am Dr.??????? ?1F???? ???the 2nd W2 PM the 4th W2 PM
6
Meeting and Activity
?? ?? Meeting Schedule ?? Note
??? 700800am Mortality and Morbidity ?2F ?????
??? 700800am NS Spine Combined Meeting ?2F 3,6,9,12??the 2nd W3
??? 10301200 ?????????? 7G
??? 8301030am Dr.??????? ?1F???? ???the 2nd W3 AM the 4th W3 AM
??? 330-430pm ????????? 7G ????????????
7
Meeting and Activity
?? ?? Meeting Schedule ?? Note
??? 700800am ????????--??? 6H
??? 700800am ????????--????? ?2F
??? 700800am ????????--????? 7G
??? 700800am ??? combined meeting ?2F ?????
??? 900-1000am Clerk Case Presentation 7G
8
???????
  • ???????? ?????
  • ???? -- ?????
  • ????????????????(?????????/??) ????1301700
  • ????? ?????????????????????Intern
  • ???? -- ?????
  • ???????????????? (?????????/??) ???? 8301030
  • ???????????Intern???????Intern
  • (1). ??????????,????,????????????????,???????????
    ?????,??????????,????????
  • (2). ??????????,?????????????,?????????
  • (3). ????????????????????????,?????????
  • ?????????????,???????,????????????!

9
  • ????????????(W1 or W3)?????Teaching
    round???(W3)????????????? (W5)
  • ???????????????????CR????(??2??????)
  • ???9001000am Clerk Case Presentation
  • ?????Clerk??,???????Clerk????????????????????
    510min.?
  • ????????????????????/??????,?????????

10
Intern Clerk Instruction Course ??????
  • ??????????????????????
  • ???? ????????????
  • ???????????
  • ????????????????
  • ????????????????????
  • ?????????,?????CR??7G???/leader nurse?????????

11
??????
12
??????
13
??????
  • ???????????????,??????,??????,??????procedure
    ,????????
  • ?????????10????,??????????3?1????,?????, ??????
  • ????(?????)??????32??(?248)?????????????????????
    ,????????
  • ????????????????,?????CR????????

14
???????
  • ????????????48?????,??????????
  • ??admission note?????????, ROS? PE??????????
  • ????????,Note???, CXR ?Pre-OP Xray ? MRI
    ,Intra-OP finding,Post-OP Xray ,??????
  • Intern???????R?????

15
??????
  • ??? ? 7F,?? 701R ?? 703R
  • ?new patient ?? ?? 5? ?? 10?
  • ??430pm??????700am??New Pt,????????
  • ??11???????,???????,???,???????
  • ????, ??????????,?????
  • ?????????CR??,?????????????

16
Pre-op Order
  • Sign OP and anesthesia permit
  • Send patient to OR on call
  • NPO since midnight
  • IVF
  • Prepare PRBC , FFP , Plt ( spine, arthroplasty,
    large debridement, pelvis)
  • OP site
  • OP method
  • OP will be performed on
  • Skin prepare arthroplasty
  • Anti to OR (prophylactics) cefazolin 4 pc to OR
  • Special order ?????????
  • Op site??? (????op site)
  • ????
  • ?????????????
  • ?????????????
  • ?????IVF????
  • CXR, Lab data?????????
  • ??????????????
  • ?????????????
  • ???????????????
  • ????????????
  • ????????????
  • ???????????!!

17
?????? ????????
18
??????
  • ????????
  • ???
  • ??
  • Order
  • Mark
  • ???
  • ? ?
  • ?????
  • ? ??

19
??????
20
Time Out ????
  • ??????
  • ???
  • ???
  • ???

21
????????????
22
???????
  • ????? ????????
  • ???????????
  • ??????
  • ???????????
  • ???????????????
  • ??????????????

23
??????
  • ??????,??????????????????,???????,???????
  • ???????????,??????????,????????,?????????,????????
    ??????
  • ???????,???????,????????,??????????????,???????

24
?????????

