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.