Microsoft PowerPoint - 2014.02.10.ppt []


Taichung, Taiwan
Acquisition skill ()
(PE)*
3) A i d ( )




2015/5/15
2
History Physical Laboratory Medical
Logics in Problems Solving
taking exam tests records
History
()

Can be conducted simultaneously
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Lab
(PE begins with
are conducted simultaneously
(Brain-hands Coordination)
(Clinical medicine as in daily life)
Daily Dialogue () Clinical setting ()
Hx Diagnosis
Signs () - PE
Facial expression ()
Body language ()
() -
-
e.g. boy/girl dating
()
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(Problem-oriented Clinical Medicine)
- (Clinical problem solving)
1) * (Understand the main character (i e patient *)1) (Understand the main character (i.e. patient *)
(personal background) ()
(Medical background)
Admission Note Basic data ()
()
Basic Data () :
: Name () Age/sex (/) Occupation () Marital status () Ethnic origin () Place of residence ()
: Past History ()
? 1)
(): /: : (): : : : ?
2) (--) : /: :
:
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Steps ()Steps () 1. (Problem finding/submission) 2. (Problem analyses) 3. (Problem Solving)
[4. * (Problem managements)] * ()( )
Means () 1. (history taking) 2. (physical Exam) 3. (laboratory tests)
1. (Problem Finding/Submission) / (Means/Process)
1) (history taking)
(past history)
(present illness)
(allergy history)
(social/occupational history)
(review of systems)
2) (physical exam)
3) (laboratory data)
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•
Use patient’s own language and way of expression to
state the main worrisome symptom and the time duration
•
Avoid using diagnostic or related words implyingAvoid using diagnostic or related words, implying
diagnosis
• Examples:
Breathlessness for 2 weeks
Basic Data ( )
Name: Li, x x Age*/sex*: 60/M Occupation*: taxi driver Marital status: married Ethnic origin: Ming-Nan
Place of residence: Hu-wei
Opening Statement () – Composition ()
Past history (): hypertension and diabetes mellitus
Chief complaint: Chest pain for 3 days
Present illness ( – opening statement)
(opening statements in Chinese) 65,,, () ,
,()
2) Medical background (); and 3) Chief complaint
() 1) This 60-year old man, a taxi driver, 2) with hypertension and DM was admitted via emergency room 3) because of chest pain for 3 days.
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Record No: 000000 Date of admission: 2005-8-1 Bed No: 301
Name: Li, x x Age/sex*: 60/M Occupation*: taxi driver
Marital status: married Ethnic origin: Min Nan
Admission Note – Case 1
Place of residence: Hu-wei
Chief complaint
* (Mandatory key words)
This 60-year-old man, a taxi driver, with (a past history of)
hypertension and DM was admitted via emergency room because
of chest pain for 3 days.
(problems): 1) Chest pain; 2) hypertension; 3) diabetes
(Chest pain in a 60-year-old man with hypertension and diabetes)
Basic Data (Preliminary personal and medical backgrounds)
Record No: 000000 Date of admission: ‘5-8-1 Bed No: 301 Name: Li, x x *Age/sex: 60/M *Occupation: farmer
Admission Note – Case 2
Place of residence: Kaohsiung** Past history: hypertension and DM
Chief complaint
key words
1) * (mandatory)
2) ** (elective)
Kaohsiung - dengue fever endemic area
This 60-year-old male farmer, a Kaohsiung** resident, with hypertension and DM was admitted via emergency room because of fever for 3 days.
(problems): 1) Fever; 2) hypertension; 3) diabetes
(Fever in a 60-year-old man with hypertension and diabetes)
