OSCE ( )

1.
2.
3.

&

3F
2017.04.13 1510-1640

1

+

Chief complaint

Vital sign, general appearance

Present illness: chief complaint
(LQQOPERA)

Physical examination

Tentative diagnosis

Plan:
– Blood test, ECG, CXR
– Treatment: drug, educattion
– Admission, refer to ER, or OPD follow-up

2
105 OSCE

1. 4
2. 2
3. 1
4. 1
5. 4

3
101

4
102

5
103

6
104

7
105

8
9
10
vs.


11
12
 OSCE

13
 OSCE

14

CV: chest pain

CM: dyspnea

GI: abdominal pain

Neph: renal function impairment (AKI or CKD)
edema proteinuria

Meta: sugar control

15
v v ? v ? V ? X

X x v v X X X X
? ? ? ? v v v v

? ? ? ? v v v v

X X v X X X X X

16
 :

1.
– Eg.

2.
– Eg.

17

History PE

CXR, KUB,
ECG, CBC, AST, ALT, BUN, Cr, urine
routine

abdominal sonography, cardiac
echo, pulmonary function test

18
1. history taking
2. +-

19

:
….…onset of ..pain for ……..
Eg. Acute onset of chest pain for two days
Eg. Gradual onset of chest pain for one hour

20
Sydney Opera House

21
 LQQ-OPERA

Location

Quality

Quantity/time course

Onset mode

Predisposing factors

Exaggerating/exacerbating factors

Relieving factors

Accompanying/associated symptoms
22


– +

– +

– + (smoking, alcohol, sexual

history)

23
1. Chest pain
2. Dyspnea
3. Abdominal pain
4. Edema
5. Renal failure
6. Proteinuria

24
 LQQOPERA

:




– …
–
– (
/

25
 - History

–


–

26

AMI, Dissecting Aneurysm,
Pulmonary Embolism, Pneumothorax
– 
– 
− AMI
− pulmonary embolism
–
− dissecting aneurysm
−  pneumothorax
27

X ECG

28
 ( )
1.
2.
3. ( )  chief complaint
4.  history
5.  history
6.  onset
7.  onset
8.  location, quality, quantity
9.  location
10.  precipitating/exacerbating factors,
relieving factor
11.  accompanying/associated symptoms
12. AMI, Dissecting Aneurysm, Pulmonary
Embolism, Pneumothorax
13.

29
30
 - LQQOPERA

aaa (anemia, acidosis, anxiety)

Location

DOE? PND? Orthopnea

Onset:

: fever, productive cough, pale

conjuntiva, hypotension, GI bleeding?

31

COPD: cough, wheezing, DOE, URI S/S

CHF: PND, orthopnea, peripheral edema,
chest pain while exertion

Anemia: pale, weakness, fatigue, palpitation

Hemoptysis: TB, lung cancer…

Pneumonia: fever, chillness

Bronchitis: retrosternal pain

GERD: heart burning sensation

32
 History

Past history and personal history
– Asthma, COPD, smoking history
– Heart failure history
–

Allergy history

Drug history
– Aspirin, Warfarin, blocker
–

–
33


34
 ( )

ECG, cardiac enzyme

CXR, SpO2
a
ABG
a
Hb, stool OB

pulmonary function test,

cardiac echo, MDCT….

35
36
 others

Lung cancer, TB, vasculitis

37
-

38
Refer pain

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 - LQQOPERA

Location:

Quality: (dull) (crampy)
sharp

Quantity:

Onset: (
)

Predisposing factor:

Exacerbating factor:

Reliving factor/radiation:

Associated s/s:
diarrhea(stool ) hemturia, frequency,
inferior wall MI GYN (LMP)
40
 噁 )

Past history: OP history

HBV, HCV

Alcoholic

Drug history: softer

41



KUB, ECG, cardiac enzyme, stool routine,

Bilirubin, amylase, lipase, LDH, CBC

Sonography: ascites, liver, GB, biliary tract

42
 -

8
–

43

S/S: BW leg edema

–
−
− cellulitis trauma Popliteal
cyst rupture
–

44

+1 hormone heart
failure, cirrhosis, renal disease + hypoThyroid
1. Heart failure dyspnea on exertion, orthopnea,
PND, weakness
2. Cirrhosis jaundice, ascites, spider
angioma, , albumin
3. Nephrotic syndrome primary
(MGN….)+ secondary (DM, SLE…), proteinuria
Serum albumin TC TG

Myxedema ( )

45
 Low albumin

Albumin loss
– Nephrotic syndrome
– Protein losing diarrhea gastric cancer…

Albumin production
– poor nutrition
– Cirrhosis

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 LQQOPERA

Location:

Quality: pitting or non-pitting edema

Quantity: ,
Grade 1-4?

