Q&A

Size: px

Start display at page:

Download "Q&A"

Rolf Norman
5 years ago
Views:

1 Page 1

2 Page Q&A

3 Page

4 . Page 4

5 Page : :

6 Page 6

7 Page 7

8 Page 8

9 Page 9, 1. ;

10 Page 10 Problem-Based Learning (PBL) Evidence-Based Medicine (EBM) am Mortality & Morbidity am CPC am am am am 9 M & M am am am 9 : 9:00 ~ 10:00 am X- CT 9:00 10:00 am Surgical Pearls am :

11 Page 11 (1). (2). (4). A., 7:00 ( I&O CXR CBC Biochemistry ), (5:00PM) B. a.

12 Page 12, b. Pre OP assessment Form: a. Diagnosis b. Chief complaint c. Past history d. PE (Positive finding) including GU system e. LAB data. EKG, echo, and imaging f. Op method and plan g. Op Indication h. ASA class c ( 2F ) d. C. a., b. c. d. 4. morbidity and mortality

13 Page 13 (2). MPE4.1 ( ) : Clerk medical student ( ) : / ( ) / ( ) ( OSCE Mini-CEX) / ( ) 5 ( ) : Observation and simulation Direct supervision Supervisor available

14 Page 14 ( ) : : 2 3

15 Page 15

16 Page 16

17 Page 17. (2011/03/08) -

18 Page 18 ( 1. IV ) (Communication skills) 2. ( 3. ) 4. (Patient education) IV ( 4. ) 1. IV (Literature appraisal) (1) (2) (3) ( (4) (5) )

19 Page 19 (Presentation) (Bedside and conference) 1. V ( 2. ) 1. V (Team work) 2. ( 3. ) 4. (Documentation 1. ( V 2. ) ( )

20 Page 20 Q&A : ( ) (1).Immobilization:,, (2).Blood pressure: hypotension, I.V. fluid, Dopamin atropin (3).O2 intubation: on nasal Endo (4).NG tube: aspiration pneumonia (5).Foley (6).Temperature control: (7).Medication: methylpredmisolone ( ) Methylpredmisolone 8 15 bolus 30mg/kg 45, mg/kg/hr ( ) (laminectomy) incomplete spinal cord injury, (1). (2). CT, Myelo or MRI canal bone chip, HIVD, Hematoma mass lesion (3). fracture-dislocation, :locked facets (4). radiculopathy ( root ).

21 Page 21 ( ) : (A) : spinal cord :laminectomy root : disectomy (B) : : Cervical -- Caspar plate Thoracic & Lumbar -- Kaneda : Cervical-- Halifax clamp, Lateral mass plate Thoracic-- Hook Lumbar-- TPS (VSP, Isolar, RF) ( ) Cervical and lumbar microdisectomy cervical laminectomy,,. ( )? spinal cord,. : a. urine and stool: b. BP & Hb: blood loss c. : d. pain: PCA(bolus demerol ) ( ), : a. Halo-jacket, b. Four poster c. Miami neck collar, Hard neck collar

22 Page 22 d. Soft neck collar : body jacket ( ) a. X-ray: AP, Lat, Flexion-extension, Oblique b. CT: bone, myelogram, MRI c. MRI:.

23 Page 23 : :, ( ) GCS (Glasgow Coma Scale)( 4 ) ( ) Children s Coma Scale( 4 ) Best Eye Best Verbal Best Motor 6 Obey 5 Smile, oriented to 4 Spontaneo us scans follow objects, interacts Localize pain Crying Interaction Withdraws to pain Consolable 3 To speech Inconsistently consolable Inappropriate Moaning Flexion 2 To pain Inconsolable Restless Extension 1 None None None None