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Basic Data Record No: 00000001 Date of admission: 2009-8-1 Bed No: 301 Name: Li, x x *Age/sex::56/M Occupation: farmer*
Admission Note – Case 3
Occupation: farmer Marital status: married Ethnic origin: aborigine** Place of residence: Tong-shi Past history: peptic ulcer
Chief complaints Weakness and black stool for 2 days
Present illness This 56 year old aborigine** farmer with a past history of peptic
**Elective key word
This 56-year-old aborigine** farmer with a past history of peptic ulcer was admitted via ER because of weakness and black stool for 2 days.
(): 1. Black stool; 2. Peptic ulcer
(GI bleeding in a 56-year-old male with peptic ulcer)
8. Review of Systems ( - )
Because symptoms are non-specific and may be related to multiple systems,
each symptom is assigned to the system in which it is more or most
commonly associated as follows.
1. Generalweakness, fatigue, anorexia, fever, insomnia
2. Integument (skin, hair and nails)changes in color (pigmentation, *jaundice,
cyanosis), pruritus, rash, hair loss
3. HEENT
b. Eyes - visual acuity, color vision, corrective lenses, photophobia, diplopia,
pain
c Ears - pain discharge hearing loss tinnitusc. Ears - pain, discharge, hearing loss, tinnitus
d. Nose - epistaxis, discharge, stuffiness, sense of smell
e. Throat - status of teeth, gums, dentures, taste, soreness, hoarseness, lump
4. Respiratory dyspnea, wheezing, cough, sputum, hemoptysis, chest distress/pain
5. CVdyspnea, edema, dizziness, syncope, palpitation. chest distress/pain:
intermittent claudication, cold limbs, cyanosis
*jaundice, quantitative problem: others, non-quantitative;
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6. GI: dysphagia, nausea, vomiting, abdominal distress pain, change in bowel habit (diarrhea, constipation, character of stool), hematemesis, melena, bloody stool
7 GU rinar
7. GU: urinary frequency, hesitancy, urgency, dribbling, incontinence, dysuria, hema turia, nocturia, polyuria, impotence
Female - menarche, menstrual history (including the date of last period), vaginal bleeding or discharge; pregnancy
8. Metabolic and endocrine: growth and development, weight change*, heat/cold intolerance, nervousness, sweating, polydipsia
9. Hematotologic: anemia*, easy brusity or bleeding, lymphadenopathy, transfusions
10. Musculoskeletal: joint pain, stiffness, limitation of motion, muscular weakenss, wasting
11. Neuropsychiatry: dizziness, syncope, seizure, speech disturbance, loss of sensation, paresthesia, ataxia, weakness or paralysis, tremor, anxiety, depression, irritablility
* weight change, anemia (quantitative problem; The rest, non-quantitative)
8. Review of Systems (-)
Simplified (for the qualified)
3. HEENT: void (negative)
4. Respiratory: as above;
or cold limbs;
abdominal pain (-)
or abdominal pain
problems in “Present Illness” ()
Transcribe relevant positive and negative symptoms
in “Present Illness”
in “Present Illness” ()
No! No! - Headache (+), Nausea (-), dysphag\gia (-), vomiting (-), abdominal pain (-)
Right way - Elaborate headache; No dysphagia, nausea, vomiting or abdominal pain
A. (symptoms) (Non-quantitative problem)
/ (pain/distress)(dyspnea)
(p ) ( y p ) (dizziness)(syncope)(fever)
(Quantitative problem) (weight loss)
B. /(signs/findings) (non-quantitative problem)
(edema) (consciousness disturbance)
C (C. (Quantitative assessment) (anemia) (jaundice) (hypokalemia)
(hypoglycemia)
shock; CKD, stroke (ischemic or hemorrhagic)
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Submission Type Analyses* Strategy A.
Symptoms

