20140826 supervisor: VS黃允中 presenter: PGY周學璞

Outline 案例描述 問題分析與討論

Basic Information Name: 林x仲 ID: 136528xx Gender: male Age: 51 Marital Status: married Education: high school Occupation: nil Admission period: 2014/6/22~25

Chief Complaint perianal pain and swelling for 3-4 days

Present Illness perianal pain and swelling for 3-4 days came to our ED on 2014/6/22 mild fever (37.6) no pus or blood noted, no abdominal pain, no nausea/vomiting, no diarrhea

Past History anal fistula with perianal abscess, s/p OP 10 years ago and on 2009-12-16 (by Dr.方 in CYCH) DM under insulin control for years Hypertension under medical control for years

PE at ED vital signs: T/P/R= 37.6/104/18, BP= 202/106 peri-anal area: swelling over 11 o’ clock position with extension to bilateral bases of scrotum, tenderness (+) DRE: no blood tinged over finger tip other systems: no significant finding

Social, Travel, and Family History Smoking (-) Drinking (-) Betel Nut (-) Travel History (-) Family History: mother (DM)

Lab

Image EKG: no specific finding CXR: no specific finding

Problem Lists peri-anal abscess over 11 o'clock position with extension to bilateral bases of scrotum Diabetes Mellitus hypertention renal function insufficiency anemia hyperkalemia

Assessment and Plan 1. peri-anal abscess over 11 o'clock position with extension to bilateral bases of scrotum admitted for pre-OP survey and preparation A/B as Augmentin 600 mg IVD QD arrange fistulectomy

Assessment and Plan 2. Diabetes Mellitus follow HbA1c and sugar consult dietician for DM diet RI use during admission 3. hypertention keep previous CV medication

Assessment and Plan 4. renal function insufficiency record U/O follow renal function consult nephrology 5. anemia check stool OB check ferritin/SI/UIBC/TIBC

Assessment and Plan 6. hyperkalemia Kayexalate 5 mg PO TID Cal carbonate 500mg PO TID

OP on 6/23 fistulectomy wet dress the wound as usual and the send the patient to ward in stable condition

Operation on 20140623 Time: 0855-0915 Pre-OP diagnosis: peri-anal abscess over 11 o'clock position with extension to bilateral bases of scrotum Procedure: fistulectomy OP finding: induration of perianal area with pus formation at 11 o'lcock position internal opening at 11 o'clock posiiton of dentate line abscess extends to bilateral bases of scrotum Post-OP diagnosis: peri-anal abscess over 11 o'clock position with extension to bilateral bases of scrotum Operator: VS黃允中

Post-OP course 6/23: renal echo with adjustment of drugs 6/24: remove gauze from wound 6/25: remove penrose and discharge, OPD follow-up arranged on 7/2

To ED on 6/30 Vital signs: T/P/R= 36.5/100/20, BP= 155/98 CC: perianal pain and foul smelling PE: perianal wound with no discharge, but a gauze found in wound after inspect with mosquito Lab: no leukocytosis CRS duty doctor (Dr.林) was consulted - > OPD follow-up with oral medication

Lab

ED doctor record but family argue with about not found the gauge in the wound at the first look of PE exam, i should explain the wound condition should be inspected by the operation surgeon doctor, not by the ED physican, if any problem, should go back to visit the Doctor of operation because he is well known the condition of patient and the wound, there is no responsibility to answer a ED physican to find a gauge in the wound

ED doctor record patient and family is well communicated with ED physican but they want to admit to our ward again, so consult proctologist for whether admission or not, but proctologist doctor come to see, he consider there is no indication due to no any infection sign, suggest OPD follow and outpatient treatment, then family and patient is angry and argue with ED physican not to find the gauge at first look, they don't want to hear our explanation despite of i don't put anything in his wound, actually, i inspect the wound carefully with instrument and removed the gauge after family insist there is string in the wound

Brief ED History 病人表示有異物感 第一次視診未夾出 病人堅持傷口內有異物 第二次用器械夾出紗布 病人和家屬希望住院 大腸直腸科會診醫師表示不用住院 安排門診

To OPD of Dr.黃 7/2 painful sensation over previous operative wound no fever, no smell DRE: mild tender induration over 11 o'clock position; mild yellowish debris coating 7/9 improved

後續狀況 院內調解 賠償費用：60000 多元

醫療處置 置放於深處傷口中的紗布：通常會留個線頭在外面，避免移除不易或忘記移除 其餘診斷、手術、住院過程：皆符合一般醫療常規 急診的第一次視診？若對傷口有疑慮可直接會診

溝通 6/24 早上護理紀錄：病人表示黃允中醫師剛查房，予紗布協助移除 急診面對病患情緒的處理

法律問題 應不致成立 刑事 業務過失致人於死或重傷害 業務過失傷害 意圖營利 違反祕密罪或偽造文書罪 民事 侵權行為：醫療費用、生活支出、增加勞動力損失 債務不履行 雇主連帶損害賠償責任 應不致成立

何謂品質 追求品質 -> 顧客滿意（包括內部和外部） 目標、責任、一致性 醫療品質的現代趨勢 以病人為中心：提供足夠的資訊 安全性：誠實面對缺失、檢討改善流程 效果性：EBM 適時性 效率性 平等性 品質指標：病人滿意度、院內管控、政府評鑑

醫療錯誤的冰山理論 警訊、傷害 疏失、不良 醫療錯誤

不良事件的瑞士乳酪理論 設關卡、標準作業流程 ex: 對名字

Reference 醫策會：醫療品質指引 http://pic.pimg.tw/nick112802/4a1a39242bc74.jpg http://pic.pimg.tw/raindog/1407516978-3408935831.jpg