Lee HC, et al., Test Panel Based on Chief Complaint 445 이에저자들은처음병원을방문한환자들을대상으로주요호소증상에따라임상의들이의뢰하는검사종목의종류와빈도를조사하고, 환자들이흔히호소하는주요호소증상에따라패널검사를구성하는것을제안하여보았다

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1 Korean J Lab Med 2010;30: DOI /kjlm Original Article General Laboratory Medicine Proposal of Laboratory Test Panel Based on Patients Chief Complaints in Emergency Department Hyun Chul Lee, M.D. 1, Yu Kyung Kim, M.D. 1, Jung Hup Song, M.D. 2, and Kyung Eun Song, M.D. 1 Department of Clinical Pathology 1, Kyungpook National University School of Medicine, Daegu; Department of Occupational Medicine 2, Kyungpook National University Hospital, Daegu, Korea Background : A test panel is a group of tests that are simultaneously performed for diagnosis and follow-up of patients. Organ-specific or disease-specific test panels are currently available. Since the patient s chief complaint plays a key role in obtaining the personal and medical history and performing physical examinations, we proposed a test panel based on the chief complaints of the patients. Methods : We collected data from 3,127 adults with apparent symptoms who visited the emergency department from April 2009 to May Subsequently, we classified the patients chief complaints, ordered the laboratory tests on the basis of these complaints, considered the patients disease entities, and reviewed the relevant literature. Results : The patients were categorized into 14 groups on the basis of the most common chief complaints presented in the emergency department. We first selected the basic test panels and then organized the test panel for each chief complaint to enable differential diagnosis. Conclusions : We proposed test panels based on the chief complaints of the patients; these test panels could allow rapid diagnosis and be more useful than the organ-specific or disease-specific tests in critical pathway development. The next step will be evaluating the efficiency and cost effectiveness of the test panel that we suggested. (Korean J Lab Med 2010;30:444-50) Key Words : Test panel, Chief complaint, Critical pathway 서 패널검사란각질환별로진단및치료전후의환자상태를판정하기위해서기본적으로필요한진단의학검사이며, 이를기본으로하여개별환자의상황에따라필요시다른검사들을추가하거나생략할수있고, 반복검사를시행할수있다 [1]. 이는자동화검사기기의발전과더불어검사를효율적으로이용하고특정질환을보다용이하게선별하기위해많이이용되고있다. 미국의학협회에서는 9가지의장기별혹은질환별패널검사를 Received : March 24, 2010 Manuscript No : KJLM Revision received : May 11, 2010 Accepted : July 21, 2010 Corresponding author : Kyung Eun Song, M.D. Department of Clinical Pathology, Kyungpook National University School of Medicine, 101 Dongin-dong 2 ga, Jung-gu, Daegu , Korea Tel : , Fax : kesong@knu.ac.kr ISSN 론 The Korean Society for Laboratory Medicine 승인하고있으며 [2] 다른여러기관에서도선별검사의목적으로또는질환을찾기위해패널검사를추천하고있다 [3-5]. 