- (1)

Logics in Clinical Problem Solving

Dray Song Hong, MD, FACC, FAHA
Professor of Medicine,
China Medical University

Taichung, Taiwan

www.LQQOPERA.com


1) Knowledge ()*
Acquisition skills
2) Clinical Skills () (history taking)
Acquisition skill () (PE)*
History/physical exam*


Reasoning skill*

Decision making skill*


Communication skill*

Procedures skills
3) Attitudes ()

***

*
*
4) Value
(Clinical Medicine)
(Holistic Nedicine) (Science/art)
 Logics in Problems Solving

A Foundation in Clinical Medicine

History Physical Laboratory Medical

taking exam tests records

Logics in Problems Solving

Problems Solving ()/ Clinical Diagnosis ()

Problem solving
History Cross exam,
Means (trio):
verification
1) (History)
2)
(PE)
Nucleus ()
3)
Reasoning/ Supplement
(Lab tests)
Logic Lab
PE Proper ()
tests
Timely ()
Right setting
(PE begins with
()
1st encounter) (Brain-hands Coordination)

In the trained, history and PE

Can be conducted simultaneously ()
Problems Solving ()/ Clinical Diagnosis ()

Problem solving Cross exam,
Means (trio): History Urgency verification

1) (History)
2)
(PE)
Nucleus ()
3)
Reasoning/ Supplement
(Lab tests) Logic Lab
PE Proper ()
tests
Timely ()
Right setting
(PE begins with
()
1st encounter) (Brain-hands Coordination)

In the trained, history and PE

are conducted simultaneously
 Logical Interpretation of Acquisition Data

(Clinical medicine as in daily life)

Daily Dialogue () Clinical setting ()

Speech content () Symptom () - History

Facial expression ()
Signs () - PE
Body language ()
Diagnosis
Hx In context of clinical seting

(Clinical medicine, Proper ()

Logic
as in daily life) Timely ()
() - PE tests Right setting
()
-
e.g. boy/girl dating
Hx/PE anytime, anywhere
and priceless!!

(Problem-oriented Clinical Medicine)
- (Clinical problem solving)
1) * (Understand the main character (i.e. patient *)

(personal background)
Admission Note
()
Basic data

()
(Medical background)
()

2) (Problem solving)

*
 Basic Data () -

Basic Data () :
:
Name () Age/sex (/) Occupation ()
Marital status () Ethnic origin () Place of residence ()
: Past History ()

?
1)
(): /: :
(): : :
: ?

2) (--)
: /: :
:
:
:
 (Problem Solving)

()

Steps ()
1. (Problem finding/submission)
2. (Problem analyses)
3. (Problem Solving)
[4. * (Problem managements)]
* ()

Means ()
1. (history taking)
2. (physical Exam)
3. (laboratory tests)
 1. (Problem Finding/Submission)
/ (Means/Process)

1) (history taking)
(chief complaints)
(past history)
(present illness)
(allergy history)
(social/occupational history)
(family history)
(review of systems)
2) (physical exam)
3) (laboratory data)
4) (managements side effects/complications)
 2. Chief Complaints ( )

Use patients own language and way of expression to
state the main worrisome symptom and the time duration

Avoid using diagnostic or related words, implying
diagnosis
Examples:
Chest pain for 3 days
Breathlessness for 2 weeks
 Opening Statement () Composition ()
Basic Data ( )
Name: Li, x x Age*/sex*: 60/M Occupation*: taxi driver
Marital status: married Ethnic origin: Ming-Nan
Place of residence: Hu-wei
Past history (): hypertension and diabetes mellitus
Chief complaint: Chest pain for 3 days
Present illness ( opening statement)

(opening statements in Chinese)

65,,, () ,
,()
()
1) This 60-year old man, a taxi driver, 2) with hypertension and DM was
admitted via emergency room 3) because of chest pain for 3 days.

