tag:blogger.com,1999:blog-52154483109493170572024-02-07T18:42:46.469-08:00National Taiwan University Hospital (NTUH): An iNTUHnational APPEAnonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.comBlogger17125tag:blogger.com,1999:blog-5215448310949317057.post-59119179968714981732012-10-15T22:26:00.000-07:002013-01-15T22:57:27.512-08:00Pharmacy Style<span class="Apple-style-span" style="font-family: inherit;"><span class="Apple-style-span" style="color: #222222;">While it looks like we were very busy at the hospital everyday, we still had time to have fun. Although much of the footage was shot in the U.S., most do not know that the first scenes of the</span><span class="Apple-style-span" style="color: #222222;"> </span><span class="Apple-style-span" style="color: #222222;">'Pharmacy Style' music video</span><span class="Apple-style-span" style="color: #222222;"> </span><span class="Apple-style-span" style="color: #222222;"> were actually filmed in various parts of Taipei, Taiwan, featuring pharmacy students from NTU. Click below to view the video!</span></span><br />
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<span class="Apple-style-span" style="color: #222222;"><span class="Apple-style-span" style="line-height: 18px;"><i><span class="Apple-style-span" style="font-family: inherit;">*If you're interested in reading another perspective, check out my classmate <a href="http://tinaatntuh.blogspot.com/">Tina's blog</a></span><span style="font-family: arial, sans-serif; font-size: medium;">!</span></i></span></span>Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-38243555871378921712012-09-25T19:52:00.000-07:002012-10-07T23:45:06.623-07:00Last Day at NTUH<div class="separator" style="clear: both; text-align: center;">
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It is hard to believe that my NTUH APPE is coming to an end! During my time here, I have met with many great preceptors, physicians, and students, who have all been a part of my educational experience here in Taiwan. In my opinion, the greatest benefit I got was seeing the difference between Taiwan and U.S. pharmacy practice. </div>
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Generally speaking, the treatment approaches at NTUH are highly dependent on the personnel in charge of that particular medical team. In both Family Medicine and PSICU, I noticed that the treatment decisions were based on a combination of <i>evidence</i> based medicine as well as <i>experience </i>based medicine. Just as in the U.S., they referred to IDSA guidelines for infections, CHEST guidelines for antithrombotic therapy, and ATPIII guidelines for high cholesterol treatment. As for experience, they referred to their attending physicians. The main difference that I found was that, often times, experience trumped evidence. Guidelines are there as a reference, however, they were not always followed. In contrast, I felt that in my rotations at UCDMC, guidelines were followed much more closely. This is an example in which the culture of Taiwan has a profound effect on the overall treatment approach of patients. The difference in culture was especially apparent towards the beginning of my time at NTUH, during the Ghost Month or 鬼月. During this month, it is believed that ghosts and spirits of the deceased return. Many of the locals, including my family, make trips to pay homage to deceased loved ones. Since this period of time is associated with death, many people tend to postpone medical procedures as well. As a result, the patient load for many of the services was much lighter than other times of the year. </div>
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In a hospital setting, Taiwan pharmacy personnel is estimated to be 1/8 ~ 1/16 that of the U.S. The number of patients each pharmacist manages is much greater, and therefore, it is impossible to devote as much time to each individual patient. For this reason, not all clinical pharmacists attend daily rounds with the medical team. On the Family Medicine service, the pharmacists do not ever round and interventions are made primarily via telephone. On ICU services, including PSICU, the pharmacists round with the teams on a daily basis. The type of team dynamic I observed in the ICU was more similar to my experience at UCDMC, where pharmacy support is not only appreciated, but sought after. In order to have an established pharmacy department, rapport between the pharmacy personnel and other members of the healthcare team must be established. This simply cannot be done without working together on a consistent basis. Clinical pharmacy is a much younger field in Taiwan, and many aspects of pharmacy are still in the process of becoming established. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixG2Ybfm1RqxDcKdzmL4AqP-RLNoQXvu5WF7GjnOooxEN6G3PIwwHEaAGz4MysbttjRZSSsh9dhJuoKZWtJY8qAHw6FXuX8iz6wfX9tXhBfFMZs4XNCgf7YAK-Q0YR2NKe2AzCfR2cxg/s1600/DSC09775.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEixG2Ybfm1RqxDcKdzmL4AqP-RLNoQXvu5WF7GjnOooxEN6G3PIwwHEaAGz4MysbttjRZSSsh9dhJuoKZWtJY8qAHw6FXuX8iz6wfX9tXhBfFMZs4XNCgf7YAK-Q0YR2NKe2AzCfR2cxg/s400/DSC09775.JPG" width="400" /></a></div>
Photo of some of the pharmacists at PSICU on my last day.Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-20339547214783448692012-09-20T18:08:00.000-07:002012-10-05T19:51:25.343-07:00Commonly Used Medications on the PSICU Service<div class="separator" style="clear: both; text-align: left;">
Being on the PSICU service has introduced me into a completely new realm of pharmacy. This was my first pediatrics rotation, my first ICU rotation, and my first surgical rotation. As my three weeks on PSICU nears its end, I've had the opportunity to see and learn a lot. In this post, I will attempt to break down what I've learned and specifically tailor it in terms of pharmacy. </div>
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The main role of the physicians, pharmacists, nurses, and respiratory therapists is to manage the patients postoperatively. The pharmacist's job is to ensure the appropriate medication management of these patients. Once the patients are stable, they are transferred to the floors and, if all goes well, they are discharged home. </div>
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What I have found is that the medications used on this service all come down to the following classes: </div>
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1) Antibiotics</div>
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2) Inotropic agents</div>
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3) Sedation/pain relief</div>
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4) Stress Ulcer prophylaxis</div>
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5) TPN</div>
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<u>Antibiotics</u> </div>
The antimicrobial regimens used on the service are primarily for surgical prophylaxis. With any surgery, there is an increased chance of infection, and the risk is even higher in pediatric patients. For the most part, they followed the Antimicrobial Prophylaxis for Surgery guidelines from The Medical Letter, Inc. However, after listening to discussions on rounds and speaking with my preceptor, I realized that the antibiotic selection largely depends on how the surgeon felt about the surgery ie how long the surgery took, if there were any complications. From a pharmacy standpoint, my pharmacist was not as involved in the antibiotic selection, but more in the dosage adjustment for the individual patients. As the patients clinically improve after surgery, the antibiotics are peeled off gradually. Some of the considerations the physicians take into account to see if patients are improving are the number of lines and drainages remaining, whether an extracorporeal membrane oxygenation (ECMO) is required, and lab values returning to normal limits. There was not official antibiotic algorithm at NTUH, however, the basic progression of antibiotic selection consisted of the following: <br />
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no complications in surgery---------->severe complications<br />
cefazolin-->ampicillin/sulbactam-->piperacillin/tazobactam-->vancomycin + ceftazidime-->ADD fluconazole<br />
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<u>Inotropes</u><br />
Every single patient is started on dopamine and milrinone to start. If another agent is indicated, epinephrine is added on. My assessment of these agents is mentioned in a previous post. As the patient clinically improves, the inotropic agents are gradually tapered off, and eventually, discontinued. In general, the epinephrine is tapered off first, followed by the dopamine. <br />
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<u>Sedation/pain relief</u><br />
The two mainstays of sedation and pain relief on the service were fentanyl and pancuronium. The fentanyl is an analgesic and pancuronium is on mainly as a muscle relaxant. Most patients are tapered to midazolam,which has both sedative and analgesic effects. <br />
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<u>Stress Ulcers</u><br />
Surgery is putting stress on the body. With high stress, patients are at risk of stress ulcers. Famotidine is the medication used for prophylaxis. If, however, the patient experiences bloody stools, they transition them to a proton pump inhibitor. <br />
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Other medications that are commonly seen are antiplatelets such as heparin and aspirin, to prevent shunts from clotting. Coumadin is common for older patients, especially those with shunts and mechanical valves. <br />
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Everyday on rounds, I learned something new. I feel that six weeks (ore more) could easily have been devoted to a rotation like this. <br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhe-tqUhvQhHh9jMfZrU-KLHunzJlc6CAeIOnb0ijcaKnEA_6nnicI6GKIbSLPLp-1__IVN4u3wlmyZWZWkajzbuSTfuo8OxgMPpMqy-pHXsmEPIoq7BQaZX6L0PARACaDISI1amqwsnw/s1600/SANY2896.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhe-tqUhvQhHh9jMfZrU-KLHunzJlc6CAeIOnb0ijcaKnEA_6nnicI6GKIbSLPLp-1__IVN4u3wlmyZWZWkajzbuSTfuo8OxgMPpMqy-pHXsmEPIoq7BQaZX6L0PARACaDISI1amqwsnw/s320/SANY2896.JPG" width="320" /></a></div>
The front of the Children's Hospital.<br />
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Photo with my pharmacist (left), nurses on our team (middle), attending physician(second from the right).Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-89346997135192951242012-09-18T23:04:00.000-07:002012-10-04T23:42:57.588-07:00Neonatal TPN<!--StartFragment-->
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<span class="Apple-style-span" style="font-family: 'Times New Roman';">Earlier in the week, I presented a patient case on a neonate who had undergone cardiac surgery to repair his transposition of the great arteries. In his postoperative management, the patient developed a chylothorax, at which point the patient was placed on NPO until the fluid drainage from her chest tubes resolve. To provide adequate nutrients to this growing baby during this time, TPN was administered. </span></div>
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<span class="Apple-style-span" style="font-family: 'Times New Roman';">Since I was following this patient, I attached an addendum to my case presentation that included a SOAP of the TPN regimen given. As my references, I looked at both NTUH's guidelines as well as Neonatal and Pediatric Parenteral Nutrition Support Guidelines from the University of Illinois at Chicago Medical Center. </span></div>
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<b><span style="font-family: "Times New Roman"; font-size: 14.0pt;">Neonatal
TPN</span></b><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">S/O<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient is NPO due to a chlyothorax.<span style="mso-spacerun: yes;"> </span></span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt;">A</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient is NPO, and therefore, requires TPN to supply essential
nutrients crucial to promote normal growth and development. <o:p></o:p></span></div>
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<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">17%<o:p></o:p></span></div>
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<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">48.96 gm<o:p></o:p></span></div>
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<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Aminosteril Infant<o:p></o:p></span></div>
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<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2.20%<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2.64 gm/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Na<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">30 mEq/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">3.60 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 4;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">K<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">30 mEq/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">3.60 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 5;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Cl<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">30 mEq/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">3.60 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 6;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Ca<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">25 mEq/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">3 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 7;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">P<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">10 mmol/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">1.2 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 8;">
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: none; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Mg<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">5 mEq/L<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">0.6 mEq/kg/day<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 9;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Infuvita<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">5 mL<o:p></o:p></span></div>
</td>
<td nowrap="" style="height: 16.2pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 10;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Zn<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">188 ug<o:p></o:p></span></div>
</td>
<td nowrap="" style="height: 16.2pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 11;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Trace Element<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 94.0pt;" width="94">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">50 uL<o:p></o:p></span></div>
</td>
<td nowrap="" style="height: 16.2pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 12; mso-yfti-lastrow: yes;">
<td colspan="2" nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: solid windowtext 1.0pt; border-right: solid black 1.0pt; border-top: none; height: 16.2pt; mso-border-alt: solid windowtext .5pt; mso-border-right-alt: solid black .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 188.0pt;" width="188">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Rate=340 mL @ 0.2 mL/min<o:p></o:p></span></div>
