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1、实证医学的第一步实证医学的第一步2626臨床實例n n一名一名76y/o76y/o婦女，因漸進性呼吸困難和下肢水腫住婦女，因漸進性呼吸困難和下肢水腫住院。六個月前被診斷為鬱血性心衰竭併有以上症院。六個月前被診斷為鬱血性心衰竭併有以上症狀，檢查發現頸靜脈怒張、肺部囉音、狀，檢查發現頸靜脈怒張、肺部囉音、S3S3奔馬音奔馬音及雙側下肢凹陷性水腫。住院及雙側下肢凹陷性水腫。住院EKGEKG為正常竇性節為正常竇性節律，心超檢查為收縮功能不全併輸出率律，心超檢查為收縮功能不全併輸出率25-30%25-30%。以利尿劑、血管收縮素轉化脢抑制劑、乙型阻斷以利尿劑、血管收縮素轉化脢抑制劑、乙型阻斷劑、毛地黃及
2、阿斯匹靈治療。已因症狀惡化住院劑、毛地黃及阿斯匹靈治療。已因症狀惡化住院2 2次，此次為第三次入院，她為症狀所苦並對未來次，此次為第三次入院，她為症狀所苦並對未來感到憂慮擔心病情惡化、經常需住院。目前檢查感到憂慮擔心病情惡化、經常需住院。目前檢查顯示：水腫、頸靜脈怒張、肺部囉音、顯示：水腫、頸靜脈怒張、肺部囉音、S3S3奔馬音、奔馬音、腹水、腹水、EKGEKG竇性節律、竇性節律、CXRCXR肺靜脈充血併兩側肋膜肺靜脈充血併兩側肋膜少量積液。少量積液。6Ws questionsn nWhat is EKGn nHow to perform EKGn nWho is indicated to un
3、dergo EKGn nWhy do the patients receive EKG examinationn nWhen to perform EKGn nWhere to place the electrodes of EKG Foreground questionsSpecific, less granular, directed toward more Specific, less granular, directed toward more focused questions.focused questions.Usually include 4 component (PICO)
4、Usually include 4 component (PICO) n nP Patient and/or specific atient and/or specific P Problem roblem n nI Interventionsnterventionsn nC Comparison interventionomparison interventionn nO Outcomes utcomes n n心臟衰竭併心臟衰竭併竇性心律的成人，在標準療程中加入竇性心律的成人，在標準療程中加入WarfarinWarfarin治療治療3-53-5年，是否會降低其血栓栓塞的罹年，是否會降低其血
5、栓栓塞的罹病率或死亡率？勝過服用病率或死亡率？勝過服用WarfarinWarfarin的害處與不便的害處與不便？問題的產生n n臨床發現臨床發現n n病因病因n n疾病的臨床表現疾病的臨床表現n n鑑別診斷鑑別診斷n n診斷性檢查診斷性檢查n n預後預後n n治療治療n n預防預防n n經驗與意義經驗與意義n n改善改善問題的處理n n選擇n n排程n n保存要回答的問題最理想的問題記錄方式為何？n n將問題簡單扼要地記錄成一頁、分4欄位，每一個欄位分別寫出PICOn n將問題依上述編排輸入電腦，存為電子檔n n把問題記錄在可攜式口袋型錄音機內n n把問題寫在實際處方欄位中n n把問題記錄在卡
6、片上，放在隨身袋裡n n以速記方式將問題記錄在PDA裡指導臨床學生如何提出EBM問題的主要步驟：n n辨認n n選擇n n指導n n評估Educational Prescriptionn n23 項（內容）所呈現將包含:.搜尋策略(search strategy);.搜尋結果(search results);.證據的效力(the validity of this evidence);.此有效（有根據力）的證據之重要性(the importance of this valid evidence);.此有效（有根據力）的證據是否可以引用到此病人身上 (can this valid, importa
7、nt evidence be applied to your patient);.您對這整個過程的評價(your evaluation of this process).3段式段式 臨床提問臨床提問病患姓名學習者:目標疾病:填單日期與地點:介入（+/-比較）結果:練習：臨床情境n n情境一、感控室發現最近有一個問題，即同一病房中情境一、感控室發現最近有一個問題，即同一病房中爆發爆發3 3例疥瘡例疥瘡(Scabies)(Scabies)感染，因醫療人員需長期接觸病感染，因醫療人員需長期接觸病人，為預防感染擴大，故感控室考慮是否讓護理站工人，為預防感染擴大，故感控室考慮是否讓護理站工作人員使用治療
8、疥瘡之藥物作人員使用治療疥瘡之藥物 , ,不知道如何處理才最適當不知道如何處理才最適當? ?n n情境二、一位情境二、一位4545歲女性，因下腹痛而住院，經診斷為歲女性，因下腹痛而住院，經診斷為急性盲腸炎。病人不記得有無對盤尼希林過敏之病史。急性盲腸炎。病人不記得有無對盤尼希林過敏之病史。護理人員執行盤尼希林皮膚敏感試驗，護理人員執行盤尼希林皮膚敏感試驗，2020分鐘後，醫分鐘後，醫師診視盤尼希林皮膚敏感試驗為陰性，醫師開立抗生師診視盤尼希林皮膚敏感試驗為陰性，醫師開立抗生素素cefazolincefazolin及及gentamycingentamycin合併治療。護理人員注射合併治療。護理人
9、員注射cefazolin5cefazolin5分鐘後，病人突然突發呼吸困難，發紺分鐘後，病人突然突發呼吸困難，發紺(cyanosis)(cyanosis)，緊急將病人推急救室開始進行急救。，緊急將病人推急救室開始進行急救。Thanks for your attention!+A2E5H9KcNfRiUlXp#s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)z0C3F7IaLdPgSkVnYq$t*w-A1D5G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7I
10、aMdPgSkVnZq$t*x-A1D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMePhTkWnZr$u(x+A2E5H8KcNfRiUlXp#s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G7JbMeQhTkWoZr$u(x+B2E5H9KcNfRiUmXp
11、#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A2E5