올바른진단과치료계획을수립하기위해환자를대하는첫단계에서가장중요한것은현재의증상과과거병력을정확히파악하고이에따라신체검사를하는것이다. 이때병력청취와신체검사 (physical examination) 의방향을제시하고진단의학검사를의뢰하는중요한단서가되는것이바로환자가호소하는주요호소증상 (chief complaint) 이다. 주요호소증상을바탕으로의뢰한검사결과에따라서초기진단을추정하고치료를시작할수있다. 현재추천되고있는패널검사는장기별혹은질환별로관련된검사종목으로이루어져있다. 하나의주요호소증상이특정장기나한가지질병에국한되는것이아니므로 [6] 이러한패널검사를적용할경우검사가오히려중복되거나혹은빠트리는경우도생겨의심되는질환을놓칠수있게되므로저자들은주요호소증상에따른패널검사의필요성을생각하게되었다. 444

2 Lee HC, et al., Test Panel Based on Chief Complaint 445 이에저자들은처음병원을방문한환자들을대상으로주요호소증상에따라임상의들이의뢰하는검사종목의종류와빈도를조사하고, 환자들이흔히호소하는주요호소증상에따라패널검사를구성하는것을제안하여보았다. 재료및방법 2009년 4월부터 5월까지본원응급실을방문한환자중에서이미진단을받았거나타병원에서전원된경우, 또한치료후추적관찰중인환자들을제외하고, 비교적뚜렷한한가지주요호소증상을호소한성인환자 3,127명 ( 남자 1,652명, 여자 1,475 명 ) 을대상으로하였다. 환자들의주요호소증상을파악하고응급실내원당시처음에의뢰된진단의학검사종목과추가로의뢰된검사종목및최종진단명을조사하였다. 먼저검사가의뢰된빈도와여러문헌 [1-5] 을참고하여기본패널검사종목을우선적으로선정하였고, 최종진단된질병과감별해야할질병에따라반드시필요하다고생각되는검사들을추가하여주요호소증상별패널검사를구성하였다. 주요호소증상의분류는통계청에서발행한한국표준질병사인분류에따랐다 [7]. 결 1. 응급실을방문한환자들이흔히호소하는주요호소증상 응급실을방문한환자들의주요호소증상을조사한결과총 44 개의주요호소증상을파악하였고이중환자수가많은경우를우선으로 14개의주요호소증상군을선정하였다 (Fig. 1). 이들이많이호소한주요호소증상을빈도순으로보면, 급성 Abdominal pain 21.9% Fever 15.1% Chest pain Respiratory distress Headache Weakness Confusion/syncope/coma Cough/hemoptysis Dizziness/vertigo Hematemesis/hematochezia/melena Back pain 9.5% 8.8% 7.8% 7.4% 5.8% 4.7% 4.6% 3.2% 3.1% Nausea/vomitting 3.0% Seizure 2.7% Abdominal swelling/ascites 2.3% Fig. 1. The 14 most common chief complaints presented in the emergency department. 과 Number of patients 복통이 21.9% 로가장많았고그다음으로는고열로 15.1% 의환자가호소하였다. 이어서가슴통증, 호흡곤란, 두통, 전신쇠약, 의식장애 / 실신 / 혼수, 기침 / 객혈, 어지러움, 토혈 / 혈변배설 / 흑색변, 요통, 구토 / 구역, 간질경련, 복부팽만 / 복수순이었고설사, 황달, 출혈경향, 혈뇨등도소수있었다. 2. 주요호소증상별로의뢰된진단의학검사종목과빈도주요호소증상별로응급실로내원당시에의뢰된진단의학검사종목과빈도를보면, 감별혈구계산을포함한혈구수측정 (complete blood cell count with differential count, CBC with diff), 혈액요소질소 (blood urea nitrogen, BUN) 와크레아티닌 (creatinine, Cr), 나트륨 (Na) 과칼륨 (K), 총단백 (total protein, TP), 알부민 (albumin, alb), 총빌리루빈 (total bilirubin, T-bil), AST, ALT, 알칼리인산분해효소 (alkaline phosphatase, ALP) 등간기능검사 (liver function test, LFT) 6종목, 소변검사, 혈당, 반응성 C-단백 (C-reactive protein, CRP) 등은각주요호소증상별환자의 75% 이상에서의뢰되었고, 그밖에적혈구침강속도 (erythrocyte sedimentation rate, ESR), 혈액응고검사 (prothrombin time, PT/activated partial thromboplastin time, aptt), 칼슘 (Ca) 과인 (P), 요산 (uric acid) 등은 30% 이상에서의뢰되었다 (Table 1). 이외에각주요호소증상별로내원당시에 50% 이상의뢰된종목과추가로의뢰된검사들은 Table 2와같다. 3. 기본검사선정주요호소증상별로의뢰된검사종목과빈도를바탕으로, 90% 이상의환자에서의뢰되고있는검사종목을패널검사에포함되어야할기본검사로우선선정하였다 (Table 3). 이들은 CBC with diff, LFT 6종 (TP, alb, AST, ALT, T-bil, ALP), 혈당, BUN/Cr, Na/K, CRP, PT/aPTT, 소변검사와 Ca/P이다. 4. 주요호소증상별환자의진단명기본검사외에패널검사에포함되어야할종목을선정하기위해주요호소증상별로환자들의최종진단을조사해보았다. 모두열거하기가어려우므로대표적인 3가지주요호소증상에대해언급하면, 급성복통환자에서는진단명이매우다양하였는데장기별로보면간담도계질환 25%, 위장관계질환 21%, 췌장질환 9%, 비뇨생식계질환 8%, 복부외의원인으로인한연관