</td>
<td nowrap="" style="height: 16.2pt; padding: 0in 1.4pt 0in 1.4pt; width: 87.0pt;" width="87">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<br /></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l2 level1 lfo3; tab-stops: 21.0pt list 24.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Calculations<o:p></o:p></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; mso-padding-alt: 0in 1.4pt 0in 1.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: 16.2pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border: solid windowtext 1.0pt; height: 16.2pt; mso-border-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span lang="ZH-TW" style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;"> </span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;"><o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Calculation<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Assessment<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 113.4pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 113.4pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Dextrose<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 113.4pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">48.96 gm/day x 1/2.4 kg x 1 day/24h x 1h/60 min
x 1000 mg/g = 14.2 mg/kg/min<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 113.4pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Goal:<span style="mso-spacerun: yes;">
</span>11-14 mg/kg/min; patient's dextrose rate is approximately the within
the normal range<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 81.0pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Amino Acid<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2.2%=2.2 gm/100 mL/day x 288 ml x 1/2.4 kg=2.64
gm/kg/day<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Goal:<span style="mso-spacerun: yes;">
</span>~3 gm/kg/day for preterm infant; patient's rate is appropriate<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 81.0pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Lipids<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">5 mL of 20% emulsion-->20gm/100mL x 5mL/2.4
kg=0.42 mg/kg/day<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Goal: start at 1gm/kg/day, max: 3gm/kg/day;
slightly below goal<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 1.35in; mso-yfti-irow: 4;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 1.35in; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Total Calories<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 1.35in; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">dextrose:<span style="mso-spacerun: yes;">
</span>48.96 gm x 3.4 kcal/gm = 166.5 kcal; AA:<span style="mso-spacerun: yes;"> </span>6.336 gm x 4 kcal/gm = 25.3444 kcal; lipid:<span style="mso-spacerun: yes;"> </span>1 gm x 9kcal/gm = 9 kcal;
Total=83.69 kcal/kg/day<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 1.35in; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Goal:<span style="mso-spacerun: yes;">
</span>40-50% of total caloric intake; dextrose consists of 83%; dextrose
is above normal range<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 48.6pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 48.6pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 73.0pt;" width="73">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Total Fluid<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 48.6pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 150.0pt;" width="150">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">12 mL/h x 24 H = 288 mL; 288 mL/2.4 kg = 120
mL/kg/day<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 48.6pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117">
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">Max:<span style="mso-spacerun: yes;">
</span>140-150 mL/kg/day; total fluid is appropriate<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 3;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">P</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Goal</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.1pt;" valign="top" width="373">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Provide adequate nutrition while the patient is NPO</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Fluid<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Sodium<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Protein<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Carbohydrates<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Fat<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Electrolytes<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 46.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; mso-para-margin-bottom: 2.85pt; mso-para-margin-left: 2.0gd; mso-para-margin-right: 0in; mso-para-margin-top: 2.85pt; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Caloric
intake<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Increase
lipids to at least 1gm/kg/day<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Increase
amino acids to ~ 3 gm/kg/day<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Increase
concentration of dextrose, may go up to 20-25%<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo2; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Decrease
percentage of dextrose to goal of 40-50%<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -13.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
</tr>
<tr style="height: 64.05pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Monitoring</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
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<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Ca, Cl, Mg, P, K, Na<o:p></o:p></span></div>
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<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Fluid overload ie edema, renal function<o:p></o:p></span></div>
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<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Amino Acids<o:p></o:p></span></div>
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<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";">Lipid<o:p></o:p></span></div>
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<o:p>Similar to medication dosing for the pediatric population, the estimated energy needs, dextrose, protein, lipid, electrolyte and maintenance fluid requirements are based on patient weight. The normal and goal ranges for each of the components are listed in my assessment above. </o:p></div>
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In our schooling, we did not extensively go over TPN, let alone neonatal TPN. We spent one lecture going over a case with Dr. Ferrone, and that was the end of it. At NTU, the students are well trained in TPN and seem to have a relatively solid grasp on management of TPN components. This may be because TPN is considered a very specialized sector of pharmacy in the US. At NTUH, the TPN orders are done by different individuals, depending on which department of the hospital they are in. On the PSICU service, the nurses did the TPN orders. Once the orders are processed on their computer system, the TPN pharmacy verifies the order. In certain departments, the TPN pharmacy does the order as well as the verification. At UCDMC, the TPN pharmacy is a consult service, and thus, only the services that call for a consultation have the orders done by the TPN pharmacist.</div>
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Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-85175611138566350432012-09-14T17:43:00.000-07:002012-10-03T18:13:09.303-07:00Pediatric Compounding<div class="separator" style="clear: both; text-align: left;">
Today, I spent the day with Dr. Dong, the only compounding pharmacist at the Pediatric Inpatient Pharmacy. Before beginning the process of compounding, Dr. Dong stressed the importance of consistency. What it all boiled down to was the fact that uniform medication doses leads to appropriate drug levels in the blood, which leads to efficacy while minimizing toxicity. The second point of emphasis was sterile technique. In 1676, Leeuwenhoek discovered the existence of bacteria, which as we know now, is invisible to the naked eye. In 1881, the concept that bacteria can lead to illness was born and, in 1905, the concept that isolated bacteria can infect differet hosts and cause the same illness was born (Koch's postulates). All of these microbiological advancements lead to sterile technique, which is the standard of practice for compounding at NTUH.</div>
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When compounding, Dr. Dong follows three rules: 1) The drug cannot be wrong 2) the dose cannot be wrong 3) amount of drug dispensed cannot be wrong. At the same time, he understands that "to err is human." The attitude that mistakes are embarrassing and should be swept under the rug is the exact attitude that will lead to more errors in the future. Rather, mistakes should be brought to the forefront and corrected to prevent future errors of the same nature. </div>
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We started out by thoroughly washing our hands with soap and scrubbing every fold/nail/crease. We then sprayed our hands with 75% alcohol, a concentration that has been shown to effectively penetrate the bacterial cell membrane and cause cells the shrivel. Once our hands were dry, we put on gloves, hair nets, and carbon face masks. Dr. Dong explained that the carbon masks are designed to prevent dust inhalation, whereas the surgical masks used elsewhere in the hospital are designed to protect against disease transmission. The medication we were compounding was Aldactone 3.1 mg/dose. The standard tablet comes in 25 mg, and therefore, our job was to take 1/8 of each tablet and package them into unit doses packages in powder form. Since the medication would be administered to children, flavoring would need to be added as well. For liquid formulations, flavoring agents consist of syrups. For powder formulations, flavoring is done by adding lactose monohydrate for two reasons: 1) When the disaccharide is broken down to a monosaccharide, it tastes sweet 2) The lactose increases the volume so it is easier to ingest. The first step was to weigh the appropriate amount of lactose. Next, we ground up the Aldactone tablets using an automatic grinder, shown below.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHx1J5jrzaGOIjZbhdyo0lVGJk44q6pQ4PNExQpPmV2WCtqdviTPsJRIwVIyigrT1Q3X04J5MzDDlJcbNwT8Yc18AUfpzNXeo2ZYeL_wJXgeD-aUv4bsyalN37cqvPvr6DN3RvupasYw/s1600/IMG_2020.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiHx1J5jrzaGOIjZbhdyo0lVGJk44q6pQ4PNExQpPmV2WCtqdviTPsJRIwVIyigrT1Q3X04J5MzDDlJcbNwT8Yc18AUfpzNXeo2ZYeL_wJXgeD-aUv4bsyalN37cqvPvr6DN3RvupasYw/s320/IMG_2020.jpg" width="239" /></a></div>
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Before combining the two powders, we put the Aldactone powder through a sift to ensure all of the particles were of uniform size. To minimize wasting, we ground the large particles remaining with a mortar and pestle and sifted those particles once again. At this point, we were ready to combine the lactose and Aldactone. We first ground up the Aldactone with 1/2 of the preweighed lactose using the mortar and pestle. The second 1/2 was added subsequently to ensure consistency. Now that the medication and lactose were combined, the final step was the separate them into 3.1 mg unit packages. Luckily, NTUH has a Japanese made autmoatic package divider, which, in addition to separating the powder and packaging them, also prints the label so that the product is in its final form. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6dYirD6jdms2QP_uvEjuArW-zdOYu0YdOz2RdvdsGA8-Wu26kUYH7QdnVVMX9jA12MXYpQlzOS4lQbN0OTe-Dqf4mv_ooLEx35BkxFItLQcwSIrethiqPxGjeoPxS-Nml1A-bfjENEA/s1600/IMG_2019.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg6dYirD6jdms2QP_uvEjuArW-zdOYu0YdOz2RdvdsGA8-Wu26kUYH7QdnVVMX9jA12MXYpQlzOS4lQbN0OTe-Dqf4mv_ooLEx35BkxFItLQcwSIrethiqPxGjeoPxS-Nml1A-bfjENEA/s320/IMG_2019.jpg" width="239" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiQMLmuA5bOPb_eRoZ46n_QVNYHfUwHQfKshPx9t8jTRqbDyfe3pjC72eWBlJhMj3jqpzeF94EirV359Ul7pce9DzsN9nHlafEA86jVXUqS5L8u568YvWy0WQHkGXcyOl12L03CbQyIg/s1600/IMG_2021.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgiQMLmuA5bOPb_eRoZ46n_QVNYHfUwHQfKshPx9t8jTRqbDyfe3pjC72eWBlJhMj3jqpzeF94EirV359Ul7pce9DzsN9nHlafEA86jVXUqS5L8u568YvWy0WQHkGXcyOl12L03CbQyIg/s320/IMG_2021.JPG" width="320" /></a></div>
As with any pharmacy practice, the final check had to be done. Dr. Dong does a "recheck" with every order, meaning he checks his own work. Afterwards, he has another pharmacist do a "double check" to verify his work. At NTUH, the standard considered adequate for patients to take is a variance in weight of <6%. In industry, where everything is automated, the standard is 3-5%. Our batch of Aldactone 3.1 mg ended up having a variance of <5%! <br />
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<br />Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-12077827253527217882012-09-12T01:10:00.000-07:002012-10-17T20:53:52.895-07:00Patient Presentation--Transposition of the Great Arteries<!--StartFragment-->
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<b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;">Patient Profi</span></b><b><span style="color: black; font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 14.0pt;">le:<o:p></o:p></span></b></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Name: </span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Age: 13 days<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Sex: F<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Bed: 06PE-13-01<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">MRN: 5882682<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Height: 46.5 cm (BBL: 47 cm, 25-50th percentile)<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Weight: 2.4 gm (BBW: 2374 gm, 10-25th percentile)<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">BHC: 32.3 cm, 50th percentile<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">NKDA<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-language: EN-US;">Vaccinations: BCG (-), HBV (-), HBIG (-)<o:p></o:p></span></div>
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<b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;">Chief complaint: </span></b><span style="color: black; font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-weight: bold;">prenatal congenital heart disease, cyanosis, respiratory distress after
birth</span><span style="font-family: "Times New Roman"; font-size: 12.0pt;"><o:p></o:p></span></div>
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<b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;">Maternal history:</span></b><span style="font-family: "Times New Roman"; font-size: 12.0pt;"><o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt;">(1)
Maternal disease:<o:p></o:p></span></div>
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<span style="font-family: "Times New Roman"; font-size: 12.0pt;">arrhythmia
without medication treatment, HBsAg(-), HBeAg(-), VDRL(-), GBS(not done),
hyperthyroidism(-), hypothyroidism(-), DM(-), SLE(-), APS(-),