Onset: cellulitis or DVT

Predisposing factor:

Exacerbating factor:
salty

Relieving factor:

Associated factor: heart failure s/s,
cirrhosis s/s, nephrotic syndrome or CKD s/s,
hypothyroidism s/s
47
 History

:heart failure, nephrotic syndrome,
cirrhosis ;

: heart failure, nephrotic syndrome,

cirrhosis

smoking, alcohol, sexual history

48
 -


edema or foamy urine

+

–
−
−

49


1. Glomerular: renal biopsy

>3g : nephrotic syndrome or

Hematuria+ proteinuria<3g = nephritis
2. Tubulointerstitial: <1-2g

ATN, AIN, most due to drug/toxin f/u dc
drug, avoid toxin
3. Overflow: MM
4. Isolated<1g, no hematuria: fever, exercise, CHF,
orthostatic
50
-

51
 Renal dysfunction

AKI vs. CKD

serum creatinine

CKD +1 DM
– HTN, DM, hyperlipidemia, high UA

AKI GITV
– Glomerulus: protienuria, hematuira
– Interstitial: NSAID, herb, other OTCs
– Tubule
– Vessel: NSAID, contrast, dehydration (op..)
 T

I
青璜

G
1.
2.

54



…….

(
)


 perfect

55
 ~

SP 
–

xx 

1.
2.
3. /

4.

56


1.
2.
3.

57

eg.

1.

2.

, eg.

1.
2.

58




1. :
− dash (DietaryApproaches
to Stop Hypertension) CKD
purine
2.
3. :

59


– OPD
–
–

60
1. Chest pain 
2. Dyspnea 
3. Abdominal pain
4. Edema
5. Renal failure
6. Proteinuria
7. Sugar control

61
 :

1.
2.

62


– BUN 111 mg/dl
– Cr 11.1 mg/dl
– Na 135 mEq/l
– K 6.5 mEq/l
– pH 7.285 PCO2 25.5 mmHg HCO3
11.8mmol/L
– Hgb 10.2 g/dl
– 8.7cm, 9.0cm,
echogenicity
63
 -1

AKI vs. CKD

– SCr  renal size
−10 cm at least
– CKD: small kidney, except “SHAPE”
−Scleroderma
−HIV
−Amyloidosis
−PCKD
−Endocrine-DM
64
 -2

Renal replacement therapy (RRT)
– Urgent RRT: HD only, check AEIOU
−Acidosis: pH<7.2, HCO3-<12 meq/L
−Electrolyte: KKKKKKKKKKKK!!!!!!
−Intoxication
−Overload of fluid: pulmonary edema
−Uremic symptom and sign: nausea, vomiting,
coma, uremic pericarditis, uremic bleeding
– Initiate long term RRT: HD, PD, renal
transplantation

65


 indication (AEIOU)
–
– K  K=6.5

–
– Cr( )


– HD PD


–
–
66
 ( - )
1. /
2.
3.
4.

5.

6.
7.
8.
9.

67
1. /
–
– 噁
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–
2.
–

–
–

68


–

–

– K
Cr噁 )
..
– 2
–
69


– HD PD
– HD PD
–


–
噁1) 噁2) 噁3)
噁HD PD)
–
–

70


– 噁1) 噁2)
噁 : HD PD
)
–
–


– 噁1) 噁2)
:
–
–

71


–
–
–

72

55

1.
2.
3.

73


–
( onset of for .)
–
–


–
–
–

74


– heart failure
ascites
hypothyroidism
–
–


–

–
–

75


–

–
–


–

–
–

76


–
噁nephritic syndrome)
–
–


–
nephrotic range low albumin no hematuria
normal serum creatinine nephrotic
syndrome
– proteinuria hematuria normal
serum creatinine low albumin
–

77


–

–


–
albumin
–
–

78

56

79

( )

insulin, very high risk….. for 2nd opinion

80
1.
– (
) ( )

–
2. (HbA1c)

–
− 3
− 7.0%( 6.5%)

–
–

81

3
–
1. 4

2.

3.
4.
5.
–
–
82
4


1.
2. (
)
3.
4.

83
5.


–
− 2
/

–
− 2 1
( )

84

6.
–
1.
2.
3.
–
–

7.
–

− <140/90
<130/80
–

85

8.
–
( 160 mg/dl LDL-
C 100 mg/dl)
–

9.
–
–

10.
– ( )
–

86

11.
–

–
–

12.
–
–
–

13.
–

–
–
87
88
 ~

+

Chief complaint

Vital sign, general appearance

Present illness: chief complaint
(LQQOPERA)

Physical examination

Tentative diagnosis

Plan:
– Blood test, ECG, CXR
– Treatment: drug, educattion
– Admission, refer to ER, or OPD follow-up

89
90