實習醫生臨床技能教案

資料來源：NEJM

Central Venous Catheterization

PDF教學檔案連結
影片-Internal jugular vein CVC (需登入)
影片-Subclavian vein CVC (需登入)

Male Urethral Catheterization

影片-Male urethral catheterization (需登入)

Lumbar Puncture

影片-Lumbar Puncture (需登入)

Chest Tube Insertion

影片-Chest Tube Insertion (需登入)

X光判讀筆記

如何判斷一張Chest X-Ray是否照得好

1. Penetration: Spine要在心臟後方隱約可見
2. Inspiration: Diaphragm至少要在8-9 posterior rib以下
3. Rotation: Spinous process到兩端Clavicle等距
4. Angulation:  Apical lordotic view的話Clavicle會高於3rd rib

教學連結

辨識Abdomen內的Free air (Pneumoperitoneum)

有三個要注意的特徵:

1. Air beneath the diaphragm (Supine or Left decubitus view)
2. Falciform ligament sign
3. Air on both sides of the bowel wall (Rigler's sign)

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辨識Pleural effusion

1. CP angle blunting
2. Meniscus sign
3. Pleural effusions shift mediastinal structures away from the side opacified.

教學連結

辨識Bowel obstruction & ileus

姿勢：Supine position最好
Large bowel

1. Peripheral
2. Haustral markings don't extend across wall

Small bowel

1. Central
2. Valvulae extends across lumen
3. Normal diameter= 2.5cm

1. CP angle blunting
2. Meniscus sign
3. Pleural effusions shift mediastinal structures away from the side opacified.

辨別ileus/ obstruction

Ileus- Rectum, Sigmoid colon內還有空氣；Obstruction的話無

教學連結

醫院常見細菌整理

依Gram's stain分4大類：GPC(2), GPB, GNC(2), GNB

GPC: 有2種- Staphylcoccus, Streptococcus

Staphylcocci

Coagulase(+): Staphylcoccus aureus
Coagulase(-): CONS類如Staphylcoccus epidemis (表皮菌)

Streptococci

Hemolytic

β-hemolytic(完全溶血)

1. Streptococcus pyogenes (Group A, 造成pharyngitis & tonsillitis, necrotizing fascilitis)
2. Streptococcus agalactiae (Group B, 陰道normal flora, 造成neonatal meningitis)

α-hemolytic(部份溶血)

1. Streptococcus pneumonia 
2. Streptococcus viridans(牙齒上的細菌)
3. Streptococcus bovis (Group D, 造成endocarditis)

Non-hemolytic- Enterococcus (現已從Streptococcus獨立出來)

1. Enterococcus mutans
2. Enterococcus faecalis(牙科手術)

GPB:

Aerobes(4) 李白土炭

1. Listeria (李斯特菌)
2. Corynebacterium dipheriae(白喉)
3. Nocardia (土壤菌絲, 放線菌科)
4. Bacillus anthracis (炭疽)

Anaerobes Clostridium (梭狀桿菌, 腸道菌)

1. C. perfringens
2. C. difficile
3. C. botulinum
4. C. tetani

GNC: 只有兩種

Nesseria

1. N. meningitis
2. N. gonorrhea

Moraxella catarrhalis (Pneumonia)

GNB: 最多，剩下的都在這

• 腸道菌 (Proteus mirabilis, Escherichia coli, Klebsiella pneumonia, PEcK)
• Pseudomonas aeruginosa
• Yersinia pestis (黑死病)
• Haemophilus influenzae
• Mycobacteria (ex: TB, NTM)
• Bacteroides
• ...

胸部X光判讀整理

首先，檢查X光片拍得好不好

1. 兩側Clavicle的medial ends距midline是否等距→ 若不等距，可能有Rotation
2. Diaphragm位置是否到10'th~11'th肋間→ 若沒有，病人可能沒吸飽氣
3. Thoracic vertebrae應該要隱約可見→ 表示X ray有適當的穿透度

位置資訊：

• Mediastinum前中後分界：1.心臟後緣到IVC連線 2.Vertebral body前緣後1cm連線 
• Lun在CP angle最低處到L2，積水在此可積300ml
• Clavicle的位置在PA view比AP低 (PA約在2'th rib；AP在4'th rib)
• Standing position時，在Stomach常可以看到Air-fluid level (supine無)

依序檢查

1. A: Airway & Mediastinum
2. B: Bone
3. C: Cardiac & Great vessels
4. D: Diaphragm (& CP angles)
5. E: Else (lung)

Alveolar Pattern vs Interstitial Pattern

肺部最小的解剖及呼吸單位：Acinus  (3~5個acinus構成1Pulmonary lobule)

Alveolar pattern: 侵犯air space的疾病

 (ex: CHF, pulmonary edema, pneumonia)

Interstitial pattern: 侵犯Interlobular septa (造成septa水腫or變厚)

(ex: TB, Histoplasmosis, Silicosis, Asbestosis, Farmer's lung, Mushroom worker's disease, sarcoidosis, scleroderma, RA)