3 446 Korean J Lab Med 2010;30: Table 1. Laboratory test ordering done on the basis of chief complaints (%) Test items Chief complaints N CBC with diff BUN/ Cr Na/K LFT* UA/ Sedi Glucose CRP ESR PT/ aptt Ca/P Uric acid GGT D-bil Abdominal pain Fever Chest pain Respiratory distress Headache Weakness Confusion/ syncope/coma Cough/hemoptysis Dizziness/vertigo Hematemesis/ hematochezia/melena Back pain Nausea/vomiting Seizure Abdominal swelling/ ascites *LFT: assessment of total protein, albumin, total bilirubin, AST, ALT, and alkaline phosphatase. Abbreviations: N, number of patients; CBC with diff, complete blood cell count with differential count; BUN/Cr, blood urea nitrogen/creatinine; LFT, liver function test; UA/Sedi, urinalysis/sediment; CRP, C-reactive protein; ESR, erythrocyte sedimentation rate; PT/aPTT, prothrombin time/activated partial thromboplastin time; GGT, g-glutamyl transferase; D-bil, direct bilirubin. 통증이 2%, 그외비특이적인경우가 33% 나되었다. 고열의경우는감염이역시 56% 로가장많았는데감염원은다양하였고 14% 에서는악성종양으로인해고열을호소한경우였다. 가슴통증을호소한환자에서는기시부가심장인경우가 57%, 폐인경우가 15%, 위장관인경우도 2% 나되었다. 나머지 11개의주요호소증상에대해서도환자들의최종진단을확인하여검사종목선정의자료로이용하였다. 5. 주요호소증상별패널검사선정임상의들이의뢰한검사종목과빈도, 최종진단과감별하여야할진단, 여러문헌들 [1-5, 8, 9] 을종합하여주요호소증상별패널검사를선정하였다 (Table 4). 고찰잘구성된패널검사를시행하면개별검사를의뢰할때보다더많은정보를한꺼번에얻을수있어환자의내원횟수를줄일수있고따라서그만큼의료비용을낮출수있게된다 [10]. 그러나패널검사로묶여있는종목들을한꺼번에의뢰함으로써자칫불필요한검사를남용할수도있고의료보험지급에서도 문제가있을수있다. 또한패널검사를구성하는종목을신중하게선택하는것이유용한결과를얻거나잠재해있던질병을발견하는데있어비용효율을높일수있다고하였다 [11, 12]. 일본임상병리학회에서는진단의학검사종목으로구성된필수진단검사 (1) 패널외에도흉부및복부방사선검사, 심전도검사등을포함한필수진단검사 (2) 패널을정하여필요한경우초기진단을빨리내릴수있도록하고있다 [4]. 저자들의연구에서도환자가처음병원을방문하였을때조기진단에도움을주고자주요호소증상에따른패널검사를제안하였는데, 진단의학검사뿐만이아니라필수적인방사선검사도함께패널에구성되어궁극적으로는진료계획표 (critical pathway) 를만드는것이중요한목표라고생각된다. 특히촌각을다투는응급실에서는진료계획표를확립하는것이더욱필요한일이다. 이번연구에서는외래를방문한환자들은포함하지않았다. 본원은 3차의료기관이므로외래를방문한환자들은이미 1, 2 차의료기관에서어느정도의임시진단을가지고오는경우가많고, 하나의주요호소증상을중심으로하여진단에접근하는데도움을주는패널검사를제안함에있어우선은응급실환자를대상으로하는것이일차적으로저자들의연구목적에더부합했기때문이다. 그러나응급실환자를대상으로하였기때문에본연구에서선정한주요호소증상이급성증상에국한되었고

