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S*******h
发帖数: 7021 | 2 【 以下文字转载自 USANews 讨论区 】
发信人: gemini2012 (双子AB), 信区: USANews
标 题: 奥巴马急了，要给希拉里来个秘密体检
发信站: BBS 未名空间站 (Mon Oct 3 20:23:59 2016, 美东)
BREAKING : NEW DETAILS – a Worried Obama Urges “Secret Medical Checkup”
for a Very Sick Hillary
Breaking News By Amy Moreno October 3, 2016
The Daily Mail is reporting that a worried Obama attempted to set up a
medical checkup for Hillary at the Walter Reed National Medical Center.
However, Hillary, fearful of the press discovering her visit, declined.
Obama is probab... 阅读全帖 |
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T*R
发帖数: 36302 | 3 髋关节置换术后预防血栓是标准程序，美国在这些标准预防方面做得要比中国好。病人
术后一般都马上上COUMADIN和SCD。术后第二天就要你下床走动（当然美国人比中国人
体质好也是很重要原因，在中国，可能很多人承受不了这种大手术后第二天就下床运动
）。
上次那个北大医院教授术后因为PE死亡也是因为术后预防血栓做得不够，这种和手术没
有直接相关但是又影响很大的因素，国人往往忽略了。
美国做完髋关节置换术后，一般在医院也就呆3-5天，这个比中国要短多了，然后大部
分病人去REHAB，这个MEDICARE是COVER的。这个比中国要强多了。REHAB有专业医生护
士物理治疗师。 |
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u***e
发帖数: 611 | 4 内科的同修们能不能进来交流一下有趣的病历，可以共同学习一下。
晚上一直在想前天值班收的一个病人，简单说一下，70yo female, cc:breast
swelling, PMH of breast cancer s/p mastectomy, PE/DVT on coumadin. 病人来时
血压有点低，80/50，但她没有什么不舒服的complaint, 看上去也挺好的，不像septic
。其他vital都没什么不稳定的，我也没在意，她之前有mammogram是另一侧乳房癌复发
了，就order了lab，给她1L NS bolus，就去看别的病人了。3-4个小时后护士page我说
病人心率有150，我觉得自己也要跳到150了，飞跑过去，EKG一拉 A-fib.......急了，
几个小时前还好好的sinus rhythm，怎么在我手里给fib了，死了死了。
你们觉得是什么原因，应该怎么处理？
下回再分解。 |
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a*********d
发帖数: 2763 | 5 PE is always high on the list of any patients with active malignancy,
heparin is a no brainer at those situations, esp if pt has DVT/PE in the
past, and her INR is subtherapeutic.
also very important, she should be on lovenox lifelong as long as her cancer
is not cured, instead of coumadin.
but I am not that sure her rapid onset of Afib in this case is caused by
another epside of PE because she did not present with related symptoms(breas
swelling is her chief complain) and her afib only happened |
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u***e
发帖数: 611 | 6 最后更新一下最新进展，attending还是决定hydrate病人后送去CT，CT结果是。。。。
。。。。没有PE. 病人on heparin同时加了coumadin，明天我去问问她为什么不用
lovenox.
cardiologist给用了amiodarine drip, 病人不久就恢复了sinus rhythm. 病人血压还
是出奇的低，对fluid没有反应，一度降到70，很吓人，但病人却没什么不舒服的。他
们还是给上了dopamine.