1) Personal background () keywords ()

* (mandatory) - age/sex/occupation; (elective) - , if any
2) Medical background (); and
3) Chief complaint
 Admission Note Case 1
Basic Data ( )
Record No: 000000 Date of admission: 2005-8-1 Bed No: 301
Name: Li, x x Age/sex*: 60/M Occupation*: taxi driver
Marital status: married Ethnic origin: Min-Nan
Place of residence: Hu-wei
Past history: hypertension and diabetes mellitus
Chief complaint *
Chest pain for 3 days (Mandatory key words)

Present illness ( opening statement)

This 60-year-old man, a taxi driver, with (a past history of)
hypertension and DM was admitted via emergency room because
of chest pain for 3 days.
(problems): 1) Chest pain; 2) hypertension; 3) diabetes
(Chest pain in a 60-year-old man with hypertension and diabetes)
 Admission Note Case 2
Basic Data (Preliminary personal and medical backgrounds)
Record No: 000000 Date of admission: 5-8-1 Bed No: 301
Name: Li, x x *Age/sex: 60/M *Occupation: farmer
Marital status: married Ethnic origin: Hakka
Place of residence: Kaohsiung**
key words
Past history: hypertension and DM
1) * (mandatory)
Chief complaint 2) ** (elective)
Fever for 3 days Kaohsiung - dengue fever
endemic area
Present illness ( opening statement)
This 60-year-old male farmer, a Kaohsiung** resident, with
hypertension and DM was admitted via emergency room because
of fever for 3 days.

(problems): 1) Fever; 2) hypertension; 3) diabetes

(Fever in a 60-year-old man with hypertension and diabetes)
 Admission Note Case 3
Basic Data
Record No: 00000001 Date of admission: 2009-8-1 Bed No: 301
Name: Li, x x *Age/sex::56/M
Occupation: farmer*
Marital status: married Ethnic origin: aborigine**
Place of residence: Tong-shi
Past history: peptic ulcer **Elective key word
Chief complaints
Weakness and black stool for 2 days
Present illness
This 56-year-old aborigine** farmer with a past history of peptic
ulcer was admitted via ER because of weakness and black stool
for 2 days.

(): 1. Black stool; 2. Peptic ulcer

(GI bleeding in a 56-year-old male with peptic ulcer)
Admission Notes

8. Review of Systems ( - )
Because symptoms are non-specific and may be related to multiple systems,
each symptom is assigned to the system in which it is more or most
commonly associated as follows.

1. Generalweakness, fatigue, anorexia, fever, insomnia

2. Integument (skin, hair and nails)changes in color (pigmentation, *jaundice,
cyanosis), pruritus, rash, hair loss
3. HEENT
a. Head - headache, dizziness, vertigo
b. Eyes - visual acuity, color vision, corrective lenses, photophobia, diplopia,
pain
c. Ears - pain, discharge, hearing loss, tinnitus
d. Nose - epistaxis, discharge, stuffiness, sense of smell
e. Throat - status of teeth, gums, dentures, taste, soreness, hoarseness, lump
4. Respiratory dyspnea, wheezing, cough, sputum, hemoptysis, chest distress/pain
5. CVdyspnea, edema, dizziness, syncope, palpitation. chest distress/pain:
intermittent claudication, cold limbs, cyanosis

*jaundice, quantitative problem: others, non-quantitative;

Admission Notes
8. Review of Systems ( - )
6. GI: dysphagia, nausea, vomiting, abdominal distress pain, change in
bowel habit (diarrhea, constipation, character of stool), hematemesis,
melena, bloody stool
7. GU: urinary frequency, hesitancy, urgency, dribbling, incontinence,
dysuria, hematuria, nocturia, polyuria, impotence
Female - menarche, menstrual history (including the date of last
period), vaginal bleeding or discharge; pregnancy
8. Metabolic and endocrine: growth and development, weight change*,
heat/cold intolerance, nervousness, sweating, polydipsia
9. Hematotologic: anemia*, easy brusity or bleeding, lymphadenopathy,
transfusions
10. Musculoskeletal: joint pain, stiffness, limitation of motion, muscular
weakenss, wasting
11. Neuropsychiatry: dizziness, syncope, seizure, speech disturbance, loss
of sensation, paresthesia, ataxia, weakness or paralysis, tremor,
anxiety, depression, irritablility

* weight change, anemia (quantitative problem; The rest, non-quantitative)

 8. Review of Systems (-)
Simplified (for the qualified)

1. General: weakness and fever as above;

2. Integument: void (negative)
3. HEENT: void (negative)
4. Respiratory: as above;
5. CV: (dyspnea, edema, chest distress/pain, palpitation)
as above; no dizziness, syncope, intermittent claudication,
or cold limbs;
6. GI: void (negative)

No, No! - Headache (+), Nausea (-), dysphag\gia (-), vomiting (-),
abdominal pain (-)
Right way - Elaborate headache; No dysphagia, nausea, vomiting ,
or abdominal pain
 Review of Systems ( - )
Objectives ()