24 Page 24 (IICP) 1. : : ICP<10-15 mmhg, IICP >16 mmhg 2.. Cushing trial: Hypertension, Bradycardia, Irregular respiration full trial, patient 3. : (hyperemia) 4. : (1) ICP (2) Brain CT: third ventricle, perimesencephalic cistern, basal cistern, midline shift (3) Lumbar puncture: brain CT 5. : (1) Hyperventilation: keep PaCO mmhg (2) Hyperosmolar therapy: (Mannitol, Glycerol, Lasix ---) (3) Head elevation : (4) CSF drainage (5) Adequate sedation, control HTN (6) Barbiturate coma (7) Hypothermia (8) Surgical removal of mass, if possible (9) Steroid

25 Page 25 Classification of head injury (1) By mechanism (a) closed head injury (b) Penetrating head injury (Gun shot, other open injuries) (2) By severity (a) Mild head injury: GCS (b) Moderate head injury: GCS 9-12 (c) Severe head injury: GCS 3-8 (3) By morphology (a) Skull fracture Vault fracture (linear or depressed) Basilar fracture (CSF leakage, cranial nerve palsy) (b) Intracranial lesions Focal (epidural, subdural, intracerebral) Diffuse (concussion, coup & counter-coup contusion, diffuse oxonal injury) ( ) Specific Examination for Head Injury Patient (A) General PE 1. Granium inspection & palpation (a) Evidence of basilar skull fracture Raccoon s eyes, Battle s sign, CSF rhinorrhea/otorhea hemotympanum (b) Check for facial fracture Le Fort fracture Orbital rim fracture 2. Cranio-cervical auscultation (a) Carotid artery: bruit of carotid dissection (b) Around the eye: bruit for CCF 3. Physical signs of spinal trauma (B) Neurologic Examination

26 Page Cranial nerve examination: (a) Pupil; resting position, size, light response (b) Cranial nerve palsy: oculomotor palsy, abducent palsy, facial palsy --- (c) Fundus examination 2. Level of consciousness/ mental staus (a) GCS (b) Orientation 3. Motor examination (a) All 4 limbs motor strength, cooperative patient (b) Motor response to noxious stimulus (c) Rectal examination, anal tone, bulbocavernous reflex 4. Reflexes (a) DTR (b) Plantar reflex (Babinski sign) (c) Anal wink & bulbocavernous reflex Admitting Orders for Mild Closed Head Injury 1. Activity: bed rest with head elevation Vital sign, GCS q.2.h 3. NPO until alert; then clear liquids, advance as tolerated 4. Isotonic IVF urn at maintenance (average size adult:=75 cc/hr, ped: cc/m 2 /day) 5. Mild analgesics: acetaminophen; codeine p.r.n. 6. Anti-emetics, carefully used if indicated (avoid over sedation) 7. Notify duty Dr. if conscious change ( ) Scalp Injury & Subgaleal Hematoma Five layers of scalp in cross section SCALP 1. Skin 2. subcutaneous fascia 3. Galea Aponeurosis 4. Loose areolar tissue 5. Pericranium Vascular anatomy of scalp

27 Page 27 5 major arteries supply the scalp on each side, which anastomosed each other freely & profoundly. Mainly located in scalp Just above galea 1. Supra-orbital artery 2. Supra-trochlear 3. Superficial temporal artery (largest) 4. Posterior auricular artery 5. occipital artery Scalp injury 1. Simple linear 2. Large, stellate with or without tissue defect may need flap reconstruction (sonsultation with Plasty Dr.) Management of simplest linear scalp laceration 1. Focal compression strongly before closure (to avoid massive bleeding) 2. Shaving around the lesion 3. Extensive debridement & irrigation 4. Two layer suture Galea absorbable suture is better Skin monofilament Nylong 5. Tetanus toxoid 6. Drains, rarely necessary 7. Antibiotics, may be not necessary if wound is clear Subgaleal hematoma 1. May cross sutures (D/D with cephalhematoma) 2. May occur without bony trauma 3. Soft, fluctuate mass. Usually not communicated with CSF Treatment 1. Almost never require treatment beyond analgesics 2. Avoid percutaneously aspiration 3. Closely watch for intra-vascular content, serial hemoglobin & hematocrit check is necessary in large lesions 4. If persist > 6 weeks, obtain a skull film ( ) Mild Closed Head Injury Definition: The patient is awake, and may be orientated (GCS 13-15)

