看門診的小技巧

雖然現在各種

看始看門診一年、還好，看每個主治醫師是如何管自己的門診病歷
做為一個待辦事項，最好是所有人都懂
師長的經驗、模版的重要，特別是初診的評估
以 oncology 為例
要有一段小小段落，有閒的時候來改
走進、輪椅、跟誰來、寫一下住哪裡
模版 for AEs, grading
每次跟誰來，都要寫一下
assessment plan
assessment
總結一下今天的抽血報告，變好、變壞？不重要？
plan: 要有大戰略
我提供了病人哪些選項，然後有哪些可能的考慮
以 HCC 病人為例，用 ASCO 最新的治療 Guideline 為例
代辦事項 project, context
列出一行的 Trial 結論
要有長期計畫藥、什麼時候要再評估
剩藥
他科問題
例子

[S]

YYYY-MM-DD: come with his wife, son.
Refer from GI for systematic treatment.
- YYYY-MM-DD: abdominal pain, back pain resolved after...
- YYYY-MM-DD: back pain...

Summary:
65-year-old man, live in ..., work as... with ...


[O]
ECOG:
AEs:

(per CTCAE v5 2017)

{paste lab}

[AP]
# cHCC, ...
- YYYY-MM-DD: stable lab, image wnl
- YYYY-MM-DD: stable lab, image wnl
- YYYY-MM-DD: stable lab, image wnl
- YYYY-MM-DD: stable lab, image wnl

Plan:
- Treatment Strategy: slavage chemoimmunotherapy, treat until PD
- [x] contine chemotherapy (YYYY-MM-DD)~
- [ ] check CT three month later: YYYY-MM-DD

- Follow-up parameters: CEA, CA19-9, CA125, symptoms and images

Alternative Options:
<option 1>
- A + B dosage, $xxxx per cycle, totally n cycles
  - per KEYNOTE 123, III, r/r after xxx,
  - {A+B}:{P}, PFS 12m:7m, ORR: 55%
<option 2>
<option 3>
<option 4>

---<other issues>---

# HTN, on meds
# DM, followup at endocrine, on meds and insulin
# Psy-social, followed by social worker Ms. #1234