4 Lee HC, et al., Test Panel Based on Chief Complaint 447 Table 2. Additional tests ordered, other than those in table 1 Chief complaints Tests ordered, other than those in table 1, at visit Additional tests Test items (%) Test items (%) Abdominal pain Amylase/lipase 73.0 Blood culture 30.4 Fever Blood culture Chest pain CK-MB/Troponin I 87.6 NT pro-bnp 64.0 Blood culture 73.2 ABGA 73.2 Respiratory distress NT pro-bnp 58.5 CK-MB/Troponin I 54.9 LDH 50.0 Headache CK-MB 64.4 Weakness CK-MB/Troponin I 71.0 Blood culture 21.7 Ca/P/Uric acid 21.7 Confusion/syncope/coma CK-MB/Troponin I 85.2 ABGA 81.5 Amylase/lipase 57.4 NH Cough/hemoptysis ABGA 75.0 Blood culture 70.5 D-dimer 65.9 LDH 61.4 PB smear 61.4 Respiratory specimen study* 61.4 NT pro-bnp 59.1 Procalcitonin 59.1 Dizziness/vertigo CK-MB/Troponin I 58.1 Ca/P/Uric acid 20.9 Lipid study 18.6 Hematemesis/hematochezia/melena NH Cross Matching 26.7 Back pain CK-MB/Troponin I 72.4 ABGA 65.5 Seizure NH ABGA 92.0 Ionized calcium 80.0 Abdominal swelling/ascites Amylase/lipase 61.9 Ascitic fluid study 38.1 *Respiratory specimen study: wet smear, Gram stain, acid-fast bacilli (AFB) stain, AFB culture, potassium hydroxide mount, and culture for fungal growth; Lipid study: total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglyceride; Ascitic fluid study: albumin, cell count, glucose, LDH, protein, wet smear, Gram stain, culture for fungal growth, AFB stain/culture, and KOH mount. Abbreviations: CK-MB, creatine kinase-mb; NT pro-bnp, N-terminal pro-b-type natriuretic peptide; ABGA, arterial blood gas analysis; LDH, lactate dehydrogenase; PB smear, peripheral blood smear. Table 3. included in the panel CBC with diff LFT (TP/alb/T-bil/AST/ALT/ALP) UA/sedi Coagulation test (PT/aPTT) Na/K BUN/Cr CRP Glucose (blood/serum) Ca/P Abbreviations: CBC with diff, complete blood cell count with differential count; LFT, liver function test; TP, total protein; alb, albumin; T-bil, total bilirubin; ALP, alkaline phosphatase; UA/sedi, urinalysis/sediment; PT/ aptt, prothrombin time/activated partial thromboplastin time; BUN/Cr, blood urea nitrogen/creatinine; CRP, C-reactive protein. 외래에서볼수있는만성적증상들은제외되었다는제한점을가지게되었다. 또한특정한주요호소증상을호소하더라도일시적이거나진단과의직접적인관계규명이어려운경우들도포함되어있었다. 앞으로는이번연구에서제안한패널검사를처음방문하는외래환자들을대상으로적용하여그타당성을검토하고, 만성적인증상을호소하는주요호소증상에대해서도패널검사를구성해볼필요가있다고생각한다. 이번연구자료를분석해보면, 내과계열에서는환자의주요호소증상에비특이적인검사도의뢰하는경우가많았다. 특히호흡곤란이나기침 / 객담 / 객혈이주요호소증상인환자들에대해의뢰되는검사종목이가장많았는데, 물론감별진단을위해필

5 448 Korean J Lab Med 2010;30: Table 4. Proposed test panel based on patients chief complaints Chief complaints Essential test panel Extended test panel Abdominal pain * b-hcg (women of child-bearing age) Direct bilirubin Amylase/lipase Fever HIV antibody Blood smear Body fluid study (stain, culture, and chemistry) Blood/urine culture Chest pain Lipid study CK-MB/Troponin I (or Troponin T) Myoglobin NT pro-bnp (or BNP) D-dimer