() (Accounting rules)
Quantitative Lab tests
4) Pathologic

(Strategies)
• (ground)
• (sea)
• (air)
• (biological)
• (chemical)
• (psychological)
• (e-information)
(Strategies)
1) Systems
2) Anatomic
3) Pathophysiologic
4) Pathologic ( Sun-Tse) - a great military strategist in Confucius era - “Knowing self and opponent wins every battle”
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Submission Type Analyses* Strategy A.
Symptoms

() (Accounting rules)
Quantitative Lab tests
4) Pathologic
2. (Problem Analysis) Hong () LQQOPERA (Acronym) - History Taking
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LQQOPERA: (The very old, singing Taiwan opera)
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8 items):
(migratory), (radiation) etc.
2. (Quality)
(unbearable, excruciating) etc.
(intervals between episodes)
4. (Onset mode)
5. (Precipitating factors)
6. (Exacerbating or aggravating factors)
7. (Relieving factors)
8. (Accompanying symptoms)
(,) (Abrupt/Dramatic Onset)
(abrupt onset) : 1) (neurogenic); or, 2) ( dd l f i /2) (sudden loss of tissue/organ
continuity) (for exampples)
(systems approach - examples) 1. Integument: laceration; 2. HEENT: subarachnoid hemorrhage 3. Respiratory: pneumothorax 4. CV: aortic dissection, rupture of aneurysm, (AMI) 5. GI: 1) Halo/solid organ rupture/perforation:
esophagus, stomach, intestines, spleen, liver 2) gall stone
6. GU: ureter stone, ectopic pregnancy, ovarian torsion 7. Musculoskeletal: tissue laceration, bone fracture,
tendon rupture
turning (), twisting () etc.
2) Tenderness ()
4) Food intake (), swallowing (),
defecation (), urination () etc.
5) Exercise
7) Climatie change
- LQQOPERA - (modification)
LQQOPERA 8, In principle, alll 8 items are essential. For example,
1) / (analyses of pain/distress): LQQOPERA 8 (all 8 items, essential)
2) (jaundice): *LQQOPERA *L: skin urine sclerae stool (color changes)
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L: skin, urine, sclerae, stool (color changes) (for example): However, modification is applied depending on problem characteristic, as follows
1) (dyspnea): QQOPERA ( L , omitted) P – P defines type of dyspnea (next slide)
2) (consciouness change): QQOPERA ((L) , omitted)
3) (fever): QQA (3) QQ fever pattern (as reference*)QQ e e patte (as e e e ce )
*Not necessarily reliable because of drug interference Drugs – aspirin, acetaminophen, steroids, prior antibiotics etc.. Infant (inmature immuse system), Immune compromised hosts; elderly, DM, chemotherapy
patients etc.. A (): To identify or Search for pathological focus or foci ()
in organ systems () and/or anatomic sites ()
1. 2. * 3.
Submission Type Analyses* Strategy A.
Symptoms

30
Quantitative Lab tests
4) Pathologic
( ti l ) 1) () 2)
3. Problem Solving ()
A. (Quantitative problem)
3) ()

Means () in Problem solving
1) (History); 2) PE (); 3) (Lab tests)
Out/Loss ()
Renal GI tract
Skin (Burn, psoriasis)
Out/Loss ()Source () Distribution
( ) GI tract; renal
Es = - KT x Ln ([Ki/Ko]) = - KT (150/4) = - 90 mV; KT – constant; [Ki/Ko], Ko change, critical, as Ki >> Ko
Acidosis Cell destruction
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______________________________________
Spot urine during hypokalemia K+ > 20 meq/L suggests renal K loss
1. 2. * 3.
Submission Type Analyses* Strategy A.
Symptoms

