A Red Flag

A CLINICAL PROBLEM-SOLVING article by Reza Fazel from Emory University, Atlanta, Georgia.
A 64-year-old man was brought to the emergency department because of sudden-onset blurred vision in both eyes and diplopia, as well as a frontal headache that had begun earlier that day. On presentation, he was noted to have an altered mental status. His visual symptoms spontaneously resolved shortly after his arrival at the emergency department.
On physical examination, the patient was lethargic, was oriented to person and place but not to time, and had difficulty with word finding.
The hemoglobin level was 11.8 g per deciliter; the platelet count 234,000 per cubic millimeter, and the white-cell count 10,300 per cubic millimeter with  59% eosinophils.
Chest radiography revealed bilateral apical opacities.
This illness is distinguished by its multisystem involvement and the marked eosinophilia.
Complicated cases with multisystem manifestations often force clinicians to consider numerous diagnostic possibilities that span the major categories of disease, including infections, cancer, autoimmune disorders, and metabolic derangements. On occasion, the initial evaluation reveals a distinctive finding, or clinical red flag, that allows the clinician to transform a broad question (What is causing this multisystem illness?) into a more circumscribed problem (What explains this marked eosinophilia?).

Kiss of Death

A CLINICAL PROBLEM-SOLVING article by Brian Graham from University of Colorado Health Sciences Center, Denver.
A 23-year-old South African man presented to an emergency department with a 2-day history of fever, mild dyspnea, headache, nausea, and myalgias. His symptoms had begun 5 days after he had traveled to Colorado to ski with friends. He was thought to have a viral illness, was treated with intravenous fluids, and was discharged with a prescription for acetaminophen–hydrocodone. After 2 days, his symptoms worsened and he returned to the emergency department. A chest radiograph was clear, and he was treated with intravenous fluids and ibuprofen, again without relief. The following day, he returned to the emergency department with vomiting, dyspnea, and photophobia. He was admitted to the hospital for further evaluation and treatment. He was sexually active and had had more than 15 sexual partners in his lifetime. He had traveled extensively the preceding year and had recently driven across South Africa in an uncovered vehicle.
In this patient, disease acquired in Africa as well as more “routine” causes of infection must be considered.
He remained episodically febrile. On day 5 of the patient's hospitalization, the antibiotic regimen was broadened. Liver-function values continued to increase. The patient's mental status declined. He had a generalized tonic–clonic seizure. He was transferred to a tertiary care hospital for further evaluation and possible liver transplantation. Patient's friends revealed that he had left a nightclub with a female companion several days before he became ill.

"kiss of death" というのは、最後の晩餐後、ゲッセマネの祈りを終えたキリストにユダが売り渡す合図のとしての接吻をすることに由来するそうです。「一見ためになるようで実は破滅をもたらすもの」とか、「ありがたくない方面からの（計略的な）候補者支持」、「命取りになるもの」、「災いの元」、「致命傷」などの比喩として使われるようです。
一方、"kiss of life" という表現もあり、イギリス英語で「口移しの人工呼吸」のことで、アメリカ英語のmouth-to-mouth resuscitationのことです。

A Fragile Balance

A CLINICAL PROBLEM-SOLVING article by Asaf Bitton from Brigham and Women's Hospital, Harvard Medical School, Boston.
A 31-year-old man presented to the emergency department with pain in the left shoulder. He had tripped over the shoulder strap of his backpack earlier in the day and noted immediate severe pain around his left shoulder, without paresthesias or neck pain. Physical examination revealed bony point tenderness over the humeral head. Shoulder x-rays revealed an impacted fracture of the left humerus and evidence of osteopenia. His medical history was notable for multiple fractures of the femur, elbow, and wrist, without previous evaluation.
Plain x-rays are not sensitive for bone loss; the fact that osteopenia was detected on such imaging suggests considerable bone loss, and a formal assessment of bone mineral density is warranted. When osteopenia is suspected in a male patient who is younger than 50 years, a careful history taking is essential. The key components should include questions about fractures and the circumstances in which they occurred, growth and pubertal development in childhood, medication use, a thorough review of systems to screen for systemic diseases, and a family history of fractures or systemic diseases. The initial laboratory evaluation should include an assessment for secondary causes of bone loss in young men, with tests of thyroid, parathyroid, renal, and gonadal function, as well as vitamin D levels.

The Essential Element

久々にディクテーションの復活。

A CLINICAL PROBLEM-SOLVING article by Nathan Houchens from University of Michigan Medical School, Ann Harbor
A 21-year-old female college student presented with a 10-day history of progressive fatigue, weakness, light-headedness, exertional dyspnea, and dark-colored urine, followed by an episode of syncope without injury.
On physical examination, the temperature was 38.1°C (100.6°F). There was scleral icterus. Auscultation of the heart revealed regular tachycardia without extraneous sounds.
Laboratory analysis revealed profound anemia, leukocytosis, reticulocytosis, elevated bilirubin and aminotransferase levels, coagulopathy, and hypoalbuminemia.
Three units of packed erythrocytes were transfused, and the hemoglobin level increased from 3.9 g per deciliter to 7.8 g.
However, the patient continued to require multiple erythrocyte transfusions for refractory anemia.
A peripheral-blood smear obtained after the transfusion revealed immature granulocytes and nucleated erythrocytes, marked anisopoikilocytosis, and numerous spherocytes and echinospherocytes.
In this case, although several test results appear to be consistent with hemolysis, the pattern of the aminotransferase levels — that is, the level of alanine aminotransferase being greater than that of aspartate aminotransferase — along with the elevated bilirubin level and coagulopathy continue to suggest an underlying hepatic disorder.