25
??? ???????
26
?????
  • 1.???
  • ??(????????)
  • ?????
  • 2.???
  • ?????(?2ml)????????
  • ????????????????????
  • ???????????????????2???
  • 3.???
  • ?????????
  • 4.???
  • ???????????????????????,
  • ?????(?????????)

27
??????


  • Fat Embolism Syndrome
  • Consciousness disturbance, respiratory distress,
    petechiae
  • Compartment syndrome
  • 5 Ps Pain, Paresthesia, Paralysis, Pallor,
    Pulseless
  • Cauda equina syndrome
  • Bowel and bladder dysfunction, saddle anesthesia,
    lower extremity sensorimotor changes

28
Fat Embolism Syndrome
  • Incidence
  • Trauma
  • 3-4 with isolated long bone trauma
  • 10-15 with polytrauma
  • Fatal in 10-15
  • Hip arthroplasty , knee arthroplasty
  • Clinical onset 24-48 hours post trauma
  • Treatment
  • Prevention
  • Early stabilization of long bone fracture
  • Nonoperative
  • PEEP ventilation
  • Diagnosis Criteria 1 major and 3 minor or 2 major
    and 2 minor
  • Major
  • Hypoxemia (PaO2 lt 60)
  • CNS depression (MS changes)
  • Petechial rash
  • Pulmonary edema
  • Minor
  • Tachycardia
  • Pyrexia
  • Retinol emboli
  • Fat in urine or sputum
  • Thrombocytopenia
  • Decreased HCT
  • Additional
  • PCO2 gt 55
  • pH lt 7.3
  • RR gt 35
  • Dyspnea
  • Anxiety

29
Thromboembolism (PE DVT)
  • DVT frequency with operations
  • Spine fracture with paralysis (100)
  • Hip and knee arthroplasty (80)
  • Hip fracture (60)
  • Polytrauma (35)
  • Pulmonary Embolism
  • Hip fracture (3.5)
  • Hip knee arthroplasty (2)
  • Spine fracture with paralysis (1)
  • Virchow's triad 
  • Venous stasis
  • Hypercoagulobility
  • Hntimal injury
  • Physical exam
  • DVT
  • Pain, swelling, Homan's sign
  • PE
  • Acute onset pleuretic pain
  • Tachypnea (90)
  • Evaluation
  • DVT
  • Venography is gold standard
  • Duplex ultrasound 
  • PE
  • EKG ,CXR ,ABG
  • Nucleur medicine ventilation-perfusion scan (V/Q)
  • Pulmonary angiography
  • Helical chest CT
  • Treatment
  • Continous IV heparin infusion (7-10
    days) followed warfarin therapy (3 months)
  • Vena cava filter placement
  • Thrombolytics

30
Compartment syndrome
  • Higher incidence with
  • Crush injuries
  • Open fracture more
  • Lower limb gt upper limb
  • Physical exam
  • Pain out of proportion to injury
  • Pain with passive stretch of ankle or toes (most
    reliable test)
  • Tense lower extremity
  • Pulses (presence of pulses is not a reliable
    factor for excluding the diagnosis)
  • Compartment pressure measurement
  • Absolute value of 30 to 45 mm Hg or
  • Within 30 mm Hg of diastolic BP (delta p)
  • Treatment
  • Emergent fasciotomy

31
Cauda equina syndrome
  • Mechanism space-occupying lesion within
    lumbosacral canal
  • Disc herniation (most common)
  • Tumors
  • Epidural hematoma
  • Epidural abscess
  • Symptoms
  • Saddle anesthesia
  • Bilateral lower extremity pain
  • Sensorimotor loss in lower extremity
  • Bowel and bladder symptoms (urinary retention is
    more common)
  • Physical exam
  • Areflexia or hyporeflexia
  • Decreased rectal tone
  • Examination of sacral nerve root sentation
    (perianal area)
  • Treatment
  • Urgent surgical decompression within 48 hours 

32
??????
??????
33
???????
34
??????? ????
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