今年の振り返り

本ブログの投稿から

1. Clinical Problem-Solving の起源と略史
2. Speed Input & Rational Output
3. SIROメソッドのゴール
4. 診断プロセスの稼業五段活用
5. 臨床推論のムーブ 暫定版"GESTALT"
6. Differential Diagnosis Schema 
7. The 10 Most Common Opening Moves
8. 優先順位付けされた鑑別診断の覚え書き
9. ドラマERから１２個の引用
10. シャーロック・ホームズの推理と診断学

Differential Diagnosis Schema

談話分析(discourse analysis)をDiagnostic Problem-Solvingに適用した"Investigating Diagnostic Problem Solving in Medicine through Cognitive Analysis of Clinical Discourse "という文献から鑑別診断のスキームを抜き出してみた。

1. Collect Patient Data
　1.1 Patient History (Subjective Data)
　1.2 Physical Exam (Objective Data)
2. Develop / Revise List of Hypotheses
　2.1 Generate Diagnostic Hypotheses
　2.2 Relate Hypotheses to Patient Data (Causal Models)
3. Evaluate Hypotheses (Differential Diagnosis)
　3.1 List Differential Hypotheses
　3.2 Evaluate Confidence in Hypotheses
　3.3 Identify Leading Hypotheses
　3.4 Identify Loose Ends
　3.5 Account for Evidence Coherence
4. Obtain Lab Tests / Other Test Results
　4.1 Select Lab Tests / Procedures
　4.2 Interpret Results
　4.3 Add Lab Findings to Patient Data
5. Develop Case Management Plan

• loose ends、OALDの説明では、" a part of something such as a story that has not been completely finished or explained"とある。日本語で言うと、男女の仲では、中途半端とか、ビジネスでは懸案事項とか訳される。逆に懸案事項を和英で引くと、concernとか、pending issueとか出てくる。

Search for the Complication

A CLINICAL PROBLEM-SOLVING article by Francis Salamon from Rabin Medical Center in Israel and colleagues. A 58-year-old woman was hospitalized for evaluation of prolonged fever and hemoptysis. She reported having had intermittent fevers, a productive cough, shortness of breath, and hemoptysis during the previous eight months. CT of the chest revealed peripheral infiltrates in the upper lobe of the left lung and lingula and a calcified left hilar opacity, with additional, small mediastinal lymph nodes. Bronchoscopy demonstrated hyperemic bronchi. Culture of a bronchial-lavage specimen was positive for a nontuberculous, slow-growing mycobacterium. Staining and culturing were negative for M. tuberculosis. A tuberculin skin test was positive. The patient had a history of hypertension, chronic atrial fibrillation, inflammatory bowel disease, and hypothyroidism that was attributed to the use of amiodarone. She had undergone catheter ablation procedure one year earlier, after which the amiodarone had been stopped. The laboratory finding and the results of CT angiogram and ventilation–perfusion lung scans are discussed. A diagnosis made after much testing sometimes raises the question of why the correct diagnosis was not made earlier. In some cases, diseases are overlooked because they are rare, mimic other diseases, or present atypically. The diagnosis of a relatively new clinical syndrome is especially challenging. This case concerns such a challenge. (211 words)

The 10 Most Common Opening Moves

Clinical Problem-SolvingのResponderの第一声のコーパスでよく使われるものを集めてみました。

1. This patient presents with ... 症例の要約をする。
2. The first thing that come to mind is ... 素直に思い浮かぶことから。
3. I would worry about ... 素直に思い浮かぶことから。
4. My first concern would be ... 素直に思い浮かぶことから。
5. The differential diagnosis of/for symptoms is broad/includes ... 早速、鑑別診断を。
6. The possible causes of symptoms include ... 早速、鑑別診断を。
7. The combination of symptoms suggest ... 早速、鑑別診断を。
8. The patient's initial presentation is consistent with the presence of ... 早速、鑑別診断を。
9. My approach begins with two questions: Where is the lesion? What is the lesion? アプローチの一般論から始める例。
10. One of the most important first steps in approaching a patient is to frame the problem -- that is, to define it in terms of either a diagnosis or a syndrome and then to think about it both pathophysiologically and probabilistically. アプローチの一般論から始める例。

NLPでいう"eye accessing cue"では、左は過去、右は未来と関連付けられています。診断過程におけるsign, symptomは過去（既知）、diagnosis, diseaseは未来（未知）で、それぞれsinistral(左側)、dextral(右側)と頭文字が一致するのは、興味深いですね。

Empirically Incorrect

"Empirically Incorrect" by Amy Schmitt from Legacy Emanuel and Legacy Good Samaritan Hospitals in Portland, Oregon. A 46-year-old Mexican immigrant presented with epigastric pain and vomiting of coffee-grounds material. He reported fatigue, malaise, jaundice, and a weight loss of 20 lb during the previous two months. He had also had dark stools, light-headedness, and mild shortness of breath, but no fever, chills, or night sweats. Analysis of a peripheral-blood smear showed nucleated red cells. Endoscopy revealed a duodenal ulcer; a urease enzyme test of a biopsy specimen was positive for H. pylori. A liver biopsy was performed. On the basis of the insidious nature of this patient's illness, the fever and lymphadenopathy, and the history of exposure to livestock, he was treated empirically for brucellosis and he was treated for H. pylori. When his condition did not improve, he was treated with empirical prednisone for presumed granulomatous hepatitis. In this case, the delay in diagnosis, compounded by the subtlety of the finding on the initial liver-biopsy specimen, resulted in a substantial delay in identifying the cause of the patient's jaundice. When a patient's condition worsens despite the use of empirical therapy, clinicians must decide whether to continue the empirical therapy, change the empirical therapy, or repeat diagnostic testing. (208 words)

• H. pylori エイチ・パイロウリ

一貫性、一致性、整合性

ヒルの９つの因果性判断基準(Bradford Hill Criteria)にもあるConsistencyとCoherence、右記本では、それぞれ「一致性」、「整合性」と訳されており、問題点でもその異同が問題点として挙げられている。Clinical Problem-Solvingの過去のコメントには、coherence  = consistency with known pathophysiology の記述さえある。
一方、EU統計局 “ESS Quality Glossary 2010” Unit B1 “Quality; Classifications” 品質関係用語集（対訳）では、同じ語が「整合性」、「一貫性」と訳されており、きちんと峻別されている。
そこで、実際のこれらの語の運用を過去のClinical Problem-Solvingのコーパスで調べてみる。

一貫性、整合性(Coherence)

• Rather than try to deal with all these issues, we have chosen to try to devise a coherent explanation for the principal clinical features of the patient's case.
• When making a diagnosis a physician looks for a coherent pattern among a patient's symptoms and signs.
• Despite remittent fever (temperature, up to 40°C), he continued to feel well, to be coherent, and to have a good appetite.
• If they are too broad, even an experienced clinician can find it difficult to sift through large amounts of sometimes irrelevant information and formulate a coherent picture.
• The process of verification involves assessing each possibility with respect to coherency, adequacy, and parsimony.
• Nor did these hypotheses meet the test of diagnostic coherence.

一致性、整合性(Consistency)

• The physical examination was consistent with a hypovolemic state.
• Laboratory results were consistent with a systemic inflammatory response, possibly of rheumatologic origin.
• The electrocardiographic findings are consistent with an acute myocardial infarction.
• An electrocardiogram showed an irregular rhythm with high-amplitude, mildly prolonged QRS complexes that were consistent with atrial fibrillation with a rapid ventricular response, left ventricular hypertrophy, and interventricular conduction delay.
• She had a history of episodic retrosternal burning that was consistent with gastroesophageal reflux.
• Several test results appear to be consistent with hemolysis.
• Specimens from random colonic biopsies were consistent with nonspecific chronic inflammation with marked eosinophilia.
• A chest radiograph reportedly revealed scattered nodules and increased interstitial markings that were considered to be consistent with sarcoidosis.
• An electrocardiogram showed an acute injury pattern in the anterolateral wall of the heart that was consistent with ST-segment elevation myocardial infarction (STEMI) in the territory of the left anterior descending coronary artery.
• Primary neurologic processes that are consistent with this presentation include subdural hematoma, subarachnoid hemorrhage, stroke, and meningoencephalitis. 
•  Her skin had diffuse patchy areas of depigmentation on the arms, chest, neck, face, and scalp that were consistent with vitiligo.
• The constellation of hypotension, narrow pulse pressure, and cool extremities is consistent with what has been described as the “cold and wet” classification of acute heart failure, which is a type of cardiogenic shock.

一覧して、coherentは、一般論や患者の意識状態を述べるとき、consistentは、be consistent with の熟語で、suggest と同様、所見と疾患の関連を述べるときに使われていることがわかる。示さないが、後者は、suggest に比べると、より具体的な疾患に関連していることを示す傾向がある。従って、具体的なclinical reasoningにおいては、初盤でsuggestが、中盤以降でbe consistent withが多用される。

蛇足だが、consistent の最後の例文は、Nohriaの心不全の分類の記載。

Needle in a Haystack

A 63-year-old man presented to the emergency department with shortness of breath that had begun the evening before, after he had gone to bed, and worsened progressively during the night. He had had no fevers, chills, cough, hemoptysis, chest pain, or peripheral edema and had no history of congestive heart failure. Five months earlier, a pulmonary embolus had been diagnosed, for which he received warfarin maintenance therapy; the results of prothrombin-time testing, expressed as an international normalized ratio, were consistently above 2.0. The patient had a history of smoking and hypertension in conjunction with evidence of peripheral vascular disease. Many disorders can present with a sudden onset of shortness of breath, some of which are medical emergencies. This clinical problem-solving article by Krishna Polu of the Brigham and Women's Hospital and Myles Wolf of Massachusetts General Hospital highlights the the challenge of diagnosing a syndrome with nonspecific symptoms and indolent nature. (152 words)

• needle in a haystack: Something that is difficult or impossible to locate; something impossibly complex or intractable.