1. To supplement overlooked symptoms, relevant to

problems in Present Illness ()
Transcribe relevant positive and negative symptoms
in Present Illness
2. To Identify new problems, unrelated to problems
in Present Illness ()
If positive, elaborate
No! No! - Headache (+), Nausea (-), dysphag\gia (-), vomiting (-),
abdominal pain (-)
Right way - Elaborate headache;
No dysphagia, nausea, vomiting or abdominal pain
 1. Classification of Clinical Problems
- 4 classes (4)
A. (symptoms)
(Non-quantitative problem)
/ (pain/distress)(dyspnea)
(dizziness)(syncope)(fever)
(Quantitative problem)
(weight loss)
B. /(signs/findings)
(non-quantitative problem)
(edema) (consciousness disturbance)
C. (Quantitative assessment)
(anemia) (jaundice) (hypokalemia)
(hypoglycemia)
D. /(syndrome/disease)
congestive heart failure, hypertension; diabetes;
shock; CKD, stroke (ischemic or hemorrhagic)

1. 2. * 3.
Submission Type Analyses* Strategy
A.
Symptoms LQQOPERA (Mass preservation law)
Quantitative ()
(Accounting rules)
B.
Signs Strategies ():
LQQOPERA 1) Systems
C. Non- 2) Anatomic
Quantitative
Abnoramal
3) Pathophysiologic
Quantitative 4) Pathologic
Lab tests

D. /(syndrome/disease (Guidelines)

* -


 (Strategy)
Similarity between Warfare and Clinical Problem Solving

(Warfare)
() (Clinical Problem Solving)
(Intelligence Gathering)
(Problem Analysis)
(Strategies) LQQOPERA
(ground)
(sea)
(air) (Non-quantitative problem)
(bomb, missile) (Strategies)
(biological)
1) Systems
(chemical)
2) Anatomic
(psychological)
(e-information) 3) Pathophysiologic
( Sun-Tse) - a great military strategist in Confucius era 4) Pathologic
- Knowing self and opponent wins every battle

1. 2. * 3.
Submission Type Analyses* Strategy
A.
Symptoms LQQOPERA (Mass preservation law)
Quantitative ()
(Accounting rules)
B.
Signs Strategies ():
LQQOPERA 1) Systems
C. Non- 2) Anatomic
Quantitative
Abnoramal
3) Pathophysiologic
Quantitative 4) Pathologic
Lab tests

D. /(syndrome/disease (Guidelines)

* -

 24
2. (Problem Analysis)
Hong () LQQOPERA (Acronym) - History Taking

LQQOPERA 8
(L)
Location ()
Quality ()
Quantity/time course (/)
Onset mode ()
Precipitating or provocation factors ()
Exacerbating factors ()
Relieving factors ()
Accompanying symptoms ()
LQQOPERA: (The very old, singing Taiwan opera)
 / (Pain/Distress)
LQQOPERA 8
(Symptom analyses should include the following
8 items):
1. (Location)
(localized - somatic)
(diffuse visceral or diffuse somatic)
(migratory), (radiation) etc.
2. (Quality)
(needling), (sharp pain),
(dull ache), (oppressive),
(unbearable, excruciating) etc.
 / (Pain/Distress)
3. / (Quantity/Process)
(persistent)
(intermittent):
(frequency),
(duration of each episode),
(intervals between episodes)
4. (Onset mode)
(insidious) (sudden)(abrupt)
5. (Precipitating factors)
6. (Exacerbating or aggravating factors)
7. (Relieving factors)
8. (Accompanying symptoms)
 (,) (Abrupt/Dramatic Onset)

(abrupt onset) :
1) (neurogenic); or,
2) (sudden loss of tissue/organ
continuity) (for exampples)

(systems approach - examples)

1. Integument: laceration; 2. HEENT: subarachnoid hemorrhage
3. Respiratory: pneumothorax
4. CV: aortic dissection, rupture of aneurysm, (AMI)
5. GI: 1) Halo/solid organ rupture/perforation:
esophagus, stomach, intestines, spleen, liver
2) gall stone
6. GU: ureter stone, ectopic pregnancy, ovarian torsion
7. Musculoskeletal: tissue laceration, bone fracture,
tendon rupture
 / (Pain/Distress) -
(Exacerbating factors)

