問診と身体診察を極めよう、OSCEにむけて：腰痛 / Unleash your Mastery - The art of history taking and physical examination: lower back pain

Hey there,

Today, I've put together a summary on lower back pain, which is just as common as the joint pain we discussed last time.

I thought I'd share it with you all.

こんにちは～、

今日は前回まとめた関節痛と同じくらい出会うであろう

腰痛についてまとめてきたので、皆さんに共有しますね

Whether you’re in the countryside or the city, men and women alike suffer from back pain. But don’t be fooled

—it’s not always something to take lightly.

There are some types of back pain you definitely don’t want to ignore,

so let’s take a good look and review!

田舎でも都会でも、男女問わず腰痛に悩んでいる人は多いと思います

しかしながら一口に腰痛と言っても、なかなか侮れませんでした

見逃してはいけない腰痛も存在するので、ここで一度しっかりと復習していきましょう

今回も英語のボリュームがかなり多くなったので、

日本語はつけていません、、、

ご了承ください

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Lower back pain is something most of us will experience at some point in our lives.

It's one of those pesky issues that can range from a mild annoyance to a major disruption in your daily routine.

Let's dive into the different causes of lower back pain, what symptoms to look out for, and some red flags that might indicate a more serious problem.

What Causes Lower Back Pain?

Lower back pain can stem from various sources.

Here’s a breakdown:

Primary Back Pathology:

1. Musculoligamentous Injury (Lumbosacral Strain): This is often due to overexertion or physical activity.
2. Spondylosis: Degenerative arthritis of the spine.
3. Intervertebral Disc Herniation: When a disc in your spine slips out of place.
4. Anatomic Abnormalities: Such as scoliosis or spondylolisthesis.
5. Compression Fracture: Can be traumatic, spontaneous (due to osteoporosis), or pathologic (from metastatic disease).

Systemic Diseases with Back Manifestations:

• Infection: Like epidural abscess or vertebral osteomyelitis/discitis.
• Metastases: 
        Vertebrae: From lung, breast, prostate, renal, thyroid, myeloma
        Leptomeningeal Carcinomatosis: From lung, breast, melanoma, lymphoma,                                                                     leukemia
• Inflammatory Back Pain: Conditions like ankylosing spondylitis or psoriatic arthritis.

Referred Pain:

1. Aorta: Dissection or aneurysm.
2. Pancreas: Pancreatitis or pancreatic pseudocyst.
3. Kidney: Pyelonephritis, perinephric abscess, or nephrolithiasis.
4. Retroperitoneal Hemorrhage: Bleeding behind the abdominal cavity.

The Big Five: Major Types of Back Pain

Understanding the specifics can help you pinpoint what's going on. Here are the five major types of back pain:

1. Lumbosacral Strain:

• Risk Factors:
  Physical activity leading to muscle or ligament injury.
• Pain Description:
  Worsens with movement, improves with rest.
• Age of Onset:
  Any
• Exam Findings:
  Diffuse tenderness, usually not over the vertebral bodies.
• Imaging:
  Typically none needed.

2. Lumbar Disc Herniation:

• Risk Factors:
  Male sex, smoking, obesity, certain occupations.
• Pain Description:
  Acute onset, pain usually radiates to one leg (sciatica),
  worsens with sitting, improves with back extension.
• Age of Onset:
  Typically 35-50
• Exam Findings:
  Decreased sensation in a specific dermatome,
  decreased patellar or ankle reflex,
  positive straight leg raising (SLR) test.
• Imaging:
  MRI confirms the diagnosis.

3. Spinal Stenosis:

• Risk Factors:
  Narrowing of the spinal canal or neural foramen due to conditions
  like spondylosis or spondylolisthesis.
• Pain Description:
  Leg pain more than back pain,
  worsens with standing/walking,
  improves with sitting/flexion.
• Exam Findings:
  Symptoms induced by bending backwards,
  negative SLR test,
  possible neurological findings.
• Imaging:
  MRI to confirm and rule out serious conditions.

4. Inflammatory Back Pain (Spondyloarthritis):

• Risk Factors:
  Autoimmune conditions linked to HLA-B27.
• Pain Description:
  Worse in the morning, improves with movement,
  night pain,
  morning stiffness > 30 minutes.
• Exam Findings:
  Decreased back range of motion, other joint findings.
• Imaging:
  Plain films of sacroiliac joints,
  MRI if needed.

5. Vertebral Compression Fracture:

• Risk Factors:
  Trauma,
  osteoporosis,
  prolonged corticosteroid use,
  bone metastasis.
• Pain Description:
  Varies in location and quality,
  worsened with movement.
• Age of Onset:
  Over 70 years old
• Exam Findings:
  Midline tenderness at a specific vertebral body,
  kyphosis.
• Imaging:
  Plain film of the affected spinal level.