28 Page 28 Initial Work-up: History (1) Name, age, sex, race, occupation (2) Mechanism of injury (3) Time of injury (4) LOC immediately post-injury (5) Subsequent level of alertness (6) Amnesia: retrograde, antegrade (7) Headache: mild, moderate, severe; vomiting (8) Seizure General examination Limitted neurological examination Skull X-ray C-spine & other radiography as indicated Blood alcohol level and urine toxic screen CT scan of the head should ideally be ottained in best but the completely asymptomatic p t After Initial Work-up Admission, if there is 1. Significant amnesia 2. History of LOC, seizure 3. Deterioration of consciousness 4. Moderate to severe headache 5. Significant alcoholic/drug intoxication 6. Skull fracture, sign of basilar skull fracture 7. CSF leakage 8. Significant associated injuries 9. No reliable companion at home 10. Abnormal brain CT Discharge, if 1. The patient does not meet any of the criteria for admission 2. Discuss need to return if any problems develop and issue a warning sheet (head injury sheet) 3. Schedule follow-up clinic visit, usually within one week

29 Page 29 ( ) Moderate Head Injury Definition : GCS 9-12 Initial work-up: 1. Same as for mild head injury, except that baseline blood work (CBC, Chemo, PT/APTT) may be obtained 2. CT scan is advisable in all cases 3. Admission for observation is the safest option, even if the CT scan is normal Admission order 1. Orders as for minor head injury. (NPO, if surgicalintervention is intended) 2. More frequent neurologic checks (q.1.h, better) 3. Admit to NSICU(I) or NSICU(II), if Ct shows any significant abnormality 4. Follow-up CT scan if condition deteriorates or preferably prior to discharge Hyper-osmolar therapy for IICP Mannitol (A) Contra-indication: 1. Hypotnesion 2. Relative: allergy, --- (B) Indication: 1. Evidence of herniation (localizing sign) 2. Evidence of mass effect (focal deficits) 3. Sudden deterioration prior to CT 4. After CT: if a lesion responsible for IICP is identified any on going to OR 5. To assess salvageability (C) Dosage: 1. Bolus: 1gm/kg, over 20 min 2. Onset of effect: 1-5 min, peak:20-60 min 3. Maintance: gm/kg, q 4-6 hr ( ) Severe Head Injury Definition : GCS 3-7 Management;

30 Page 30 (A) History 1. Age of patient and type and time of accident 2. Drug or alcohol intake 3. Neurologic progression 4. Vomiting, aspiration, anoxia, seizure 5. Past history: including medication & allergies, CRF(?), anticoagulant --- (B) Cardiopulmonary stabilization 1. Airway: intubate early 2. Blood pressure: normalize promptly using saline or blood 3. Catheters: Foley, NG (or OG), CVP 4. Diagnostic film: Brain CT, Chest X-ray, C-spine, Abdomen, Pelvis, Extremities, if indicated (C) General examination (D) emergency measures for associated injuries 1. Tracheostomy 2. Chest tubes 3. Spine stabilization: collar, traction 4. Abdominal paracentesis (E) Neurological examination 1. GCS (eye opening, motor response, verbal response) 2. Pupil (resting position, movement, size, light reflex) 3. Oculocephalic response (Doll s eye) 4. Oculovestibular response (Caloric test) (F) Therapeutic measure 1. Surgical intervention for mass lesion, responsible 2. Hyperventilation, hypersomolar tyerapy, steroid (?), CSF drainage 3. Adequate sedation 4. ICP & blood flow monitor 5. Dilantin (?) 6. Barbiturate therapy 7. Hypothermia Therapy for Severe Head Injured Patient (A) General supportive measures 1. Adequate CPP (MAP-ICP), avoid hypotension, hypoxemia 2. Seizure prophylaxia 3. Sedation & paralysis (codeine, propofol ---)