1) Body position/motion
Supine (), sitting up (), leaning (),
turning (), twisting () etc.
2) Tenderness ()
3) Coughing (), sneezing (), Inspiration ()
4) Food intake (), swallowing (),
defecation (), urination () etc.
5) Exercise
6) Emotional changes: anxiety (), rage etc.
7) Climatie change
 - LQQOPERA - (modification) 29
LQQOPERA 8,
In principle, alll 8 items are essential. For example,
1) / (analyses of pain/distress):
LQQOPERA 8 (all 8 items, essential)
2) (jaundice): *LQQOPERA
*L: skin, urine, sclerae, stool (color changes)
(for example): However, modification
is applied depending on problem characteristic, as follows
1) (dyspnea): QQOPERA ( L , omitted)
P P defines type of dyspnea (next slide)
2) (consciouness change):
QQOPERA ((L) , omitted)
3) (fever): QQA (3)
QQ fever pattern (as reference*)
*Not necessarily reliable because of drug interference
Drugs aspirin, acetaminophen, steroids, prior antibiotics etc..
Infant (inmature immuse system),
Immune compromised hosts; elderly, DM, chemotherapy
patients etc..
A (): To identify or Search for pathological focus or foci ()
in organ systems () and/or anatomic sites ()
 30
1. 2. * 3.
Submission Type Analyses* Strategy
A.
Symptoms LQQOPERA (Mass preservation law), or
Quantitative ()
(Accounting rules)
B.
Signs Strategies ():
LQQOPERA 1) Systems
C. Non- 2) Anatomic
Quantitative
Abnoramal
3) Pathophysiologic
Quantitative 4) Pathologic
Lab tests

D. /(syndrome/disease (Guidelines)

* -

 3. Problem Solving ()
A. (Quantitative problem)

(law of preservation), ()
(accounting rules) 1) (); 2)
3) ()

1) (source) 2) (distribution) 3) (out, loss)

Metabolized

Exogenous Destruction

Endogenous Loss

Excretion
 A. (Quantitative problem) (Anemia)

Means () in Problem solving

1) (History); 2) PE (); 3) (Lab tests)

Out/Loss () Hemolysis
Distribution
Source () ()
() Metabolized Extravascular
X ()

Destruction Intravascular
Endogenous
Intra- ()
Bone marrow
vascular
Hemorrhage
Exogenous Loss
()
X Internal ()
Transfusion Excretion
Normally External ()
if, indicated
intravascular
 A. (Quantitative Problem)
(Hypoalbuminemia)
Source ()
Protein Intake Distribution
Digestion* Out/Loss ()
Absorption ()
(amino acids)


Exogenous
(intravascular)

Endogenous Loss ()
Extra-vas GI tract; renal
Hepatic synthesis Renal
(from amino acids) GI tract
Skin
*Proteolytic enzymes: pepsin, chymotrypsin. trypsin (Burn, psoriasis)
 A. (Quantitative Problem)
(Hypokalemia)
Distribution Out/Loss ()
Source ()
() Metabolized
Intra-cellular

Destruction
> 98%
Exogenous
Oral intake Extra-cellular
Excretion ()
< 2% Renal
Endogenous
Loss ()
GI tract; renal

Acidosis Alkalosis; Insulin/glucose

Cell destruction Mineral corticoid; 2 agonist

Es = - KT x Ln ([Ki/Ko]) = - KT (150/4) = - 90 mV;

KT constant; [Ki/Ko], Ko change, critical, as Ki >> Ko
 TTPG (Transtubular Potassium Gradient)

TTPG = [KS/KU]/[OS/OU]
KS = serum potassium
KU = urine potassium
OS = serum osmolarity
OU = urine osmolarity
Renal K+ loss - TTPG > 7
______________________________________
Spot urine during hypokalemia
K+ > 20 meq/L suggests renal K loss
 36
1. 2. * 3.
Submission Type Analyses* Strategy
A.
Symptoms LQQOPERA (Mass preservation law), or
Quantitative ()
(Accounting rules)
B.
Signs Strategies ():
LQQOPERA 1) Systems
C. Non- 2) Anatomic
Quantitative
Abnoramal
3) Pathophysiologic
Quantitative 4) Pathologic
Lab tests

D. /(syndrome/disease (Guidelines)

* -



1. 2. * 3.