Taking a History: What to Ask

When assessing lower back pain,
here's a handy guide for history taking (remember the acronym OPQRST):

• O: Onset
  -"When did it start?" "Did you get injured?" "Any unusual physical activity?"
• P: Provocation/Palliation
  -"What makes it better or worse?"
• Q: Quality
  -Describe the pain (sharp, dull, etc.).
• R: Radiation
  - Does the pain travel anywhere else?
• S: Severity
  - Rate your pain on a scale of 1-10.
• T: Timing
  - How long have you had it? Is it constant or intermittent?

Exam Time: Physical Examination

A thorough physical exam is crucial:

• Cardiac auscultation: If infection is suspected.
• Abdominal exam: To rule out referred pain.
• Back exam: Look for visible abnormalities, palpate, and perform the SLR test.
• Neurological exam: Check for any nerve involvement.

Labs and Imaging: When to Dig Deeper

Laboratory Tests (if infection is suspected):

• CBC, UA, blood and urine cultures.

Radiology:

• Start with X-rays.
• Move to MRI if further detail is needed or if serious pathology is suspected.

🚩 Red Flags: When to Worry

Certain symptoms and signs should prompt more urgent evaluation:
Cancer:

• Age over 50
• History of cancer
• Unexpected weight loss
• No improvement with conservative therapy
  (like physical therapy, activity modification, NSAIDs).

Infection:

• Fever
• Immunosuppression
• Focal midline tenderness
• Known or suspected bacteremia
• Indwelling venous catheter
• IV drug use

Final Notes

Lower back pain, or ぎっくり腰 as it’s known in Japan,is something many of us have experienced.

It can range from a minor nuisance to a major disruption.

Here are some common terms and phrases you might hear related to back pain:

Strained Back (Strained Muscle):
This is a common cause of lower back pain and usually not serious.

It’s often referred to as "throwing your back out" or having a "pulled muscle."

Rest, gentle stretching, and over-the-counter pain meds can often help.

Sciatica:

This term is used when pain radiates from your lower back down through your buttocks and legs, often caused by a herniated disc.

People might say they have a "pinched nerve" or feel "shooting pain" down their leg.

Herniated Disc:

Sometimes called a "slipped disc" or "ruptured disc," this occurs
when the soft cushion of tissue between the bones in your spine pushes out.

Spinal Stenosis:

This condition involves the narrowing of the spaces within your spine,which can put pressure on the nerves.

It’s sometimes referred to as having a "narrowing spine."

Degenerative Disc Disease:
This isn’t actually a disease but a term used to describe normal changes in your spinal discs as you age.

Laymen might just call it "wear and tear" on the spine.

Lumbago:

A general term for lower back pain. It’s a bit old-fashioned but still used sometimes, especially in medical contexts.

Bone Spurs:

These are bony projections that develop along the edges of bones, often where bones meet each other in your joints or along the spine.

People might call them "knobs" or "growths" on the spine.

Slipped Vertebra (Spondylolisthesis):

This happens when one of your vertebrae slips forward over the bone below it.

It’s often described as a "shifted" or "out of place" vertebra.

Facet Joint Pain:

Facet joints are small stabilizing joints located between and behind adjacent vertebrae. Pain from these joints is often referred to as "arthritis of the spine."

Layman's Tips for Dealing with Lower Back Pain:

• Heat and Ice:
  Applying heat or ice packs can help reduce pain and inflammation.
  Heat packs are often referred to as "heat wraps" or "heating pads," while ice packs can be called "cold packs" or "ice wraps."
  
• Stretching and Exercise:
  Gentle stretching and exercises can strengthen the muscles supporting your spine. Common stretches include the "cat-cow stretch," "child’s pose," and "pelvic tilts."
  
  
• Posture:
  Maintaining good posture, both sitting and standing, can prevent back pain.
  Terms like "slouching" and "hunching" are often used to describe poor posture.
  
  
• Lifting Techniques:
  Use your legs, not your back, to lift heavy objects.
  This is often referred to as "lifting with your legs" or using the "power lift" technique.
  
  
• Ergonomics:
  Setting up your workspace to support good posture can help.
  This includes using "ergonomic chairs," "standing desks," and "footrests."

Idioms and Phrases Related to Back Pain:

• "Back-breaking work":
  This phrase is used to describe extremely hard physical labor that can lead to back pain.
  
  
• "Carrying the weight of the world on your shoulders":
  This idiom means feeling overwhelmed by responsibilities, which can sometimes lead to actual back pain from stress.
  
  
• "A pain in the neck/back":
  Used metaphorically to describe something or someone very annoying or troublesome, similar to how actual back pain can feel.

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お疲れさまでした

一緒に学んできたように、誰もが経験したことのある腰痛ですが

考えなければいけないことがたくさんあって、これだけまとめていてもまだまだ足りないくらいです、、、

ですが、

しっかりマスターしておけば、自信をもって診療のできる患者さんも増えると思うので

少しずつ落とし込んでいきましょう

Lower back pain can be frustrating and debilitating,
but with the right approach and understanding, it can be managed effectively.