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14、0C4F7IaMdPgSkVnZq$t*x-A1D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z1C4G7JbMePhTkWnZr$u(x+A2E5H8KcNfRiUlXp#s%v)y0y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9Kc
15、OfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8KbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMePhTkWnZr$
16、u(x+A2E5H8KcNfQiUlXp#s%v)y0B3F6IaLdOgSjVmYq!t*w-z1D4G7JbMeQhTkWoZr$u(x+B2E5H9KcNfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbMeQhTlWoZr%u(x+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmXp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7J
17、aMePhSkWnZq$u*x+A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A2E5H8K8KcNfQiUlXp#s%v)y0B3F6IaLdOgSjVmYq!t*w-z1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s&v)y0C3F6IaLdPgSjVnYq!t*w-A1D4G8JbMeQhTlWoZr%u(x+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaLdPgSkVnYq$t*w-A1D5G8JbNeQhTlWo#r%u(y+B2E6H9LcOfRjUm
18、Xp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYmYq!t&w-z1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s&v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+
19、B2E5H9KcOfRiUmXp#s&v)z0C3F7IaLdPgSkVnYq$t*w-A1D5G8JbNeQhTlWo#r%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMeP
20、hTkWnZr$u(x+A2E5H8KcNfRiUlXp#s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr$u(x+B2E5H9KcNfRiRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9LcOgRjUmYp!t
21、&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiUlXo#s%v(y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMePhTkWnZr$u*x+A2E5H8KcNfQiUlXp#s%v)y0B3F6IaLdOgSjVmYq!t*w-z1D4G7JbMeQhTkWoZr$u(x+B2E5H9KcNfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq!t*w-A1D4G8JbMeQhTlWoZoZr%u(x+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaMdPgSkVnYq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6
22、H9LcOfRjUmYp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlXo#r%v(y+B3E6I9LcOgRjUmYp!t&w)z1C4F7JaMePhSkWnZq$u*x+A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhTkWnZr$u*x+A2E5H8KcNfQiUlXp#s%v)y0B3F6IaLdOgSjVmYq!t&w-z1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s&v)y0C3F6IaLdPgSjVnYq!t*t*w-A1D4G8JbMeQhT
23、lWoZr%u(x+B2E6H9KcOfRiUmXp!s&v)z0C3F7IaLdPgSkVnYq$t*w-A1D5G8JbNeQhTlWo#r%u(y+B2E6H9LcOfRjUmXp!s&w)z0C4F7IaMdPhSkVnZq$t*x-A2D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkWnZq$u*x-A2D5H8KbNfQiTlXo#s%v(y0B3E6I9LdOgRjVmYp!t&w-z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgSjVmYq!t&w-z
24、1D4G7JbMePhTkWoZr$u(x+A2E5H9KcNfRiUlXp#s%v)y0C3F6IaLdLdPgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)z0C3F7IaLdPgSkVnYq$t*w-A1D5G8JbNeQhTlWo#r%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8KbNeQiTlWo#r%v(y+B3E6H9LcOgRjUmYp!s&w)z1C4F7JaMdPhSkVnZq$u*x-A2D5G8KbNfQiTlXo#r%v(y0B3E6I9Lc
25、OgRjVmYp!t&w)z1C4G7JaMePhSkWnZr$u*x+A2D5H8KcNfQiUlXo#s%v)y0B3F6I9LdOgRjVmYq!t&w-z1C4G7JbMePhThTkWnZr$u(x+A2E5H8KcNfRiUlXp#s%v)y0C3F6IaLdOgSjVnYq!t*w-z1D4G8JbMeQhTkWoZr%u(x+B2E5H9KcOfRiUmXp#s&v)y0C3F7IaLdPgSjVnYq$t*w-A1D4G8JbNeQhTlWoZr%u(y+B2E6H9KcOfRjUmXp!s&v)z0C4F7IaMdPgSkVnZq$t*x-A1D5G8JbNeQiTlWo#r%u(y+B3E6H9LcOfRjUmYp!s&w)z0C4F7JaMd结束语结束语谢谢大家聆听！谢谢大家聆听！23