A.
LQQOPERA
()

Approaches ():
B. LQQOPERA 1) Systems
2) Anatomic
C.
3) Pathophysiologic

4) Pathologic

D. / (Guidelines)

* -


10
sites 10 systems in human body listing order

Cover whole body
1. Integument* *
2. HEENT** (including hairs and nails)

3. Respiratory

(chest) 4. Cardiovascular Top to down

5. Gatrointestinal
(abdomen) 6. Genitourinary 3/4; 5/6 - (order)
7. Hematologic (exchangable)
8. Metabolic/endocrine
(wide
distribution) 9. Muscloskeletal** **
9
10. Neuropsychiatric*
*
HEENT **
= head, eyes, ears, nose and throat 10
 (Chest Pain)
Systems Approach ()

1. Integument (skin, hair and nails) ()

2. HEENT ()
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
7. Metabolic and endocrine (/)
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
 (Abdominal Pain)
Systems Approach ()

1. Integument (skin, hair and nails) ()

2. HEENT ()
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
7. Metabolic and endocrine (/)
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
 (Retroperitoneal Structures)
1) Systems Approach ()

1. Integument (skin, hair and nails) ()

2. HEENT ()
3. Respiratory ()
4. Cardiovascular ()
5. Gastrointestinal ()
6. Genitourinary ( )
7. Metabolic and endocrine (/)
8. Hematologic ()
9. Musculoskeletal ()
10. Neuropsychiatry ( )
 42
(Headache)
Systems Approach ()

1. Integument
2. HEENT
3. Respiratory
4. Cardiovascular
(5 sytems) 5. Gastrointestinal
6. Genitourinary
7. Metabolic and endocrine
8. Hematologic
9. Musculoskeletal
10. Neuropsychiatry
 B. (Non-quantitative Problem) 43
1) Systems Approach ()

(Dyspnea)

QQOPERA 1. Integument (IT)

2. HEENT (HT)

3. Respiratory
4. Cardiovascular
5. Gastrointestinal (GI)
(5 sytems)
6. Genitourinary (GU)
7. Metabolic/endocrine*
*Hyperthyroidism 8. Hematologic**
**Anemia 9. Musculoskeletal (MS)
10. Neuropsychiatry
 - QQOPERA
P (Dyspnea classification, based on P)

1) Exertional (QOPERA)
Specify level of exertion and accompanying
symptoms (A), if any: wheezing, chest tightness
e.g. Three months before admission, the patient developed
non-progressive exertional dyspnea on 1 flight of stairs,
associated with chest tightness (QQOPERA)
2) Positional
Supine - orthopnea, PND
Lateral decubitus - trepopnea
Upright platypnea (Hepatopumonary stndrome liver cirrhosis )
3) Non-exertional/non-positional anytime, any setting
Asthma attack, acute pulmonary edema (any cause),
pulmonary embolism, pneumothorax
Neuropsychiatric disorder myasthenia, anxiety, panic disorder
 Trepopnea
Infrequent or Rare Positional Dyspnea
Dyspnea that is sensed while lying on one side but not
on the other. It results from respiratory (one lung, one
major bronchus), or cardiac disease (chronic CHF)
Respiratory
1) unilateral intrapulmonary disorders (e.g. destroyed
parenchyma, major airway obstruction)
Contra-lateral decubitus (dyspnea better on
good side down) because, bad-side down
increase in V/Q mismatch
2) Pleural effusion, massive (better, bad side down)
psi-lateral decubitus)
Chronic CHF - left decubitus (heart-side down, feeling better)
- Severely impaired LV filling - marked cardiomegaly
- better blood return, better cardiac output 45
 Part II
Anatomy of Respiratory Ventilation System
Computer controlled ventilation hardware
Central control system
Respiratory centers Cerebral cortex
Cerebral cortex
Nerves (wires)*
Neuromuscular junction Pons
(socket)
Medulla
Respiratory apparatus
(hardwares))
Thorax ()
Pleural cavity
Lungs parenchyma
Airways
*Spinal cord and its its motor
neurons to respiratory mucles
46
 Central Regulation of Breathing
(rate, depth and rhythm)
Feedback systems
Respiratory Centers Cerebral cortex

(Control rate, depth/rhythm )

1) Chemoreceptors
a) Central (medulla)
Pons
upper pons Pons
H+ sensor
pneumotaxic center Medulla
b) Peripheral
inhibits inspiration/ Carotid body
control rate pO2/pCO2 sensor
lower pons
apneustic center Aortic body
Medulla rhythm control pO2 sensor
---------------------------------- 2) Stretch receptor
(Cerebral cortex) Thorax
 Central Regulation of Breathing
(rate, depth and rhythm)
Feedback systems
Respiratory Centers Cerebral cortex

(Control rate, depth/rhythm )

1) Chemoreceptors
a) Central (medulla)
Pons
upper pons Pons
H+ sensor
pneumotaxic center Medulla
b) Peripheral
inhibits inspiration/ Carotid body
control rate pO2/pCO2 sensor
lower pons
apneustic center Aortic body
Medulla rhythm control pO2 sensor
---------------------------------- 2) Stretch receptor
(Cerebral cortex) Thorax
 3) Dyspnea, Anytime, Any setting

