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1、<p><p>&lt;p&gt;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 eaminations History TakingHistory Taking 問診問診 Before start hist
2、ory takingBefore start history taking Identification data ? Name ? Se ? Age ? Race ? Marrital status ? Occupation 範例 Date of admission: 2009-Aug-28 General Data: Name: Se: male Age: 65 y/o Occupation: Farmer Ethnic origin: Taiwanese Martial status: Married Place of residence: Tao-Yuan Travel history
3、: Denied Source 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 LQQOPERA 1. 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 (n
4、eedling)、銳利 (sharp pain)、頓痛 (dull ache) 、壓迫性 (oppressive)、難忍的 (ecruciating) 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 (Eaggerating factors) 7. 緩解因素 (Relievi
5、ng 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 edema Kidney disease Heart failur
6、e / Cor pulmonale Liver cirrhosis Deep vein thrombosis Lymphatic obstruction Present illness (4) 喘 ( Dyspnea ) Dyspnea of nephrogenic origin - ? Dyspnea on eertion ? Orthopnea ? Persistent Present illness (5) 尿量減少 ( Oligouria ) ? Amount / Frequency ? Differential diagnosis of acute renal failure ? C
7、omplications Renal failure Pre-renal Renal Post-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 o
8、f renal diseases Drug history ? What drugs ? For what purposes ? ? Herbal medicines ? ? Health foods ? ? History of allergy ? Find / Avoid Nephrotoic agentsFind / Avoid Nephrotoic agents Review of systems ? General symptoms ? Diet ? Head and neck: Head; Eyes; Ears; Noses; Throat and mouth ? Chest an
9、d 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 ? “ “ Wh
10、at problems concerns you most ? “ “ What do you think is the matter with you ? “ Physical eaminationsPhysical eaminations About nephrologyAbout nephrology Before starting physical eaminationsBefore starting physical eaminations Record of physical eaminations ? Consciousness ? Head / Neck ? Chest ? H
11、eart ? Abdomen ? Etremities ? Skin / Nail Head / Neck nEye: conjunctiva, pale ? nNeck: jugular vein engorgement ? Chest nBreathing pattern Kussmaul respirations nAbnormal breathing sound Fine crackles, wheezing nPercussion, palpation Heart ? Palpation: heave ? Thrill? ? Percussion: cardiomegaly ? ?
12、Auscultation: regular heart beat ? S3 ? S4 ? Abdomen ( esp. kidneys ) (i) Review of anatomy Abdomen ( esp. kidneys ) (ii) ? Inspection ? Auscultation ? Percussion ? Palpation Abdomen ( esp. kidneys ) (iii) nInspection nAuscultation nPercussion nPalpation For bruit Aorta Right renal a. R iliac a. R f
13、emoral a. Abdomen ( esp. kidneys ) (iv) nInspection nAuscultation nPercussion nPalpation Abdomen ( esp. kidneys ) (v) nInspection nAuscultation nPercussion nPalpation Right kidney nInspection nAuscultation nPercussion nPalpation Abdomen ( esp. kidneys ) (v) Left kidney Etremities nAssessing for pitt
14、ing edema 1+ : Slight pitting, no distortion 2+ : Deeper pitting than 1+, no visible distortion 3+ : The pit is noticeably deep, the dependent etremity looks swollen 4+ : The pit is very deep, the dependent etremity is grossly distorted Skin / Nails Testing skin turgor Special nails pattern Terrys n
15、ails (left) Seen in liver cirrhosis. White proimal nail, reddened distal nail Half-and-half nails (right) Seen in renal failure. White proimal nail, brown distal nail Eamination for arterio-venous fistula AV Graft (Gorte) AV Fistula (native) Tunneled cuffed catheter (Hickman, Permcath) Double lumen catheter Peritoneal dialysis (Tenckhoff) catheter Renal Transplant &lt;/p&gt;</p></p>
