21 2017/7/23

21 2017/07/23

!?

dr.kenta.sato@gmail.com

GPMEC

GPMEC

1053050

1
21 2017/7/23

ER

HP http://www.min-iren.gr.jp/ikei-gakusei/igakusei/zi5_medi/2011/049/mw-ken-49.html
HP http://www.chidoribashi-hp.or.jp/chidoribashi-hph/index.html

WebSNS

NPO

2
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clinical reasoning

ex:



1

3
21 2017/7/23

3
Most likely
Must rule out-

Most likely

Must rule out

Most likely
9


Must rule out 8

4
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Common disease

!!

24

ABC COMPLAINTs

5
21 2017/7/23

1

!

JCS0BP 114/80HR 114RR24SpO2 97BT 37.2

ABC
Anatomy Byoutai

Common or Critical Curable

6
21 2017/7/23

Anatomy Anatomy

organSystem

Byoutai Byoutai

Sudden
Rapid
Acute
or Subacute
Chronic
Reccurent

Acute

ABC
Anatomy Byoutai

Critical

7
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!
COMPLAINT
!! C: Chief complaints Byoutai

O: Onset
M: Magnitude
P: Pattern or

!! L: Location Anatomy

A: Associated symptom System

: Improvement Review

N: Negative stimuli
! T: Type of pain
S: Similar episode

C: Chief complaints Allergy
O: Onset Medication
M: Magnitude
P: Pattern
Past history
L: Location Pregnancy
A: Associated symptom 28


Last meal
I: Improvement
N: Negative stimuli Event
T: Treatment
S: Similar episode

Anatomy COMPLAINTs Byoutai
Sudden
Rapid

Acute

8
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!
ABC

!!





Carnett sign
Murphy
!
TraubeCVA

CVA

9
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JCS 0BP 114/80HR 114Shock index>1 WBC6800Neut78CRP2.3
HR 114RR 26BT 37.2 SIRS2

(+)(+)(-)

Xp

(+)

CVA()
CT
Psoas sign()Obturator sign(+)

Xp

Pelvic Inflammatory DiseasePID

free air

PID
35
13

ABC
PID
COMPLAINTs


!
STD


QOL

10
21 2017/7/23

A

55

3


Anatomy

Byoutai

A A


JCS0BP120/80HR100

RR22SpO2 97 BT37.3




FortyFifty, Fatty, Female

Murphy sign
Murphys sign

LR+0.4LR-2.0

Murphys sign LR+2.8LR-0.5

Sonographic Murphy LR+9.9LR-0.4

11
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5


Anatomy

!!

Byoutai

B

?
JCS0BP107/74HR79
RR16SpO2 98 BT37.5 ?

??


Murphys sign

B
Take Home Message
PID --

D




Murphy



Under Forty Female

12
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C
ER Anatomy
78

1410

3



Anatomy
Byoutai

C: Chief complaints Allergy
O: Onset Medication ACE-ICCB
M: Magnitude
Past history
P: Pattern
L: Location
A: Associated symptom Last meal
Event
I: Improvement
N: Negative stimuli
T: Type of pain
S: Similar episode

13
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JCS1
124/649224SpO2 9237.8
Anatomy Byoutai
/S3(+)
Sudden Late-inspiratory crackles


Rapid

Acute
MMT4/42/4
PTR/ATR+/-

?
Most likely diagnosis CRP10.8ESR
Must rule out WBC10300Neut82%Hb8.2MCV78PLT25
BUN25/Cr1.21
AST45/ALT24CK25
?
?
? (+)(-)

Xp
CPPD

Common disease

or

14
21 2017/7/23

D

78

1410
3
CTMRI


Common ECG
Critical Xp
Curable RAetc CT

S3

Critical


(ACE-INOAC
LSCS

15
21 2017/7/23

#1.
#2. AFCHF#1
#a. LSCS
or
or
Crackles14
NOAC2

LSCS
S3 (ACE-INOAC
LSCS

? !
!!
Most likely diagnosis !

Must rule out
NSAIDs

?
?
ECG
Xp XpCT
CT

Take Home Message

!
CPPD
IE

RA



XpECG


CDSCT

16
21 2017/7/23

E
Anatomy
1.
:
: 2.

Anatomy? 3.

Byoutai?
4.

:
:
:

:

: COMPLAINTs Byoutai
: Anatomy

Sudden

: Rapid
:
Acute
:
:

17
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? ?
JCS0BP134/50mmHgHR108bpm
RR28SpO2 86%room airBT 37.4



CHF or COPD?

Wheeze2Crackles ?

ER
:WBC1200080CRP11.5


NT-ProBNP 400T

:
(-)()

CT :LVHQ
:AsynergyEFLVH

!

ACS

COPD!