hypertension(-), Rh-(-), pre-eclampsia(-), PIH(-), GDM(-), APH(-), placenta
abruptio(-), infection(-) <o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .65in; mso-yfti-irow: 1;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: .65in; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">(2)
Prenatal exam:<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: .65in; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 356.0pt;" width="356"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">congenital
heart disease (suspect TGA) noted since GA 20wk, IUGR(-), oligohydramnios(-),
polyhydramnios(-), thalassemia(-), chromosome anomaly(-), other inherited
disease(-) <o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">(3) Drug
exposure:<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 356.0pt;" width="356"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">MgSO4(-),
ritodrine(-), steroid(-), antibiotics(-), others(-) <o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 117.0pt;" width="117"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">(4)
Radiation exposure:<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 356.0pt;" width="356"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">(-)<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;">History of present illness:</span></b><span style="color: black; font-family: "Times New Roman"; mso-bidi-font-size: 14.0pt;"><o:p></o:p></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: .6pt; mso-padding-alt: 0in 1.4pt 0in 1.4pt; width: 478px;">
<tbody>
<tr style="height: 81.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border: solid windowtext 1.0pt; height: 81.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 52.0pt;" width="52"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">2012/9/4<o:p></o:p></span></div>
</td>
<td style="border-left: none; border: solid windowtext 1.0pt; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 425.8pt;" width="426"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Female
baby was born to her mother, G2P2, GA 26+2 weeks (preterm), and delivered via
NSD/CS.<span style="mso-spacerun: yes;"> </span>Congenital heart
disease, TGA was suspected on prenatal examination since GA 20 weeks.<span style="mso-spacerun: yes;"> </span>Baby was delivered without
complications and cyanosis and heart murmur were noted after birth (SpO2 80%
on room air, 85% under free flow O2).<span style="mso-spacerun: yes;">
</span>PGE1 started and tapered down gradually. <o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 81.0pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 52.0pt;" width="52"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">2012/9/6<o:p></o:p></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 81.0pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 425.8pt;" width="426"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">CVS
specialist consulted.<span style="mso-spacerun: yes;"> </span>Total
correction performed (arterial switch operation, PDA division, ASD closure,
VSD patch repair) and the patient was transferred to ICU for post op
care.<span style="mso-spacerun: yes;"> </span>Vancomycin and ceftazidime
were started for infection prophylaxis.<span style="mso-spacerun: yes;">
</span>Dopamine and milrinone started for hemodynamic support.<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 52.0pt;" width="52"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">2012/9/9<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 425.8pt;" width="426"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Sternum
closure performed.<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 3;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 52.0pt;" width="52"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">2012/9/11<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 425.8pt;" width="426"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Phototherapy
started for neonatal jaundice.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 52.0pt;" width="52"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">2012/9/12<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 425.8pt;" width="426"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Chylothorax
discovered, patient NPO and TPN administered.<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; text-autospace: none;">
<b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;">Systemic
disease and Past medical history: </span></b><span style="color: black; font-family: "Times New Roman"; font-size: 14.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; text-autospace: none;">
<br /></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: .15in; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: .05pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td colspan="3" style="border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 480.6pt;" valign="top" width="481"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<b><span style="font-family: "Times New Roman"; font-size: 14.0pt;">1.<span style="mso-spacerun: yes;"> </span>Chylothorax</span></b><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">S/O<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 451.1pt;" valign="top" width="451"><div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: 21.3pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l9 level1 lfo1; tab-stops: 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -21.3pt;">
<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Milky fluid in chest tube drainage</span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: 21.3pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l9 level1 lfo1; tab-stops: 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -21.3pt;">
<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Consolidation in right lung noted on several CXR’s</span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">A</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 451.1pt;" valign="top" width="451"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l13 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Chylothorax occurs when lymph fluid accumulates in the
pleural space due to disruption or obstruction of the thoracic duct.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l13 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Traumatic vs nontraumatic; surgical procedures (traumatic)
are commonly associated with chylothoraces<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l13 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Diagnosis:<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l12 level1 lfo15; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Chest radiograph<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l12 level1 lfo15; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Milky fluid from thoracentesis or chest tube drainage<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l12 level1 lfo15; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Pleural fluid analysis—predominance of lymphocytes,
elevated TG (>110 mg/dL)<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l13 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Postsurgical chylothorax:<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l8 level1 lfo16; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Pleural drainage to control symptoms—monitor electrolytes,
lymphocyte counts, albumin, total protein, weight<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l8 level1 lfo16; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Fasting or reduced fat diet—decrease flow of chyle through
thoracic duct allows spontaneous closure of a thoracic duct leak<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l8 level1 lfo16; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Pleurodesis—not responding to thoracentesis, dietary
control measures<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l8 level1 lfo16; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Thoracic duct ligation—high volume chylothorax<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l13 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: 0in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Current tx:<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l3 level1 lfo17; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Chest tube drainage—drainage has become more clear, volume
drained is trending down, mediastinal chest tube pulled last night <o:p></o:p></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; mso-padding-alt: 0in 1.4pt 0in 1.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: 16.2pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border: solid windowtext 1.0pt; height: 16.2pt; mso-border-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span lang="ZH-TW" style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;"> </span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體;"><o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">LP<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">RP<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">M<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2012/9/11<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">150<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">160<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">10<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2012/9/12<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">40<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">40<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">--<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 16.2pt; mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">2012/9/13<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">50<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div align="right" class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; text-align: right;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">50<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 16.2pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-right-alt: solid windowtext .5pt; padding: 0in 1.4pt 0in 1.4pt; width: 62.0pt;" width="62"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體;">pulled<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l3 level1 lfo17; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient NPO on 9/12<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l3 level1 lfo17; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">May start dextrose and taper down TPN today (9/14)<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 3;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">P</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Goal</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.1pt;" valign="top" width="373"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Resolve chylothorax<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Prevent infection</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Restart oral intake</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 64.05pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Monitoring</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: 64.05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.1pt;" valign="top" width="373"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Drainage volume,
clarity<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Signs and symptoms of
infection:<span style="mso-spacerun: yes;"> </span>leukocytosis, fever</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Clinical signs of
improvement</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Electrolytes, CBC,
protein, body weight</span><span style="font-family: 新細明體; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 14.2pt; text-autospace: none;">
<br /></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: .15in; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: .05pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td colspan="3" style="border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 480.5pt;" valign="top" width="481"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<b><span style="font-family: "Times New Roman"; font-size: 14.0pt;">2.<span style="mso-spacerun: yes;"> </span>Cardiovascular management</span></b><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="mso-layout-grid-align: none; text-autospace: none;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">S/O<o:p></o:p></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 451.1pt;" valign="top" width="451"><div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l26 level1 lfo13; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">UOP (4.15 mL/kg/hr on 9/12, 5.29 mL/kg/hr on 9/13)<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l26 level1 lfo13; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">SCr elevated (0.8 on 9/12); should be <0.6</span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l26 level1 lfo13; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">HR (190’s on 9/7, trending down, 130-150 now)</span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l26 level1 lfo13; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">BP (70-80/50’s on 9/14)</span><span style="font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">A</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 451.0pt;" valign="top" width="451"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l38 level1 lfo28; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Pediatric patients are
at high risk of being in a low cardiac output state post CV surgery.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l30 level1 lfo29; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Hypovolemia from operative/postoperative bleeding<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l30 level1 lfo29; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Inflammatory cascade<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l30 level1 lfo29; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Stunning of myocardium<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l38 level1 lfo28; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">In the ICU:<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l21 level1 lfo30; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Closely monitor heart ie HR, rhythm, perfusion to other
organs<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l21 level1 lfo30; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Pharmacological support—vasoactive agents are initiated
post-op and tapered down gradually as cardiac output, perfusion improves<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l21 level1 lfo30; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Mechanical support if needed<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l38 level1 lfo28; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Currently treating
with:<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level1 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Dopamine—preferred:<span style="mso-spacerun: yes;">
</span>depressed CO, normal, moderately elevated PL, mod to severe
hypotension; MOA:<span style="mso-spacerun: yes;"> </span>dose-dependent
positive inotropic and chronotropic effects on the myocardium<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level2 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Courier New"; font-size: 12.0pt; mso-bidi-font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Dose:<span style="mso-spacerun: yes;">
