臨床診斷學 臨床診斷學 腎臟科腎臟科
臨床診斷學 臨床診斷學 腎臟科腎臟科
2010 2010 共同教材 共同教材
Outline• History taking Occupation, Name, Age… Chief complaint Present illness Past history Family history Drug history Review of systems
• Physical examinations
History TakingHistory Taking問診問診
History TakingHistory Taking問診問診
Before start history takingBefore start history taking
Identification data• Name• Sex• Age• Race• Marrital status• Occupation
範例Date of admission: 2009-Aug-28General Data:Name: 胡 xxSex: maleAge: 65 y/oOccupation: FarmerEthnic origin: TaiwaneseMartial status: MarriedPlace of residence: Tao-YuanTravel history: DeniedSource of Information: Patient
Chief complaints• 腰痛…• 尿尿有泡泡、混濁、顏色異常…• 腳或身體水腫…• 喘…• 尿量減少…• 尿尿時不舒服,頻尿 , 發燒…
Present illness (1)
腰痛 ( Flank pain )• Anatomy • Questions about pain
LQQOPERA1. 位置 (Location): 局部性 (localized) 、瀰漫性 (diffuse) 、移位性 (migratory) 、放射性 (radiation) 等等2. 形態 (Quality): 刺痛 (needling) 、銳利 (sharp pain) 、頓痛 (dull ache) 、壓迫性 (oppressive) 、難忍的 (excruciating) 等3. 歷時 / 時相 (Quantity): 持續性 (persistent) 、間歇性 (intermittent): 其頻率、單次持續時間及發作間隔4. 起病狀態 (Onset mode): 超急性 (abrupt) 、突然 (sudden) 、 緩慢性 (insidious)5. 情境、誘發因素 (Precipitating factors)6. 加重因素 (Exaggerating factors)7. 緩解因素 (Relieving factors)8. 伴隨因素 (Accompanying symptoms)
Present illness (2)
尿尿有泡泡、混濁、顏色異常 ( 血尿 )…
• Foamy urine Edema / Proteinuria
• Turbid urine
• Hematuria ( Gross ) Painful / Painless
Cappuccino !
Present illness (3)
腳或身體水腫 (Edema)…
• Symmetric / Asymmetric
Common causes of legs edemaKidney diseaseHeart failure / Cor pulmonaleLiver cirrhosisDeep vein thrombosisLymphatic obstruction
Present illness (4)
喘… ( Dyspnea )
Dyspnea of nephrogenic origin --
• Dyspnea on exertion• Orthopnea• Persistent
Present illness (5)
尿量減少 ( Oligouria )• Amount / Frequency • Differential diagnosis of
acute renal failure• Complications
Renal failurePre-renalRenalPost-renal
Present illness (6)
尿尿時不舒服 , 頻尿 , 發燒• Urinary tract infection (UTI) 三
寶 : Dysuria / Frequency / Urgency
• With flank pain ? • Pain / Burning ?• Nocturia
Past medical history• Past renal disease
• Systemic diseases
Family history• Family history of renal diseases
Drug history• What drugs ? For what
purposes ?• Herbal medicines ?• Health foods ?
• History of allergy ?
Find / Avoid Nephrotoxic agentsFind / Avoid Nephrotoxic agents
Review of systems
• General symptoms• Diet• Head and neck: Head; Eyes; Ears;
Noses; Throat and mouth• Chest and lungs• Heart and blood vessels• Gastrointestinal symptoms• Genitourinary symptoms• Neurologic symptoms• Skin, hair and nails• Musculoskeletal symptoms• Endocrine
Before the conclusion of obtaining the history…
“ Is there anything else that you think would be important for me to know ? “
“ What problems concerns you most ? “
“ What do you think is the matter with you ? “
Physical examinationsPhysical examinations
About nephrologyAbout nephrology……
Physical examinationsPhysical examinations
About nephrologyAbout nephrology……Before starting physical examinationsBefore starting physical examinations
Record of physical examinations
• Consciousness• Head / Neck• Chest• Heart• Abdomen• Extremities• Skin / Nail
Head / Neck Eye: conjunctiva, pale ? Neck: jugular vein engorgement ?
Chest
Breathing pattern
Kussmaul respirations
Abnormal breathing sound
Fine crackles, wheezing
Percussion, palpation …
Heart • Palpation: heave ? Thrill?
• Percussion: cardiomegaly ?
• Auscultation: regular heart beat ? S3 ? S4 ?
Abdomen ( esp. kidneys ) (i)
Review of anatomy
Abdomen ( esp. kidneys ) (ii)
• Inspection• AuscultationAuscultation• PercussionPercussion• PalpationPalpation
Abdomen ( esp. kidneys ) (iii)
InspectionInspection Auscultation PercussionPercussion PalpationPalpation
For bruit
Aorta
Right renal a.
R iliac a.
R femoral a.
Abdomen ( esp. kidneys ) (iv)
InspectionInspection AuscultationAuscultation Percussion PalpationPalpation
Abdomen ( esp. kidneys ) (v) InspectionInspection AuscultationAuscultation PercussionPercussion Palpation
Right kidney
InspectionInspection AuscultationAuscultation PercussionPercussion Palpation
Abdomen ( esp. kidneys ) (v)
Left kidney
Extremities Assessing for pitting edema
1+ : Slight pitting, no distortion2+ : Deeper pitting than 1+, no visible distortion3+ : The pit is noticeably deep, the dependent extremity looks swollen4+ : The pit is very deep, the dependent extremity is grossly distorted
Skin / Nails
Testing skin turgor
Special nails patternTerry's nails (left)Seen in liver cirrhosis. White proximal nail, reddened distal nail
Half-and-half nails (right)Seen in renal failure. White proximal nail, brown distal nail
Examination for arterio-venous fistula
AV Graft (Gortex)
AV Fistula (native)
Tunneled cuffed catheter (Hickman, Permcath)
Double lumen catheter
Peritoneal dialysis (Tenckhoff) catheter
Renal Transplant