31 Page 31 (B) Treatment of IICP 1. Hyperventilation PaCO2: Onset of action : < 30 second, peak effect = 8 min Over hyperventilation should be avoided Prolonged hyperventilation (> hrs) is not advocated 2. CSF drainage Posture drainage (head elevation 30º - 45º) Surgical drainage (ventricular puncture --- ) 3. Hyperosmolar therapy with/without diuretics 4. Steroid (value in head injury is not clear) 5. Barbiturate therapy (C) Systemic & medical care 1. Pulmonary care (hypoxia, pneumonia, neurogenic, pulmonary edema --- ) 2. Cardiovascular care 3. Deep vein thrombosis & pulmonary emboli 4. Electrolyte abnormality (especially hyponatremia) 5. Coagulapathy & DIC 6. UTI & bed sore prevention 7. Nutrition

32 Specific Types of Head Injury Page 32 (A) Depressed skull fracture 1. Better seen in brain CT (bone window) 2. Criteria to elevate depressed fracture (a) > 8-10 mm depression (or > thicknes of skull) (b) Deficit related to underlying brain (c) CSF leakage or pneumocranium (dura defect) (d) Compound depressed fracture (B) Epidural (Extradural )Hematoma 1. Typical presentation (a) Brief ILOC lucid interval progressive deterioration (contralaternal hemiparesis + ipsilateral pupil dilation ) (b) Most often site: temporal area (middle meningeal artery tear) other sites are usually possible (c) Sources: 85% arterial bleeding (dura vessels) Others: bone marrow bleeding, venous sinus rupture ( eg. Bifrontal EDH due to SSS rupture of supra & infra-temporial EDH due to transverse sinus rupture ) (d) Classical CT presentation: biconvex high density lesion beneath the skull, homogenous or heterogeneous density (e) Optimal early diagnosis & prompt surgical evacuation can decrease the morbility & mortalty maximallly. ** An intracranial mass that produce more than 5 mm of midline shift or is large in volume (over 30 ml in supra-tentorial space or 10 ml in infratentorial fossa) has a much greater risk of developing danagerous brain herniation. (C) Subdural Hematoma (acute and subacute) 1. Source of bleeding (a) Avulsed bridging vein (b) Ruptured cortical vessels (c) Lacerated brain 2. More impact force is needed to produce acute SDH than EDH, that makes SDH more lethal 3. Time frame & density on CT for SDH: (a) Acute SDH: 1-3 days, hyperdensity (b) Subacute SDH: 4 days 2~3 weeks, isodensity (c) Chronic SDH: > 3 weeks, iso to hypodensity 4. Shape of acute SDH in brain CT: More diffuse, less uniform, usually concave over brain surface 5. Treatment:

33 Page 33 (a) Rapid surgical evacuation for symptomatic SDH greater than 1 cm at the thickest point is considered (b) Consider conservative treatment if smaller hematoma, severe hemispheric swelling that surgery may increase the brain injury, or hgihly risk patient (D) Chronic SDH 1. Generally occurred in the elderly, other risk factories: alcohol abuse, seizure, CSF shunts, coagulopathy, patients at risk for falls 2. Usually associated with head trauma, even minor, weeks ago 3. Presentation : greatly uniform symptoms (minor symptoms as headache, confusion, language difficulty or coma, hemiplegia, seizure, focal sign ---) 4. Treatment options: (a) Burr holes drainage (two burr holes, or signle burr hole) with or without subdural drainage (b) Twist drill craniotomy (c) Formal craniotomy with excision of subdural membranes (hyperdensity or thickened wall lesions, multiple loculation, or unsatisfactory improvement after other treatment modality) (E) Confessional ITCH 1. Coup lesion: contusions occurred at the site of impact 2. Contrecoup lesion: contusions distant from the site of impact (due to impacts of moving brain on the irregular surface of bony floor, eg. Frontal base & middle fossa) 3. Shearing force ICH: due to shearing force with rapid acceleration or deceleration of brain (multiple scattered ICH eg: in deep structure, corpus callostum, brain stem) 4. Immediate ICH 5. Delayed ICH coalesce from salt and pepper lesions to form large hematomas. 6. The decision to undertake surgical intervention is individualized, however not always easy. Generally, patient who are comatose and have a significant midline shift due to hematoma usually need surgery. Special Consideration in Children Head Injury (A) The outcome of pediatric moderately severe and severe head trauma is noted to be favorable in most modern reports. (B) Growing skull fracture (post-traumatic leptomeningeal cysts)

34 Page Child < 2 Y/O linear skull fracture follow skull X-ray (AP + Lat) 8 weeks later 2. True post-traumatic leptomeningeal cysts need to be excised surgically with dural defect repair 3. However, pseudo-growing fracture should be treated conservatively (C) Extra-axial fluid collections in children 1. Benign subdural collection in infants 2. Chronic symptomatic extra-axial fluid collections or effusion (hydroma) 3. Cerebral atrophy 4. External hydrocephalus 5. Acute subdural hematoma 6. Normal variant of enlarged subarachnoid spaces and inter-hemispheric fissure (D) Child abuse 1. Usually had poor clinically outcome due to delayed treatment, seizure and / or hypoxic ischenic insult, and multiple prolonged injury 2. Factories which raise the suspicion (a) Retinal hemorrhage (b) Bilateral chronic SDH in child < 2 Y/O (c) Multiple skull fracture (d) Multiple or staged wounds within the body 3. Notify social worker

35 Page 35 疼痛量表徐鵬偉疼痛量表是根據自我評估他人觀察行為或者是生理數據所訂定現行有許多種評估方式, 然而現有的疼痛測量工具 - 即 McGill 疼痛測量問卷, 過於繁複及冗長, 並不適用於門診問診或者是身體健康狀況不佳的患者所以現階段較被廣泛使用的是經過整理簡化過的簡易疼痛量表 (Cleeland et al., 1994) 然而在問診時若是希望在短時間之內做一個疼痛程度評估, 最常使用的即是視覺類比量表 (Visual Analogue Scale: VAS) 10 cm 量表 (Numerical Scale) 及臉譜量表 (Face Rating Scale), 方便我們用來評估治療後的改善程度簡易疼痛量表 (Cleeland et al., 1994): 1. 在我們一生當中, 大多數人都曾經體驗過輕微的頭痛扭傷和牙痛, 最近一週內您是否有其他不常見的疼痛? (1) 有 (2) 沒有 2. 請您在下圖中用筆圈出您感到疼痛的部位, 並在最痛的部位打 " X " 3. 請圈出一個數字以表示您在最近一週內疼痛最厲害的程度不痛痛極了 4. 請圈出一個數字以表示您在最近一週內疼痛最輕微的程度不痛痛極了 5. 請圈出一個數字以表示您在最近一週內平均疼痛 ( 大部份時間 ) 的程度不痛痛極了 6. 請圈出一個數字以表示您現在疼痛的程度不痛痛極了 7. 您覺得哪些情況可以減輕您的疼痛?( 如熱敷服藥休息 ) 8. 您覺得哪些情況會加重您疼痛的程度?( 如走路站立抬東西 ) 9. 目前您正接受什麼藥物和什麼治療法來治療您的疼痛? 藥物方面 : 治療方面 : 10. 若有接受止痛藥物或治療, 請圈出一個百分數, 以表示您在最近一週內經治療或用藥後, 疼痛減輕了多少? 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 沒減輕完全減除

