2017/4/27

6935211

1

1

1

415
185

5 1000

1 14
151
1
1
2

416
1

47
194
50

47
7 80

2
7
14 3
45 Sz 1
Twitter
http://www.danshihack.com/2014/01/27/junp/twitter_yoku

wakaru.html

dr.kenta.sato@gmail.com http://todo-ran.com/
104 55 199 3

WebSNS
NPO

10530 IT

etc.
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

1
 2017/4/27

3













SO

AP

POS
Problem Oriented System
POS
SOAP


AP

SOAP /



SOAP

http://kensankai.lolipop.jp/pukiwiki/

2
 2017/4/27

2015614

18 O-124 140

120
100
10 31%
80

60

40

20

0
3 6 9 12 15 18 21 24

2.1SD0.8
160
140 35
120
100

80
60 1
40

GPMEC 20
0

1 2

Simple, Complicated, Comprex, Chaotic

3 4

160

140
10 56)
120
100

Problem Oriented System

80

60

40
1 1
20 SOAP
0
0 5 10 15 20 25 30 35 40 45 50 55 60


100

50
0
1 2 3 4 5 6 7 8 9

1.5SD0.6)
200
175

100
0
1 2 3 Google
https://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05
Light, Medium, Heavy

3
 2017/4/27

0


3 1
Multimorbidity
2

Semantic qualifier : SQ
Complexity Brief title
3

ACCCC
SOAP
4

Multimobidity
10
20
#1.


#2.



#3.

22

4
 2017/4/27

#1.
10 7/10
#1. #2.

#2. #3.
#3. #4. OA
(-)(-)
5 (-) #5.
CKD
#6.
ACE-I #a.
#7.
#b.
#8.
#c.
S3(+)
#9.
TV1-4ST
#10.

Complicated/MediumOrgan/Frail COPD


CHF/OMICOPD

IADL
OA
Complex/HeavyCollagen/Mental/Metabo.+Malig
OA

)



14

Complex/MediumMallig./Mental/Family




ACP DNAR

5
 2017/4/27

Simple
SimpleComplicatedComplexChaotic 11 30
A.
B.

Complicated Complex Chaotic

70

60 40
AKI DMDLNAFLDHCV

RADM









1

MaintenanceCrisis

6
 2017/4/27

Brief title
Opning statement
SOAP
Simple



SOAP
Complicated
By ploblem





Complex

Chaotic

Brief title Brief title

SimpleComplicatedComplexChaotic Complex/moderateFrail Organ13282
4
OA

LightMediumHard CHF(HFrEF AHA stage2)

LDL
AUDIT
Risk( Organ( ) Mental( )
Complicated/LOrgan+Disability142

ACP

ACP
Closed question

7
 2017/4/27

ACCCC
or


Access

Watchful waiting

Comprehensive


Context



Continuity Next plan
2017/04/27


Coordination

QOL

P


Tx
Dx
(OPQRST)
Ex
Review of Systems
Px

Next Plan

8
 2017/4/27

ACCCC
OGeneral appearance:
A


IBS

S S
PTxDxEx

Next plan
O

A P S+O
Tx
IBS Dx 5

Ex
5
IBS Brief summary

Next plan





Next plan

9
 2017/4/27

http://www.igaku-shoin.co.jp/paperDetail.do?id=PA02985_05

http://www.nanzando.com/journals/chiryo/

10
 2017/4/27

SOAP
Review of systems

Subjective

S

3
O

(OPQRST)
etc
Review of Systems

11
 2017/4/27

EBM S S

78
15
10HbA1c7
eGFR60

COPD



Review of systems

5 mg 15 mg 1
750mg32mg2

710
http://spell.umin.jp/EBM.htm



700 mL2060
2
ROS(-)(-)(-)
ADL 60

or O

General appearance
A
B RR SpO2
CBP PR



DJCS GCS
E BT


HEENT
Chest

Abd
Objective Ext
Neuro.

Xp
Vasc. CT
MRI

12
 2017/4/27

O General appearance

Ns


GoodSosoBad

General appearance
First impressionABCD

Vital signs
Head to Toe
BMJ
https://www.facebook.com/journalofI/posts/287005368067429

https://www.jstage.jst.go.jp/article/generalist/35/4/35_299/_article/-char/ja/

O O

Pertinent


General appearance General appearance
A
JCS0BP9456PR96RR26 SpO2 92%R/ABT36.8
B RR SpO2

CBP PR
DJCS GCS

S3(+)(-)
Pertinent positive
E BT
(-)(-)(-) Pertinent negative
(+)
HEENT
Chest
Non-pertinent positive Jolt
Abd BUN20.1Cr1.23T Non-pertinent negative Kernig
Ext
Xp PVCHR90V1-4ST
Neuro. XpCTR55
Vasc. CT Non-pertinent
MRI
Pertinent negative

13
 2017/4/27

A A
#1.

Brief summary
Brief summary

Probable
Less likely
Ruled out

Assessment

Brief summary A
#1.
Opening statement I think ~~~, because Brief summary

SO
SOData Probable
STT
Warrant Less likely

Pertinent STEMI(2013) Ruled out

30 definite probable possibleless likelyunlikely
ruled out


S/O R/O

14
 2017/4/27

A


SOAP
#1ACS
SO
Brief summary

30

Definite
Less likely

AP
AHASTEMI

#2
Plan

ACS
ACS

P
P

Assessment
Tx Tx


Dx
Dx
Ex
Plan
Ex
Px 52319

Px

15
 2017/4/27

P

Air way
Breathing
7 Tx
ABG
Circuration
Blood Dx
Dysfunction of CNS

CXR
Environment Dextor Ex

Infection P&C ECG
Insulin & Nutrition FAST & FEER Px
Ion & fluid Gram
Rest or Rehabilitation

P

SOAP

PCI
Tx20mg550mL4mL/ CVA

100mg275mg4

Dx
ECGSpO25

Ex IE

PxACE
UpToDate


Fever work-up
MRI

16