</span>conc:<span style="mso-spacerun: yes;"> </span>80 mg/100 mL D5W,
initial rate: 0.9 ml/h<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">80 mg/100 ml x 0.9
ml/hr x 1hr/60 min x 1/2.7 kg x 1000 ug/1mg = 4.44 ug/kg/min<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.25in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">reference
range:<span style="mso-spacerun: yes;"> </span>2-4 ug/kg/min, 4-8
ug/kg/min<o:p></o:p></span></i></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level2 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Courier New"; font-size: 12.0pt; mso-bidi-font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">4-8 ug/kg/min:<span style="mso-spacerun: yes;">
</span>stimulation of </span><span style="font-family: Symbol; font-size: 12.0pt; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">b</span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">1, </span><span style="font-family: Symbol; font-size: 12.0pt; mso-ascii-font-family: "Times New Roman"; mso-char-type: symbol; mso-hansi-font-family: "Times New Roman"; mso-symbol-font-family: Symbol;"><span style="mso-char-type: symbol; mso-symbol-font-family: Symbol;">b</span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">2 receptors; increased
renal blood flow, heart rate, cardiac contractility, cardiac output<o:p></o:p></span></div>
<table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 104.8pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: 15.0pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td nowrap="" style="border: solid windowtext 1.0pt; height: 15.0pt; mso-border-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 65.0pt;" width="65"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">α1<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-left: none; border: solid windowtext 1.0pt; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 208.0pt;" width="208"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">smooth muscle contraction<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 1;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 65.0pt;" width="65"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">α2<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 208.0pt;" width="208"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">smooth muscle, cardiac muscle relaxation<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 2;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 65.0pt;" width="65"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">β1<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 208.0pt;" width="208"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">heart muscle contraction<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 15.0pt; mso-yfti-irow: 3; mso-yfti-lastrow: yes;">
<td nowrap="" style="border-top: none; border: solid windowtext 1.0pt; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 65.0pt;" width="65"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">β2<o:p></o:p></span></div>
</td>
<td nowrap="" style="border-bottom: solid windowtext 1.0pt; border-left: none; border-right: solid windowtext 1.0pt; border-top: none; height: 15.0pt; mso-border-alt: solid windowtext .5pt; mso-border-left-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 208.0pt;" width="208"><div class="MsoNormal" style="line-height: normal; margin-bottom: .0001pt; margin-bottom: 0in;">
<span style="font-family: Times; font-size: 12.0pt; mso-fareast-language: EN-US;">smooth muscle relaxation<o:p></o:p></span></div>
</td>
</tr>
</tbody></table>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<br /></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level1 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Milrinone—inhibiting PDE III, increases CO, lowers filling
pressures, reduces pulmonary artery pressures<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level2 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Courier New"; font-size: 12.0pt; mso-bidi-font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Dose:<span style="mso-spacerun: yes;"> </span>conc:
10 mg/50mL D5W, initial rate: 0.4 ml/hr<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">10 mg/50 ml x 0.4
ml/hr x 1hr/60 min x 1/2.7 kg x 1000 ug/1mg=0.493 ug/kg/min<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<i style="mso-bidi-font-style: normal;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">reference
range: 0.25—1 ug/kg/min</span></i><span style="font-family: "Times New Roman"; font-size: 12.0pt;"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 1.5in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l20 level2 lfo31; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="font-family: "Courier New"; font-size: 12.0pt; mso-bidi-font-family: "Courier New"; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">0.25—1 ug/kg/min:<span style="mso-spacerun: yes;">
</span>systemic and pulmonary vasodilator<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none;">
<br /></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 3;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">P</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Goal</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.0pt;" valign="top" width="373"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Prevent cardiovascular collapse</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Hemodynamic stability</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Optimize preload</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Control HR, rhythm and synchrony, perfusion</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Prevent acidosis</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
</tr>
<tr style="height: 64.05pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="font-family: "Times New Roman"; font-size: 12.0pt;">Monitoring</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: 64.05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.0pt;" valign="top" width="373"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">HR</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">BP</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">UO</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">End
organ function ie Scr, LFT’s</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">Temperature</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman";">Blood
pH</span><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
</tr>
</tbody></table>
<span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;">
</span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><br />
<table align="left" border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 6.0pt; margin-right: 6.0pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-anchor-horizontal: page; mso-table-anchor-vertical: paragraph; mso-table-layout-alt: fixed; mso-table-left: 46.05pt; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-top: 22.2pt;">
<tbody>
<tr style="height: .05pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td colspan="4" style="border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 509.8pt;" valign="top" width="510"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<a href="http://www.blogger.com/blogger.g?blogID=5215448310949317057" name="women"><b><span style="font-family: "Times New Roman"; font-size: 14.0pt;">3.
Neonatal jaundice</span></b></a><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-row-margin-right: .4pt; mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">S/O<o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 478.1pt;" valign="top" width="478"><div class="MsoNormal" style="line-height: normal; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">1.<span style="mso-spacerun: yes;"> </span>Jaundice ie yellow color of skin<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">2.<span style="mso-spacerun: yes;"> </span>T. Bili levels (12.41 on 9/12,
trending down, 10.27 9/14)<o:p></o:p></span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border: none; mso-cell-special: placeholder;" width="0"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">A</span></span><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
<td colspan="3" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 478.5pt;" valign="top" width="479"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Nonpathologic jaundice is caused by<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 1.0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l23 level1 lfo19; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Increased bilirubin production—more RBC’s than adults,
increased turnover<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 1.0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l23 level1 lfo19; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Decreased bilirubin clearance—deficiency of enzyme UGT1A1
til week 14<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 1.0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l23 level1 lfo19; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Increased enterohepatic circulation<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Normally resolves within 1-2 weeks after birth<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Hyperbilirubinemia with T. Bili >25 to 30 mg/dL is
associated with increased risk of neurologic dysfunction<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Risk factors:<span style="mso-spacerun: yes;">
</span>GA <37 weeks, Asian race<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Guidelines from the AAP are not available for infants less
than 35 weeks GA due to variability in clinical manifestations, spectrum, and
lack of reliable and predive measures of bilirubin neurotoxicity.<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Times; mso-fareast-font-family: Times;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt; mso-fareast-language: EN-US;">The guideline to initiate phototherapy from Norway is based on the BW
and postnatal age of the preterm infant. In general, for infants > 4 days
of age, the following thresholds of TB are used based on BW:</span></span><span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 18.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; mso-pagination: none; tab-stops: 11.0pt .5in; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt; mso-fareast-language: EN-US;">BW >2500 g, but GA
between 34 and 37 weeks: 17.5 mg/dL (300 micromol/L)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 18.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; mso-pagination: none; tab-stops: 11.0pt .5in; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt; mso-fareast-language: EN-US;">BW between 1500 and
2500 g: 14.6 mg/dL (250 micromol/L)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 18.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; mso-pagination: none; tab-stops: 11.0pt .5in; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt; mso-fareast-language: EN-US;">BW between 1000 and
1499 g: 11.7 (200 micromol/L)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 18.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; mso-pagination: none; tab-stops: 11.0pt .5in; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: Arial; mso-bidi-font-size: 13.0pt; mso-fareast-language: EN-US;">BW between <1000 g:
8.8 mg/dL (150 micromol/L)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: .5in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l28 level1 lfo18; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Treatment<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 1.0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l17 level1 lfo25; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Phototherapy—conversion of bilirubin to lumirubin,
bilirubin isomer, polar molecules<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 1.0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l17 level1 lfo25; tab-stops: 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Exchange transfusion—if phototherapy failes<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: 64.3pt; mso-yfti-irow: 3;">
<td rowspan="2" style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.3pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">P</span></span><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.3pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 82.75pt;" valign="top" width="83"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt;">Goal</span></span><span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: solid black 1.0pt; border-top: none; height: 64.3pt; mso-border-alt: solid black .35pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 395.75pt;" valign="top" width="396"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 24.1pt; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">T. Bili levels within normal limits</span></span><span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 24.1pt; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">Resolve jaundice<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 24.1pt; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">Prevent neurological
dysfunction, auditory<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: 17.1pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 17.1pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 82.75pt;" valign="top" width="83"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: 0in; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt;">Monitoring<o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: solid black 1.0pt; border-top: none; height: 17.1pt; mso-border-bottom-alt: windowtext .5pt; mso-border-left-alt: black .35pt; mso-border-right-alt: black .35pt; mso-border-style-alt: solid; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 395.75pt;" valign="top" width="396"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: -.1pt; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">T. Bili levels<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: .1pt; margin-left: -.1pt; margin-right: 0in; margin-top: .1pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 22.2pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">Skin discoloration<o:p></o:p></span></span></div>
</td>
</tr>
<tr height="0">
<td style="border: none;" width="31"></td>
<td style="border: none;" width="83"></td>
<td style="border: none;" width="395"></td>
<td style="border: none;" width="0"></td>
</tr>
</tbody></table>
<span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;">
</span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><span style="mso-bookmark: women;"></span><br />
<table align="left" border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: 6.0pt; margin-right: 6.0pt; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-anchor-horizontal: page; mso-table-anchor-vertical: paragraph; mso-table-layout-alt: fixed; mso-table-left: 46.05pt; mso-table-lspace: 9.0pt; mso-table-rspace: 9.0pt; mso-table-top: 9.05pt;">
<tbody>
<tr style="height: .05pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
<td colspan="4" style="border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 509.8pt;" valign="top" width="510"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><b><span style="font-family: "Times New Roman"; font-size: 14.0pt;">4.
