2017/3/6

2017/03/04

GPMEC




dr.kenta.sato@gmail.com

clinical reasoning CT

ICU

1
 2017/3/6

BP134/50mmHgHR108bpm

RR 28SpO2 96%BT 37.4

Anatomy

organSystem
ABC
Anatomy
()
Anatomy Byoutai


C

Common or Critical Curable

2
 2017/3/6

Byoutai


Byoutai Common, Critical, Curable



AB
or

Common
ABC AB
Anatomy Byoutai

GERD


Critical
AB
Critical C

Common

3
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CommonRule in







CriticalRule out

10
AnatomyByoutai

CMost likelyMust rule out

C A:
O 10
M M

P P
L
A L

I E

N
OSCE
T
S

4
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CommonRule in
General appearange
Vital signs
RR<30HR<100BT<37.8-LR0.18)


CriticalRule out



Crackles
78
37

CommonRule in


CriticalRule out

0.7
31

CT

5

5
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Common disease
!



!!

!

Common disease

6
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-% LR 0.1 LR 10 +45

-% LR 0.2 LR 5 +30

-% LR 0.5 LR 2 +15

Value
QOL

http://www.slideshare.net/masatoshimizu37/3-50407563
84
NBM: Narrative based medicine

JCS0, BP134/50, HR105
RR28, SpO2 92, BT37.4
EBM: Evidence based medicine General

VBM: Value based medicine COPD
QOL(QOLYs)
Rule in Rule out
SAH

7
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ER
:
3
CT
CT
19NPPVOK

ACS :
COPD!
ADL full

SABACTRX !
NPPV
!

COPD COPD





( LR+5.8LR-0.45 45 LR+1.3LR-0.4 BNP<80 LR+2.4LR-0.08 LR+2.1LR-0.3
LR+3.1LR-0.69 40/ LR+8.3LR-0.8
COPD LR+1.7LR-0.9 LR+1.8LR-0.16
BNP>300 LR+7.6LR-0.17 LR+1.3LR-0.05
>25/hpf
COPD LR+0.8LR-1.1 (+) LR+4.2LR-0.2
Wheeze LR+1.3LR-0.5 LR+3.8LR-0.66
Crackle LR+2.6LR-0.7 90m LR+3.0LR-0.98 LR+2.5LR-0.4
LR+1.2LR-0.55

LR+2.2LR-0.7 LR+1.6LR-0.92 ECG LR+3.8, LR-0.79 LR
T LR+3.0, LR-0.83 P
LR+2.1LR-0.6
Xp / CT LR+2.2, LR-0.64
LR+5.1LR-0.66 LR+10LR-0.90
LR+6.4LR-0.79 Hoover LR+4.2LR-0.49
LR+2.3LR-0.64 LR+2.8LR-0.8
CXR LR+12, LR-0.48
LR+12, LR-0.68 LR+0.50, LR-1.0
! SABAPSL! LR+11LR-0.88 LR+10LR-0.88
LR+6.0, LR-0.95 LR+0.38, LR-1.1
BA/COPD LR+57LR-0.83 LR+4.6LR-0.94
SABAPSL LR+2.6LR-0.81 LR+3.3, LR-0.33 LR+0.11, LR-1.7

Crackle LR+2.8LR-0.51 Crackle LR+10LR-0.3
BA/COPD LR+2.6LR-0.39 LR+3.7LR-0.7 US LR19, LR-0.03 A line LR29, LR-0.11
Wheeze LR0.52LR-1.3 Wheeze LR+2.9LR-0.8 B line

8
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!
!!
CT ()

Common disease
COPDCOPD
!



!!!

VBP10
High value care in japan