If you’re experiencing severe symptoms or red flags, don’t hesitate to seek professional medical advice.

Stay mindful of your posture, engage in regular exercise, and use the tips and terms above to help navigate through your back pain journey.

問診と身体診察を極めよう、OSCEにむけて：関節痛 / Unleash your Mastery - The art of history taking and physical examination: Arthralgia/Joint pain

Welcome back to my blog

Today, let's dive right into today's joint pain, arthlargia

いつもありがとうございます～

今日も問診と診察を極めて行きましょう

本日は関節痛についてです

Joint pain is one of the more common symptoms that patients report.

People who can treat joint pain are really valued in clinical settings,

so let's learn together.

関節痛は多くのひとが悩む症状の一つで、

日常診療でも出会うことの多い疾患でもあります

関節痛をマスターして、自信をもって診察できるようになれば

できレジに一歩近づくこと間違いないでしょう

Since there's a lot of content today, I'll only post it in English.

If you'd like to read it in Japanese, please let me know! If this style is popular,

 I’d like to continue it (not because it's easier, haha)

今日の内容は相当濃いものになっているので

英語だけになってしまいました、、、

もし日本語でも読みたいという人がいたら、ぜひ教えてください～

好評なら、このまま続けていこうと思います

（決して楽だからとかではないです、、、）

Well,

let's get it started!

ではでは、始めていきましょう～

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[Approach to Joint Pains]

Well,

let’s talk about how to approach diagnosing joint pains:

Rule Out Trauma:

• Refer to orthopedics if injury-related.
• Common injury: FOOSH (Fall Onto Out-Stretched Hand) leading to possible scaphoid fracture.

Rule Out Inflammation:

• Look for classic signs: Redness, pain, heat, swelling, loss of function.
• Determine if it's acute or chronic, and if it's affecting one or multiple joints.
• Acute Monoarticular Arthritis: Bacterial infection, crystal-induced arthritis.
• Acute Polyarticular Arthritis: Bacterial or viral infection.
• Chronic Monoarticular Arthritis: TB arthritis.
• Chronic Polyarticular Arthritis: Rheumatic disorders.

Non-Inflammatory Arthritis:

• Commonly osteoarthritis (OA).

[Causes of Arthritis]

Understanding the possible causes of arthritis can help narrow down the diagnosis:

• Bacterial Infection:
• From trauma (S. epidermidis), syphilis (gonorrhea), infective endocarditis (S. aureus), Lyme disease (Borrelia burgdorferi), TB (Mycobacterium tuberculosis).
• Crystal-Induced Inflammation:
• Gout (sodium urate), pseudogout (calcium pyrophosphate).
• Rheumatic Disorders:
• RA, SLE, Sjogren’s syndrome, Behcet’s disease, Adult-onset Still’s Disease (AOSD).
• Viral Infection:
• Influenza.
• Paraneoplastic Syndrome (PNS)

[History Taking]

What's Causing Your Pain?

 First things first, you need to understand what might be causing the joint pain.

• “Do you know what might be causing your joint pain?”
• “Have you had any injuries recently?”

Diving into Details (HPI) 

Next, get into the specifics of the pain by using the OPQRST method: 

Onset, Provocation, Quality, Region/Radiation, Severity, Time.

• Is it just one joint (Monoarticular) or more (Polyarticular)?
• Is it sudden (Acute) or has it been around for a while (Chronic)?
• Acute: Could be an infection, early chronic issue, trauma, or virus. Think about RA or OA.
• Chronic: Could be conditions like RA, TB, gout, or OA.

Other Symptoms to Look Out For:

Now, 

consider if there are any other symptoms that might be associated with the joint pain:

• Infections:
• Fever, cough, breathing issues, heart palpitations, skin problems, coughing blood, pain during urination, genital issues.
• Crystal-Induced Pain:
• Back pain, pain during urination.
• Rheumatic Issues:
• Fever, fatigue, weight loss, skin rashes (like butterfly-shaped malar rash), muscle pain or weakness, dry cough, Raynaud’s phenomenon (fingers changing color), protein or blood in urine, dry eyes, dry mouth, painful sex.
• Viral Infections:
• Fever, cough, runny nose.

[Medical History]

Key Points (PAM HITS FOSS):

With the history in mind, let’s dive into the patient’s medical background:

• Past Health Issues:
• Cancer, gout, collagen diseases, TB, upper respiratory infections, STDs.
• Family History:
• Cancer, TB, collagen diseases.
• Sexual History:
• Syphilis, STDs.
• Social History:
• Alcohol use, job-related exposures, drug use.
• Patient’s Profile:
• Contacts with sick people, animal contact, recent travel.