A Hole in the Argument

This CLINICAL PROBLEM-SOLVING article describes an 80-year-old man who was evaluated of shortness of breath and fatigue four weeks after repair of a hiatal hernia. He reported a mild, nonproductive cough and abdominal bloating. Prior to the surgery, he had been very active and had had no dyspnea. The patient had a history of coronary artery disease but no history suggested pulmonary disease. He was found to have a substantial reduction in arterial oxygen saturation, with a a partial pressure of oxygen of 35 mm Hg. The findings on physical examination were unremarkable. The normal cardiac examination and clear lung fields suggest that heart failure or significant pulmonary parenchymal disease is unlikely to explain his dyspnea. Pure oxygen was administered, but it did not improve his severe hypoxemia. Transthoracic echocardiography was performed and videos of these may be reviewed at www.nejm.org. This discussion by Donald Hegland highlights the challenge of determining the clinical significance of a common anomaly. (160 words)

• challenge: 課題、難題

A Perfect Storm

"A Perfect Storm" by William Janssen. This clinical problem solving article concerns a 21-year-old male college student who presented to the student health center after two days of extreme fatigue. Over the course of the previous two months, frequent headaches, difficulty concentrating, and a decrease in his capacity for exercise had developed. He recently had had several days of nasal congestion and sore throat, but these symptoms had improved. A cursory physical examination showed no abnormalities, but his oxygen saturation on pulse oximetry was only 55 percent, which was most unexpected. The blood gas values indicated a respiratory acidosis. The discussant and clinical analysis examinee approached to the diagnosis in the patient with the evidence of hypoventilation. (117 words)

• perfect storm: A situation where a calamity is caused by the convergence and amplifying interaction of a number of factors. 
• cursory: hasty; superficial; careless

A Shocking Development

A CLINICAL PROBLEM-SOLVING article by Joshua Levenson from University of Michigan, Ann Arbor.
A 20-year-old female college student presented in the winter with a 2-week history of fatigue, cough, sinus congestion, and rhinorrhea, followed by 2 days of vomiting, diarrhea, and abdominal pain.
The patient was brought to an urgent care center for evaluation. At that time, she reported abdominal pain related to emesis but said she had no dyspnea, chest pain, fever, or chills.
The pulse was 130 beats per minute, and systolic blood pressure ranged from 60 to 70 mm Hg. Emergency medical services were called, and 2 liters of normal saline were administered while the patient was being transported to the emergency department of a local hospital. On arrival, the oral temperature was 34.7°C, pulse 126 beats per minute, blood pressure 99/52 mm Hg, respiratory rate 18 breaths per minute, and oxygen saturation 100% while she was breathing ambient air. Cardiac examination revealed a regular tachycardia without extra heart sounds.
This patient contracted an acute, influenza-like illness, along with members of her family, and while the others recovered, her condition rapidly deteriorated. In a young person with a febrile illness and severe hypotension, the differential diagnosis is broad and must be addressed quickly, given the potentially catastrophic consequences. Any diagnostic evaluation must proceed in tandem with appropriate life-saving measures that include hemodynamic support.

A Curious Case of Chest Pain

A CLINICAL PROBLEM-SOLVING article by Joshua Liao, from Brigham and Women's Hospital, Boston.
A 67-year-old man presented to the emergency department with chest pain. 10 days before presentation, nausea, nonbloody emesis, bloating, and epigastric pain developed. A presumptive diagnosis of gastroesophageal reflux was made. Over the course of several hours on the day of presentation, heaviness of the chest developed on exertion and progressed to pain at rest accompanied by diaphoresis and dyspnea. The pain was substernal and nonradiating, and it did not change with a change in position or with food intake.
On examination, the patient appeared uncomfortable, pale, and diaphoretic, and he was using his accessory muscles to breathe. The patient appears to have acute heart failure, with evidence of elevated right-sided and left-sided filling pressures and impaired perfusion. Potential causes of acute biventricular failure include myocardial ischemia, a mechanical complication caused by a recent myocardial infarction, acute regurgitant valvular lesions, an acute aortic syndrome, or acute myocarditis.
The patient's rapidly downhill course despite appropriate treatment of heart failure differentiated his condition from other disorders. This NEJM.org to use an interactive medical case associated with this article.

Venting the Spleen

A CLINICAL PROBLEM-SOLVING article by Neal Varughese from Yale University School of Medicine, New Haven, CT.
A 19-year-old woman presented with a 4-day history of abdominal pain, located in the right upper quadrant and epigastrium, with occasional radiation to her back. She also noted profound fatigue and a 13.6-kg weight loss during the preceding months. The patient had a history of hereditary spherocytosis. Ten years earlier, she had undergone laparoscopic splenectomy and cholecystectomy for chronic hemolytic anemia with symptomatic gallstones, with complete resolution of the hemolytic crises.
At current presentation, ultrasonography and CT showed a well-defined, noncystic lesion, measuring 4.5 cm in diameter, originating from the inferomedial aspect of the right side of the liver. One month later, abdominal pain, fatigue, and sore throat persisted. Several tender, slightly firm, mobile lymph nodes measuring as large as 2 cm in diameter were palpated in the anterior and posterior cervical, left supraclavicular, and bilateral inguinal regions.
In this patient, a lymphoproliferative, infectious, or inflammatory disorder seems likely. In the case of a common disease in a patient with an uncommon coexisting condition, a close collaboration among clinicians, pathologists, surgeons, and radiologists was required.

A Patient with Syncope

A CLINICAL PROBLEM-SOLVING article by Michelle Fox from Brigham and Women's Hospital, Boston.
A 35-year-old man presented to the emergency department after having an episode of syncope while playing soccer. Loss of consciousness which lasted only seconds was preceded by a brief period of light-headedness. The patient reported no nausea, diaphoresis, chest pain, or dyspnea. He did not take medications. Witnesses reported no tonic–clonic movements.
He was born in Mexico, immigrated to the United States as a teenager, and lived with his wife in western Massachusetts, where he worked as a dairy farmer.
At initial presentation, the patient had normal vital signs, and the physical examination was unremarkable. The patient was discharged with an event monitor. 2 weeks later he had an episode of monomorphic wide-complex tachycardia, with a heart rate of almost 300 beats per minute, while playing soccer. At the time, he noted mild dyspnea and neck discomfort. He was admitted for further evaluation and management of his condition.
At the time of this patient's initial presentation, idiopathic ventricular tachycardia was the most likely diagnosis. However, the clinical features of recurrent arrhythmia and the patient's region of origin argued for a more complicated process. It is essential in such cases to perform a reassessment for the presence of structural heart disease, which can evolve over time.

Weak in the Knees

A CLINICAL PROBLEM-SOLVING article by Walter Conwell from University of Colorado, Denver.
A 61-year-old woman presented to her primary care physician with a 4-week history of progressive leg weakness, bilateral leg pain, and difficulty walking. The weakness was symmetric, and did not fluctuate during the course of the day. The patient also reported depression, anxiety, memory problems, and intermittent headaches that had begun several months earlier. She had a dry mouth but no difficulty swallowing. Previously very active, she had become homebound over a period of several months because of the leg weakness.
On examination, she had moderate weakness in hip flexion and in knee flexion and extension bilaterally. Strength in the feet, ankles, hands, and arms was normal. Knee and ankle reflexes were normal, and plantar reflexes were flexor bilaterally. Sensation of light touch and vibratory sensation were normal throughout her body.
During the following 2 months, her symptoms progressed, and she required a walker to ambulate. Arm weakness, difficulty eating without assistance, and increasing memory problems also developed.
Nonspecific symptoms such as weakness can pose a diagnostic challenge for even the most astute clinicians. In this case which involved an uncommon disorder, the key was to carefully consider all the available information in order to identify patterns that pointed to specific diagnoses and ruled out others.

Risky Business

症例：31歳女性、再発性心内膜炎、重症僧帽弁逆流
語句

• doomed to failure 《be ～》失敗する運命にある

例文

• Discharging her to her sister's house, even with follow-up by visiting nurses, is probably doomed to failure.

The Landlady Confirms the Diagnosis

症例：43歳男性、悪心、嘔吐、息切れ、なにやら音がする。（本文リンク）
語句：

• high on the list 《be ～》リストの上位にある
• out of the picture 無関係で ・He is totally out of the picture ever since he bothered her. : 彼女に面倒をかけて以来、彼の出番は全くない。
• proviso【名】〔契約などの〕条件、ただし書き（の規定）レベル12、発音prəváizou、カナプロバイゾウ、変化《複》provisos、分節pro・vi・so

例文：

• Although salicylate intoxication is highest on the list, I cannot absolutely say that methanol, ethylene glycol, or sepsis is totally out of the picture.
• I would start by giving him large volumes of saline, with the proviso that if the salicylate level is markedly elevated hemodialysis be considered.

参考：

• http://en.wikipedia.org/wiki/High_anion_gap_metabolic_acidosis
• http://en.wikipedia.org/wiki/Aspirin_poisoning

A Shocking Development

インフルエンザやノロウイルスの流行るこの時期にタイムリーなケースです。

症例：20歳女性、2週間の倦怠感、咳、鼻閉、鼻汁に続く2日間の嘔吐、下痢、腹痛。（本文リンク）

語句：

• fluid resuscitation： Wikipedia "Fluid replacement"、NEJMレビュー記事 "Resuscitation Fluids" を参照
• pending 【前】 ～を待つ間、～の間、～の結果がでるまで、～まで（待って）

例文：

• Fluid resuscitation should be started immediately.
• Pending the results of testing, I would administer a neuraminidase inhibitor empirically for influenza, in addition to broad-spectrum antibiotics.

When to Let Go

珍しく、医療倫理に関わるテーマ。参考図書として右の本も挙げられているが、実情は、国ごとの慣習、法律等の影響をうけるので、日米比較の資料リンクも記しておく。

症例：53歳男性、急性白血病再燃（本文リンク）
語句：

• embark on ～に乗り出す、～に着手［従事］する ・Ian embarked on an ambitious project to learn Arabic in three months. : イアンは3カ月でアラビア語を学ぶという大胆な計画を実行に移しました。 ・We will embark on the topic of equation in Math next week. : 来週の数学では方程式の話題に着手します。
• attune【他動】同調［調和・適合］させる〔楽器を〕調音［調律］する
• over the long haul 長期（間）にわたって、長い目で見れば ・The real question is whether it will help this country's economy over the long haul. : 問題は、長期的に見て、それがこの国の経済のためになるかどうかということだ。

例文：

• Some sense of proportion must be added to the quest on which the patient has embarked.
• If we have kept open our lines of communication with members of the man's family and if they appear fully attuned to how he thinks, decisions will be facilitated.
• The physician involved with this patient over the long haul should also have come to understand the man's treatment desires.

参考文献：医療事故・紛争対応研究会 第４回年次カンファレンス   『末期医療と患者の意思』  末期医療と患者の意思の尊重 ――日米比較から 神戸大学大学院法学研究科 丸山英二

How Sure Is Sure Enough?