afib的病人自然是查了TSH了，呵呵，是正常的，troponin也正常。
明天又要on call了，看看会不会收到有趣的病人再来和大伙讨论讨论。 |
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u***e
发帖数: 611 | 7 都没看到美国有用这个药的，一般我们都用aspirin，痛的话可以用pletal来控制症状
。有的vascular surgeon把手术后的病人上heparin,coumadin 抗凝，我不知道为什么
。另外，把烟给戒了吧。PVD的病人心梗几率会大大增加，要注意预防。 |
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a*********d
发帖数: 2763 | 8 这段时间因为经常开会面试，在路上的时间比较多，所以摆弄itouch的时间比较多（题
外话，大家尽量避免芝加哥机场吧，天气变化多，飞机场应急能力又差，误点是正常的）
epocrate，这个就不用提了，反正人人都应该有。
skyscape，我用的是WM endocrine subspecialty，还有很多其他学科的。
medcalc/ mediquations:两个差不多，但是后者更加详细，而且不管是计算公式，还包
括了生理生化方面的知识。
medcalc endocrine:计算公式，diagnostic criteria,decision tree, unit
converters
NEJM this week: 适合经常翻看，尤其是有audio play，读每期的abstract，很不错。
我还用的专业的是FRAX，是用来计算骨质疏松的骨折风险的。还有一个是endocrine atlases，动画的，很好玩。
今天看到一个是计算coumadin用量的软件，真是包罗万象阿。
还有的软件是"my clinic","my surgery"之类的，可以记录自己的病人情况，keep trac |
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R**********n
发帖数: 473 | 9 OB
CS后立马开始找ob. 这个ob真难找啊，先是给偶宝宝的儿医office每个医生写信，贴邮
票的。杳无音信。然后上门找了几家私人诊所，有位医生给介绍了另一位医生，于是约
好去见，结果是人家不接受ob. 最后没有办法，找出cmg physician database, http://med.yzhang.com/ , 开始一个一个打电话，从近到远，打了整整3天，留言。看似没什么希望，谁会给一个素不相识的人回电话？却偶然接到一位邻城医生的电话，说偶可以去看看，可能可以做。约好了去，见了executive, human resource, 签了HIPPA, 结果就成了。就这样偶在考完cs后2周就开始ob了。第一周偶轮了好几个医生和nurse practitioner, 除了这位都是美国人。后来发现老美医生一天看40个病人，根本没时间跟偶罗嗦。而这位中国医生临近退休，一天只看10-15个病人，偶就跟牢他了（你不可能让一个跟你说不上话的医生写推荐信是不是）。这位医生我觉得是office里最优秀的, 是难得的英文超级好，医术，人品和与病人交流一个顶的老医生。而且对偶非常照顾---那时偶肚子已... 阅读全帖 |
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m*******e
发帖数: 1886 | 10 我倒是看明白了。
这事儿挺常见的，一般无关紧要的药，我直接就chart病人拒绝吃就完了。但是关于
coumadin，我觉得还是得上点心。前面说了，那个shift上你的charge nurse是你那个
shift的头，你得找她说清楚。也不必正儿八经说，抽时间提一句就好，看看charge nurse怎么说。
不是你shift上的药你没给，你没做错什么，但是我觉得哈你有把事情说清楚的责任，也算是保护你自
己。另外detailed charting也很重要。
我那个懒惰的preceptor就从来不写 progressive note，特不好～
我那manager基本不大管我们practice的事情，所以我就信任charge nurse，有一个麻利的（帮着
admin），负责的（纠正错误），力气大的（帮干翻身这样的体力活），公平的（不让MD欺负我）的
charge nurse，我们就是有福气的RN。 |
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T*R
发帖数: 36302 | 11 很多医院的护士扎针是比较弱.
我现在做AGENCY的医院就是,动不动就上PICC或是MIDLINE.护士都懒得干.
我自己医院不行,不要说IV,就是抽血都是自己干.CNA抽不了的都是护士抽.所以俺还行.
不过我也是很懒的.IV只要不出来或是INFILTRATE我是绝对不上新的,管它多少天了,谁
爱上谁上.
做HOME HEALTH还是要有点自立的.
比如你去某一个人家给人换伤口,病人比较重你怎么办? 不换了?
COUMADIN的病人都要抽血. |
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y******7
发帖数: 17 | 12 The following is what I collected when I was a student doing capstone in a
local hospital. Not sure if it is useful.
Lidocaine topical is a amide-type local anesthetic. for production of
topical anesthesia, relief of pain associated with postherpetic neuralgia,
reduction of gagging during dental procedures, prevention and control of
urethral pain, anesthetic lubricant for endotracheal intubation, and relief
of hemorrhoidal pain.