[Physical Exam]

Now, move on to a thorough physical examination:

General Check:

• Fatigue, skin issues

Head, Eyes, Ears, Nose, Throat (HEENT):

• Pale eyes (anemia), red eyes (RA or viral), specific rashes (like heliotrope rash for polymyositis/dermatomyositis), tonsillitis, dry mouth, cavities, butterfly rash (SLE), swollen lymph nodes.

Heart and Lungs:

• Arrhythmias (Lyme disease), valve issues (infective endocarditis), lung hypertension (collagen diseases)

Skin and Joints:

• Tenderness, swelling, specific signs like Gottron’s sign (PM/DM), nail fold bleeding, erythema migrans (Lyme disease)

Nervous System:

• Muscle strength testing, facial nerve issues (Lyme disease)

[Tests to Consider]

After the physical exam, consider the following tests to get a better understanding of what might be causing the joint pain:

• Blood work (CBC, CRP, etc.)
• Imaging (X-ray, CT/MRI)
• Specific tests (ANA, RPR for syphilis, blood cultures for infections)
• Joint-specific tests (arthroscopy, arthrocentesis, polarizing microscopy).

[Useful Expressions]

Here are some useful expressions to describe joint pain and related conditions:

• Joint pain: Arthralgia
• Joint: Articulation
• Adjective: Articular
• One joint: Monoarticular
• 2-4 joints: Oligoarticular
• 5 or more joints: Polyarticular

Carpal Bones Mnemonic:

• "So Long To Pinky, Here Comes The Thumb"
• Scaphoid, Lunate, Triquetrum, Pisiform, Hamate, Capitate, Trapezoid, Trapezium

Useful Phrases and Idioms:

1. Ache like the devil: To experience severe pain.
   Example: "My knees ache like the devil after that hike."
2. A pain in the neck: Something or someone that is very annoying. It can also be used literally for neck pain.
   Example: "This arthritis is a real pain in the neck."
3. Creaky joints: Referring to joints that make noises or feel stiff, often due to arthritis.
   Example: "My creaky joints are acting up again today."
4. To be laid up: To be confined to bed or unable to move around much due to illness or injury.
   Example: "I was laid up with a bad case of gout last week."
5. On pins and needles: Feeling anxious or in a state of suspense. It can also describe a tingling sensation in the body.
   Example: "I've been on pins and needles waiting for my test results."

Layman's Terms:

1. Joint pain: Simply called "sore joints" or "aching joints."
2. Arthritis: Often referred to as "joint inflammation" or "joint trouble."
3. Swelling: Sometimes called "puffiness" or "bloating" in the affected area.
4. Stiffness: Often described as "feeling tight" or "hard to move."
5. Inflammation: Commonly referred to as "swelling and redness."

Slang and Casual Expressions:

1. Old bones:

 A colloquial way to refer to someone who feels the effects of aging, especially joint pain.
Example: "These old bones aren't what they used to be."

1. Bone tired: 

Extremely tired or fatigued, often used when joint pain is involved.
Example: "I'm bone tired after all that walking."

1. To feel like you’ve been hit by a truck: 

Feeling very sore and achy, usually after strenuous activity or due to an illness.
Example: "I woke up feeling like I'd been hit by a truck; my whole body hurts."

1. Cracking up: 

When joints make a cracking noise, often due to air bubbles in the joint fluid.
Example: "My knees keep cracking up every time I stand up."

1. Stiff as a board: 

Feeling very stiff and unable to move easily.
Example: "I'm stiff as a board after sitting for so long."

Medical Terms in Casual Language:

1. Bursitis: Often referred to as "joint bursitis" or "bursa inflammation."
2. Tendinitis: Commonly called "tendonitis" or "tendon trouble."
3. Gout: Sometimes called "rich man's disease" because it was historically linked to a diet high in rich foods.
4. Rheumatoid Arthritis: Often shortened to "RA."
5. Osteoarthritis: Sometimes referred to as "wear-and-tear arthritis."

[Specific ds]

# Rheumatic Diseases

Rheumatic diseases are often referred to as ‘invisible illnesses’ because their symptoms are not always visible.

Time-course: Flare vs. Remission

• Flare up: Worsening of symptoms

Key Features:

• SLE/Lupus: Butterfly-shaped malar rash
• RA: Affects MCP & PIP joints (OA affects DIP joints), causes deformities like swan-neck and boutonniere, measured by the Simplified Disease Activity Index (SDAI).

# Lyme Disease

Lastly, let’s touch on Lyme disease, a tick-borne illness:

Cause: Borrelia burgdorferi (from deer ticks) Symptoms:

• Bulls-eye rash (erythema migrans), arthritis, facial nerve paralysis (Bell’s palsy), arrhythmia (AV block).