症例：40歳女性、左胸部の鋭い痛み（本文のリンク）
語句：

• take issue with ～に反論する ・We take issue with your claim that we didn't inform you of the problem. : われわれがあなたに問題を知らせなかった、とあなたはおっしゃいますが、それは違います。

例文：

• She had none of the other usual symptoms that go along with angina.

The Many Pitfalls in the Diagnosis of Myeloma

症例：71歳男性、発汗、不明熱、体重減少、貧血（本文リンク）
語句：

• track down 【句動】 見つけ出す ・I spent two months tracking you down. : あなたを見つけ出すのに2カ月かかった。 追い詰める、追跡して捕らえる ・The police tracked down the criminal. : 警察は犯人を追い詰めて逮捕しました。
• left with 《be ～》（感情などを）もち続ける、（責任などを）押し付けられる ・We were left with resentment against the intruders. : 侵略者に対するわれわれの憤りは消えなかった。
• loom large 〔危険・心配などが〕大きく迫る［立ちはだかる］ ・The risks loomed large in their minds. : その危険が彼らの心に大きくのしかかった。
• harbor【他動】 〔悪意・考え・邪念・計画などを〕心に抱く ・I cannot help but harbor such doubts. : そんな疑問を感じざるを得ない。 ～に隠れ場所を提供する、～をかくまう

例文：

• The excretion of 7 g of protein must reflect a monoclonal protein, since there is no evidence of any monocytic disorder that could be providing lysozyme.
• The multiple features of anemia, lytic bone lesions, hypercalcemia, renal failure, and proteinuria in the absence of albuminuria make the diagnosis of myeloma loom large, although a lymphoma might create the same constellation.

Trapped by an Incidental Finding

症例：74歳男性、夜間頻尿（本文リンク）
語句：

• hesitancy　遷延性排尿　＊「遷」のピンインは、qiān。排尿開始が遅延すること。
• dribbling　苒延性排尿　＊「苒」は紅楼夢の史湘雲の対菊詩に用例がある。「秋光荏苒休辜負、相対原宜惜寸陰(Qiūguāng rěnrǎn xiū gūfù, xiāngduì yuán yi xī cùnyīn)」
• conceivably【副】考えられる限りでは、ことによると、もしかしたら
• inconsequential 【形】 重要ではない、重要度が低い、取るに足りない ・The first job is inconsequential in long-term career goals. : 最初の仕事は長期的な職業上の目的から見ればあまり重要ではありません。 不合理な、論理的でない◆【同】inconsequent
• sinking feeling 悪い予感、虚脱感無気力、無力感、気がめいる感じ
• incapacitating pain まともに生活できないほどの痛み

例文：

• In autopsy series many men in their eighties have foci of prostate cancer.
• My index of suspicion for malignancy is not high.

読書百遍、董遇三余

"Clinical Problem-Solving"のディクテーションを休んで、はや三ヶ月。とある試験の準備がきっかけだが、冷静に意義を考え直すと、音声一部をくり返し聴いて書き取ることと、一回性のある音声全体を聴いて分かるようになることは、根本的に違うことなのだ。聴いて分かるようになるには、至極当然、聴かなければならないし、読んで分からないことは聞いて分かるわけがない。決定的にインプットの回数が不足している為に分かるようにならないのだ。

董遇、字季直、性質納而好学。.......人有従学者、遇不肯教，而云：“必当先読百遍。”言読書百遍而义自見。従学者云：“苦渴無日”遇言：“当以三余。”或問三余之意、遇言：“冬者歳之余、陰雨者時之余也。”由是諸生稍従遇学。 出典：「三国志」魏書の王朗伝

そう、100回とは言わなくても、同じ素材を30回くらいは咀嚼することが必要なのだ。そのための素材の準備方法を３つほど提案。

1. podcastからAudacityでCPSの部分を切り出し、10回繰り返し、-40から+70に速度を徐々に上げていく音声を作る。
2. DropboxとWappwolfを連携して、pdf書類をダウンロードしたら、自動的にKindleに転送するように設定する。
3. 身も蓋もないが、pdf書類を印刷して持ち歩く。

A 68-Year-Old Man with Metastatic Melanoma

A CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by Ryan Sullivan and colleagues.
A 68-year-old man was seen in the cancer center at this hospital because of metastatic melanoma. Eleven years earlier, a superficial spreading melanoma had been excised from the right lower leg. The patient had been well until approximately 5 weeks before presentation. Examination revealed a mass in the right groin, with surrounding erythema. An ultrasound-guided biopsy of a lymph node in the right groin was performed at the other hospital. Pathological examination showed metastatic melanoma.
Masses were present in the right groin and right medial thigh. CT of the chest, abdomen, and pelvis revealed enlarged retroperitoneal, pelvic sidewall, and inguinal lymph nodes on the right side, with the largest lymph node in the right groin.
The diagnostic test in this case was a repeat biopsy of the groin lesion to obtain tissue for genetic testing which was suggest new treatment options for this patient with advanced metastatic disease.

A Patient with Migrating Polyarthralgias

A CLINICAL PROBLEM-SOLVING article by Jonathan Casey from Brigham and Women's Hospital, Boston.
A 28-year-old woman with no clinically significant medical history presented to the emergency department for evaluation of fatigue and joint pain. She initially noted pain and swelling in her right foot and ankle, which limited her ability to walk. These symptoms resolved, but pain in her knees and hips then developed, along with swelling and pain in her right elbow.
The physical examination was notable for a temperature of 38.3°C (101.0°F) and for diffuse tenderness of the joints on palpation.
The patient was born in Brazil and moved to the northeastern United States 10 years before presentation. The patient recalled that when growing up in Brazil, she became short of breath easily and was unable to play with other children.
Transthoracic echocardiography revealed severe mitral regurgitation and mild aortic insufficiency. There was thickening of the mitral valves and evidence of chronic mitral stenosis. Titers for antistreptolysin and antiDNase B antibodies were high.
The range of possible causes of joint pain and fatigue is broad, but the polyarticular, migratory nature of the joint pain in this patient helps to narrow the possibilities. The patient has no documented risk factors for infective endocarditis, but the fact that she was born in Brazil puts her at increased risk for rheumatic heart disease. 

リウマチ熱診断基準の覚え方　 J♡ NES PEACE

Major criteria

• Joints: A temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards. 
• ♡ (Carditis): Inflammation of the heart muscle (myocarditis) which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur. 
• Nodules, subcutaneous: Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees. 
• Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.
• Sydenham's chorea(St. Vitus' dance): A characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease for at least three months from onset of infection.

 · Minor criteria:

• Prolonged PR interval 
• ESR elevated
• Arthralgias 
• CRP elevated 
• Elevated temperature

A 29-Year-Old Man with Anemia and Jaundice

Cabot CaseとClinical Problem-Solving、双方の聞き取りを継続することとする。

A CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by Alberto Puig and colleagues.
A 29-year-old man was admitted to this hospital because of anemia and jaundice. 

The patient had been in his usual health until 4 days before admission, when increasing fatigue, malaise, headache, intermittent testicular discomfort, yellowed eyes, dark urine, nausea, and diffuse body aches developed and chronic leg pain worsened.

The patient had been generally well, with intermittent asthma, acne, and chronic leg pain until 4 months earlier, when he traveled from an urban area of New England to his family's home in North Africa and stayed for 3 months. While he was there, a prolonged cough productive of green sputum developed, associated with fatigue, subjective fevers, chills, drenching night sweats, and intermittent dyspnea at rest, and he reportedly had a weight loss of 9.1 kg. 

There are several features of this case that are potentially important but are not easily correlated with the patient's presentation and, hence, leave us wondering about their clinical significance. Specifically, fever, cough, and weight loss developed while the patient was visiting North Africa, where he encountered a dying brother, was exposed to sheep, and drank unpasteurized milk. In addition, his medical history is notable for a previous episode of acute anemia that occurred after surgery. We must pursue a unifying diagnosis for these findings.

聴き取りをしていて、いまさらながら、Massachusettsの綴りに自信が持てない。これはネイティヴの人も同じらしく、まぁ、日本人だって北海道のアイヌ語の地名が読めなかったりするのと同じようなもんなんだろう。他にも、Cincinnatiとか、Mississippiとか、そんな類の地名で、下のように覚えたりするらしい。

Cincinnati 

Cincinnati is a word
Hard to spell but easy heard.
It need not cause you irritation,
Just drop the ON from CIN CIN NATION. 

Massachusetts 

The simple answer to this little riddle:
Two esses, two tees, with one ess in the middle. 

Mississippi 

Four simple words will get you by:
What you'll never MISS IS SIP PI.

果たしてこれで、次回はまごつかずにMassachusettsを打てますかどうか…

今回の症例は、Wikipediaで、「グルコース-6-リン酸脱水素酵素欠損症」と「ソラマメ中毒」の項目に目を通しておくと良い。

【本】三人の記号―デュパン,ホームズ,パース

積んでおいた右掲訳本の「三人の記号―デュパン,ホームズ,パース」を読了。訳本の方は、馬鹿高い値が付いているので、原著のリンクを張っておきました。シービオクの論文だけで良ければ、「シャーロック・ホームズの記号論―C.S.パースとホームズの比較研究 (同時代ライブラリー (209)) 」として、中古本がまだ安く入手できます。しかし、ウンベルト・エーコ編の右本のほうが多彩な筆者を揃え、ジョヴァンニ・モレッリ、ジークムント・フロイト、カミロ・バルディ、ヴォルテールなどの逸話が引き合いに出され、読み応えがあります。最後は、メタ・アブダクションの説明に、ブランドのZadig & Voltaireの由来になったと思われるVoltaireの小説"Zadig ou la Destinée"が引用されていますが、これまたSerendipityの語源ともなった「セレンディップの3人の王子」にインスパイアされた作品とのこと。人間の思想の連綿とした連続性に感じ入った次第。
診断学の歴史の曙を垣間見るには得るところが多いが、推理の裏技が紹介されているわけでもなく、シャーロック・ホームズが「四つの署名(The Sign of Four)」で指摘するように、推理の実際には、観察、推理、知識が必要なように、まずは、Harrisonなどの成書に依って、しっかりとした知識が無ければ、診断力の向上はあり得ないことを悟らされることになりました。

ドラマERから１２個の引用

ERのドラマ英語の字幕を見ながら聴いても聴き取りは難しい。せめてお気に入りのセリフを幾つか。

1.
Mark: See, there's two kinds of doctors. The kind that gets rid of their feelings. And the kind that keeps them. If you're going to keep your feelings, you're going to get sick from time to time. That's just how it works. - 24 Hours
2. Doug: At my age Mozart was dead. - Into that Good Night
3. Jerry: Dr. Carter, I presume. "Dr. Livingstone, I presume"の引用ですね。
4. [Randi is reading everyone's horoscope]
Randi Fronczak: Hey, Abby. What's your sign?
Abby Lockhart: "Out of order".
5. Benton's Mother: Your talent is God's gift to you. What you do with it is your gift back to God.
6.
Dr. Kerry Weaver: Did you even take the Hippocratic Oath?
Dr. Robert Romano: I had my fingers crossed.
7.
Nurse Lily Jarvik: Anyone seen Dr. Weaver?
Dr. Doug Ross: Follow the trail of partially-digested residents.
8. [In the OR]
Dr. Robert Romano: Will somebody turn down the damn heat. Feels like a hundred in here.
Nurse: The thermostat is set at 68 degrees.
Dr. Peter Benton: Maybe you're coming down with the flu.
Dr. Robert Romano: It's NOT the flu.
Nurse: Maybe you're going through "The Change."
9. Dr. Robert Romano: I'm beginning to think that "ER" stands for "everyone's retarded".
10. Dr. John Carter: [Instructing his med student] Grab that penis and show it who's boss.
11.
Dr. Susan Lewis: I think you should talk to him, he seems depressed.
Abby Lockhart: He's european, it's his baseline.
12. Abby Lockhart: These are the desk clerks, Jerry and Frank, please don't feed them.