タイトルは、「（診断過程における）必須の要素」と「必須元素」を掛けた、上手い洒落。Discussantのパートのテキストを、Word Cloudsを作ってくれる"Wordle"というオンラインサービスに流し込んでみたのが、下図。

臨床推論のムーブ 暫定版"GESTALT"

Generate a hypothesis. (inductive phase)
例）

• This patient's age, sex and presentation suggest a pathologic process with organ involvement.
• The first things that come to mind are the usual causes of respiratory distress, such as pneumonia, congestive heart failure, or a pulmonary embolus.

Explore the worst case scenario.
例）

• ... are among the “must not miss” diagnoses and should be ruled out.
• ... are not compelling possibilities with this history, but they should be kept in mind.

Sharpen the hypothesis.
例）

• The finding narrowed the broad differential diagnosis.
• The finding leads me to broaden my differential diagnosis.

Tweak the probability
例）

• The presence of ... reduces the likelihood of ...
• The absence of ... raises the possibility of ...

Ask for further information (Proposal of further investigation, Question ... )
例）

• I would also check for the presence of antineutrophil cytoplasmic antibodies and consider a sural-nerve biopsy.
• To look for other possible sources of sepsis, I would order an abdominal CT scan and an echocardiogram.

List some hypotheses in order of priority.
例）

• My three major considerations at this point are ...
• The three most likely diagnoses at this point are ...

TEST the hypothesis (deductive phase) - Timeline review, Explain the findings?, Simple adequately?, Theory-based?
例）

• Because her diagnosis continues to elude me, I would also carefully review her previous test results to try to discover something that is obvious only with hindsight.
• Rheumatoid arthritis could explain subacute symmetric arthralgias in a young woman, but severe pulmonary or cardiac manifestations early in the disease course would be unusual.
• Occam's razor is an issue here — that is, will one diagnosis explain all the findings?
• The pathological findings are consistent with the presence of arteriopathy, venulopathy, and secondary hemorrhagic infarcts; nothing suggests necrotizing vasculitis

SIROメソッドのゴール

目標：

• NEJMのポッドキャストでClinical Problem-Solvingの聴き取りができる。
• 上記素材を聴き取り、臨床推論を呟くことができる。
• 以上２点を３ヶ月で可能とするメソッドを開発する。

素材と方法：

• オリジナル記事から臨床推論部分を抽出、テキスト素材を準備する。済
• ポッドキャストからCPS部分を切り出し、音声素材を準備する。済
• 音声素材のスクリプトを作成。５月中
• 音声素材を10段変速に編集。６月中
• 臨床推論部分をOCHA（Observe, Classify, Hypothesize and Apply）アプローチでジャンル分析。
• ムーブを同定する。
• ムーブ毎の例文集を作成し、mp3化。(Rational Output)６月中

予定成果：

• 10段変速音声とそのスクリプト
• 頻出語のコロケーションの可視化。
• １ムーブにつき10例程度の例文集
• パーソナルユースの電子本作成(Sigil)

参考：

• "Advances in Medical Discourse Analysis: Oral and Written Contexts" Maurizio Gotti,Françoise Salager-Meyer から Philippa Mungra "Macrostructure and Rhetorical Moves in Secondary Research Articles: The Meta-Analysis and the Systematic Analysis"

Introduction section (move 1, 2, 3) 

Move 1: Establishing a territory e.g. centrality claim
Move 2: Establishing a niche e.g. indicating a gap and raising a question
Move 3: Occupying a niche e.g. introducing the aim or identifying the purpose of present study

Methods section (move 4, 5) 

Move 4: Search strategy for selection of studies

• Step 1: Identification and justification of RAs or RCTs , with inclusion and exclusion criteria of selection

• Step 2: Dealing with aberrations or disagreements between researchers

• Step 3: Defining extraction of parameters or subgroups to be compared

Move 5: Procedures used in data synthesis

• Step 1: Extraction of data from roster of publications and researcher blinding for quality control 

• Step 2: Data synthesis, statistical modeling and software used

Results section (move 6)

• Step 1: Data descriptions of tables (Present in MAs, absent in SRs)

• Step 2: Synthetic comment in each result or groups of results

• Step 3:  Generalizing comments from the data tables 

Conclusions section (move 7, 8, 9) 

Move 7: Evaluating the findings and/or claim, indicating whether the findings are concordance with other authors

• Step 1: Restating the purpose of the study and the hypothesis expected

• Step 2: Making a claim supported by data from move 6-3

• Step 3: Indicating limitation to the claim

Move 8: Clinical applications and recommendations
Move 9: Limitations of study and problem areas for further study

Clinical Problem-Solvingを考えるための12文献

と、銘打ってはみましたが、単に右本からの孫引きであります。ですから、概要を知るためには、右本を購入して第一章「内科的診断能力を鍛える」を読むのが手っ取り早いです、日本語でもありますし。ただ、概要で物足りないという方のために（実のところ、後で読む自分の為に）リンク集をこさえてみた訳です。

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