Mnemonic: ‘A key Lime pie to the FACE’

• Facial nerve paralysis
• Arthritis
• Cardiac block
• Erythema migrans

poohmedical.hatenablog.com

問診と身体診察を極めよう、OSCEにむけて：嘔気・嘔吐、腹部膨満感 / Unleash your Mastery - The art of history taking and physical examination: Nausea/Vomiting, Abdominal distension

Hey there! 

If you've ever felt queasy, thrown up, or dealt with a swollen belly, you know how unpleasant it can be.

みなさん、こんにちは〜！

今までに吐き気や嘔吐、腹部膨満感を感じたことはありますか？

今日はこれらの不快感に対してどうやって診察していくかを勉強してきました

Today, 

we’re diving into nausea, vomiting, and abdominal distention, breaking down what they are, why they happen, and how to deal with them. 

Let’s get started!

吐き気、嘔吐、お腹の膨張について、その正体や原因、対処法について詳しくまとめました

それでは始めましょう！

------------------------------------------------------------------------------------------------

The Basics: Nausea and Vomiting

基本事項：吐き気と嘔吐

What's Going On?

Nausea is that awful feeling where you think you might throw up.

何が起こっているのか？

まず吐き気とは、もどしそうになるあの嫌な感覚のことです。

Vomiting (or barfing, puking, hurling—you get the idea) is when your body forcefully expels what's in your stomach.

そして嘔吐は、吐き気の有無に関わらず

体が胃の中のものを力強く吐き出すことです。

It can be a one-time thing or happen over and over.

一度きりのこともあれば、何度も繰り返すこともありますよね

Why Does It Happen?

ではなぜ起こるのでしょうか

• Acute/Sudden: Could be food poisoning, stomach flu, or even motion sickness.
• Chronic/Ongoing: Might be GERD, pregnancy, or a reaction to medications.

What to Ask (Or Think About)：問診

1. Onset: 
• When did it start? Is this a one-time thing or does it keep coming back?
• Example: "How long have you been feeling like this? Is it the first time?"
2. Quality: 
• What's the vomit like? (Gross, I know, but important!)
• Blood in vomit could mean a serious issue like an ulcer. Bile-stained (yellow/green) might point to a blockage.
3. Severity: 
• Are there other symptoms? Weight loss, headaches, or severe pain can signal bigger problems.
4. Timing:
• When does it happen? Morning sickness is common in pregnancy, while evening nausea might be due to alcohol or certain medications.

Swollen Belly Blues: Abdominal Distention

腹部膨満感：腹部膨張

What’s the Deal?

Abdominal distention is when your belly feels full or looks swollen.

さて次は、腹部膨満感に参りましょう

何が問題なのでしょうか？

腹部膨満感とは、お腹が満腹感を感じたり、膨らんで見える状態のことを指します

It can be gas, fluid, or even a tumor.

原因としてはガス、液体、または腫瘍などが挙げられます

もう少し詳しく見ていきましょう

Why Does It Happen?

• Gas: Often from eating too quickly, carbonated drinks, or certain foods.
• Fluid (Ascites): Could be from liver disease or heart failure.
• Tumors: Sometimes, a mass or growth in the abdomen can cause distention.

How to Check It Out：身体診察

1. Look and Listen:
• Check for visible swelling, skin changes, or unusual bowel sounds.
2. Feel and Tap:
• Percussion and palpation can help figure out if the distention is due to fluid, gas, or a solid mass.

Meds to the Rescue: Anti-Nausea and Vomiting Treatments

薬物治療について

When it comes to stopping nausea and vomiting, 

there are several go-to medications:

吐き気や嘔吐に対しては、様々な薬を組み合わせて治療していきます

• Antiemetics（制吐薬）
• Serotonin Blockers: Like ondansetron (Zofran), they block the chemical that makes you feel sick.
• Dopamine Blockers: Such as metoclopramide (Reglan), they help calm the nausea signals in your brain.（プリンペラン）
• Antihistamines: Think Dramamine or meclizine, great for motion sickness.
• Steroids: Sometimes used for chemotherapy-induced nausea.
• Benzodiazepines: Can help with anxiety-related nausea.

Common Idioms and Slang

To lighten things up, here are some fun ways people talk about feeling nauseous or vomiting:

さて、

ここまでは医学的な内容ばかりで、すこし気分が悪くなってきそうなので

すこし気分を変えて、嘔吐や吐き気に関係する面白い表現を学んでいきましょう

• Barfing/Puking/Hurling: Just different ways to say vomiting.
• Tossing Your Cookies: A playful way to say you're throwing up.
• Blowing Chunks: Another colorful term for vomiting.
• Calling Ralph on the Big White Phone: Vomiting into the toilet.
• Technicolor Yawn: Vomiting with a visual twist.
• Losing Your Lunch: Self-explanatory and kind of funny.
• Talking to the Porcelain God: Another term for being sick in the toilet.
• Yacking: Simple and to the point.