出典

• Wikiquote: ER
• IMDb: ER

Waiting for the Other Foot to Drop

A CLINICAL PROBLEM-SOLVING article by Eileen Scully from Brigham and Women's Hospital, Boston.
A 65-year-old man presented with fevers and progressive weakness. He had been well until 4 months previously, when daily fevers, sweats, fatigue, impaired concentration, and weakness developed. He also reported that pain in his feet and calves.
On physical examination, strength was normal in the proximal arms but was decreased in both wrists, the fingers, the right hip, the right foot, and the great toes bilaterally. Ambulation without supportive bracing revealed a profound foot drop on the right side (a finding that is shown in the video at NEJM.org).
The patient had undergone coronary-artery bypass grafting 15 months earlier, which had been complicated by a hernia in the upper abdominal wall that was repaired with surgical mesh. The patient's medical history also included hepatitis B virus (HBV) infection, gout, hyperlipidemia, hypertension, gastroesophageal reflux, and hypothyroidism.
Ongoing fevers in a previously well patient may be caused by infection, a malignant condition, autoimmune or inflammatory disease, or medications.
Two components of the medical history that warrant attention are the hypothyroidism which may be associated with neuropathy and the HBV infection which is associated with a painful vasculitic neuropathy. (206 words/ 99sec = 125 wpm)

慢性炎症性脱髄性多発神経炎(CIDP)です。日本神経学会のHPでは、まだガイドラインの公開はないようです。

臨床医が目を通すべき１ダースのシャーロック・ホームズ関連資料

前の投稿でシャーロック・ホームズを話題にしたので、関連資料を挙げておく。

1. 「緋色の研究」の研究 via 内田樹の研究室
2. 508夜『シャーロック・ホームズの記号論』 via 松岡正剛の千夜千冊
3. 628夜『緋色の研究』  via 松岡正剛の千夜千冊
4. 神経内科医としてのシャーロック・ホームズ　− 神経内科医の視点から見たホームズ物語 - 神経内科
5. 神経内科医としてのシャーロックホームズ - ホームズ物語と中毒性神経疾患 - 神経内科
6. Faith T. Fitzgerald, Lawrence M. Tierney. The Bedside Sherlock Holmes. West J Med. 1982 August; 137(2): 169–175.
7. J Wilbush. The Sherlock Holmes paradigm--detectives and diagnosis: discussion paper. J R Soc Med. 1992 June; 85(6): 342–345.
8. James Reed. A medical perspective on the adventures of Sherlock Holmes. Med Humanities 2001;27:76-81
9. Ira Martin Grais. False Scents, False Sense, and False Cents - Why Physicians Should Read Sherlock Holmes. Tex Heart Inst J. 2012; 39(3): 319–321.
10. Richard L. Gregory. In retrospect. Nature 445, 152 (11 January 2007)
11. How to Develop the 'Sherlock Holmes' Intuition via wikiHow
12. "Sherlock Holmes" via Wikiquote

シャーロック・ホームズの推理と診断学

シャーロック・ホームズの推理を語る上で欠かせないのが、Charles Sanders Peirceが、演繹（deduction）、帰納（induction）に対する第三の思考法として用いたアブダクション(abduction)である。「仮説的推論」と訳されるこの語は、時事的には「拉致」、解剖学用語としては、「外転」の意味も有するが、共通点は、接頭辞AB-が意味する所の「離すこと」である。母国から離なして外国へ、体の中心から離して外側へ、後件（症状や犯罪）から離して前件（疾患や犯人）へ、ということである。つまり、思考法としては、因果律の反対の方向へ、後件肯定という論理学的な誤謬を使って推論する。故に、導かれた仮説は十分に因果を検証する必要がある。電池が切れていれば、懐中電灯はつかない。けれども、懐中電灯がつかないからといって、電池が切れているとは断言できない。電池がないことを確認しなければならないのである。つまり、この後件から得られた仮説とその検証の組み合わせこそが、アブダクションの本体である。だから、風邪の所見のないものに、風邪ですとは、言ってはいけないのである。

では、診断において、いかに検証すべき仮説のリストを生成するか、原則をシャーロック・ホームズが語っている。

One should always look for a possible alternative and provide against it. It is the first rule of criminal investigation. "Black Peter"

つまり、はなから診断を決めつけるのではなくて絶えず代替案を準備しておけということである。
ICD-10のコードのついている疾患をすべて想起して、除外していけば確実なはずなのだが、時間や費用がかかりすぎる。対極にあるのが、臨床的勘である。敢えて言語化すると、待合室での音声情報（話し声や咳）、入室時の足取り、挨拶の声や表情、着席までの機敏さなどに始まり、主訴とその発症時間と持続期間、患者属性から季節、地域・施設の特性という疫学的フィルターを通して、瞬時に数個のリストに絞り込んでしまう方法である。勘とは言っても、占い師やメンタリストのようにコンテキストに依存しており、タネも仕掛けもあるわけで、完全な第六感とは意味合いが違う。MECE的な方法とコンビニエントなメソッドは、お互いメリット、デメリットがあり、トレードオフの関係にあるので、実際には、これら極端の折衷法を用いて、暫定的な鑑別診断を作り、さらには、先の探偵の言にある通り、最終診断が鑑別診断外である可能性も担保しておくわけである。

このように、シャーロック・ホームズの物語には、criminalをclinicalに言い換えると、そのままパールとなるようなセリフが多く。臨床医の骨休みには、お勧めである。

高齢者症例集（３）

13. "A Sleeping Giant" July 7, 2011 [ORIGINAL] [SCRIPT] [PODCAST] 11:45 - 13:30

228 words / 105 sec = 130 wpm

７１歳女性、腹痛と寝汗。巨細胞性動脈炎と合併症として潜む巨人を掛けたタイトルですね。

14. "A Bird's-Eye View of Fever" November 3, 2011 [ORIGINAL] [SCRIPT] [PODCAST] 10:55 - 12:27

213 words / 92 sec = 139 wpm

７８歳男性、播種性ヒストプラズマ症のケース。この疾患、Ohio Valley disease、Central Mississippi River Valley disease、Appalachian Mountain diseaseの別名を持つが、Great Smoky Mountains国立公園からの想起は難易度が高い。俯瞰的な視点には、鳥の糞の知識も必要なのです。

15. "Worth a Second Look" February 2, 2012 [ORIGINAL] [SCRIPT] [PODCAST] 11:15 - 13:11

268 words / 116 sec = 139 wpm

72歳男性、クロンクハイト・カナダ症候群。冠名の筆者が論文"Generalized Gastrointestinal Polyposis — An Unusual Syndrome of Polyposis, Pigmentation, Alopecia and Onychotrophia"を発表したのもNEJMでした。検査の繰り返しの重要性が指摘されています。

16. "A Startling Decline" March 1, 2012 [ORIGINAL] [SCRIPT] [PODCAST] 9:59 - 11:41

218 words / 102 sec = 128 sec

89歳男性、Creutzfeldt–Jakob病( ICD-10コードはA810) 。発症後の平均余命は約1.2年。まさに、"startling decline"です。

17. "The Eyes Have It" September 6, 2012 [ORIGINAL] [SCRIPT] [PODCAST] 9:43 - 11:26

226 words / 103 sec = 132 wpm

69歳男性、ボツリヌス症。症状を纏めた"Dozen D's"には、目の症状が多い。

18. "The Search Is On" February 7, 2013 [ORIGINAL] [SCRIPT] [PODCAST] 11:13 - 12:56

238 words / 103 sec =139 wpm

81歳男性、大動脈十二指腸瘻。所見が無くとも、探し続ける根性が大事。

高齢者症例集（２）

7. "An Unintended Consequence" April 3, 2008 [ORIGINAL] [SCRIPT] [PODCAST] 12:34 - 14:16

220 words / 102 sec = 129 wpm

79歳男性、5ヶ月に及ぶ倦怠感、体重減少を主訴に来院。診断は膀胱内BCG注入治療の副作用としての動脈瘤。まさに意図せぬ結末。

8. "A Gut Feeling" July 3, 2008 [ORIGINAL] [SCRIPT] [PODCAST] 11:51 - 13:50

253 words / 119 sec = 128 wpm

72歳男性、3ヶ月に渡る水溶性下痢にて受診。診断は腸管毛頭虫症。ここまでレアだと、知っているか否か、直感できるか否かが分かれ目。

9. "Keeping an Open Mind" January 1, 2009 [ORIGINAL] [SCRIPT] [PODCAST] 10:53 - 12:31

218 words / 98 sec = 133 wpm

67歳男性3ヶ月に渡る疲労感と発熱にて受診。診断はクリプトコッカス髄膜炎。事前確率が高い場合は、検査結果が陰性でも「盲目的従順」するのではなく、検査を繰り返したり、他の検査を考慮する必要がある。

10. "A Heavy Heart" October 7, 2010 [ORIGINAL] [SCRIPT] [PODCAST] 11:47 - 13:56

261 words / 129 sec = 121 wpm

73歳男性、6ヶ月にわたり進行してきた両下肢の浮腫。診断はALアミロイドーシス。タイトルは、心不全と結末に対する演者の悄然たる思いを掛けたのかな。

11. "Avoiding a Rash Diagnosis" February 3, 2011 [ORIGINAL] [SCRIPT] [PODCAST] 12:21 - 14:01