Polyethylene glycol(Miralax) is a nonabsorbed solution used to trea... 阅读全帖 |
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u*****d
发帖数: 1009 | 13 I don't think there's any relationship between potassium and warfarin, at
least i never mention anything about potassium when i go over coumadin stuff
with my patients
remember |
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f****o
发帖数: 2770 | 14 Either in Hopsital or retail, Pharnacy is boring job.
and by way, you spelled "hospital" and "pharmacy" wrong in the title of your
post. and coumadin wrong in your post (not coumdine)
for someone who has practiced pharmacy for years and still can't spell "
PHARMACY" correctly, and have such NEGATIVE opinion towards your own
profession, maybe you should consider another career. |
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T*R
发帖数: 36302 | 15 I think what he said is true.
Docs are lazy so they left Vanco/Genta/coumadin or even zosyn orders to
pharmacist. That does not mean they trust you, simple because they are lazy.
Some doctors always write order" antibiotics pharmacy to dose", when you are
fresh, you might be excited about this, but when you make same orders for
years, you will feel different.
They always do that, even you are only a staff pharmacist, say in night
shift admission orders.
But on the other hand, job is job, boring |
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p*******8
发帖数: 67 | 16 Lucky you!!!
You only need to do vanco/gent/coumadin!
I have to do OE/clarification/PK/TPN/Chemo/precepting students/answer
questions from MD/RNs.
Back to my old hospital, I had to do JClub, Noon conferences, precepted 1st/
3rd/4th year pharmacy students on the top of my dail clinical duties.
My day is never boring, just busy and carzy busy. I love what I am doing. I
think no matter how many years you have been working in the same field, it
is up to "YOU" to make your day either "BORING" OR "EX |
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b**o
发帖数: 5769 | 17 我知道你现在是在糖尿病呀。我们也有的，还有coumadin/warfrain clinic，也有HIV
。感觉HIV的最神秘了。
有一次我还fill了个HIV的药，就是那个3合一的，可是病人都没有show up来拿药。 |
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A*******s
发帖数: 9638 | 18 昨天晚上睡得晚， 3am医院ICU page我， 我迷迷糊糊打电话， 刚说我不oncall，对方
说了个名字，我一下子全醒了。
这个病人是我的一个老病人， 在医院工作，67岁，她有osler-weber-rendu disease，
epistaxis是常事， 最近出现A-Fib， 因为coumadin引起出血， 所以不能服。
一个星期以后， 她出现中风，因为出血的原因， 不能上heparin， 第二天她在医院又出现右手臂动脉栓塞。 所幸手术后没事。 没办法，她需要抗凝， 所以开始服用Pradaxa。
出院后epistaxis似乎没大问题， 没想到她出现贫血， 血色素只有6。 入院后输血， Pradaxa只能停掉。
(中文太难打了。。。）
I started her on heparin. Consulted GI/Surgery for endoscopy. Surgery did
the upper and lower GI scope and I was told she has possible AVM but no
active bleeding.
I do not kn... 阅读全帖 |
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A*******s
发帖数: 9638 | 19 I am aware of the study. Thanks for the link.
Her CHA2DS2-vasc score is 4, same as HAS-BLED Score. Risks for stroke and
bleeding are 2% and 8% respectively. But we can not only use the numbers.
These numbers tell us she is on high risks for stroke as well as bleeding.
She was not started on OAC after being found to have A-fib. After she had
the stroke, she was not started on heparin either. But on the 2nd day of stroke, she had
the 2nd emboli to right arm. Then she was started on heparin. Aft... 阅读全帖 |
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A*******s
发帖数: 9638 | 20 A new drug. So far I had no problem with it. I only use it when the
patient could not take coumadin.
case |
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y******a
发帖数: 590 | 21 I probably didn't ask the questions in a clear way. My question is, if pt
does have a condition require anticoagulation, when would you start it after
the stroke? for example, if a pt came in with a massive MCA ischemic
stroke, and a newly identified a fib, when is the appropriate time to give
heparin/coumadin, considering the risk of hemarrhagic conversion? and will
you give both aspirin and plavix for anti platelet agent or only one of them
? I am not a neurologist, but my experience with ... 阅读全帖 |
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A*******s
发帖数: 9638 | 22 Usually start coumadin within 2 wks after a massive infarct with a-fib. There
is a guideline for this.