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Quantitative Lab tests
4) Pathologic
A.
B.
4) Pathologic
1. Integument*
2. HEENT**
* (including hairs and nails)
Cover whole body
3/4; 5/6 -
9
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(Chest Pain) Systems Approach ()
g ( , ) ( )
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
(Abdominal Pain) Systems Approach ()
g ( , ) ( )
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
1. Integument1. Integument 2. HEENT 3. Respiratory 4. Cardiovascular 5. Gastrointestinal 6. Genitourinary 7 Metabolic and endocrine
(5 sytems)
7. Metabolic and endocrine 8. Hematologic 9. Musculoskeletal 10. Neuropsychiatry
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(Dyspnea)
1. Integument (IT) 2. HEENT (HT) 3. Respiratory 4. Cardiovascular 5. Gastrointestinal (GI) 6 G it i (GU)
QQOPERA
7. Metabolic/endocrine* 8. Hematologic** 9. Musculoskeletal (MS) 10. Neuropsychiatry
( y )
*Hyperthyroidism
**Anemia
P (Dyspnea classification, based on “P”)
Specify level of exertion and accompanying symptoms (A), if any: wheezing, chest tightness e.g. “Three months before admission, the patient developed
non-progressive exertional dyspnea on 1 flight of stairs, associated with chest tightness” (QQOPERA)
2) Positional Supine - orthopnea, PND L t l d bit tLateral decubitus - trepopnea Upright – platypnea (Hepatopumonary stndrome – liver cirrhosis )
3) Non-exertional/non-positional – anytime, any setting Asthma attack, acute pulmonary edema (any cause), pulmonary embolism, pneumothorax Neuropsychiatric disorder – myasthenia, anxiety, panic disorder
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Trepopnea Infrequent or Rare Positional Dyspnea
Dyspnea that is sensed while lying on one side but not on the other. It results from respiratory (one lung, one major bronchus), or cardiac disease (chronic CHF)
Respiratory – 1) unilateral intrapulmonary disorders (e.g. destroyed
parenchyma, major airway obstruction) Contra-lateral decubitus (dyspnea better on
“good side down”) because, bad-side down – increase in V/Q mismatch
2) Pleural effusion, massive (better, ”bad side down”) psi-lateral decubitus)
Chronic CHF - left decubitus (“heart-side down”, feeling better) - Severely impaired LV filling - marked cardiomegaly - better blood return, better cardiac output
Cerebral cortex
Central control system Respiratory centers
Pons
Medulla
*Spinal cord and its its motor neurons to respiratory mucles
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Cerebral cortex Feedback systems
lower pons –
b) Peripheral Carotid body – pO2/pCO2 sensor
(Control rate, depth/rhythm )
Aortic body – pO2 sensor
Cerebral cortex Feedback systems
lower pons –
b) Peripheral Carotid body – pO2/pCO2 sensor
(Control rate, depth/rhythm )
Aortic body – pO2 sensor
Central control system
Pons
Medulla
*Spinal cord and its its motor neurons to respiratory mucles
following components:
1) Computer
programming system
1) Respiratory System
Lung parenchyma:
noxious agents; high altitude
Pleural space: pneumothorax; hemothorax
Respiratory muscles: acute paralysis,
2) Cardiovascular: acute cardiogenic pulmonary edema
3) Endocrine/metabolic
4) Hematology
Hyperventilation (anxiety neurosis/panic disorder)
1 I t t
(Consciousness Disturbance)*
(analysis) QQOPERA
7. Metabolic/endocrine
8. Hematologic
9. Musculoskeletal
10. Neuropsychiatry
(analysis): Q QOPERA
confused; stupor; obtunded; semi-comatous; comatous
Systems approach - Systems approach
1) (Neuropschiatry)
()
2) (Cardiovascular)
Osmolarity () = 2Na+ + glucose/18 + BUN/2 8 + α (> 0)
α > 0 mannitol, contrast media, ethanol, methano l etc
Osmolarity () = 2Na+ + glucose/18 + BUN/2.8 + α (> 0)
(Na+), (Ca++)
(DM): (hypoglycemia); HHS; ketoacidosis
(myxoedematous coma)
2) Gasoline shortage (quantity)
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1) Systems approach ()
2, ,
B. (Non-quantitative problem) 2) Anatomic Approach ()
Used in conjunction with, or as an auxiliary (
) strategy to Systems Approach
For examples:
Fever
B. (Non-quantitative problem)
Problem: Chest pain ();
1. Integument 2. HEENT 3. Respiratory 4. Cardiovascular 5. Gastrointestinal
GERD
Peptic ulcer
Acute cholecystitis
Acute pancreatitis
Esophageal tears
Problem: abdominal Pain ()
Systems
approach
y ( )
Anatomic
pproach
Problem: abdominal Pain ()
1. Integument
2. HEENT
3. Respiratory
4. Cardiovascular
5. Gastrointestinal
Pneumonia (esp. lower lobe
Myocardial ischemia (angina, AMI)
7. Metabolic/endocrine
8. Hematologic
9. Musculoskeletal
10. Neuropsychiatric
Boerhaave's syndrome
- Edema ()
1) Excessive extravasation (
) a) Hydrostatic pressure ()a) Hydrostatic pressure () b) Colloid oncotic pressure (albumin) c) Capillary permeability ()
[a), b) and c) – variables in Starling’s equation]
2) Impaired drainage – lymphedema ()
quantitative problem
QQOPERA
Cerebral hemispheres
(brainstem) *ARAS
(hemispheres)
External stimuli
pathophysiology: organic or functional dysfunction Organic: brainstem (small lesion); cerebral hemispheres (diffuse) Functional: brain stem (diffuse); cerebral hemispheres (diffuse) arousal, ( brain death) arousal, diffuse dysfunction ()
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2) Non infectious (inflammatory) ()
3) Neoplasm ()
5) Metabolic/endocrine (/)
6) Hematologic ()
Applications1) Infectious (inflammation)
2) Non-infectious (inflammation)
3) Others f
Benign Malignant
5) Metabolic/endocrine 6) Hematologic 7) Degeneration 8) Physical/chemical injury
1) Infectious (inflammatory) 2) N i f ti (i fl t )
B. Non-quantitative Problem 4) Pathologic Approach
Elevated Body temperature
Benign Malignant
2) Hyperthermia Heat dissipation <
acquisition** *Endogenous –
Hyperthyroidism **Exogenous –
, fire
1. Integument
1) Systems
approach
g 2. HEENT 3. Respiratory 4. Cardiovascular 5. Gastrointestinal 6. Genitourinary 7. Metabolic/endocrine 8. Hematologic 9. Musculoskeletal
Downwards - abdomen Upwards - neck
(abdominal Pain)
: LQQOPERA
Step I. 1) + 2)
: QQOPERA
Lesion
Bingo!
1
2
4
: ,
: [1 + 2] + 4
Combined Sequential
1) Systems Bingo!
Combined Sequential
:
1.Systems 3.Patho-
Pathophysiologic PathologicPathophysiologic Approach
pp
Anatomic
approach
Approach
Lesion
()
Submission Type Analyses* Strategy A.
Symptoms