209 words / 100 sec = 125 wpm

74歳男性、譫妄。発疹が手掛かりになってせっかちな診断が避けられた一例。“rash”には、ドイツ語の"rasch"と同起源の「せっかちな」とスペイン語の"rascar"（掻く）と同起源の「発疹」の意味とがある。West Nile virus による脳脊髄炎。実際の皮疹は、"Characteristics of the Rash Associated with West Nile Virus Fever"などの文献を参照。

12. "Lying Low" March 3, 2011 [ORIGINAL] [SCRIPT] [PODCAST] 13:23 - 15:05

231 words / 102 sec = 136 wpm

88歳女性、錯乱状態。"neuroglycopenia"から低血糖発作を想起し、身を潜めたインスリノーマを探し出せるか。

高齢者症例集（１）

1. "A Hole in the Argument" December 1, 2005 [ORIGINAL] [SCRIPT] [PODCAST]　14:24 - 15:32

168 words / 68 sec = 148 wpm

80歳男性、食道裂孔ヘルニアの術後の息切れの症例。卵円孔開存が落とし穴だったというオチ。

2. "Ring around the Diagnosis" May 4, 2006 [ORIGINAL] [SCRIPT] [PODCAST] 12:49 - 14:32

249 words / 103 sec = 145 wpm

71歳元教師、2週間続く倦怠感、熱、食欲不振、発汗の症例。肝生検の病理像のFibrin ring肉芽腫、俗にいうドーナッツ肉芽腫がヒントになった。マザーグース"Ring around the Rosie"のもとになったとも言われるペスト同様、起因菌が発見されるまで不明熱(query fever)であったQ熱が最終診断である。

3. "Into the Woods" March 1, 2007 [ORIGINAL] [SCRIPT] [PODCAST] 11:12 - 12:52

228 words / 100 sec = 137 wpm

79歳女性、1ヶ月続く呼吸困難、湿性咳嗽の症例。写真撮影の趣味で森林に踏み入る機会が多いという生活歴の聴取が、ノカルジア症の診断に結びつく。

4. "Nothing to Cough At" October 4, 2007 [ORIGINAL] [SCRIPT] [PODCAST] 13:04 - 4:45

230 words / 101 sec = 137 wpm

73歳男性、4日間続く乾性咳嗽の症例。咳嗽の鑑別診断は難しい。この回の最終診断は百日咳。

5. "No Respecter of Age" November 1, 2007 [ORIGINAL] [SCRIPT] [PODCAST] 11:04 - 12:40

237 words / 96 sec = 148 wpm

65歳女性、主訴は3週間前から続く右下肢の皮疹。年齢を問わない感染症の１つ、パルボウイルスB19感染が最終診断。

6. "A Key Miscommunication" March 6, 2008 [ORIGINAL] [SCRIPT] [PODCAST] 13:10 - 14:44

194 words / 94 sec = 124 wpm

81歳女性、腹部膨満、悪心、嘔吐を主訴に救急部を受診。血管系の交通のミス、動脈管の開存が最終診断。

風土病 - From the Soil by the Wind

5月27日にＴＶ東京で放送された「実録世界のミステリー」のホントに怖い！危険な病原菌 Case4 「恐怖の病原菌 大都市の空を舞う」の正体は、アメリカ南西部の風土病、コクシジオイデス症でした。地中の胞子がノースリッジ地震にて空中に舞い上がり、砂塵雲となって拡散したケースです。土から舞い上がり、風に乗って拡散、字義通りの風土病です。Soil & Windが、SouthWestの頭文字と一致するのも、何かの縁。

アメリカの風土病については理解するには、その地理についての知識が必須。大雑把にアメリカ本土の臍がカンザス州で、南北に貫くフロンティアフロント以西で、カンザス州以南が、広義の南西部、狭義には、フォーコーナーの南半分、つまりアリゾナ、ニューメキシコあたりが南西部の中核となる。

合衆国の国勢調査局による地域区分は次のとおり。

北東部

• ニューイングランド：メイン州、ニューハンプシャー州、バーモント州、マサチューセッツ州、ロードアイランド州、コネチカット州 (6)
• 大西洋側中部：ニューヨーク州、ニュージャージー州、ペンシルベニア州(3)

中西部

• 東北中部：ミシガン州、ウィスコンシン州、オハイオ州、インディアナ州、イリノイ州 (5)
• 西北中部：ミネソタ州、ノースダコタ州、サウスダコタ州、アイオワ州、ネブラスカ州、ミズーリ州、カンザス州 (7)

南部

• 大西洋側南部：デラウェア州、メリーランド州、ウエストバージニア州、バージニア州、ノースカロライナ州、サウスカロライナ州、ジョージア州、フロリダ州(8)
• 東南中部：ケンタッキー州、テネシー州、アラバマ州、ミシシッピ州(4)
• 西南中部：アーカンソー州、オクラホマ州、ルイジアナ州、テキサス州(4)

西部

• ロッキー山脈地帯：モンタナ州、ワイオミング州、アイダホ州、コロラド州、ユタ州、ネバダ州、ニューメキシコ州、アリゾナ州(8)
• 太平洋側：ワシントン州、オレゴン州、カリフォルニア州、アラスカ州、ハワイ州(5)

References

• Holenarasipur R. Vikram, M.D., Gurpreet Dhaliwal, M.D., Sanjay Saint, M.D., M.P.H., and C. Blake Simpson, M.D. CLINICAL PROBLEM-SOLVINGA Recurrent Problem  N Engl J Med 2011; 364:2148-2154June 2, 2011
• Schneider E, Hajjeh RA, Spiegel RA, et al. A Coccidioidomycosis Outbreak Following the Northridge, Calif, Earthquake. JAMA. 1997;277(11):904-908. 

A Perfect Storm

"A Perfect Storm" by William Janssen.
This clinical problem solving article concerns a 21-year-old male college student who presented to the student health center after two days of extreme fatigue. Over the course of the previous two months, frequent headaches, difficulty concentrating, and a decrease in his capacity for exercise had developed. He recently had had several days of nasal congestion and sore throat, but these symptoms had improved. A cursory physical examination showed no abnormalities, but his oxygen saturation on pulse oximetry was only 55 percent, which was most unexpected.
The blood gas values indicated a respiratory acidosis.
The discussant and clinical analysis examinee approached to the diagnosis in the patient with the evidence of hypoventilation.

"perfect storm"は、ほぼ"worst-case scenario"と同義である。1991年に合衆国東海岸を襲ったハリケーンやそれを題材とした小説、映画のタイトルとして日本においてもこの語法が認知されるようになった。

A Hole in the Argument

This CLINICAL PROBLEM-SOLVING article describes an 80-year-old man who was evaluated of shortness of breath and fatigue four weeks after repair of a hiatal hernia. He reported a mild, nonproductive cough and abdominal bloating. Prior to the surgery, he had been very active and had had no dyspnea.
The patient had a history of coronary artery disease but no history suggested pulmonary disease.
He was found to have a substantial reduction in arterial oxygen saturation, with a a partial pressure of oxygen of 35 mm Hg. The findings on physical examination were unremarkable.
The normal cardiac examination and clear lung fields suggest that heart failure or significant pulmonary parenchymal disease is unlikely to explain his dyspnea. Pure oxygen was administered, but it did not improve his severe hypoxemia.
Transthoracic echocardiography was performed and videos of these may be reviewed at www.nejm.org.
This discussion by Donald Hegland highlights the challenge of determining the clinical significance of a common anomaly.

Needle in a Haystack

A 63-year-old man presented to the emergency department with shortness of breath that had begun the evening before, after he had gone to bed, and worsened progressively during the night. He had had no fevers, chills, cough, hemoptysis, chest pain, or peripheral edema and had no history of congestive heart failure. Five months earlier, a pulmonary embolus had been diagnosed, for which he received warfarin maintenance therapy; the results of prothrombin-time testing, expressed as an international normalized ratio, were consistently above 2.0.
The patient had a history of smoking and hypertension in conjunction with evidence of peripheral vascular disease.
Many disorders can present with a sudden onset of shortness of breath, some of which are medical emergencies.
This clinical problem-solving article by Krishna Polu of the Brigham and Women's Hospital and Myles Wolf of Massachusetts General Hospital highlights the the challenge of diagnosing a syndrome with nonspecific symptoms and indolent nature.

Empirically Incorrect

A CLINICAL PROBLEM-SOLVING article by Amy Schmitt from Legacy Emanuel and Legacy Good Samaritan Hospitals in Portland, Oregon.
A 46-year-old Mexican immigrant presented with epigastric pain and vomiting of coffee-grounds material. He reported fatigue, malaise, jaundice, and a weight loss of 20 lb during the previous two months. He had also had dark stools, light-headedness, and mild shortness of breath, but no fever, chills, or night sweats.
Analysis of a peripheral-blood smear showed nucleated red cells. Endoscopy revealed a duodenal ulcer; a urease enzyme test of a biopsy specimen was positive for H. pylori. A liver biopsy was performed.
On the basis of the insidious nature of this patient's illness, the fever and lymphadenopathy, and the history of exposure to livestock, he was treated empirically for brucellosis and he was treated for H. pylori.
When his condition ??? improve, he was treated with empirical prednisone for presumed granulomatous hepatitis.
In this case, the delay in diagnosis, compounded by the subtlety of the finding on the initial liver-biopsy specimen, resulted in a substantial delay in identifying the cause of the patient's jaundice.
When a patient's condition worsens despite the use of empirical therapy, clinicians must decide whether to continue the empirical therapy, change the empirical therapy, or repeat diagnostic testing.

Search for the Complication

A CLINICAL PROBLEM-SOLVING article by Francis Salamon from Rabin Medical Center in Israel and colleagues.
A 58-year-old woman was hospitalized for evaluation of prolonged fever and hemoptysis. She reported having had intermittent fevers, a productive cough, shortness of breath, and hemoptysis during the previous eight months. CT of the chest revealed peripheral infiltrates in the upper lobe of the left lung and lingula and a calcified left hilar opacity, with additional, small mediastinal lymph nodes. Bronchoscopy demonstrated hyperemic bronchi. Culture of a bronchial-lavage specimen was positive for a nontuberculous, slow-growing mycobacterium. Staining and culturing were negative for M. tuberculosis. A tuberculin skin test was positive.
The patient had a history of hypertension, chronic atrial fibrillation, inflammatory bowel disease, and hypothyroidism that was attributed to the use of amiodarone. She had undergone catheter ablation procedure one year earlier, after which the amiodarone had been stopped.
The laboratory finding and the results of CT angiogram and ventilation–perfusion lung scans are discussed.
A diagnosis made after much testing sometimes raises the question of why the correct diagnosis was not made earlier. In some cases, diseases are overlooked because they are rare, mimic other diseases, or present atypically. The diagnosis of a relatively new clinical syndrome is especially challenging. This case concerns such a challenge.