などなど、英語にも頓智の効いた表現が色々ありますね

ぜひ気に入ったものがあれば使ってみてください

 

Dealing with It：対処法

Practical Tips：臨床で使えるパール

• Stay Hydrated: Sip water or an electrolyte solution.
• Eat Light: Stick to bland foods like crackers or toast.
• Rest Up: Give your body time to recover.
• Avoid Triggers: Keep away from strong smells or foods that make you feel worse.

 

Conclusion：まとめ

Nausea, vomiting, and abdominal distention can be really uncomfortable, 

but understanding what's going on and how to handle it can make a big difference.

お疲れ様でした

吐き気、嘔吐、腹部膨満感は患者さんにとっては非常に不快な症状であり

何が起こっているのかを理解し、それに対処する方法を知っておくことは臨床においてとても役立つことでしょう

Keep these tips in mind, 

and you'll be better prepared to tackle these symptoms head-on. 

Stay well!

今日皆さんと共有してきたことを頭に入れて、

臨床の現場に出れば、きっと自信をもって診察していけるはずです

これからも頑張っていきましょう！

問診と身体診察を極めよう、OSCEに向けて：失神 / Unleash your Mastery - The art of history taking and physical examination: Syncope

Hello!

Today,

I studied about syncope, which is a common reason for patients to be brought to the emergency room.

こんにちは～

今日は救急外来にもよく運ばれてくる

失神について勉強しました～

Since syncope is also related to symptoms like palpitations and dizziness

that we studied in the previous sessions, let’s learn about them together.

前回、前々回勉強した

動悸やめまいとも関係のある症状なので

絡めて学んでいきましょう

poohmedical.hatenablog.com

poohmedical.hatenablog.com

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Syncope / 失神

Approach to Transient Loss of Consciousness (LOC)

失神（一過性の意識障害）へのアプローチ

When faced with a patient who has experienced a transient LOC,

the first step is to classify the event. Here’s the roadmap:

一過性の意識障害を経験した患者さんを見るときは、

まず何が起こったのかをはっきりさせることが大切です。

以下の3つに大別して考えてみましょう

1. Traumatic: Resulting from head injury. / 頭部外傷
2. Syncope: Our main focus—transient loss of consciousness due to temporary global cerebral hypoperfusion. / 一過性の脳虚血
3. Non-syncopal attacks: Includes conditions like epileptic seizures, psychological pseudosyncope, and others. / てんかん、心因性などの偽性失神

 

What Causes Syncope? / 失神の原因は？

Etiology: Cerebral Hypoperfusion or Low Blood Pressure?

病因：一過性の脳虚血なのか？低血圧性なのか？

Okay, folks,

here’s one of the most challenging parts: understanding the causes of syncope.

Let’s break down the common causes into three main groups:

では、みなさん

ここが失神を理解していくうえで、肝心要となるところです

原因についても3つに分けて考えていきます

• I) Low Peripheral Resistance (Reflex Mechanisms) / 末梢血管抵抗の低下

   

  • Reflex Syncope / 反射性
  • Vasovagal Syncope : 迷走神経反射

  This is the most common type and can happen when someone is stressed, in pain, or stands for too long.
  Look for symptoms like nausea, sweating, and pallor before they faint.
  
  

  最も多い原因。ストレス、痛み、長い時間立っているなどが誘因
  随伴症状：吐き気、発汗、蒼白など
  
  

  • Situational Syncope : 状況性失神

  Ever heard of someone fainting after coughing, swallowing, or even urinating?
  These specific triggers can cause it.
  
  

  咳や嚥下、排尿などが誘因となる
  
  

  • Carotid Sinus Syndrome : 頸動脈洞反射

  This happens when pressure on the carotid sinus, like from a tight collar, causes fainting.
  
  頚部に強い圧力、頸椎カラーなどが誘因となる

  • Orthostatic Syncope / 起立性失神

  This occurs when a person stands up quickly and their body fails to adjust blood pressure appropriately.

  素早く立ち上がったときに、血圧の調節が上手くいかないことが誘因

  • Causes: Volume depletion (dehydration, blood loss), anemia, certain medications (like diuretics), autonomic dysfunction (think Parkinson’s disease), and environmental factors (like a hot day).
  • 原因：血管内ボリュームの低下（脱水、失血）、貧血、薬剤（利尿剤）、自立神経障害（パーキンソン病、DM）、環境因子（熱射病）

  II) Low Cardiac Output (Cardiac Syncope) / 低心拍出力（心性失神）

  This type is related to the heart’s ability to pump blood:

  1. Structural Heart Diseases:
  • Myocardial Infarction (MI): Reduced blood flow to the heart muscle.
  • Aortic Stenosis (AS): Narrowing of the aortic valve.
  • Cardiac Tamponade: Fluid accumulation around the heart.
  • Hypertrophic Cardiomyopathy (HCM): Thickened heart muscle.
  • Cardiac Myxoma: A tumor in the heart.
  • Pulmonary Embolism (PTE): Blood clot in the lungs.
  • Aortic Dissection (AD): Tear in the aorta.
  • Pulmonary Arterial Hypertension (PAHtn): High blood pressure in the lungs.
  2. Arrhythmias:
  • Bradycardia: Slow heart rate due to conditions like Sick Sinus Syndrome (SSS) or Atrioventricular Block (AVB).
  • Tachycardia: Fast heart rate from Supraventricular Tachycardia (SVT) or Ventricular Tachycardia (VT).
  • Electrolyte Imbalance: Abnormal levels of potassium or calcium.