B. Signs
C.
Quantitative Lab tests
4) Pathologic
1) (Hypertension per se) (detected, when/how) (severety –
staging) (past treatments)
(essential) (secondary) 3) (Complications)
: : : aortic dissection


4) (Associated risk factors) (DM) (smoking) (hyperlipemia) etc.
5) (Co-morbidity)
(beta-blockers); (alpha-blockers); hyperuricemia, gout – thiazide
(DM) (Evaluation Guidelines)

steroids)
3) (Complications?)
(acute)DKAHHS (HHNK) (chronic): Microangiopathy:
Macroangiopathy: CAD, CVD, (PAOD)
4) (
)
1. - hypovolemia, 2. - anemia
4) e.g. tendency, drugs
(NSAID, anticoagulants, ti l t l t t )anti-platelets, etc)
5) (Co-morbidity) Liver cirrhosis hepatic encephalopathy CAD acute coronary syndrome CKD acute renal failure
Precipitation?
1) (lung cancer per se)
(TNM, stage)
2) (Etiology)
3) (Complications)
(metastasis): (bone) (brain) (liver)
Paraneoplastic syndrome: (hyponatremia)(Eaton Lambert Syndrome - SCLC) (hypercalcemia -SqCC)DVT (AdC) etc(AdC) etc.
4) (Associated risk factors)

5) (Co-morbidity)
(Cisplatin)()
(Taxol) 75