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