Avoid anticoagulation for any new massive infarct. But it depends.
after
will
them |
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A*******s
发帖数: 9638 | 23 昨天晚上睡得晚， 3am医院ICU page我， 我迷迷糊糊打电话， 刚说我不oncall，对方
说了个名字，我一下子全醒了。
这个病人是我的一个老病人， 在医院工作，67岁，她有osler-weber-rendu disease，
epistaxis是常事， 最近出现A-Fib， 因为coumadin引起出血， 所以不能服。
一个星期以后， 她出现中风，因为出血的原因， 不能上heparin， 第二天她在医院又出现右手臂动脉栓塞。 所幸手术后没事。 没办法，她需要抗凝， 所以开始服用Pradaxa。
出院后epistaxis似乎没大问题， 没想到她出现贫血， 血色素只有6。 入院后输血， Pradaxa只能停掉。
(中文太难打了。。。）
I started her on heparin. Consulted GI/Surgery for endoscopy. Surgery did
the upper and lower GI scope and I was told she has possible AVM but no
active bleeding.
I do not kn... 阅读全帖 |
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A*******s
发帖数: 9638 | 24 I am aware of the study. Thanks for the link.
Her CHA2DS2-vasc score is 4, same as HAS-BLED Score. Risks for stroke and
bleeding are 2% and 8% respectively. But we can not only use the numbers.
These numbers tell us she is on high risks for stroke as well as bleeding.
She was not started on OAC after being found to have A-fib. After she had
the stroke, she was not started on heparin either. But on the 2nd day of stroke, she had
the 2nd emboli to right arm. Then she was started on heparin. Aft... 阅读全帖 |
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A*******s
发帖数: 9638 | 25 A new drug. So far I had no problem with it. I only use it when the
patient could not take coumadin.
case |
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y******a
发帖数: 590 | 26 I probably didn't ask the questions in a clear way. My question is, if pt
does have a condition require anticoagulation, when would you start it after
the stroke? for example, if a pt came in with a massive MCA ischemic
stroke, and a newly identified a fib, when is the appropriate time to give
heparin/coumadin, considering the risk of hemarrhagic conversion? and will
you give both aspirin and plavix for anti platelet agent or only one of them
? I am not a neurologist, but my experience with ... 阅读全帖 |
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A*******s
发帖数: 9638 | 27 Usually start coumadin within 2 wks after a massive infarct with a-fib. There
is a guideline for this.
Avoid anticoagulation for any new massive infarct. But it depends.
after
will
them |
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n**v
发帖数: 2109 | 28 81mg 阿司匹林一天一片，让血液不要太黏稠；放心吧,81mg叫baby aspirin，要是能增
加出血风险，那coumadin之类真正的blood thinner真要吓死人啦，哈哈。
这就是国内医疗的问题，大城市大医院，还是有章可循的；小城市小医院，根本就是乱
来的，每个医生自己说了算。不像美国，再大再小的地方，所有医生都是统一的
guideline学出来的，从诊断到治疗,step1上什么药，step2上什么药，到哪儿都差不多。 |
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I****a
发帖数: 407 | 29 From hematological point of view, I would like a entire diff including RBC
indices and reticount before and after the blood transfusion.
From the cardiology point of view, I would like to have electrolytes
including Mg and an ECHO.
From endocrinology point of view, I would like a complete thyroid panel, FT3
, FT4 and TSH.
In addition, I also like information of her PMH/PSH, medication including
any OTC stuff, habits etc.
My hunch at this point is that everything is originated from her thyroid.
... 阅读全帖 |
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V*****G
发帖数: 337 | 30 I will ask what was used for antiemetics (drug side effect for Torsades) and
check electrolyte.
Also would like to know any vomitting and diarrhea for electrolyte
perspective.
Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
one
coumadin
without
was
. |
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a*******n
发帖数: 82 | 31 They are all valuable points!
She was given Zofran, Phenergan and compazine in the other hospital.
MRI of brain was done for evaluation of severe nausea.
For her PMH/PSH, significant for iron-deficiency anemia, treated with iron
supplements in the past; HTN; DLP; h/o C. diff colitis 6 months ago; pAF
with RVR 8 months ago; yearly normal mammogram; normal colonoscopy 3 years
ago; chronic lymphedema from lower extremities; lung nodule with stable CT
followup. She was on dig, amiodarone, coumadin, ... 阅读全帖 |
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I****a
发帖数: 407 | 32 From hematological point of view, I would like a entire diff including RBC
indices and reticount before and after the blood transfusion.
From the cardiology point of view, I would like to have electrolytes
including Mg and an ECHO.
From endocrinology point of view, I would like a complete thyroid panel, FT3
, FT4 and TSH.
In addition, I also like information of her PMH/PSH, medication including
any OTC stuff, habits etc.
My hunch at this point is that everything is originated from her thyroid.
... 阅读全帖 |
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V*****G
发帖数: 337 | 33 I will ask what was used for antiemetics (drug side effect for Torsades) and
check electrolyte.
Also would like to know any vomitting and diarrhea for electrolyte
perspective.
Amiodarone can cause torsades, and since it's half life is so long, and this is also one reasonable culprit.
one
coumadin
without
was
. |
|
a*******n
发帖数: 82 | 34 They are all valuable points!
She was given Zofran, Phenergan and compazine in the other hospital.
MRI of brain was done for evaluation of severe nausea.
For her PMH/PSH, significant for iron-deficiency anemia, treated with iron
supplements in the past; HTN; DLP; h/o C. diff colitis 6 months ago; pAF
with RVR 8 months ago; yearly normal mammogram; normal colonoscopy 3 years
ago; chronic lymphedema from lower extremities; lung nodule with stable CT
followup. She was on dig, amiodarone, coumadin, ... 阅读全帖 |
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D**i
发帖数: 325 | 35 óD2?
one
coumadin
without
was
. |
|
A*******s
发帖数: 9638 | 36 1. For ischemic stroke, tpa if within 3 hours , otherwise supportive only.
fib,
No heparin for most strokes, but for A-fib or dissection, it depends.
Correct.
No consensus. Even TPA was proven safe but no enough data.
Probably not. But Coumadin is recommended afterwards.
fib, |
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I****a
发帖数: 407 | 37 Paget-Schroetter disease, the one that can get you into malpractice trouble
if you just send those patients home with Lovenox and Coumadin. Untreated
symptomatic patients can sustain long-term disability from venous
obstruction resulting in significant loss of occupational productivity and
quality of life.For the same reason, early catheter directed thrombolysis
followed by anticoagulation and surgical intervention are recommended.
It is also known as Paget-von Schrötter disease or upper ex... 阅读全帖 |
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A*******s
发帖数: 9638 | 38 发信人: Icetea (冰瓜儿), 信区: Medicalpractice
标 题: Re: 【征文活动】 有趣的临床综合症。
发信站: BBS 未名空间站 (Sat Oct 8 15:17:55 2011, 美东)
Paget-Schroetter disease, the one that can get you into malpractice trouble
if you just send those patients home with Lovenox and Coumadin. Untreated
symptomatic patients can sustain long-term disability from venous
obstruction resulting in significant loss of occupational productivity and
quality of life.For the same reason, early catheter directed thrombolysis
followed by anticoagula... 阅读全帖 |
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A*******s
发帖数: 9638 | 39 Since green leaf contains vit K, daily consumption of green leaf vegi could
lower the INR. But as long as the consumption is at a consistent base, INR
should be stable.
But the diet Vit K is hard to keep at a daily consistent base, so adding a
base Vit K will reduce the range of fluctuation, for instance:
Daily lettuce salad contains Vit K 100 mcg; regular food without salad
otherwise is only 10 mcg. So eating salad will increase Vit K by 10 times.
