大家好，我是楊宗衡醫師，台中醫學中心中山附設醫院訓練完畢，取得家庭醫學、老人醫學、肥胖醫學，這三張專科醫師執照後，就來到苗栗清安診所山地醫療執業至今已經過了五個年頭，對於家醫科來說，每個患者都像是無法割捨的老朋友。於是在苗栗市成立實現家庭醫學科願景的診所，希望不只是治癒疾病，而是預防保健、健康促進，全人的慢性病管理。我們以平實的價格提供先進設備、高品質服務、優秀的醫療人員，守護在地民眾的健康。

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Leopold's Maneuver

首先讓媽媽頭一點點抬高，膝蓋微微的彎曲，接著用四個步驟來看看到底胎兒在媽媽子宮裡的胎位如何。

a.面對媽媽摸宮底的位置，確認是頭還是屁股。
b.輪流摸肚子兩側看看背部跟四肢的位置。背部通常是一片平坦，四肢的話會有不規則的小突起。
c.於恥骨聯合上方觸診，以定位胎兒的先露部(presentin part)。
d.此時要背對母親，面對媽媽的腳。從子宮往恥骨聯合方向觸摸看何處是額頭(cephalic prominence)。



現代因為超音波進步，我想應該沒什麼機會用這個技術，不過在臨床上還是有可能被問到，至少還是能說出個大概才好。

kerley's line A B C

Kerley’s A lines (arrows) are linear opacities extending from the periphery to the hila; they are caused by distention of anastomotic channels between peripheral and central lymphatics.
Kerley’s B lines (white arrowheads) are short horizontal lines situated perpendicularly to the pleural surface at the lung base; they represent edema of the interlobular septa. 
Kerley’s C lines (black arrowheads) are reticular opacities at the lung base, representing Kerley’s B lines en face. 

These radiologic signs and physical findings suggest cardiogenic pulmonary edema. 

2010 ADA DM criteria

x-ray notes

胸部X光判讀(CXR reading)的原則與順序

•字母記法

–A (airway, aorta)

–B (bones, breasts, bronchus)

–C (cardiac)

–D (diaphragm)

–E (esophagus)

–F (fissure)

–G (gastric)

–H (hilum)

–I (inominate artery/vein)

–J (jugular artery/vein)

–K (kerley lines)

–L (lungs)

–M (mediastinum)

–N (neck)

Korotkoff sounds

西元1905年，一位俄國心血管外科醫生Nikolai Korotkov發現讓醫生以非侵性的方式，經由聲音來辨別血壓的方法。

以前我們在幫別人量血壓都只知道，選擇合適的cuff，接著加壓應高於收縮壓20-30mmHg以上，每秒下降2-3mmHg的速度放氣。一開始血管完全被壓扁，所以是聽不見聲音的，隨著cuff慢慢降壓，此時血壓大於cuff壓力，開始有一些血液流過，因為是亂流(turbulent blood flow)的關係會有聲音產生，這時候的壓力就是收縮壓(systolic pressure)，接著再繼續放氣，直到聲音完全消失的時候，此時血管完全放鬆，就是所謂的舒張壓(diastolic pressure)。
一直以來量血壓的步驟就被視為理所當然，綁cuff→打氣→放氣→有聲音(收縮壓)→再放氣→沒聲音(舒張壓)，一直到後來才知道，原來一開始有的第一聲是Korotkoff sounds(phase I)，而最後聲音完全消失是Korotkoff sounds(phase V)。

克羅克夫聲(Korotkoff sounds) 總共可以分成5 phase，一開始的聲音較大聲也較為響亮，隨著壓力的減弱，聲音的質地也有所改變，變得比較減弱且不清楚(muted and muffled)

1. The first Korotkoff sound is the snapping sound first heard at the systolic pressure. Clear tapping, repetitive sounds for at least two consecutive beats is considered the systolic pressure.
2. The second sounds are the murmurs heard for most of the area between the systolic and diastolic pressures.
3. The third = A loud, crisp tapping sound.
4. The fourth sound, at pressures within 10 mmHg above the diastolic blood pressure, were described as "thumping" and "muting".
5. The fifth Korotkoff sound is silence as the cuff pressure drops below the diastolic blood pressure. The disappearance of sound is considered diastolic blood pressure -- two mm Hg above the last sound heard.

The second and third Korotkoff sounds have no known clinical significance.

華昇珊瑚公司 楊北中 先生 拾金不昧

最近看到成大女學生撿到錢要求1/3報酬的新聞，讓我想到去年我老爸去年參加珠寶大展，在展覽結束時，我爸在停車場發現了一箱珍珠?，趕緊拿去服務台找尋失主，據說價值好幾千萬呢！當然我老爸是沒有要求任何的報酬，但在失主的堅持之下，還是去接受表揚。

New year resolution

As the new year coming, we get into a exam hell. The first thing I wish is all past. If I want to have a good Chinese new year at home, getting a good grade is essential. The second I wish I can keep attention on study and pay more time on it. The lastest, I want to have more exercise. In the past year, I’m to lazy to do that, to do a couch potato is not good to my health. To wish is easy, but it’s hard to achieve. The best wish for me maybe is wishing I can really do that.

Early birds or late owls?

There are many kinds of people in this world. Someone like to get up early and the other doesn’t. If you are always get up early to do start the daily life, you are the early birds.
One the other hand, always getting up and sleeping late, we call that’s kind of men as late owls. Both of them have advantages and disadvantages, it depends on how you see these two types of lifestyle to decide which one is better.
For me, I prefer to get up late and work until late at night. It’s a very nice thing to sleep late and lie on the bed. To sleep well is the most important thing for people. That’s help you work with energy.
Because I get up late, I often work until night. If I don’t feel tired, sometimes I still be awake at am. 3 o’clock. That’s not a good habit, whatever style need to keep a regular life.
No matter what you choice, you are the early birds or late owls type of person, the most important thing is that, you must find the best suitable way for yourself.