Infection</span></b></span><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-row-margin-right: .4pt; mso-yfti-irow: 1; page-break-inside: avoid;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-layout-grid-align: none; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; line-height: 115%; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">S/O<o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 478.1pt;" valign="top" width="478"><div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">WBC
elevated<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">afebrile<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">peripheral
blood cx (-) 9/4<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">surgical
wound site cx (-) 9/10<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">sputum
cx (-) 9/13<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: normal; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l27 level1 lfo38; tab-stops: list .25in left 21.0pt 120.7pt 127.8pt 134.9pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-bidi-font-size: 11.0pt;">CRP
decreased since 9/11<o:p></o:p></span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border: none; mso-cell-special: placeholder;" width="0"><div class="MsoNormal">
<br /></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 2;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">A</span></span><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
<td colspan="3" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 478.5pt;" valign="top" width="479"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient has persistent leukocytosis despite treatment with
antibiotics throughout course<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient has been afebrile throughout<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">No cx’s have grown<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Currently being treated with Ceftazidime, Vancomycin (9
days)<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Ceftaz dose is appropriate<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Vanco dose is low, trough on 9/11 was 6.75<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Physician changed CVP line on 9/11, opted to stay with
current doses of antibiotics<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: .25in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l33 level1 lfo39; tab-stops: list .25in left 21.0pt; text-autospace: none; text-indent: -.25in;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt; mso-fareast-font-family: "Times New Roman";"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: "Times New Roman"; font-size: 12.0pt;">Patient is at risk with many lines<o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: 64.3pt; mso-yfti-irow: 3;">
<td rowspan="2" style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.3pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 31.3pt;" valign="top" width="31"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: "Times New Roman"; font-size: 12.0pt;">P</span></span><span style="mso-bookmark: women;"><span style="font-family: 新細明體; mso-bidi-font-family: 新細明體; mso-hansi-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
</td>
<td style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.3pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 82.75pt;" valign="top" width="83"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt;">Goal</span></span><span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: solid black 1.0pt; border-top: none; height: 64.3pt; mso-border-alt: solid black .35pt; mso-border-bottom-alt: solid windowtext .5pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 395.75pt;" valign="top" width="396"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">Resolve infection</span></span><span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">Reduce WBC count to
normal<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">Next step: consider
increase dose of antibiotics<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt; mso-bidi-font-family: 新細明體; mso-bidi-font-size: 11.0pt;">Consider adding
antifungal agent<o:p></o:p></span></span></div>
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<tr style="height: 17.1pt; mso-yfti-irow: 4; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 17.1pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: solid windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 82.75pt;" valign="top" width="83"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; text-autospace: none;">
<span style="mso-bookmark: women;"><span style="font-family: Times; font-size: 12.0pt;">Monitoring<o:p></o:p></span></span></div>
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<td colspan="2" style="border-bottom: solid windowtext 1.0pt; border-left: solid black 1.0pt; border-right: solid black 1.0pt; border-top: none; height: 17.1pt; mso-border-bottom-alt: windowtext .5pt; mso-border-left-alt: black .35pt; mso-border-right-alt: black .35pt; mso-border-style-alt: solid; mso-border-top-alt: solid windowtext .5pt; mso-border-top-alt: windowtext .5pt; padding: 0in 5.4pt 0in 5.4pt; width: 395.75pt;" valign="top" width="396"><div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">WBC<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">Temperature<o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-element-anchor-horizontal: page; mso-element-anchor-vertical: paragraph; mso-element-frame-hspace: 9.0pt; mso-element-left: 46.1pt; mso-element-top: 9.05pt; mso-element-wrap: around; mso-element: frame; mso-height-rule: exactly; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span style="mso-bookmark: women;"><span style="font-family: Symbol; font-size: 12.0pt; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";">
</span></span></span><span style="font-family: Times; font-size: 12.0pt;">S/sx’s of sepsis ie vital signs<o:p></o:p></span></span></div>
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</tr>
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<td style="border: none;" width="31"></td>
<td style="border: none;" width="83"></td>
<td style="border: none;" width="395"></td>
<td style="border: none;" width="0"></td>
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</tbody></table>
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<br /></div>
<div class="MsoNormal" style="mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 3;">
<span class="Apple-style-span" style="font-family: 新細明體; font-size: large;"><span class="Apple-style-span" style="font-size: 18px; line-height: 20px;"><b><br /></b></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;"><b>Discussion</b></span></span></div>
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<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;">One of the most important things I have learned on rotations is to look at patients as a whole and individualize their treatment. This concept is even more critical in pediatrics. In adults, slightly overestimating a dose, in most cases, will not have fatal consequences. In children, it very well can. Children cannot be treated as miniature adults. When I was working up patients on the PSICU, there were many things that I had to take into account in addition to the normal parameters, lab values, etc in an adult workup. The most basic was the patient's size ie weight, height, and head circumference and the percentiles they fit into compared with others of their age. Secondly, it was important to collect an extensive maternal history, given that the patient him/herself does not a considerable past medical history. Thirdly, the normal ranges for many lab values (ie potassium, T. bili, albumin, serum creatinine) and vital signs (ie blood pressure, heart rate) changes with age. Lastly, there was a bigger emphasis on documentation of urine output, especially in neonates where serum creatinine within the first few days of birth is actually indicative of the mother's serum creatinine rather than the child's. </span></span></div>
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<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;"><br /></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;">In this patient, the my concern during the workup was her antibiotic regimen. Following the patient's cardiac surgery, she was started on ceftazidime and vancomycin for surgical prophylaxis. Based on the patient's weight and age, she should have been started on q12 dosing of vancomycin at least. She was treated with daily dosing of vancomycin for a period of 4 days before obtaining a trough that turned out to be 6.75. After discussing this with my pharmacist, she made the recommendation to the attending physician. However, he opted to stay with the underdosed vancomycin. In class and on my ID rotation, I have always learned to "go big or go home" with antibiotics. Underdosing is merely breeding a resistant strain of the organism. In addition to the dosing error, the choice of antibiotics was also peculiar to me. Based on the <i>Antimicrobial Prophylaxis for Surgery</i> guidelines from The Medical Letter, Inc., the common pathogens for a cardiac surgery include <i>Staphylococcus aureus </i>and <i>Staphylococcus epidermidis</i>. Therefore, the recommended antimicrobials are ONE of the following: cefazolin, cefuroxime, or vancomycin. The patient was being treated with two drugs that have similar activity towards the likely pathogens. </span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;"><br /></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;">After talking to my preceptor, I found that it comes down to the difference in culture. Even in the U.S., there are cases when older attendings are set in their ways and are more likely to follow their own experience based medicine rather than the evidence that is out there. I feel that there is a greater degree of reverence in Taiwan for older generations, that medical residents, etc. do not feel it is their place to disagree with an attending physician. Although NTUH as an institution preaches evidence based medicine, in some cases, this experience may outweigh evidence. This is not to say one way better than the other; it merely places the spotlight on a difference in culture. </span></span><br />
<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;"><br /></span></span>
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Photo of the right and left pleural drainages.</div>
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IV medications for this patient.<br />
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<span class="Apple-style-span" style="font-family: 新細明體;"><span class="Apple-style-span" style="line-height: 20px;">Crash cart, present in every patient room.</span></span></div>
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Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-23674082068394723902012-09-10T23:30:00.000-07:002012-10-05T20:14:56.500-07:00Day in the OR<div class="separator" style="clear: both; text-align: left;">
As I mentioned in the previous post, every single neonate on the PSICU service had some form of congenital heart disease that required surgery within days of birth. After speaking with my preceptor and my cousin who is an anesthesiologist at NTUH, I was given the unique opportunity of observing a pediatric cardiac surgery of one of the patients on my service! </div>
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The patient was born with Tetralogy of Fallot, which involves four defects of the heart and blood vessels: ventricular septal defect, overriding aorta, right ventricular hypertrophy, and narrowing of pulmonary outflow. Surgery is necessary because the condition causes low oxygen in the blood and can lead to cyanosis. </div>
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The image above is of the cardiopulmonary bypass, which essentially takes over the function of the heart and lungs during surgery. </div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2eYOU2c3zMQb5gEuUKeIsq4o1lG4SggVZA1H-_A8lCpuEqgrjs7rQafVLdFu-oneGrxY6iiwDDjGi1fTKuWNbUmFv8ErsrWnAj2FuQH4HCyJyCt3FsvzgEik24-ydCwOLEnMkCe3Mug/s1600/IMG_2048.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj2eYOU2c3zMQb5gEuUKeIsq4o1lG4SggVZA1H-_A8lCpuEqgrjs7rQafVLdFu-oneGrxY6iiwDDjGi1fTKuWNbUmFv8ErsrWnAj2FuQH4HCyJyCt3FsvzgEik24-ydCwOLEnMkCe3Mug/s320/IMG_2048.JPG" style="cursor: move;" width="320" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOoRCNfgHqsbcgEIDdyVPZoQhzTnA0vDeL8RV8rOhxfpM1gyZ8XkU8Yv1fJjfzbCRWMRV3l0Ym51lOhmWjQfcVra0zu_0oHtT4m9XpE6V22tHthZSgESQxGWjgQXBTg1OVNT6yjI7hlA/s1600/IMG_1994.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOoRCNfgHqsbcgEIDdyVPZoQhzTnA0vDeL8RV8rOhxfpM1gyZ8XkU8Yv1fJjfzbCRWMRV3l0Ym51lOhmWjQfcVra0zu_0oHtT4m9XpE6V22tHthZSgESQxGWjgQXBTg1OVNT6yjI7hlA/s320/IMG_1994.JPG" style="cursor: move;" width="320" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOoRCNfgHqsbcgEIDdyVPZoQhzTnA0vDeL8RV8rOhxfpM1gyZ8XkU8Yv1fJjfzbCRWMRV3l0Ym51lOhmWjQfcVra0zu_0oHtT4m9XpE6V22tHthZSgESQxGWjgQXBTg1OVNT6yjI7hlA/s1600/IMG_1994.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a>Pre-made trays of medications put together by the pharmacy for surgery.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvyEEGir5LDh5xBz39cFpNsCig3w8FKP2CP-Pf_vfrG23MksjrU848U77xlqOJ8rl1-YvVhPf4Mf0CV3YW32KCD1VZQkz1LPn3BLs9QEMyh6yK6zzUzlwyS4c2-T_SIqqFCCH5Gp67oQ/s1600/IMG_1993.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="239" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjvyEEGir5LDh5xBz39cFpNsCig3w8FKP2CP-Pf_vfrG23MksjrU848U77xlqOJ8rl1-YvVhPf4Mf0CV3YW32KCD1VZQkz1LPn3BLs9QEMyh6yK6zzUzlwyS4c2-T_SIqqFCCH5Gp67oQ/s320/IMG_1993.jpg" width="320" /></a></div>
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These pre-made trays was a system developed to minimize medication errors during surgery. </div>
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I felt very anxious as I watched the surgeons work on the tiny heart of patient. Each and every maneuver had to be so precise. It was a bit unsettling to see that the HR was zero during the surgery. However, it was almost miraculous to see the heart start beating after the surgeons reconnected the heart to its blood vessels. Now it was time to manage my patient postoperatively!Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-80204127150555071462012-09-06T00:30:00.000-07:002012-10-05T20:03:39.899-07:00PSICU: first day<div class="separator" style="clear: both; text-align: left;">
One rotation down, one to go! After three weeks in Family Medicine, I switched over to the Pediatric Surgical Intensive Care Unit (PSICU). This would be a new experience for me in two respects: this would be my first peds rotation AND my first ICU rotation. I was introduced to my new preceptor, who went over the expectations and objectives. One of the main differences between ICU and Family Medicine that I noticed right off the bat was, ICU pharmacists at NTUH attend daily rounds with the physicians. Every morning at 8:30 am, I would be joining in on rounds with my pharmacist. I would also have the opportunity to attend an outpatient infectious disease clinic with an ID physician as well as a day doing pediatric compounding. </div>