演者の施設、イツハク・ラビンの名を冠したRabin Medical Centerは、Clalit Health Care Serviceが運営するイスラエルのトップレベルの病院。

A Jaundiced Eye

A CLINICAL PROBLEM-SOLVING article by John Amory from University of Washington, Seattle and colleagues.
A previously healthy 27-year-old man presented to his primary care physician six days after the onset of a nonproductive cough, sore throat, and a feeling of being “run down.” During the preceding week, he had also noted fever and diffuse abdominal pain that was mild to moderate in intensity. Two days before presentation, he noticed dark-colored urine and that his eyes were red and itchy, with a clear, thick discharge.
Three days after the initial clinic visit, the patient began to have nausea and vomiting, jaundice, and worsening cough. He had a temperature of 39°C.
Two days later, the patient returned to his primary care physician with dyspnea, worsening cough, and a pruritic rash on both arms. A chest X ray revealed bilateral pulmonary infiltrates. The patient had scleral icterus with mild conjunctivitis. In addition, shotty anterior cervical lymphadenopathy was noted.
In this case, some atypical features may have increased the difficulty of finding the correct diagnosis of a severe multisystem disorder in a previously healthy host. In making the diagnosis, the discussant places weight on the most important features of the patient's presentation, and is not overly distracted by anomalous findings.

"jaundiced eye"には、「偏見の目を持った見方」という意味があり、この場合、jaundicedは、prejudiced, biased, distortedなどと同義。

Ring around the Diagnosis

A CLINICAL PROBLEM-SOLVING article by Maria-Fernanda Bonilla from Cleveland Clinic Foundation, Ohio and colleagues.
A 71-year-old retired schoolteacher from rural Ohio presented to his local hospital with a two-week history of malaise, fever, anorexia, chills, and sweats. He had not had a cough or symptoms involving the upper respiratory, gastrointestinal, or urinary tract.
The patient appeared diaphoretic. The blood pressure was 113/58 mm Hg, the heart rate 66 beats per minute, and the respiratory rate 18 breaths per minute and not labored. The temperature was 38.4°C orally.
Three months before his illness, his wife had had an influenza-like febrile illness that left her bedridden for two weeks; she had recovered fully. The reported no travel outside the Midwest.
The patient was admitted with a presumptive diagnosis of urinary tract infection and was treated with intravenously administered ampicillin–sulbactam. Despite continued antibiotic therapy, the patient's clinical status deteriorated during the ensuing two weeks. The fever persisted, and the creatinine level increased to 2.9 mg per deciliter. The total bilirubin level increased to 6.0 mg per deciliter and the conjugated bilirubin level increased to 5.3 mg per deciliter.
In this patient, rapid clinical deterioration mandated an aggressive strategy.
This case discussion explains have the evidence directed the team toward a potentially risky diagnostic procedure, a liver biopsy in a patient with mild coagulopathy. But the result of the liver biopsy changed the diagnostic approach.

今回は、Q熱。不明熱の場合、字義的に筆頭であってもよさそうだが、症例がレアなこともあり、漏がちな疾患。少なくともペット飼育や職業について聴いておくことが重要。

Thinking outside the Box

A CLINICAL PROBLEM-SOLVING article by Ramin Farzaneh-Far from Brigham and Women's Hospital, Boston and colleagues.
A 35-year-old man with advanced AIDS presented to the emergency department after a witnessed syncopal event. He had light-headedness after walking from the bathroom. While speaking to his partner, he suddenly became unresponsive and lost motor tone, and his breathing appeared shallow and labored, prompting his partner to call 911. The man regained consciousness after approximately two minutes and had no recollection of the event. There was no evidence of tonic–clonic seizure activity or postictal confusion. He reported no chest pain, cough, palpitations, pleurisy, vertigo, shortness of breath, fevers, chills, nausea or vomiting, or incontinence.
A detailed history from an eyewitness is invaluable in evaluating a patient with syncope and distinguishing true syncope from seizure. Although this patient's history of HIV infection puts him at risk for several conditions that might result in seizure, the absence of observed sustained tonic–clonic movements, confusion or drowsiness after the syncopal event, and urinary incontinence argue against this diagnosis.
This case highlights the effect of the ability to “think outside the box” is critical to avoid missing this diagnosis, particularly in patients whose underlying diseases may otherwise suggest alternative explanations for presenting symptoms.

重要視されていても正確な診断が困難なのが肺塞栓症。 エコーの所見を2つほどメモ。

• McConnell's sign(hypokinesis of the right ventricular free wall with sparing of the right ventricular apex in the presence of preserved left ventricular systolic function) : sensitivity 77%, specificity 94% 
• 60/60 sign (Pulmonary ejection acceleration time in RVOT of 60ms in the presence of tricuspid insufficiency oressure gradient 60mmHg): sensitivity 26%, specificity 89%

Heading Down the Wrong Path

A CLINICAL PROBLEM-SOLVING article by Michael Detsky from University of Toronto, Ontario, Canada.
A 52-year-old woman experienced the sudden onset of bilateral arm tingling and numbness, and noted that the words on her computer screen appeared “mixed up.” Her condition improved during the next 24 hours, but difficulty swallowing and slurred speech developed, and worsened during the next three days until she was unable to speak. The day before presentation, bilateral impairment of the left visual field developed and she became lethargic. Her family sought medical care for her.
A chest x-ray revealed no abnormalities. Blood studies were within normal limits. CT of the brain showed no obvious lesions.
Follow-up cardiovascular examination was normal. Neurologic examination revealed a number of abnormalities that suggested the presence of lesions in the cerebellum and right hemisphere.
MRI of the brain demonstrated multiple hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery images.
The paitient was treated with cyclosporine and thyroxine. Although there was apparent resolution of some lesions, progression of others is evident elsewhere, indicating active disease.
This case reveals the rare condition, facing the challenging cause, the patient's physicians headed down the wrong path before ultimately reaching the correct diagnosis.

「第303回　東京レントゲンカンファレンス」を参照。

A Sharp Right Turn

A CLINICAL PROBLEM-SOLVING article by Anupam Mohanty from University of South Florida College of Medicine in Tampa.
A 60-year-old man presented to the emergency department for evaluation of rectal bleeding, syncope, and pain in the right leg. Five days earlier, diffuse abdominal pain that worsened with movement had developed in association with nausea, anorexia, and malaise. He had not traveled recently or ingested any unusual foods. Approximately six hours before admission, he had a single episode of gross hematochezia and hematuria followed by syncope and an intense pain in his right leg.
This patient presented with multisystem findings, for which a unifying diagnosis is not immediately clear. This case involves collaboration with internist, gastroenterologist and vascular surgeon to reveal an unusual surgical condition with signs and symptoms that are similar to those of several intraabdominal diseases.

ちょいと脱線。面舵、取舵は、それぞれ干支の卯（東）、酉（西）に由来するそうだ。それに対し、英語のstar board、portは、操舵席のある側が右なのでsteer boardが訛り、接岸する左側がportというらしい。前者は、接岸する反対側なので星が良く見え、star boardという説もあるとか。

More Than Meets the Eye

A CLINICAL PROBLEM-SOLVING article by John Nguyen from Johns Hopkins University School of Medicine, Baltimore, Maryland.
A 61-year-old woman was hospitalized with a two-day history of palpitations and dyspnea. She was found to be in atrial fibrillation with a rapid ventricular response, and intravenous diltiazem and a heparin infusion were begun. Her condition improved, but on the third hospital day, she reported feeling weak and nauseated and began passing dark red urine. She did not have a urinary catheter, dyspnea, back pain or dysuria.
The hematocrit 30% was compared with 35% at admission. Urinary dipstick testing revealed high levels of hemoglobin and 3 plus protein. Results of urine testing for myoglobin were negative.
Often, clinicians encounter new problems during the course of a patient's hospitalization that are unrelated to the initial reasons for admission. In this case, the patient's symptoms developed while she was being treated with anticoagulants for atrial fibrillation. 

最近は、英語に合わせて「発作性夜間ヘモグロビン尿症」と呼ばれるのですね。Marchiafava-Micheli症候群という冠名もあるようですが。

Lost in Transcription

A CLINICAL PROBLEM-SOLVING article by Robert Kalus from University of Washington, Seattle.
Urinary urgency and fever developed in a 55-year-old, bedridden woman with multiple sclerosis, a long-term indwelling Foley catheter, and multiple prior urinary tract infections. The patient had recently been transferred from an assisted-living facility to a skilled-nursing facility because of progressive disability. On the day of presentation, she reported urinary urgency and dysuria, despite a normally functioning urethral catheter; her temperature was 38.5°C.
Her long-term medications included ranitidine for reflux symptoms, rofecoxib for pain control, baclofen for spasticity, gabapentin for neuropathic pain, and weekly methotrexate as corticosteroid-sparing therapy for her progressive multiple sclerosis. She had also mouth pain and fatigue for several days before presentation.
On examination at the emergency department, the patient was thin, somnolent, diaphoretic, and ill-appearing. She had notable dry oral mucosa, with desquamation of her tongue, palate, and buccal surfaces.
Laboratory testing revealed a white-cell count of 330 per cubic millimeter, with an absolute neutrophil count of 50; the platelet count was 7000, and the hematocrit was 34%; serum creatinine, 1.0 mg per deciliter, increased from 0.5 mg 10 weeks earlier.
In this case, after initially considering a broad differential diagnosis, the discussant quickly focused on the possibility of medical error.

メソトレキセート処方の転記(transcription)ミスによる骨髄抑制のケース。この薬剤は、「白質脳症」にも気をつける必要がある。

The Missing Piece

A CLINICAL PROBLEM-SOLVING article by Kathryn Robertson from University of Colorado Health Sciences Center in Denver.
A 21-year-old man presented to the emergency department after a 2-day history of increasing pain in the right lower quadrant. He had had exertional dyspnea and a cough productive of scanty yellow sputum for a month.
He had previously been employed as a sushi chef, but he had not worked for 3 months. He had not ingested raw shellfish but had prepared raw crayfish and crab. 4 years before presentation, he had spent 3 months visiting relatives in rural areas of South Korea.
Laboratory analysis revealed peripheral blood eosinophilia and a chest X ray showed moderate-sized, bilateral pleural effusions.
One of the most effective strategies involves pattern recognition, in which the clinician breaks the case down into manageable pieces and compares features of the current case with ones he or she has seen in the past. New cases are then recognized as similar or identical to old ones that have already been solved. In the case under discussion, the clinician focused on two patterns of disease with which he was familiar: abdominal pain and respiratory disease.