  III) Subarachnoid Hemorrhage (SAH) / クモ膜下出血

  • SAH can cause a sudden severe headache ("thunderclap headache") followed by fainting. This happens when the pressure in the skull gets too high, cutting off blood supply to the brain.
  • SAHは激しい頭痛に失神が伴うことがある。頭蓋内圧が上昇した結果、脳血流を著しく下げることが原因。圧力の関係により、意識が変容する。

How to Examine a Patient with Syncope : 診察方法

Alright,

now that we’ve covered the causes, let’s talk about what to do when a patient presents with syncope.

以上で失神の大きな原因を理解できたので

次は診察で重要となる部分をまとめていきます

Vital Signs:

• Check blood pressure (BP), heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and body temperature (BT).

History Taking:

• Onset: Ask about the circumstances of the fainting episode. Did they remember it? What were they doing?
• Symptoms: Look for associated symptoms like palpitations, shortness of breath (SOB), chest pain/discomfort, sweating, nausea, headache, feverish feeling, and general malaise.
• Timing: How long did it last? Is this the first time or has it happened before?
• Past Medical History (PMH): Heart disease, diabetes (DM), medications, hypertension (HTN), dyslipidemia (DL).
• Family History (FHx): Any family history of heart issues, sudden death, or cancers?
• Social History (SHx): Smoking, occupation, diet/drugs, alcohol consumption, exercise habits, and stress levels.

Physical Examination:

• HEENT: Check the eyes and listen for carotid bruits.
• Chest: Perform a thorough heart and lung exam.
• Extremities: Look for signs of dehydration, edema, and assess skin temperature and moisture.

Investigations:

• Electrocardiogram (EKG): To check for arrhythmias or ischemia.
• Laboratory Tests (L/D): Blood count, electrolytes, glucose, and cardiac enzymes.
• Imaging: CT scan if necessary to rule out structural causes.
• Autonomic Function Tests: To assess the autonomic nervous system.
• Transthoracic Echocardiography (TTE): To evaluate heart structure and function.
• Exercise Tolerance Test: For exercise-induced arrhythmias or ischemia.
• Holter Monitor: 24-hour monitoring for intermittent arrhythmias.

Managing Syncope in the Emergency Room (ER) : 救急外来では？

In the ER, your immediate goal is to rule out life-threatening conditions such as arrhythmias, severe anemia, aortic dissection (AD), or acute coronary syndrome (ACS). Quick and efficient assessment is key!

救急外来においては、

喫緊の目標は命に関わってしまう原因を除外していくこと、

不整脈や深刻な貧血、大動脈解離、冠動脈疾患などです

頭の中にこれらを浮かべ、一つ一つ診察していくことが大切です

Additional Notes on Syncope and Stroke : 失神と脳卒中について

• Cerebrovascular Accident (CVA) and Syncope : 
• CVA rarely causes syncope unless it significantly compresses the brain tissue
• 脳卒中は、実質への圧迫が高度にならない限り失神を起こすことは稀
• Subarachnoid hemorrhage (SAH) can cause syncope when the pressure inside the skull gets too high, cutting off the blood supply to the brain.
• その中でも、くも膜下出血に関しては圧力の関係によって起こすこともある

Pearls for Junior Doctors 

• Always Consider Common Causes First : まずはcommon dsを念頭に

 　　Start with the most likely culprits like vasovagal and orthostatic syncope, especially 　　in younger patients.

　　まずは頻度の高い原因から探っていくことが大切。

　　特に若者では、迷走神経反射や起立性失神を考えていく。

• Detailed History is Key : 問診が一番大事

　　The patient’s history often provides the best clues.

　　現病歴が診断に至るうえで、重要な情報を与えてくれる

• Use a Systematic Approach : 系統的なアプローチを

　　Categorize causes as reflex, cardiac, or neurologic.

　　反射性、心性、神経原性の3つから系統的に

• Know Your Red Flags : Red Flagsも確認を

　　Symptoms like chest pain, palpitations, and a family history of sudden death require 　　urgent attention.

　　胸痛、動機、家族歴といったRed Flagsを見逃さないように

• Collaboration : ためらわずコンサルすることも大事

　　Don’t hesitate to consult with specialists if the cause is unclear or the patient has 　　significant risk factors.