Anatomy of Respiratory
Ventilation System
Central control system Cerebral cortex

Respiratory centers
Cerebral cortex
Nerves (wires)* Pons
Dyspnea
Neuromuscular junction Medulla
(socket) Any time, Any setting
Respiratory apparatus Malfunction of any of
(hardwares)) following components:
Thorax () 1) Computer
Pleural cavity
programming system
Lungs parenchyma
Airways 2) Program transmission
*Spinal cord and its its motor 3) Hardware
neurons to respiratory mucles
Dyspnea of Acute Onset (seconds to hours)
1) Respiratory System
Airway resistance: functional (spasm): organic (obstruction)
Lung parenchyma:
Acute non-cardiogenic pulmonary edema
ARDS; flush pulmonary (renal artery stenosis),
noxious agents; high altitude
Pulmonary vasculature: acute pulmonary embolism
Pleural space: pneumothorax; hemothorax
Respiratory muscles: acute paralysis,
myasthenia crisis
2) Cardiovascular: acute cardiogenic pulmonary edema
3) Endocrine/metabolic
4) Hematology
5) Neuropsychiatric: Up-regulated respiratory drive
Hyperventilation (anxiety neurosis/panic disorder)
 B. (Non-quantitative Problem)
1) Systems Approach ()

(Consciousness Disturbance)*
(analysis) 1. Integument
QQOPERA 2. HEENT
(strategy) 3. Respiratory
(systems) 4. Cardiovascular
5. Gastrointestinal
(3 sytems) 6. Genitourinary
7. Metabolic/endocrine
* (analog)
Engine dysfunction 8. Hematologic
9. Musculoskeletal
(automobile/motor cycle)
10. Neuropsychiatry
 (Consciousness Disturbance)
Systems Approach ()
(analysis): Q QOPERA
(): Alert/well oriented; irritable; agitated; drowsy; somnolent;
confused; stupor; obtunded; semi-comatous; comatous
- Systems approach
1) (Neuropschiatry)
()
2) (Cardiovascular) >0
(shock) mannitol, contrast media,
3) / (metabolic encephalopathy ethanol, methanol etc
Ph changes; low pO2; high pCO2; hyper-, or hypo-osmolarity
Osmolarity () = 2Na+ + glucose/18 + BUN/2.8 + (> 0)
(Na+), (Ca++)
(DM): (hypoglycemia); HHS; ketoacidosis
(myxoedematous coma)
Analog - Engine malfunction*
Endogenous chemicals {hepatic/renal failure);
1) Mechanical
Exogenous chemicals (drugs,alcohol, CO etc) 2) Gasoline shortage (quantity)
3) Changes in gasoline quality
 3. Problem Solving ()
B. (Non-quantitative problem)

, (strategy or approach)
2, ,

1) Systems approach ()
2) Anatomic approach ()
3) Pathophysiologic approach
()
4) Pathologic approach ()
 B. (Non-quantitative problem)
2) Anatomic Approach ()

Used in conjunction with, or as an auxiliary ()

strategy to Systems Approach

For examples:
Pain/distress,
Chest pain; abdominal pain etc.
Fever
Lesions ()
Palpable lesions (PE)
Abnormal lesions (imaging tests)
 B. (Non-quantitative problem)
2) Systems/Anatomy Combined Approach
(Chest Pain) 1. Integument
2. HEENT
: LQQOPERA 3. Respiratory
4. Cardiovascular
: 5. Gastrointestinal
6. Genitourinary
Systems 7. Metabolic/endocrine
8. Hematologic
approach
9. Musculoskeletal
10. Neuropsychiatric
Anatomic
approach Downwards - abdomen
Upwards - neck

?Any bad neighbors (?)

upstairs ()? Downstairs ()?
 B. (Non-quantitative problem)
1) Systems and 2) Anatomic Approach

Problem: Chest pain ();

Analysis (): LQQOPERA
Strategy (): Bad neighbors downstairs? (?)
1. Integument
2. HEENT GERD
3. Respiratory
Mallory Weiss syndrome
4. Cardiovascular
Boerhaave's syndrome
5. Gastrointestinal
Peptic ulcer
6. Genitourinary
7. Metabolic/endocrine Acute cholecystitis
8. Hematologic Acute pancreatitis
9. Musculoskeletal
10. Neuropsychiatry Esophageal
tears
Abdomen
 B. (Non-quantitative problem)
1) Systems and 2) Anatomic Approach
1. Integument
Problem: abdominal Pain ()
2. HEENT
Analysis (): LQQOPERA 3. Respiratory
Strategy (): 4. Cardiovascular
5. Gastrointestinal
Combined 6. Genitourinary
7. Metabolic/endocrine
8. Hematologic
Systems 9. Musculoskeletal
approach 10. Neuropsychiatry