36 Page 如果您吃了止痛藥後, 經幾個小時疼痛會再出現? 止痛藥完全無效 1 小時 2 小時 3 小時 4 小時 5-12 小時 12 小時以上未曾吃過止痛藥 12. 我覺得我的疼痛原因是 :( 複選 ) (1) 治療引起的 ( 如化學藥物手術放射治療裝義肢其他 ) (2) 我原來的疾病 ( 即現在正接受診療的疾病 ) (3) 與原來疾病無關的病 ( 如關節炎 ) 13. 下列各個描述疼痛的詞, 請您圈選出最恰當描述您疼痛的程度合適不合適 (1) 持續而固定位置的 (2) 律動的 (3) 快速穿過的 ( 觸電的 ) (4) 刀割的 (5) 咬噬的 (6) 尖銳的 (7) 觸痛的 ( 一觸即痛的 ) (8) 灼熱的 (9) 精疲力竭的 (10) 累人的 (11) 貫穿的 (12) 煩人的 ( 纏人的 ) (13) 麻麻的 (14) 可憐的 (15) 無法忍受的 14. 請圈出一個數字以表示您在最近一週內受疼痛影響的程度 : 1) 一般活動 ( 吃飯上廁所洗澡 ) 不受影響 -- 完全受影響 2) 情緒不受影響 -- 完全受影響 3) 行走能力不受影響 -- 完全受影響 4) 正常工作 ( 包括外出工作和做家事 ) 不受影響 -- 完全受影響 5) 與他人交往 ( 如與親人朋友的交往 )

Page 37 0 1 2 3 4 5 6 7 8 9 10 不受影響 -- 完全受影響 6) 睡眠 0 1 2 3 4 5 6 7 8 9 10 不受影響 -- 完全受影響 7) 生活樂趣 0 1 2 3 4 5 6 7 8 9 10 不受影響 -- 完全受影響 1.

37 Page 不受影響 -- 完全受影響 6) 睡眠不受影響 -- 完全受影響 7) 生活樂趣不受影響 -- 完全受影響 1. 視覺類比量表 (Visual Analogue Scale: VAS): 一條實際為 100mm 的直線, 最左邊標出 0 mm, 最右邊標出 100mm, 兩端並畫上兩個臉譜 ( 左邊為笑臉右邊為哭臉 ), 向病患解釋 0 mm 代表不痛 100 mm 代表非常非常的痛, 由左端往右移表示愈來愈痛, 拿一隻筆讓病患在這條直線上垂直畫一短線, 代表他疼痛的位置, 再將測量 cm 值記錄下來 cm 量表 (Numerical Scale): 一條實際為 10 cm 的直線, 在最左邊標出 0, 最右邊標出 10 cm, 當中每 1 cm 即畫出一條垂直短線, 分別標出 1,2,3, 向病患解釋 0 代表都不痛 10 代表非常的痛, 由左到右疼痛程度增加, 讓病患以筆垂直畫出疼痛的感覺在幾公分處, 以所測量的 cm 值記錄下來不痛非常的痛 3. 臉譜量表 (Face Rating Scale): 在一張紙上畫了 6 個卡通臉譜, 由左到右是 : 很愉快的笑臉 (0) 微微笑的臉(1) 有些不舒服(2) 更多些不舒服(3) 想哭(4) 到流眼淚大哭 (5), 臉譜下方標出 0~5, 讓患者選出最能代表他疼痛感覺的臉譜, 以 0~5 分別記錄所選擇的臉譜如 : 完全不痛一點點痛稍微痛蠻痛很痛非常痛考題與任務 23 歲的林小姐, 於一家外貿公司擔任會計出納員最近兩三個星期來常感覺頭痛的症狀, 而且有越來越加重的趨勢 ; 於是她到神經內科門診求治你的任務是針對疼痛的基本特徵加以詢問及記錄 ( 不須做鑑別診斷 )