Respiratory distress Thyroid function test ABGA D-dimer Headache Lipid study CSF study Weakness Lipid study Uric acid CK-MB/Troponin I (or Troponin T) Confusion/syncope/coma Direct bilirubin ABGA GGT CSF study NH3 Osmolality Cough/hemoptysis Sputum culture/stain/cytology D-dimer Dizziness/vertigo CK-MB/Troponin I (or Troponin T) Aldosterone Hematemesis/hematochezia/melena Fecal occult blood Fecal leukocyte count Back pain Nausea/vomiting ABGA Amylase/lipase Direct bilirubin Seizure Abdominal swelling/ascites NH3 Uric acid Toxicology (alcohol, drug screen) CSF study Ascitic fluid study Direct bilirubin GGT Amylase/lipase Uric acid *: Refer to Table 3; Lipid study: Refer to Table 2; CSF study: culture, Gram stain, and cell count; Ascitic fluid study: Refer to Table 2. Abbreviations: b-hcg, b-human chorionic gonadotropin; CK-MB, creatine kinase-mb; NT pro-bnp, N-terminal pro-b-type natriuretic peptide ; BNP, B-type natriuretic peptide; ABGA, arterial blood gas analysis; GGT, g-glutamyl transferase. 요한검사종목도포함되어있었지만비특이적인검사로인해검사시간이지연되고환자의부담이증가되는것이문제점이라할수있다. 또한외과계열에서는환자의주요호소증상에꼭필요한진단의학검사보다는영상의학검사에의존하여검사에 대한정보와이해가부족하다는것을알수있었다. 저자들이패널검사를구성하는기본검사를선정할때선정한 14개의주요호소증상에서 90% 이상의환자를대상으로의뢰되는항목으로구성하였다. 이들은 CBC with diff, LFT 6종,

6 Lee HC, et al., Test Panel Based on Chief Complaint 449 BUN/Cr, Na/K, CRP, PT/aPTT, 혈당, 소변검사와 Ca/P 등이었으며, 다음으로의뢰빈도가높은검사종목들은 ESR, 요산, 직접빌리루빈등이었다. 일본임상병리학회에서언제어디에서나필요한필수진단검사 (1) 패널로소변검사 3종, ESR과 CRP, 백혈구수, 적혈구수, 혈색소와헤마토크리트등의혈액검사, 총단백, 알부민등의화학검사를정하고, 입원할경우나외래를첫방문한환자의임상적평가를위해필요한경우에필수진단검사 (2) 패널로많은검사들을제시하고있다 [4]. 저자들의경우에도기본검사에 ESR을포함할것인가에대해고민이많았지만, ESR은결과에영향을미치는간섭인자들이많아특이도가낮고 CRP로충분히염증이나감염뿐만아니라심혈관질환등환자의급성상태를파악할수있으며, 기본검사는되도록최소한의검사로구성하고각주요호소증상에맞게필요한검사를추가하는것이좋을것으로생각하여포함하지않았고, 주요호소증상별패널검사를제안함에있어서도이번연구에서검사종목의진단적효율성을검토하지못하고, 현재의처방빈도와이미많은증거로확인되어교과서 [8] 등의문헌에실린검사들을위주로선정하였다. 또한감별해야할질환들을충분히고려하여패널검사종목을선정해야하는데, 질환에대한국내의유병률에관한체계적인자료가마련되어있지않아부득이외국자료를사용할수밖에없다는것도한계점이었다. 그러나아직첫연구단계이기는하지만주요호소증상별패널검사가종래에사용하던장기별혹은질환별패널검사에비해환자의빠른진단에더도움이되리라생각하고제안하였다. 이번연구는환자의주요호소증상을바탕으로의뢰되는검사의종류와빈도를조사하여일차적으로정리한단계이다. 앞으로저자들이제안한패널검사의실용성과비용효과적인면을평가하고, 이번에다루지못한주요호소증상들에대해서도패널검사종목을제안하는것이다음과제라고생각한다. 요약배경 : 패널검사는질환의진단및치료전후의환자상태를판정하기위해서필요한진단의학검사종목으로구성된것으로, 현재장기별혹은질환별패널검사가이용되고있다. 환자의주요호소증상은병력청취와신체검사의방향을제시하고진단의학검사를의뢰하는중요한단서가되므로, 저자들은처음병원을방문한환자들을대상으로주요호소증상에따라패널검사를구성하는것을제안하였다. 방법 : 2009년 4월부터 5월까지본원응급실을방문한환자중에서비교적뚜렷한한가지주요호소증상을호소한성인환 자 3,127명을대상으로주요호소증상을파악하고내원당시와추가로의뢰된진단의학검사종목과빈도, 최종진단명을조사하였고감별해야할질환과문헌들을참고하였다. 결과 : 응급실을방문한환자들을대상으로흔한순서로 14개의주요호소증상군을선정하였다. 이에따라기본패널검사종목을우선적으로선정하였고, 최종진단된질병과감별해야할질병에따라반드시필요하다고생각되는검사들을추가하여주요호소증상별패널검사를구성하였다. 