Upwards chest
Anatomic Downwards inguinal
pproach hernia, testis torsion
?Any bad neighbors (?)
upstairs ()? Downstairs ()?
 B. (Non-quantitative problem)
1) Systems and 2) Anatomic Approach

Problem: abdominal Pain ()

Analysis (): LQQOPERA
Strategy (): Bad neighbors, upstairs? (?)
1. Integument Pneumonia (esp. lower lobe
2. HEENT
3. Respiratory
Myocardial ischemia (angina, AMI)
4. Cardiovascular
Aortic dissection
5. Gastrointestinal
Right heart failure congested liver
6. Genitourinary
Boerhaave's syndrome
7. Metabolic/endocrine
8. Hematologic
Mallory Weiss syndrome
9. Musculoskeletal
Boerhaave's syndrome
10. Neuropsychiatric
Chest
 B.
3) Pathophysiologic Approach ()
- Edema ()
Definition - Excessive accumulation ()
of water/Na+ in interstitial tissues ()
Analyses - LQQOPERA
Solving pathophysiologic approach
1) Excessive extravasation (
)
a) Hydrostatic pressure ()
b) Colloid oncotic pressure (albumin)
quantitative problem
c) Capillary permeability ()
[a), b) and c) variables in Starlings equation]
2) Impaired drainage lymphedema ()
 B. -
(description of metal status): Cerebral hemispheres
QQOPERA

(): alert; well oriented; irritable;

agitated; drowsy; somnolent; confused;
stupor; obtunded; comatose *ARAS

(consciousness)
1) (basic) - (arousal)
External
(brainstem) *ARAS stimuli

2) (high level) - (awareness) Pearson education Inc. 2003

(hemispheres)

pathophysiology: organic or functional dysfunction

Organic: brainstem (small lesion); cerebral hemispheres (diffuse)
Functional: brain stem (diffuse); cerebral hemispheres (diffuse)
arousal, ( brain death)
arousal, diffuse dysfunction ()
*ARAS = ascending reticular activating system)
 B. (Non-quantitative Problem)
4) Pathologic Approach ()

1) Infectious (inflammatory) ()
2) Non-infectious (inflammatory) ()
3) Neoplasm ()
Benign ()
Malignant ()
(primary) (metastaatic)
4) Circulatory ()
5) Metabolic/endocrine (/)
6) Hematologic ()
7) Degeneration()
8) Physical/chemical injury (/)
 B. (non-quantitative Problem)
4) Pathologic Approach ()

1) Infectious (inflammation) Applications

2) Non-infectious (inflammation)
1) Lesion
3) Neoplasm by PE, Imaging tests
Benign 2) Specimen
Malignant (primary, metastatic) by biopsy, surgery etc.
4) Circulatory 3) Others
fever
5) Metabolic/endocrine
structural
6) Hematologic abnormality etc..
7) Degeneration
8) Physical/chemical injury
B. (Non-quantitative Problem)
4) Pathologic Approach ()

1) Infectious (inflammatory)
2) Non-infectious (inflammatory)
3) Neoplasm
Benign
Arthropathy Malignant
Joint diseases 4) Circulatory
5) Metabolic/endocrine
6) Hematologic
7) Degeneration
8) Physical/chemical injury
 B. Non-quantitative Problem
4) Pathologic Approach
Elevated
Body temperature 1) Infectious (inflammatory)
() 2) Non-infectious (inflammatory)
3) Neoplasm
1) Fever ()
Set point elevation Benign
in hypothalamus Malignant
2) Hyperthermia
Heat dissipation <
4) Circulatory
Production* or 5) Metabolic/endocrine
acquisition** 6) Hematologic
*Endogenous
Hyperthyroidism 7) Degeneration
**Exogenous 8) Physical/chemical* injury
heat stroke, fire
* Always consider inclusion of drugs
, fire
 B. (Non-quantitative problem) 57
Combined/Sequential Approaches