38 Page 38 詢問內容頭痛部位疼痛史發作的形式疼痛的頻率疼痛的特性緩解因子誘發因子疼痛程度生活受影響程度詢問重點前後側邊, 或者是整個頭以前是否曾同樣的疼痛經驗突發式或者是漸進式間歇性或者是持續性刀割的或者是律動的等等藥物休息或者是局部治療等等勞累睡眠不足或者是月經週期等等視覺類比量表 10 cm 量表或者是臉譜量表十分評量法

39 Page 39 長庚紀念醫院神經外科臨床基本能力評分量表評量名稱 : 疼痛的測量及記錄學員姓名 : 職級 : 六年級實習醫學生七年級實習醫學生第一次評核第二次評核日期 : 日期 : 病歷號碼 : 病歷號碼 : 臨床診斷 : 臨床診斷 : 指導老師簽章 : 指導老師簽章 : 疼痛的部位疼痛的範圍開始時間疼痛型態疼痛週期長短疼痛性質誘發因素緩解因素輻射痛的有無相關症狀 Numeric Pain Scale/ Visual Analog Scale * 做到請打勾第一次評核第二次評核

40 Page 40 -DOPS ( ) : : : : 3. :

41 Page : 1 : 2 : 3 : 4 : ( ) 5 : 2. : 1 : 2 : 3 : 4 : 5 : 3. : 3-1 : 1 : 2 : 3 : 4 : 5 : 3-2 : 1 : 2 : 3 : 4 : 5 : 3-3 : 1 : 2 : 3 : 4 : 5 : 4. : 1 : 2 :, 3 : 4 :, 5 :

42 Page 42 ( ) PBL-EBM 6 評核項目評分標準參考請見背頁

43 Page 43

44 Page 44 ( ) PBL-EBM 6 評核項目評分標準參考請見背頁

45 Page 45

46 Page 46 神經外科訓練學員回饋評核表你的職級是 : 受訓時間 : 年月六年級實習醫學生七年級實習醫學生畢業後一般住院醫師第一年住院醫師第二年住院醫師臨床指導教師姓名 : 主治醫師 : 住院醫師 : ( 請填 R3( 含 ) 以上職級 ) 專科護理師 : 1. 臨床教師具教學熱忱 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 2. 臨床教師能耐心指導學員 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 3. 臨床教師指導學員時, 內容難易度適當 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 4. 臨床教師以 PBL-EBM 之精神教學 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 5. 臨床教師定期批閱指導病例寫作 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 6. 臨床教師對於學員的表現都能給於即時的回饋 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 7. 對於該科訓練課程安排滿意非常同意同意普通不同意很不同意 8. 臨床教師有定時迴診 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 NSP: 非常同意同意普通不同意很不同意

47 Page 臨床教師能清楚掌握病人病情發展 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 NSP: 非常同意同意普通不同意很不同意 10. 臨床教師與醫護同仁相處融洽 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 NSP: 非常同意同意普通不同意很不同意 11. 臨床教師與病患家屬互動良好, 能彼此信賴扶持 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 NSP: 非常同意同意普通不同意很不同意 12. 您覺得臨床教師能視病猶親 V: 非常同意同意普通不同意很不同意 R: 非常同意同意普通不同意很不同意 NSP: 非常同意同意普通不同意很不同意 13. 您認為在現定的訓練期中, 有否尚待加強的課程? 課程為何? 14. 您認為臨床指導教師的制度, 有否需改善之處? 謝謝您的填答, 您的寶貴意見是我們持續改善精進的動力!

Uncertainty of Measurement Application to Laboratory Medicine 鏡檢組蔡雅雯 2014/09/09

Uncertainty of Measurement Application to Laboratory Medicine 鏡檢組蔡雅雯 2014/09/09 Objectives Definitions Methodology Equation of Measurement Uncertainty Measurement Uncertainty Goal Examples Uncertainty