Adding Vit K 1000 mcg (1 mg) a day will make th... 阅读全帖 |
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m********4
发帖数: 607 | 40 We currently have these 2 patients. As a Doctor, how do you feel if they are
your patients?
Life is unfair, isn't it?
---------------------------------------------------
A: 46 yo patient multiple times hospital admissions.
-PAST MEDICAL HISTORY INCLUDES:
1. Hypertension.
2. Hyperlipidemia.
3. Diabetes type 2.
4. Hypothyroidism.
5. Obesity.
6. Congestive heart failure secondary to mitral stenosis status
post mitral and tricuspid annuloplasty in 2003 with known
physiology compl... 阅读全帖 |
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A*******s
发帖数: 9638 | 41 If just had a TIA, bridge of course. Otherwise, you may titrate coumadin
slowly. |
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P*********8
发帖数: 168 | 42 if no contraindication, should be on coumadin. Not like DVT/PE, bridging
form heparin or LMWH is not required.
TIA itself does not require AC, should be treated like stroke, start ASA and
statin if not contraindicated.
terms |
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a*********d
发帖数: 2763 | 43 mm你是IR的阿？好牛啊，容我葱白一下！以后做甲状腺穿刺还要跟你多探讨。
如果病人在吃plavix或者coumadin的，你做么？ |
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R*******t
发帖数: 367 | 44 不是介入的，他们做的东西难，我这个是body IR，住院医时候训练的。
俺们的流程是plavix和coumadin以及Arixtra至少要停4-5天。heparin drip至少停六个
小时。baby aspirin没事。
Solid organ biopsy, such as thyroid, liver, kidney, etc., PLT至少75以上，
para/thoracentesis至少PLT在50以上，不然就得至少输血小板6 units，要不就不干。 |
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T*R
发帖数: 36302 | 45 不是这样。如果是重要药，主要副作用我都详细和病人说。包括饮食禁忌。
这不是一个普通药，这是一个副作用很强的药。类似COUMADIN，INSULIN，化疗药。实
际上在美国就是属于化疗药。
这个在我们医院，普通FLOOR不给这药，ONCOLOGY FLOOR才能给。 |
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T*R
发帖数: 36302 | 46 大部分时间是没时间教育病人的。但是对于比较重要的药，还是要多说几句的。
我们医院，新上COUMADIN/LOVENOX的病人都有PHARMD和病人谈话。新的INSULIN都有
DIABETIC EDUCATOR和病人谈。 |
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e******e
发帖数: 118 | 47 a 70 y/o female with hx of ischemic stroke twice in the past (1st was right
CVA with residual left side weakness,2nd was left CVA with transit aphasia
resolved, previous MRA negative) on ASA 81 and aggrenox bid now presented
with AMS. she was noted to be on the floor unresponsive in the morning and
she was last time seen well the night before. Pt regained conciouness in 45
min, eyes open, moving all extremities but aphasic. She is mildly lethargic,
looked confused, but following command. positiv... 阅读全帖 |
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e******e
发帖数: 118 | 48 she has no afib.her coagu panel is nl. previous MRA was negative for vasular
deficit.
we consider to repeat MRA if pt can tolerate. I think she may also need some
work up to r/o vasculitis or hypercoagulabe state.
as for 2nd prevention of stroke, there is no data suggesting which is
superior among ASA, plavix vs aggrenox. In practice, physician alternatively
choose them. eg, if one fails on asa, physician may change it to plavix or
aggrenox.
coumadin,it is only indicated in pts with afib or intr... 阅读全帖 |
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m********e
发帖数: 148 | 49 来自主题: Medicalpractice版 - 心脏病咨询 Atrial fibrillation, on Coumadin already with high INR. Must already have
cardiology on board. Only 55 year old. |
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A*******s
发帖数: 9638 | 50 来自主题: Medicalpractice版 - 语言的艺术 For Q2, apparently cardiology said no to my Coumadin pursuit by declining
TEE on their incapability. :)
It will be interesting to see how hospitalists say no to admission and
Consultants say no to consult requests.
when
we
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