1NPPV
SABA
CTRX
http://tnagao.sblo.jp/article/161908474.html

18
21 2017/7/23

:
:
3
or ECGXp
CT

19NPPV
!

:

!

F
COPD

Wheeze
: Crackle
:

Xp / CT

Anatomy?

Byoutai?
! SABAPSL!
SABAPSL

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COPD

LR+5.8LR-0.45 45 LR+1.3LR-0.4
LR+3.1LR-0.69 40/ LR+8.3LR-0.8
LR+1.7LR-0.9 LR+1.8LR-0.16
? COPD LR+0.8LR-1.1

v.s. COPD

LR+1.3LR-0.5
LR+2.6LR-0.7

90m
LR+3.8LR-0.66
LR+3.0LR-0.98
LR+1.2LR-0.55
LR+2.2LR-0.7 LR+1.6LR-0.92
LR+2.1LR-0.6

LR+5.1LR-0.66 LR+10LR-0.90
H&PECGXp? LR+6.4LR-0.79 Hoover LR+4.2LR-0.49
LR+2.3LR-0.64 LR+2.8LR-0.8
?
LR+11LR-0.88 LR+10LR-0.88
? BA/COPD LR+57LR-0.83 LR+4.6LR-0.94
LR+2.6LR-0.81
?
Crackle LR+2.8LR-0.51 Crackle LR+10LR-0.3
!? BA/COPD LR+2.6LR-0.39 LR+3.7LR-0.7
Wheeze LR0.52LR-1.3 Wheeze LR+2.9LR-0.8

COPD

BNP<80 LR+2.4LR-0.08 LR+2.1LR-0.3

BNP>300 LR+7.6LR-0.17 LR+1.3LR-0.05
>25/hpf NG
(+) LR+4.2LR-0.2

LR+2.5LR-0.4 Rule in

ECG LR+3.8, LR-0.79 LR

T LR+3.0, LR-0.83 P
LR+2.2, LR-0.64


CXR LR+12,
LR-0.48
LR+12,
LR-0.68 LR+0.50, LR-1.0
CT
LR+6.0,
LR-0.95
LR+0.38, LR-1.1 303000

LR+3.3,
LR-0.33
LR+0.11, LR-1.7 CT

US LR19, LR-0.03 A line LR29, LR-0.11

B line

Take Home Message

5% 180!

10
CHFCOPD

Wheeze
A line SABAPSL2


1

1

5
30

20
21 2017/7/23

G

32


JCS0, BP104/58, HR98Reg,
RR 20, SpO2 97%, BT37.4
General

PIDetc.

:
:
: JCS0BP104/58mmHgHR98bpm
: RR20SpO2 97%room airBT 37.4
L:
:1 :
:
: :
N: McBerney
: :
:

G G

1000mg

Xp/ECG
10

CT

!
!!

OK

21
21 2017/7/23

H

32


JCS0, BP104/58, HR98Reg,
RR 20, SpO2 97%, BT37.4
General

H





10



1
!




62100()
114700()

88800183800

127% ?
2448h 7 ?
10
?
47
83
10% ?
?
OK?
7 36+12371008 ?
LVFX+MNZ71707132681 ?

2015
http://rokushin.blog.so-net.ne.jp/2015-06-24

22
21 2017/7/23

H
Take Home Message

RCT
CT




SSRI





OK

Common


! !?
!!

23
21 2017/7/23

Value Based Medicine

-% LR 0.1 LR 10 +45
-% LR 0.2 LR 5 +30
-% LR 0.5 LR 2 +15

QOL
Value

EBM
NBM: Narrative based medicine


EBM: Evidence based medicine
Step4

VBM: Value based medicine
QOL(QOLYs)
Value

24
21 2017/7/23

Complexity care
Conference type selection

Difficult PatientDifficult Encounter

Cannarella Lorenzetti, R. , et, al. (2013). Managing difficult encounters:
understanding physician, patient, and situational factors. American family physician, 87(6), 41925.

Simple Complicated
11 60
30 AKI
RADM

Compex Chaotic
70

40
DMDLNAFLDHCV

MaintenanceCrisis

25
21 2017/7/23

by Wikipedia

Design by WPThemeDesigner.com.

4


Simple

Complicated

Compex

Chaotic

26
21 2017/7/23

Incertitude
Shared Decision Making

Risk

60
Tcho260210160

107NNT29
10

5mg1T/day154056

27
21 2017/7/23

Ignorance SGLT2
SGLT21

RCT


SGLT2
http://www.jds.or.jp/modules/important/index.php?page=article&storyid=48

Uncertainty








NEJM( )
()

70


COPD


B12
COPD


Informed concent


Polypharmacy

28
21 2017/7/23

Ambiguity

QOL

Common health problem

Complicated
Comprex / Chaotic

29