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Following orientation, my preceptor provided me some handouts on pediatric dosing. Since I have had very limited exposure to pediatric patients, it was difficult for me to compare NTUH and the U.S. From what I saw, they appeared to use many of the same resources, one of them being the Pediatric Handbook. Dosing would be mostly weight-based, which I would have to get used to. In addition, many of the normal ranges for lab values, blood pressure, heart rate that I was so familiar with, would all be different! </div>
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Looking at the patient list for my service, I noticed that every single patient had a heart problem. It turns out that this service, being a <i>surgical</i> ICU, dealt most of the time with neonates with congenital heart problems. As a result, the focus of pharmacy on this type of service would not be treatment and resolution of disease states, but rather, post-operative management of patients. Needless to say, it's going to be an interesting experience the next three weeks!</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglik1N5mcxxm-Ty9C7U9SKRDkT3rqbkTZN51RZe0FqpHTEpdV8elmlQW4fUS6zBvzyfVzZWLmgv5QYF4Q_cYYMpd2bJlYCA4XfDJXkqLmDZISLKxQrLOdwpuDYIkR2UaHf63Pvr7u4yw/s1600/IMG_2022.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglik1N5mcxxm-Ty9C7U9SKRDkT3rqbkTZN51RZe0FqpHTEpdV8elmlQW4fUS6zBvzyfVzZWLmgv5QYF4Q_cYYMpd2bJlYCA4XfDJXkqLmDZISLKxQrLOdwpuDYIkR2UaHf63Pvr7u4yw/s320/IMG_2022.jpg" width="239" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglik1N5mcxxm-Ty9C7U9SKRDkT3rqbkTZN51RZe0FqpHTEpdV8elmlQW4fUS6zBvzyfVzZWLmgv5QYF4Q_cYYMpd2bJlYCA4XfDJXkqLmDZISLKxQrLOdwpuDYIkR2UaHf63Pvr7u4yw/s1600/IMG_2022.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a>My home for the next three weeks.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj17L8VtfQSyfMNtge1Q-ttRgtSXrIKYNC0Leuq4MO2cUVTYaHiqyH0yPGb_OnXFmOQnNf1XEmQdBaybRC4GMcja7WdXeiVU__PQuch-gzHQyoaM6rtUofw0BkYV3LdsiKZY-supptqcg/s1600/IMG_2069.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj17L8VtfQSyfMNtge1Q-ttRgtSXrIKYNC0Leuq4MO2cUVTYaHiqyH0yPGb_OnXFmOQnNf1XEmQdBaybRC4GMcja7WdXeiVU__PQuch-gzHQyoaM6rtUofw0BkYV3LdsiKZY-supptqcg/s320/IMG_2069.jpg" width="239" /></a></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDaC7fVs83CVB4txGMFWg6Vr-raqiUz6CYuvtZGpO2NsAMrcrCE_BckkLqKuc-nEkwSpU88stXgPgZnIXoyC-OY9sATgiFdb04Ajv_iPW6qZBb1H3KHI4Scv5naXhAtpr2OS6WYaL1sA/s1600/IMG_1959.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="297" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgDaC7fVs83CVB4txGMFWg6Vr-raqiUz6CYuvtZGpO2NsAMrcrCE_BckkLqKuc-nEkwSpU88stXgPgZnIXoyC-OY9sATgiFdb04Ajv_iPW6qZBb1H3KHI4Scv5naXhAtpr2OS6WYaL1sA/s400/IMG_1959.JPG" width="400" /></a></div>
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A view from the 14th floor of the pediatric hospital. </div>
<br />Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-46506161647173931552012-09-04T09:02:00.000-07:002012-09-30T08:23:07.458-07:00Geriatrics Interdisciplinary Team MeetingOne of my favorite parts of the Family Medicine was the weekly Geriatrics Interdisciplinary Team Meetings. Every Tuesday, instead of morning meeting, we attended a meeting with various healthcare professionals including medical residents, nurses, physicians, dietitians, physical therapists, social workers, and clinical psychologists. It was the most complete interdisciplinary team that I had ever seen. The meeting began with a medical resident presenting a patient case. On this particular day, the patient case revolved around an elderly gentleman with an ileus. After presenting the chief complaint, history of present illness, relevant labs and imaging, and medications, the resident passed the case on to the other health care professionals to comment on.<br />
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It was exciting to see so many different specialties contributing their expertise on the patient case: <br />
<b>Pharmacist:</b> did not make any changes to the medications, but recommended monitoring of renal function and electrolytes due to the patient being on diuretics<br />
<b>Physical Therapy: </b>assessed the patient's day to day progress in terms of mobility<br />
<b>Social Worker:</b> commented on the patient's living situation at home prior to admission, relatives that could be potential caretakers, and discharge plans<br />
<b>Clinical Psychologist:</b> assessed the patient's understanding of reality and discussed with family members about the patient's mental state at his age<br />
<b>Attending Physician: </b> chimed in with relevant questions from time to time<br />
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Once all of the different specialties made their comments, the resident presented the current literature on the topic discussion, which this week was, the treatment of ileus. Usually, the resident presented it by going over the literature, and then comparing it with the course of therapy they chose to go with at NTUH. At the end, the attending physician provided closing comments and additional points. <br />
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Although there are rarely situations in which there is enough time and resources to devote to one patient case such as this, I do think that it stresses the importance of looking at a problem from different perspectives. Every health care professional brought up points that the other professions would not have considered otherwise. The concept of a healthcare team in improving patient care is at work here and it would be great to see more of it. <br />
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Here is a photo of the resident going over imaging during the meeting.</div>
Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-38953164606307746802012-08-31T07:43:00.000-07:002012-09-28T08:37:55.684-07:00Joint Commission InternationalIn the United States, many hospitals and health organizations are accredited by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Depending on the state, accreditation may be required for licensure and other government reimbursement programs such as Medicaid in California. NTUH is accredited by the Joint Commission International (JCI), a not-for-profit affiliate of the JCAHO established about 15 years ago. Similar to U.S. hospitals., NTUH undergoes inspections by JCI every three years for accreditation. The overall objective of these inspections is to assess their level of performance compared to healthcare organizations around the world and to ensure they are on par with a certain standard established internationally. Additionally, these inspections push the hospital to find ways to continually improve their quality of care, medical ethics, patient safety, evidence-based medicine, and many other aspects. <br />
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During my time at NTUH, the hospital staff was in the process of preparing for the next upcoming inspection. My UDD preceptor was on the hospital committee in charge of this preparation for JCI. She said that NTUH is one of the only hospitals in Taiwan that is currently accredited by JCI. Although it is not required for licensure as it is in California, NTUH wants to stay on the same level as the leading healthcare organizations in the world. When I went to the floors with my pharmacist, she noted many operational details that could still be improved upon before the inspection ie leaving charts out in view of the public, hospital staff not sanitizing hands before and after entering patient rooms. All of these inspections and accreditation processes, though grueling from a day to day standpoint, are the best way for health care organizations to continually improve their quality of care and increase their standards. In the end, it all goes towards serving one population: the patient.Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-69860053248987925762012-08-29T05:40:00.000-07:002012-09-06T05:42:49.168-07:00EMR Terminology<table border="0" cellpadding="0" cellspacing="0" style="border-collapse: collapse; width: 331px;">
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<col style="mso-width-alt: 3218; mso-width-source: userset;" width="88"></col>
<col style="mso-width-alt: 5010; mso-width-source: userset;" width="137"></col>
<col style="mso-width-alt: 3876; mso-width-source: userset;" width="106"></col>
<tbody>
<tr height="13">
<td class="xl24" height="13" width="88"><b>Chinese</b></td>
<td class="xl24" width="137"><b>Pinyin</b></td>
<td class="xl24" width="106"><b>English</b></td>
</tr>
<tr height="14">
<td class="xl25" height="14">處方</td>
<td class="xl26">chǔ fāng</td>
<td class="xl26">prescription</td>
</tr>
<tr height="14">
<td class="xl25" height="14">急診</td>
<td class="xl26">jí zhěn</td>
<td class="xl26">emergency</td>
</tr>
<tr height="14">
<td class="xl25" height="14">病人</td>
<td class="xl27">bìng rén</td>
<td class="xl26">patient</td>
</tr>
<tr height="14">
<td class="xl25" height="14">過敏紀錄</td>
<td class="xl26">guò mǐng jì lù</td>
<td class="xl26">allergies</td>
</tr>
<tr height="14">
<td class="xl25" height="14">身高</td>
<td class="xl26">shēn gāo</td>
<td class="xl26">height</td>
</tr>
<tr height="14">
<td class="xl25" height="14">體重</td>
<td class="xl26">tǐ zhòng</td>
<td class="xl26">weight</td>
</tr>
<tr height="14">
<td class="xl25" height="14">血壓</td>
<td class="xl26">xiě yā</td>
<td class="xl26">blood pressure</td>
</tr>
<tr height="14">
<td class="xl25" height="14">住院醫師</td>
<td class="xl26">zhù yuàn yī shī</td>
<td class="xl26">resident physician</td>
</tr>
<tr height="14">
<td class="xl25" height="14">主治醫師<span style="mso-spacerun: yes;"> </span></td>
<td class="xl26">zhǔ zhī yī shī</td>
<td class="xl26">attending physician</td>
</tr>
<tr height="14">
<td class="xl25" height="14">主訴</td>
<td class="xl26">zhǔ sù</td>
<td class="xl26">chief complaint</td>
</tr>
<tr height="14">
<td class="xl25" height="14">病史</td>
<td class="xl26">bìng shǐ</td>
<td class="xl26">history of present illness</td>
</tr>
<tr height="14">
<td class="xl25" height="14">身體檢查</td>
<td class="xl26">shēn tǐ jiǎn chá</td>
<td class="xl26">physical exam</td>
</tr>
<tr height="14">
<td class="xl25" height="14">影像報告</td>
<td class="xl26">yǐng xiàng bào gào</td>
<td class="xl26">imaging report</td>
</tr>
<tr height="14">
<td class="xl25" height="14">病理報告</td>
<td class="xl26">bìng lǐng bào gào</td>
<td class="xl26">pathology report</td>
</tr>
<tr height="14">
<td class="xl25" height="14">抗生素</td>
<td class="xl26">kàng shēng sù</td>
<td class="xl26">antibiotics</td>
</tr>
<tr height="14">
<td class="xl25" height="14">抗生素感受性報告</td>
<td class="xl26">kàng shēng sù gǎn shòu bào gào</td>
<td class="xl26">antibiogram</td>
</tr>
<tr height="14">
<td class="xl25" height="14">洗腎</td>
<td class="xl26">xǐ shèn</td>
<td class="xl26">dialysis</td>
</tr>
<tr height="14">
<td class="xl25" height="14">門診</td>
<td class="xl26">mén zhěn</td>
<td class="xl26">outpatient</td>
</tr>
<tr height="14">
<td class="xl25" height="14">診斷</td>
<td class="xl26">zhěn duàn</td>
<td class="xl26">diagnosis</td>
</tr>
<tr height="14">
<td class="xl25" height="14">檢驗報告</td>
<td class="xl26">jiǎn yàn bào gào</td>
<td class="xl26">labs</td>
</tr>
<!--EndFragment-->
</tbody></table>
Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-24290311531871296322012-08-28T01:22:00.000-07:002012-09-06T05:06:12.161-07:00Patient Presentation--Acute Pyelonephritis<span class="Apple-style-span" style="line-height: 16px;"><span class="Apple-style-span" style="line-height: normal;">
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<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: x-large;"><span class="Apple-style-span" style="font-size: 19px;"><b><span class="Apple-style-span" style="font-family: Arial, Tahoma, Helvetica, FreeSans, sans-serif; font-size: 15px; font-weight: normal; line-height: 20px;"></span></b></span></span><br />
<span class="Apple-style-span" style="font-family: 'Times New Roman'; font-size: x-large;"><span class="Apple-style-span" style="font-size: 19px;"><b><div class="Section1">
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><span class="Apple-style-span" style="font-size: small; font-weight: normal;">At the end of my first week, my preceptor had me present a patient to her and the pharmacist assigned to the Family Medicine service. The case a chose was among the patients I had been following throughout the week. </span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><span class="Apple-style-span" style="font-size: small;">ID: <span class="Apple-style-span" style="font-weight: normal;">55 year old female</span></span></span></div>
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<span class="Apple-style-span" style="font-weight: normal;"><b><div class="Section1" style="display: inline !important;">
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">CC:</span></span></span></b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> <span class="Apple-style-span" style="font-weight: normal;">Fever x 6 days</span></span></span></span></div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">HPI: </span></span></span></b></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Date</span></span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Note</span></span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Before 8/5<o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Patient
visited outpatient clinic for lower abdominal pain and dysuria. She was given
an oral antibiotic for a suspected UTI<o:p></o:p></span></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">8/5</span></span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Patient
developed a subjective fever.<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">8/7<o:p></o:p></span></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">She went to the ER, WBC 18650 with left
shift (Seg 91.2%), UA: pyuria
(WBC >100), sent home on cephalexin</span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></div>
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<span style="color: black;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">8/9</span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">She returned
to the ER, WBC 11070 with left shift (Seg 89.7), UA: pyuria (WBC 20-35). Renal ECHO revealed parenchymal renal
disease. Admitted for further
evaluation and management.<o:p></o:p></span></div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">PMH:</span></span></span></b><span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><span lang="EN-US"><span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><div class="Section2" style="display: inline !important;">
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<span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><div class="Section2" style="display: inline !important;">
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<span lang="EN-US"><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span></div>
</div>
</span></b></span></div>
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</span></b></span></span></span></b></span></div>
<div>
<b><span class="Apple-style-span" style="font-weight: normal;"><div class="Section1" style="display: inline !important;">
<span class="Apple-style-span" style="line-height: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Hyperlipidemia</span></span></span></div>
</span></b></div>