결론 : 주요호소증상별패널검사가종래에사용하던장기별혹은질환별패널검사에비해환자의빠른진단에더도움이되고진료계획표 (critical pathway) 의한부분으로서도필요하리라생각되었다. 앞으로저자들이제안한패널검사의실용성과비용효과적인면을평가하고, 이번에다루지못한주요호소증상들에대해서도패널검사종목을제안하는것이다음과제라고생각한다. 참고문헌 1. Korean Society for Laboratory Medicine. Laboratory test panels for diseases. In: Laboratory medicine. 4th ed. Seoul: E-PUBLIC, 2009: ( 대한진단검사의학회. 질환군별기본검사패널. In: 진단검사의학. 제4판. 서울 : 이퍼블릭, 2009: ) 2. Jaros ML, Lifshitz MS, De Cresce RP. Financial management. In: McPherson RA and Pincus MR, eds. Henry s clinical diagnosis and management by laboratory methods. 21st ed. Philadelphia: Saunders Elsevier, 2007: Glenn GC. Practice parameter on laboratory panel testing for screening and case finding in asymptomatic adults. Laboratory Testing Strategy Task Force of the College of American Pathologists. Arch Pathol Lab Med 1996;120: Takemura Y, Ishida H, Inoue Y, Beck JR. Common diagnostic test panels for clinical evaluation of new primary care outpatients in Japan: a cost-effectiveness evaluation. Clin Chem 1999;45: Boland BJ, Wollan PC, Silverstein MD. Yield of laboratory tests for case-finding in the ambulatory general medical examination. Am J Med 1996;101: Fleischer AB Jr, Gardner EF, Feldman SR. Are patients chief complaints generally specific to one organ system? Am J Manag Care 2001;7: Korea National Statistical Office. Korean standard classification of diseases. Seoul: Korea National Statistical Office, ( 통계청. 한

7 450 Korean J Lab Med 2010;30: 국표준질병사인분류. 서울 : 통계청, 2008.) 8. Fauci AS, Braunwald E, et al. eds. Harrison s principles of internal medicine. 17th ed. New York: McGraw-Hill, 2008: Realdi G, Previato L, Vitturi N. Selection of diagnostic tests for clinical decision making and translation to a problem oriented medical record. Clin Chim Acta 2008;393: Lehmann C and Leiken AM. Influence of selective vs. panel chemistry tests on cost and diagnostic time. Am J Med Technol 1982;48: Takemura Y, Ishida H, Inoue Y, Kobayashi H, Beck JR. Opportunistic discovery of occult disease by use of test panels in new, symptomatic primary care outpatients: yield and cost of case finding. Clin Chem 2000;46: Takemura Y, Ishida H, Inoue Y, Beck JR. Yield and cost of individual common diagnostic tests in new primary care outpatients in Japan. Clin Chem 2002;48:42-54.

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<30382EC0C7C7D0B0ADC1C22E687770> 대한내과학회지: 제 76 권 제 2 호 2009 의학강좌-개원의를 위한 모범처방(Current Clinical Practice) 간기능검사의 이해와 적용 인제대학교 의과대학 일산백병원 내과학교실 김 경 아 Understanding and application of liver function tests Kyung-Ah Kim, M.D. Department of