今回は、폐흡충(肺吸蟲)でした。

Sum of the Parts

A CLINICAL PROBLEM-SOLVING article by Meeta Prasad from Yale University School of Medicine in New Haven, Connecticut.
A 36-year-old Pakistani woman presented to the emergency room with a 10-day history of a nonproductive cough, dyspnea, and fever. She reported having no night sweats and no contact with anyone who was ill, including anyone with known tuberculosis. She had been seen 1 week earlier at a walk-in clinic, where she received a prescription for moxifloxacin for presumed bronchitis, but her symptoms persisted.
At the emergency room, she presented with petechiae, pulmonary hemorrhage, azotemia, proteinuria, and hematuria.
This case represents an uncommon presentation of a common disease. Recognizing the sum of the parts of this patient's complicated presentation ultimately led to the correct diagnosis and to effective therapy.

参考文献

• 本邦のC型慢性肝疾患におけるクリオグロブリン血症についての検討　日消誌94(4)242-247, 1997

A Stain in Time

A CLINICAL PROBLEM-SOLVING article by Jeremy Jones from University of Toronto, Canada.
A 45-year-old woman from northern Ontario presented to her local hospital with a 2-year history of asymmetric migratory arthralgias involving the left knee, ankles, elbows, and fingers. She also had morning stiffness, increasing fatigue, an erythematous, nonpruritic rash after sun exposure, and a 3-month history of chest pain that was relieved when she was in an upright position. She did not have fevers, dry eyes or mouth, oral ulcers, or eye irritation or pain.
The patient's physicians made a diagnosis of seronegative lupus and started treatment with hydroxychloroquine. However, this conclusion was premature; the patient did not meet formal criteria for the diagnosis, antinuclear antibody–negative lupus is rare, and other more common conditions (such as inflammatory bowel disease and chronic infections) warranted consideration first. As the case unfolded over a period of several years, the chronic nature of the illness, the evolution of new constitutional symptoms, and the manifestations of malabsorption led to reconsideration of the initial diagnostic hypothesis and ultimately to conclusive diagnostic testing of duodenal tissue and cerebrospinal fluid.

Whipple病に関する資料

• Whipple's Disease via NEJM 
• Whipple病は病理学者により1907年に初めて報告された疾患 via 感染症の病理学的考え方 
• Whipple 病はマクロファージ内のPAS陽性物質と脂質沈着が特徴 via 感染症の病理学的考え方

Anchors Away

A CLINICAL PROBLEM-SOLVING article by Carolyn Calfee from University of California, San Francisco.
A 50-year-old Asian woman presented with a papulonodular, erythematous rash on her legs below the knees. The skin lesions were nontender and nonpruritic and were accompanied by paresthesias.
A biopsy of one of the skin lesions showed granulomatous dermatitis. Stains and cultures for acid-fast bacilli and fungal organisms were negative. On the basis of the clinical and histopathological findings, a diagnosis of sarcoidosis was made by the patient's physician.
A chest radiograph reportedly revealed scattered nodules and increased interstitial markings that were considered to be consistent with sarcoidosis. Three months later, shortly before her appointment with the pulmonologist, dyspnea on minimal exertion, hoarseness, and dysphagia with both solids and liquids developed.
In this case, several findings support the diagnosis of sarcoidosis. None of these findings, however, are specific enough to be considered diagnostic of sarcoidosis.
Why did the physicians initially involved in this case settle on a diagnosis of sarcoidosis? They most likely fell prey to two types of cognitive bias: the availability and anchoring heuristics.
The clinicians initially accepted the diagnosis and were falsely anchored to it from that point onward.

最終診断は、リンパ腫様肉芽腫症(lymphomatoid granulomatosis)だが、Discussantはサルコイドーシスにアンカリングされてしまった。

Into the Woods

A CLINICAL PROBLEM-SOLVING article by Nasia Safdar from University of Wisconsin–Madison.
A 79-year-old woman presented with a 1-month history of dyspnea and a cough productive of yellow sputum. She reported no chest pain, hemoptysis, night sweats, or fever.
Three months earlier, the patient had been clinically diagnosed with giant-cell arteritis. And she was placed on 40 mg of oral prednisone daily which she was still taking at the time the pulmonary symptoms developed.
The patient was retired and spent a great deal of time in the woods around her home in Wisconsin.
On physical examination, the patient was a thin, elderly woman in no acute distress.
The erythrocyte sedimentation rate was 117 mm per hour; C-reactive protein was 27 mg per deciliter. A chest radiograph revealed air-space opacity in the left upper lobe.
Several days after admission, repeated chest ray showed worsening disease.
Gram's staining of a sputum specimen revealed beaded, branching, gram-positive rods.
Correctly and efficiently diagnosing the cause of pulmonary disease in an immunocompromised patient is challenging. Knowledge of the rate of disease progression and the type of immune compromise is useful in the initial differential diagnosis. A detailed history to elicit epidemiologic exposures further refines the possible diagnoses. Finally, the pattern of lung involvement can also help narrow down the possible causes.

Building a Diagnosis from the Ground Up

A CLINICAL PROBLEM-SOLVING article by Brook Watts from Louis Stokes Cleveland VA Medical Center in Ohio.
A 49-year-old man came to the clinic with a 1-week history of suprapubic pain and fever. On examination, he had a temperature of 38.1°C but appeared well. A urinalysis revealed numerous white cells, two red cells, and more than two bacteria per high-power field. A urinary tract infection was diagnosed, and oral gatifloxacin was prescribed.
The patient returned the following day, reporting an inability to urinate and he was discharged home with an indwelling urinary catheter and a prescription for oral doxazosin.
The patient's symptoms persisted and he returned 3 days later. CT of the abdomen and pelvis revealed an abscess in the right portion of the prostate gland. In addition, in the normal location of the spleen, contrast-enhanced CT showed a 4-cm soft-tissue density that was thought to be a hypoplastic or accessory spleen.
On admission, the patient reported new pruritic lesions on his arms, face, and trunk and pain in his right ankle. The patient worked as a long-distance bus driver. His normal routes were through the midwestern and northeastern United States.
The patient's condition declined and he was eventually intubated and placed on ventilatory support.
What could explain multiple nodular and pustular skin lesions, a prostatic abscess, mild fever, monoarticular joint involvement and subsequent physiologic decline? In this case, the correct diagnosis was reached only by building from the ground up, one clue at a time.

Blastomyces dermatitidis感染によるブラストミセス症。ミシシッピ川流域を侵淫する風土病。

The Drenched Doctor

A CLINICAL PROBLEM-SOLVING article by Daniel Kaul from University of Michigan Medical School in Ann Arbor.
A 55-year-old male physician was seen in August because of a 1-week history of fever and night sweats. The patient also noted a persistent cough, which had previously been ascribed to esophageal reflux.
Three months earlier, he had received empirical treatment with a 5-day course of clarithromycin for fever and cough, with initial resolution of the fever and improvement, but not resolution, of the cough. The chest radiograph at that time revealed no infiltrate. There were calcified nodules near the hilum of each lung and a densely calcified hilar lymph node which had been noted on chest radiographs over the previous 30 years and attributed to healed histoplasmosis.
Over the next week, the fever and cough continued, and the night sweats increased in severity, drenching the patient's sheets as well as his nightclothes. On several occasions, his temperature was 38.4°C or higher. He returned to his physician's office; an examination showed no abnormalities. The patient's white-cell count was now 3700 per cubic millimeter.
Five days later, the white-cell count was 7200.
He was treated with ciprofloxacin. The fever diminished, but the fever and night sweats returned after the course of medication had been completed. The cough worsened, and the patient reported that it was exacerbated by swallowing foods and liquids.
In this case, the recognition of the pivot point — coughing on swallowing — was required for the correct diagnosis.

A Hand-Carried Diagnosis

A CLINICAL PROBLEM-SOLVING article by Clinton Greenstone from Veterans Affairs Ann Arbor Medical Center, in Michigan.
A 34-year-old black woman presented to a walk-in clinic with a 3-day history of malaise. Her colleagues had noticed yellowing of her eyes over the past few days.
The patient said she had no fever, chills, sweats, nausea, vomiting, diarrhea, abdominal or chest pain, cough, or dyspnea. She had had one sexual partner for the previous 2 years, and her last sexual contact occurred 6 months earlier without barrier protection. She had taken Ortho-Novum, her only medication, for the previous 2 years, but she discontinued this medication 5 months earlier when she broke up with her last partner because of his infidelity.
On examination, her temperature was 38.0°C, blood pressure 110/78 mm Hg, and heart rate 100 beats per minute. Skin examination revealed no rash or spider angiomas. She had scleral icterus. On abdominal examination, she had mild tenderness on deep palpation in the right upper quadrant.
The patient's hepatic laboratory values showed a cholestatic injury pattern.
The patient was sent home and advised to rest and increase her fluid intake while awaiting the test results.
The patient returned to the clinic 3 days later. She now reported a new rash, which she described as having started on her abdomen and then spread to her legs, arms and palms.

手掌の薔薇疹が決め手となりました。肝炎などを呈したのは、梅毒が"the great imitator"と呼ばれる所以です。 the great imitatorに関しては、英語版wikipedia、Zebra Cardsに詳しい記載があります。

A Sinister Development

A CLINICAL PROBLEM-SOLVING article by Reza Fazel from Emory University in Atlanta, Georgia.
A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma. She also reported mild dyspnea during the previous day, with no associated chest discomfort.
Six months earlier, she had given birth to a healthy infant by vaginal delivery at term; her pregnancy had been uncomplicated. Her only medications were oral contraceptives and a multivitamin.
In the emergency department, she was not in acute distress and was afebrile. Her left leg showed no evidence of trauma but there was considerable swelling extending from her ankle to the upper thigh, and the area of the swelling was markedly tender to palpation. The leg was slightly pale with diminished but palpable pulses.
Doppler ultrasonography of the veins in her left leg showed abnormally sluggish blood flow in the proximal deep venous system but was inconclusive for thrombus. A ventilation–perfusion scan of the lung was normal.
Intravenous unfractionated heparin was started, and the patient was hospitalized for further evaluation of the cause of pain and swelling in her left leg.