(Chest Pain)
1. Integument
: LQQOPERA 2. HEENT
Strategy (): [1) + 2)] + 4) 3. Respiratory
4. Cardiovascular
5. Gastrointestinal
6. Genitourinary
7. Metabolic/endocrine
1) Systems 8. Hematologic
approach 9. Musculoskeletal
10. Neuropsychiatry
4) Pathologic
approach Downwards - abdomen
2) Anatomic
Upwards - neck
approach
?Any bad neighbors (?)
 B. (Non-quantitative problem)
Combined/Sequential Approaches

(abdominal Pain) 1. Integument

2. HEENT
: LQQOPERA 3. Respiratory
4. Cardiovascular
: Step I. 1) + 2) 5. Gastrointestinal
6. Genitourinary
7. Metabolic/endocrine
1) Systems 8. Hematologic
Step II 4)
approach 9. Musculoskeletal
10. Neuropsychiatry
4) Pathologic
Upwards chest
approach 2) Anatomic
Downwards inguinal
approach hernia, testis torsion
?Any bad neighbors ()
 Combined/Sequential Approaches
Fever () -
: QQOPERA
: [1 + 2] + 4 1
Bingo! 4
2
1) Systems

Lesion
2) Anatomic Focus 4) Pathologic
()

Combined 2) Sequential
 Combined/Sequential Approaches
/ (pain/distress), e.g. abdominal pain

: ,
: LQQOPERA 1
: [1 + 2] + 4 4
Bingo! 2
1) Systems

Lesion
2) anatomic 4) Pathologic
()

Combined Sequential
 Combined/Sequential Approaches
Abnormal Lesion on Imaging test
(e.g. chest X-ray, ultraound, CT, PE etc)

: Lesion analyses
: [1 + 2] +4 1
4
Bingo! 2
1) Systems

Lesion
2) anatomic 4) Pathologic
()

Combined Sequential
 Sequential Combined Approaches
(Consciousness Disturbance)

:
1) Neuro-
QQOPERA (Solving)
psychiatry
Cerebral
1) 2) 4) 2) CV system
hemispheres Or 3) Endocrine/
metabolic
3) 2) 4)

3.Patho-
Or 1.Systems
pysiology

Lesion
4.Pathologic 2. Anatomic
()
 Problem Solving - Combined Approaches
Obstruction of Tubular Structure

Pathophysiologic Pathologic
Approach approach
Functional ()
Organic ()
Pathologic
Systems approach
Anatomic approach
Approach
() Anatomic
Intraluminal () approach
Mural () Lesion
Extraluminal
()

1. 2. * 3.
Submission Type Analyses* Strategy
A.
Symptoms LQQOPERA (Mass preservation law), or
Quantitative ()
(Accounting rules)
B.
Signs Strategies ():
LQQOPERA 1) Systems
C. Non- 2) Anatomic
Quantitative
Abnoramal
3) Pathophysiologic
Quantitative 4) Pathologic
Lab tests

D. /(syndrome/disease (Guidelines)

* -

 (HTN) (Evaluation Guidelines)

1) (Hypertension per se)

(detected, when/how) (severety
staging) (past treatments)
(effectiveness: side effects) current medications
2) (Etiology)
(essential) (secondary) 1)
3) (Complications) 2)
: : 3)
: aortic dissection

4) (Associated risk factors)
(DM) (smoking) (hyperlipemia) etc.
5) (Co-morbidity)

(beta-blockers);
(alpha-blockers); hyperuricemia, gout thiazide
 (DM) (Evaluation Guidelines)
1)

2) 12 (drugs, e.g.
steroids)
3) (Complications?)
(acute)DKAHHS (HHNK)
(chronic): Microangiopathy:
Macroangiopathy: CAD, CVD, (PAOD)
4) (
)
5) (co-morbidity):
-blockers;
- blockers;
-blockers


1) ()
2) (etiology)
3) (Complications)
1. - hypovolemia,
2. - anemia
4)
e.g. tendency, drugs (NSAID, anticoagulants,
anti-platelets, etc)
5) (Co-morbidity)
Liver cirrhosis hepatic encephalopathy
CAD acute coronary syndrome
CKD acute renal failure
Precipitation?
 76
(Lung cancer) (Evaluation Guidelines)
1) (lung cancer per se)
(TNM, stage)
current medications and last date of C/T
2) (Etiology)
(pathological classification) (gene mutation)
3) (Complications)
(local): ///
(metastasis): (bone) (brain) (liver)
Paraneoplastic syndrome: (hyponatremia)(Eaton
Lambert Syndrome - SCLC) (hypercalcemia -SqCC)DVT
(AdC) etc.
4) (Associated risk factors)

5) (Co-morbidity)
(Cisplatin)()
(Taxol)
76