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<span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><span lang="EN-US"><span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><div class="Section2" style="display: inline !important;">
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<span class="Apple-style-span" style="line-height: normal;"><b><span class="Apple-style-span" style="font-weight: normal; line-height: 20px;"><div class="Section2" style="display: inline !important;">
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<span lang="EN-US"><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></span></span></div>
</div>
</span></b></span></div>
</div>
</span></b></span></span></span></b></span></div>
</div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Medication</span></span></span></b><b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> List (8/15)</span></span></span></b><b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">:</span></span></span></b></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Acetaminophen 500 mg 1 Tablet PO q6h PRN</span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Cefuroxime Sodium 1500 mg IV q8h </span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">NaCl 500 mL IF QD</span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Acyclovir Cream 5% </span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Magnesium Oxide 250 mg 2 Tablets PO TID</span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Bisacodyl 10 mg 2 pills qod PRN</span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">sennoside A+B calcium 12.5 mg 2 Tablets PO PRN</span></span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Allergies: </span></span></span></b><span lang="EN-US"><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">NKDA</span></span></span></span></div>
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<b><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></b></div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Physical Exam:</span></span></span></b></div>
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<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Unremarkable</span></span></span></div>
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<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">VS: </span></span></span></b><span lang="EN-US"><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">BP: </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">126/76</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">T: </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">36.6</span></span></span><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">P: </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">68</span></span></span><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">RR: </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">19</span></span></span><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Ht : </span></span><chmetcnv hasspace="False" negative="False" numbertype="1" sourcevalue="153" tcsc="0" unitname="cm" w:st="on"><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">156cm</span></span></span></chmetcnv><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Wt : </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">67</span></span></span><chmetcnv hasspace="False" negative="False" numbertype="1" sourcevalue="53.7" tcsc="0" unitname="kg" w:st="on"><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">kg</span></span></span></chmetcnv><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">BMI:</span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">27.5kg/m2</span></span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></span></b></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Labs:</span></span></span></b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">WBC 8.18</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">RBC 4.92</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Hgb 10.2</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Hct 31.6</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Plts 378</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">BUN 15.6</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 24pt; margin-right: 0cm; margin-top: 0cm; text-indent: 24pt;">
<span lang="NO-BOK"><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">SCr 0.7</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">AST 47</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">ALT 52</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Na 137</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">K 5.0</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">LDL 115</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span></span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Tg 146</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">HDL 26</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">T. Chol 174</span></span></span><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span></span></span></div>
<div class="MsoNormal" style="margin-bottom: 0pt; margin-left: 0cm; margin-right: 0cm; margin-top: 0cm;">
<b><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></b></div>
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<b><span lang="EN-US"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Problem List:</span></span></span></b></div>
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<span lang="EN-US"><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">1. </span></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> UTI</span></span></span></span></span></div>
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<span lang="EN-US"><span><span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">2. Hyperlipidemia</span></span></span></span></span></div>
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<span lang="EN-US"><span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span></span></span></div>
<div>
<span class="Apple-style-span" style="font-weight: normal;"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
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<b><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">1. Acute pyelonephritis </span></b><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">S/O</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78">
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Subjective</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Dysuria
and frequent urination for several days <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Objective</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">1.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Febrile since 8/5<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">2.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Left CVA tenderness<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">3.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Leukocytosis (WBC 11070)+left shift (Seg: 89.7%)<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">4.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">UA: pyuria
WBC 20-35, proteinuria (200), WBC esterase, bacteria (3+)<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">5.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Urine culture:
Enterococcus species, colony count 1000/ml<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 3;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">A</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
</td>
<td colspan="2" style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 451.0pt;" valign="top" width="451">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l2 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">1.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Likely pathogens for pyelonephritis: </span><i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Escherichia
coli</span></i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> (75 to 95 %), with occasional other species of Enterobacteriaceae,
such as </span><i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Proteus mirabilis</span></i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> and </span><i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Klebsiella pneumoniae</span></i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">, and </span><i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Staphylococcus saprophyticus</span></i><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l2 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: 0in;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">2.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> </span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Women with
pyelonephritis requiring hospitalization should be initially treated with IV
antimicrobial therapy: <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Fluoroquinolone<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 45.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l3 level1 lfo4; tab-stops: 21.0pt; text-autospace: none; text-indent: -24.0pt;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"> aminoglycoside ±ampicillin<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">extended-spectrum cephalosporin or extended-spectrum
penicillin ± aminoglycoside<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">carbapenem<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Regimen
should be based on local resistance data and susceptibility results.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-char-indent-count: 1.5; mso-hyphenate: none; mso-layout-grid-align: none; tab-stops: 21.0pt; text-autospace: none; text-indent: .25in;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">-Cefuroxime 1500 mg IV
q8h (8/11—)<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">3.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Antibiotics should be administered for at least 10 to 14
days.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l2 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">4.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Standard definition of positive urine culture is ≥10</span><sup><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">5</span></span></sup><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">CFU/ml
together with pyuria.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 21.0pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l2 level1 lfo2; tab-stops: 21.0pt; text-autospace: none; text-indent: -21.0pt;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">5.</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Though guidelines recommend the usage of extended-spectrum
cephalosporins, given that the colony count is low and patient is clinically
improving ie UA, the antimicrobial therapy is adequate.<o:p></o:p></span></div>
</td>
</tr>
<tr style="height: .05pt; mso-yfti-irow: 4;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">P</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: .05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Goal</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: .05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.0pt;" valign="top" width="373">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Clear infection<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Relieve dysuria, frequency of urination<o:p></o:p></span></div>
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<span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Restore WBC to normal</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 24.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 24.1pt; text-align: justify; text-autospace: none; text-indent: -24.1pt; text-justify: inter-ideograph;">
<span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Restore UA to normal</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
</td>
</tr>
<tr style="height: 64.05pt; mso-yfti-irow: 5; mso-yfti-lastrow: yes;">
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 29.5pt;" valign="top" width="30">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<br /></div>
</td>
<td style="border-bottom: solid black 1.0pt; border-left: solid black 1.0pt; border-right: none; border-top: none; height: 64.05pt; mso-border-bottom-alt: solid black .35pt; mso-border-left-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 78.0pt;" valign="top" width="78">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: 0in; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; text-align: justify; text-autospace: none; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Monitoring</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
</td>
<td style="border-top: none; border: solid black 1.0pt; height: 64.05pt; mso-border-alt: solid black .35pt; mso-border-top-alt: solid black .35pt; padding: 0in 5.4pt 0in 5.4pt; width: 373.0pt;" valign="top" width="373">
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Urine analysis</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Signs
and symptoms of infection:
leukocytosis, fever<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Side
effects of medications<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 17.0pt; margin-bottom: 2.85pt; margin-left: -.1pt; margin-right: 0in; margin-top: 2.85pt; mso-hyphenate: none; mso-layout-grid-align: none; mso-list: l0 level1 lfo3; tab-stops: 7.6pt .75in; text-align: justify; text-autospace: none; text-indent: 0in; text-justify: inter-ideograph;">
<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Renal
function<o:p></o:p></span></div>
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<br /></div>
</td>
</tr>
</tbody></table>
<span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><br /></span></span><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span><!--EndFragment--></span></div>
<div>
<span class="Apple-style-span" style="font-family: Times;"><span class="Apple-style-span" style="font-size: small; font-weight: normal;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span><!--StartFragment--><table border="0" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; margin-left: .15in; mso-padding-alt: 0in 5.4pt 0in 5.4pt; mso-table-layout-alt: fixed;">
<tbody>
<tr style="height: .05pt; mso-yfti-firstrow: yes; mso-yfti-irow: 0;">
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<b><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">2. Hyperlipidemia</span></b><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">S/O</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Subjective</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Nil</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Objective</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">8/11/2011: LDL-C: 135<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">8/13/2012:<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">TG: 146<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">T-CHO: 174<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">LDL-C: 115<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">HDL-C: 26<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">A</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Previously
on Mevalotin 40 mg PO qHS<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">10-Year
Risk by Total Framingham Point Score:
2%<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">ATP
III LDL goal is <130 mg/dL <o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Initiation
of treatment now is not necessary</span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">P</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Monitoring </span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">·</span><span style="font: 7.0pt "Times New Roman";"><span class="Apple-style-span" style="font-size: small;"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">
</span></span></span><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Lipid panel<o:p></o:p></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">Goal</span><span lang="ZH-TW"><span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;"><o:p></o:p></span></span></div>
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<span class="Apple-style-span" style="font-family: Times, 'Times New Roman', serif;">LDL-C<130 mg/dL</span><o:p></o:p></div>
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<span class="Apple-style-span" style="font-family: Times;"><span class="Apple-style-span" style="font-size: small;">Case Discussion</span></span></div>
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<span class="Apple-style-span" style="font-family: Times;"><span class="Apple-style-span" style="font-size: small; font-weight: normal;">At first, I felt the approach to the treatment of UTI's in Taiwan, and infections in general, was very similar to that of the U.S. However, as I looked at more patients and spoke with my preceptor, I found that the treatment strategies are actually different. In the case of pyelonephritis, this patient would be classified as a complicated UTI and would require a broad spectrum cephalosporin ie at least a 3rd generation to treat the likely pathogens. However, I've seen many cases similar to this where they have treated with 1st and 2nd generation cephalosporins. My preceptor noted that the physicians are, for the most part, aware of the IDSA guidelines and recommendations, however they utilize it literally as a guideline and do not follow it as closely as the U.S. does. In addition, I noticed many cases where antibiotic changes are made without any rhyme or reason, except that the patient spiked a fever. The scenario is usually a patient spiking a fever while on an antibiotic regimen. The antibiotic is switched to another class without regard for whether there was any additional microorganism coverage. I feel that in the area of infectious diseases, pharmacists have many opportunities to make interventions.</span></span></div>
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Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-86552852591611150842012-08-24T23:33:00.000-07:002012-09-03T23:32:50.823-07:00Electronic Medical Record<div style="font-family: Times; font-size: medium; margin: 0px;">
I was surprised at how modern the electronic medical record system at NTUH was. The computer system is similar to that of UC Davis Medical Center in many ways. Just from briefly perusing the interface, it reminded me of the Epic system I used in my previous inpatient rotations. Almost everything is online, including the labs, imaging results, HPI on admission, discharge summary, medication administration record, etc. Day to day progress notes and nursing notes, however, are still handwritten. In order to follow a patient's hospital course, I had to travel to the nursing stations to look through patient binders, something that I had never done in my previous rotations. Even though the progress notes were often times difficult to decipher, I realized that handwritten notes are much more concise and to the point. At UCDMC, the pet peeve of many attending physicians is that progress notes are notoriously lengthy, with too much copying and pasting. The benefit of making people hand write their notes is that it forces them to focus on the most prevalent points.</div>
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The medication administration process is also reminiscent of UCDMC: doctors order prescriptions online, the pharmacy fills it, it gets verified by a pharmacist, and the medications are sent to the wards on carts. Dispensing, on the other hand, is quite different. All oral medications are provided in unit-dose packages. Liquid medications are bottled by an automated machine and parenteral medications are dispensed in their original packaging. All pharmacy interventions are documented in the computer system. I was unable to obtain permission to post a screenshot of the home screen, so I will do my best to describe it in words. I mentioned in a previous post that reading Chinese characters would be a challenge for me. Most of the links and tabs are in Chinese. I took this as an opportunity to compile a list of medical terminology, which I will include in my next post. The interface is split up into three sections. The top 1/3 is the banner, where the patient information and the most current labs are displayed. The middle 1/3 consists of tabs which serve as quick links to various reports including labs, cultures, pathology, imaging, discharge planning, MAR, diagnoses, inpatient medications, outpatient medications, etc. The bottom 1/3 contains a list of the active medications the patient is on, along with both brand and generic name, dose, route, and schedule. Under the generic name of certain medications, there is an icon, indicating that dose adjustment algorithms are available for that particular drug. The algorithm can be viewed by simply clicking on the icon. I found this to be a very helpful function.</div>
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<div style="font-family: Times; font-size: medium; margin: 0px;">
My preceptor noted that NTUH is moving in the direction of acquiring a point of care dispensing system, similar to a Pyxis machine, to automate the dispensing process and allow pharmacists to focus more on the clinical aspect of their work. In addition, there are plans to upgrade the software system to allow direct communication between pharmacy and the health care professionals on the wards. Currently, even though doctors can place orders electronically, communication from pharmacy to the wards is strictly done by phone.</div>
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View from the UDD (10th floor of the new hospital building)</div>
Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-77299163287943908842012-08-22T00:37:00.000-07:002012-09-06T02:51:02.636-07:00Monday Conference<strong><span class="Apple-style-span" style="font-family: inherit;">Pharmacy Degree</span></strong><br />
<span class="Apple-style-span" style="font-family: inherit;">In U.S., college students choose their undergraduate major and then decide along the way, or possibly even after finishing college, if they want to pursue a graduate degree. In Taiwan, students who want to pursue a health professional degree ie medicine, dentistry, pharmacy, need to make that decision at the end of high school. For medicine, instead of having 4 years of undergraduate studies and 4 years of medical school, it is all lumped into a 7-year program. Pharmacy is a Bachelor's degree, and therefore, graduates can take the licensure exam right after completion of the 4-year program. The graduates have the option of doing a Master's program for an additional 2 years, where there is a focus on clinical rotations. At NTU, there is also a 6-year program (starting right after high school) which is the closest equivalent to the Pharm.D. program in the U.S. It is currently the only one in the country. </span><br />
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</span><strong><span class="Apple-style-span" style="font-family: inherit;">Informal Discussion</span></strong><br />
<span class="Apple-style-span" style="font-family: inherit;">On Monday, 8/20, we were invited to attend what was referred to as an "Informal Discussion". It was reminiscent of our Monday Conferences at UC Davis, where the students from their Master's program meet to go over patient cases. The conference is faciliated by two faculty members from the school of pharmacy, one of which is a Pharm.D. graduate from Purdue who did 2 years of residency at the University of Michigan. Every week, two students present patients and the facilitators ask questions or make teaching points out of the case discussions. This conference started out with the previous week's presenters following up on questions they had to research. The students for this week proceeded to present their cases. Although the majority of the presentation was in Mandarin, many of the diagnoses and treatments were discussed using English terminology. One thing I noticed about one of the patient cases, and in many other cases where patients have infections, is that they commonly switch antibiotics if the patient spikes a fever without having a target of therapy. Although a switch in therapy may be warranted, in some cases, I've noticed the microorganism coverage of the new antibiotic is no better than the previous treatment. It's something I will ask my preceptor about and look into more as I go through more patients. </span>Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-64334267364164176482012-08-21T23:48:00.000-07:002012-09-06T02:48:29.440-07:00Inpatient Pharmacy Overview<div style="font-family: Times; font-size: medium; margin: 0px;">
<span class="Apple-style-span" style="font-family: inherit;">From the amount of time we spent searching the hospital on our first day, it is probably apparent that NTUH is a very large hospital. There are only two inpatient pharmacies that service the 2100 bed hospital. On average, 19,000 prescriptions are processed per day. There are approximately 150 pharmacists working at the hospital. Their duties consists of dispensing as well as clinical services such as dose adjustments, drug therapy selection, drug information, adverse drug reaction reporting and patient education. Legally, pharmacists are the only ones that are allowed to dispense medications. As a result, the ratio of pharmacist:technician is vastly different from that of the U.S. In the UDD, there are 45 pharmacists, 10 clerks, and just 3 pharmacy technicians. With each pharmacist covering 1-2 wards, their patient load is very high and most of the patient monitoring is done from the electronic medical record computer system. One of the pharmacists I shadowed, 簡郁芳, said she was following about 60 patients. In contrast, the Intensive Care Units have clinical pharmacists who attend morning rounds with physicians on a daily basis.</span></div>
Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-29506527493262606882012-08-17T06:07:00.000-07:002012-09-06T02:50:16.252-07:00Language Barrier<span class="Apple-style-span" style="font-family: inherit;">I was born in the U.S. However, the majority of my extended family resides in the country of Taiwan. The official language of Taiwan is Mandarin. At home, the "official" language my family speaks is Mandarin as well, with some English mixed in there. Ever since I was young, my parents have spoken to me in their native tongue. They sent me to Chinese school every Sunday until the end of high school. I consider myself a fluent Mandarin speaker. Where I am lacking, as many ABC's (American born Chinese) are, is the ability to read characters. I am fairly confident in my ability decipher menus, billboards, and television advertisements. Reading and understanding medical terminology, however, is a different story and will be the main obstacle on this rotation. I have found, in my first two days, that even figuring out the interface of the electronic medical record system is a challenge. After spending some time clicking around aimlessly, I've noticed that many of the functions are very similar to the Epic system we use at UC Davis Medical Center ie labs, MAR, diagnoses, etc. I did find comfort in the fact that most of the pharmacy resources they refer to are not only, in English, but also, are the exact same resources we use in the U.S.</span><br />
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<br />Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0tag:blogger.com,1999:blog-5215448310949317057.post-46163467636459713662012-08-15T23:52:00.000-07:002012-10-03T18:15:19.261-07:00Getting Oriented<span class="Apple-style-span" style="font-family: inherit;">For the next six weeks, I will be doing my international Advanced Pharmacy Professional Experience (APPE) at National Taiwan University Hospital (NTUH). The APPE is split up into two 3-week rotations, allowing me to gain experience in two different hospital departments. My first 3 weeks will be spent in the Unit Dose Dispensing (UDD) pharmacy that services the Family Medicine wards (家庭部常). </span><br />
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<span class="Apple-style-span" style="font-family: inherit;">A day after arriving in Taipei, Taiwan, I was scheduled to start my rotation. I had not even oriented myself to the hospital, let alone, the surrounding area. Tina and I left the dorms an hour and a half early to grab breakfast and find the room and somehow arrived only a few minutes early (the dorms are located less than 5 minutes from the nearest hospital building). The first part of the day was a pretty standard orientation: getting our ID badges, logins for their electronic medical record, figuring out the layout of the hospital, and meeting a few faculty members of the NTU School of Pharmacy. </span><br />
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<span class="Apple-style-span" style="font-family: inherit;">After orientation, I met up with my preceptor for the Family Medicine rotation, </span><span class="Apple-style-span" style="border-collapse: collapse; color: #222222;"><span class="Apple-style-span" style="font-family: inherit;">陳文慧. </span></span><span class="Apple-style-span" style="border-collapse: collapse; color: #222222;"><span class="Apple-style-span" style="font-family: inherit;"> </span></span><span class="Apple-style-span" style="border-collapse: collapse; color: #222222;"><span class="Apple-style-span" style="font-family: inherit;">She gave me a tour of the inpatient pharmacy and went over the goals and objectives of the rotation. Every morning, I will be attending Morning Meeting at 7:40 am along with physicians, residents, and pharmacists. From my understanding, residents will go over either patient cases or topic discussions for educational purposes. Once a week, there is a Geriatric Interdisciplinary Team Meeting where health professionals from different specialties go over a case for a geriatric patient. At the end of each week, I will be doing formal patient presentations to my preceptor. By the end of the 3 weeks, I expect to be able to efficiently follow 8-10 patients on the Family Medicine service. I am looking forward to observing the differences between the various aspects of pharmacy between the U.S. and Taiwan, including the electronic medical records, health care systems, pharmacists' roles, health care team dynamics, and treatment approaches. </span></span><br />
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Let the journey begin.</span>Anonymoushttp://www.blogger.com/profile/10110688350811137067noreply@blogger.com0