May-Thurner症候群、aka腸骨静脈圧迫症候群：左総腸骨静脈は右総腸骨動脈と交差して いますが、この交差する部分で腸骨静脈が腸骨動脈と背側にある椎体との間で圧排されることで血流障害が生じ、何らかの誘因で左下肢のDVTを引き起こすものです。左ということが肝で、タイトルの"sinister"には、「不遇な」と同時に「左の」という意味があります。

A Growing Problem

A CLINICAL PROBLEM-SOLVING article by Wendy Yeh from Brigham and Women's Hospital, Boston.
A 36-year-old pregnant woman at 21 weeks of gestation presented with a 4-week history of a dry, nonproductive cough.
She had no fever, chills, dyspnea, chest pain, or weight loss. It was her first pregnancy, and there were no complications. She had no new pets, environmental exposures, or sick contacts. In the past, she had traveled to Australia, Central Asia, and sub-Saharan Africa.
Her cough improved, but did not resolve, with the use of an inhaled bronchodilator. Her symptom persisted for another month, and she was started on an H2-blocker for empirical treatment of gastroesophageal reflux disease. She continued to use an H2-blocker for the remainder of her pregnancy. She had an uncomplicated vaginal delivery 4 months later. She continued to have intermittent dry cough and presented again 2 months after delivery for a reevaluation of her cough.
A chest radiograph revealed a soft-tissue mass, 7 cm in diameter, adjacent to the right heart border.
This patient had an uncommon cause of a common symptom.
This case illustrates the importance of not ignoring a growing problem, even if the presentation seems benign.

A Stitch in Time

A CLINICAL PROBLEM-SOLVING article by Christopher Graber from University of California at San Francisco.
A 64-year-old man with a history of coronary artery disease and peripheral vascular disease with an aortobifemoral bypass seventeen months before was admitted with a several-month history of fevers, chills, and fatigue. These symptoms had begun soon after he had undergone percutaneous coronary intervention with placement of a stent in the left anterior descending coronary artery. He had initially been treated empirically with a 5-day course of ciprofloxacin. However, the symptoms returned 1 week after discontinuation of the antibiotic, and 3 weeks later he was admitted to a hospital. Blood cultures obtained at that time were positive for group C streptococcus. He was discharged with instructions to complete 6 weeks of therapy with ceftriaxone.
1 month after finishing the antibiotics, he reported the recurrence of fatigue, malaise, and low-grade fever.
At the outset of the case, the lack of blood cultures before the patient received antibiotic therapy on multiple occasions clouded the clinician's ability to make the diagnosis. However, the history of recurrent low-grade fevers and malaise despite antibiotic therapy and eventual multiple, positive blood cultures prompted a strong clinical suspicion of an endovascular infection.

タイトルは、A stitch in time saves nine.（転ばぬ先の杖）の諺から。

Nothing to Cough At

A CLINICAL PROBLEM-SOLVING article by Paul Cornia from Veterans Affairs Puget Sound Health Care System in Seattle, Washington.
A 73-year-old man presented to the emergency department with a 4-day history of nonproductive cough that worsened at night. He did not have fever, nasal congestion, sore throat, hemoptysis, chest pain, or dyspnea.
The patient had a history of coronary-artery disease, hypertension, and possible aortic stenosis. He reported that none of his medications had been started recently. His vital sign was normal. A chest radiograph was normal.
The emergency department physician thought the patient's cough was probably related to the use of lisinopril and advised that the drug be replaced with an angiotensin-receptor blocker.
One week later, the patient returned to the clinic and reported that, despite the change in medication, the cough had worsened. It was present throughout the day but remained particularly bothersome at night and disrupted sleep.
Cough is one of the most common symptoms for which patients see their primary care physicians. The differential diagnosis for cough is broad and encompasses disorders that range from those that are relatively benign to those that are potentially life-threatening. The duration of cough at the time of presentation is a useful first step toward narrowing the differential diagnosis.
This case describes an important, but often overlooked, cause of cough.

coughは厄介だ。その名のジャーナルがあることからも察することができる。臨床的においてのみならず、語学的な意味においても、また厄介だ。

• [ɔ́ː] bought, brought, thought, fought, sought, nought, daughter, naughty...
• [óu] though, although, dough（３語）
• [uː] through（１語）
• [áu] bough, drought, plough（３語）
• [ou/ə] thórough, bórough（２語）
• [ʌ́f] enough, rough, tough（３語）
• [ɔ́(ː)f] cough, trough（２語）
• [ʌp] hiccough（１語）

No Respecter of Age

旬な感染症の話。「診断のゲシュタルトとデギュスタシオン 」にも取り上げられています。

A CLINICAL PROBLEM-SOLVING article by Don Martin from Johns Hopkins University School of Medicine, Baltimore, Maryland.
A previously healthy 65-year-old woman went to her primary care physician in late August, seeking evaluation of a “spot” that had appeared on her right leg 3 weeks earlier. Her physical examination was notable only for a low-grade temperature elevation and a 7-to-8-mm erythematous macule on her right leg.
One week later, the skin lesion had resolved, but the patient returned, reporting malaise and diffuse arthralgias that had progressively worsened, with intense, disabling pain and stiffness in her neck, shoulders, wrists, hands, knees, and ankles. In addition, she noted pain in the left anterior part of her chest that had awakened her from sleep, was exacerbated by respiration, and was partially relieved by sitting up.
She reported no recent contact with anyone who was sick and had last seen her grandchildren 6 weeks earlier.
The patient's constitutional symptoms and polyarticular involvement suggest the development of a systemic inflammatory arthritis. Although the initial skin lesion may have been unrelated to her subsequent symptoms, this history points to a possible infectious cause.
Bacterial, atypical, and viral infections can cause inflammatory arthritis, and arthritis can also follow infection with a variety of organisms.
As this case illustrates, the absence of known contact with someone who is sick does not rule out infection.

The Leading Diagnosis

A CLINICAL PROBLEM-SOLVING article by Thomas Baudendistel from California Pacific Medical Center in San Francisco.
A 23-year-old black woman presented to the emergency department with diffuse, colicky abdominal pain of 1 hour's duration. The pain was followed by nausea and episodes of bilious vomiting and did not radiate or change with the patient's position.
The patient reported that a similar episode had occurred 6 months previously. At that time, she passed red blood from the rectum once but did not seek medical attention.
On examination, she was restless and clutching her abdomen. Abdominal examination revealed hyperactive bowel sounds and a CT scan of the abdomen showed intussusception of a segment of small intestine.
On closer inspection, several small hyperpigmented lentigines were detected on the patient's fingers, tongue, and everted lips.

Failure to Respond

A CLINICAL PROBLEM-SOLVING article by Michael Ezzie from Ohio State University, Columbus.
A 52-year-old man presented to his primary care physician with dyspnea and cough. For the past 15 years, he had recurrent episodes of cough that were relieved only by intermittent courses of oral corticosteroids. He had been treated on three occasions during the past year with 20 mg of prednisone daily for 2 weeks. In the previous 3 weeks, his cough had increased in frequency, and severe dyspnea had developed. This time, 2 weeks of prednisone had not provided relief. He had occasional chills but no fever. His cough was productive of yellow sputum.
The patient's medical history included complete resection of a thymoma 5 years earlier.
The patient was admitted to the hospital. Chest X ray showed bilateral alveolar infiltrates.
The patient was started on moxifloxacin for community-acquired pneumonia. Gram's staining of a sputum specimen showed gram-positive diplococci with many leukocytes; two blood cultures grew penicillin-sensitive Streptococcus pneumoniae. The patient was switched to intravenous penicillin G but continued to be hypoxemic. Chest X ray showed no improvement after 5 days of therapy.
Clinical improvement with pneumococcal pneumonia is generally observed within 3 days after the initiation of appropriate therapy, and the limited improvement in the patient's condition was a concern.
When a patient's condition does not improve despite appropriate therapy, the clinician must reconsider the course of action. This requires critical appraisal of the original diagnosis and a thorough investigation of possible causes of treatment failure.

What's the Connection?

A CLINICAL PROBLEM-SOLVING article by Aharon Sareli from University of Pennsylvania, Philadelphia.
A 26-year-old man presented with 1-month history of persistent cough productive of white sputum, which was occasionally tinged with blood. He reported mild pleuritic chest pain. His cough had been treated with azithromycin with no resolution of his symptoms.
Five years before this presentation, the patient had been treated for a right-sided spontaneous pneumothorax. Three years before presentation, he was found to have a spontaneous left renal-artery dissection with renal infarction.
On present examination, the patient appeared comfortable and was in no acute distress. He had generalized joint hypermobility involving both small and large joints.
A chest radiograph revealed a left lower-lobe cavity with an air–liquid level, small left-sided apical pneumothorax, and left hydrothorax. Chest CT revealed subcentimeter nodules with surrounding haziness.
The patient received 14 days of intravenous ampicillin–sulbactam to treat a presumed lung abscess. Seventeen weeks later, the patient presented with massive hemoptysis.
In this case, both the discussant and the clinical team did what experienced diagnosticians often do when confronted with a patient whose illness does not lend itself to a simple diagnosis: try to find the connection between the present illness and past abnormalities.

In the Thick of It

A CLINICAL PROBLEM-SOLVING article by Deepak Rao from Brigham and Women's, Boston.
A 52-year-old man presented to the emergency department with an acute onset of palpitations and chest pressure. Two days earlier, epigastric burning, fatigue, weakness, and emesis had developed. On presentation, his heart rate was 200 beats per minute. An electrocardiogram showed an irregular rhythm with high-amplitude, mildly prolonged QRS complexes that were consistent with atrial fibrillation with a rapid ventricular response, left ventricular hypertrophy, and interventricular conduction delay. Intravenous fluids and intravenous metoprolol were given without effect, after which electrical cardioversion was performed and sinus rhythm was restored. He was transferred to a tertiary care hospital for further care.
The patient's medical history was notable for hypertension and renal dysfunction (cause unknown) and renal transplantation.
A transthoracic echocardiogram showed severe, concentric biventricular hypertrophy.
In this case, although the patient's history of hypertension offered a straightforward explanation for the observed hypertrophy, several aspects of his presentation were not consistent with hypertensive cardiomyopathy, including the presence of biventricular hypertrophy and preexcitation which suggested the presence of a metabolic storage disorder.

タイトルは、心筋の肥厚(thickness)と酣（たけなわ）の意のthickを掛けたのでしょうか。