　　理由がはっきりしないときや、上記のRed Flagsを認めたときにはためらわずにコン　　

　　サルしていくことも大切

Understanding syncope and its underlying causes is crucial for providing effective patient care.

By following a systematic approach and keeping key considerations in mind, you can navigate the complexities of this common clinical problem with confidence.

Remember, a calm and thorough evaluation can make all the difference for your patients.

And remember, folks, as Dr. House might say, "Everybody lies," but fainting? That's usually pretty honest. 😄

最後の部分、有名なテレビドラマ「House, M.D」からの一節です

日本では「ドクターG」のようなものになりますが、

ジョークの意味わかりましたか？笑

患者さんが伝えてくる主観的な症状のすべてを信じることはできませんが

失神に関しては、偽ることのできない、唯一信じられる症状

といううことです

Well,

This has gotten quite long, so let's wrap it up here for today.

Good job, folks

さて、

長くなりましたが、今日はこの辺で

お疲れさまでした

American Heart Association (AHA): Offers extensive resources on cardiovascular diseases, including syncope.

National Institute for Health and Care Excellence (NICE): Clinical guidelines on syncope and its management.

Mayo Clinic: Detailed articles on various types of syncope and their causes.

UpToDate: An evidence-based clinical resource with detailed syncope guidelines.

Harrison’s Principles of Internal Medicine: Comprehensive coverage on the pathophysiology, diagnosis, and treatment of syncope.

New England Journal of Medicine (NEJM): Research articles and reviews on syncope.

Journal of the American Medical Association (JAMA): Studies and reviews on the latest findings related to syncope.

American Academy of Neurology (AAN): Guidelines on neurologic causes of syncope, including subarachnoid hemorrhage.

European Society of Cardiology (ESC): Provides guidelines and position papers on the diagnosis and management of syncope.

問診と身体診察を極めよう、OSCEに向けて：めまい / Unleash your Mastery - The art of history taking and physical examination: Dizziness

Hello everyone!!!

Let's continue mastering history taking and physical examination!

こんにちは～

今日も問診・診察を極めて行きましょう！

Today, I studied dizziness.

It seems like a complex symptom with many considerations

By focusing on the basics and studying it carefully

it feels like my aversion to it has decreased a bit..., though

今日は、めまいについて勉強しました

考えることが多そうで、複雑そうな症状ですが

基本を押さえて丁寧に勉強していくと、少しは苦手意識がなくなってきたような、、

I've summarized this often-avoided topic of dizziness

And I'm sharing it with all of you.

そんな敬遠されがちなめまいについてまとめたので

みなさんに共有しますね

If you come across any new insights or important points that I've missed,

Please feel free to share them with me

もし、新しい発見とか、これも大事だよ～ってことがあったら

せひせひ教えてください～～

------------------------------------------------------------------------------------------------

Understanding Dizziness: A Clinical Overview

Dizziness is a common yet complex symptom encountered in clinical practice, often posing a diagnostic challenge due to its broad differential diagnosis.

Definition and Types of Dizziness

Dizziness is a nonspecific term that describes a range of sensations, including lightheadedness, unsteadiness, and a false sense of motion. It can be broadly categorized into four main types:

1. Vertigo: A false sense of spinning or motion, typically associated with inner ear disorders.
2. Presyncope: A feeling of impending fainting or lightheadedness, often due to cardiovascular causes.
3. Disequilibrium: A sense of unsteadiness or imbalance, frequently related to neurological or musculoskeletal issues.
4. Non-specific Dizziness/Lightheadedness: A vague sensation that does not fit into the above categories, often associated with anxiety or hyperventilation.

Pathophysiology and Approach

Vertigo

• Central: Characterized by vertical nystagmus. Causes include:
• Cerebellar lesion (stroke, infection, multiple sclerosis)
• Peripheral: Characterized by horizontal nystagmus. Causes include:
• Benign Paroxysmal Positional Vertigo (BPPV)
• Vestibular neuritis
• Vestibular neoplasm
• Meniere’s disease
• Acute otitis media (AOM)

Presyncope

• Cardiac Causes:
• Arrhythmias
• Valvular disease
• Hypertrophic obstructive cardiomyopathy (HOCM)
• Pulmonary thromboembolism (PTE)
• Orthostatic Causes:
• Hypovolemia
• Autonomic dysfunction
• Medications
• Reflex Causes:
• Vasovagal
• Situational

Disequilibrium

• Sensory Input Issues:
• Neuropathy
• Visual impairment
• Medications/Toxins (e.g., ethanol, anticholinergics)
• Autonomic Dysfunction:
• Parkinson’s disease
• Diabetes mellitus
• Amyloidosis
• Coordination/Strength Issues:
• Vitamin B12 deficiency
• Cerebellar disorders
• Radiculopathy

Lightheadedness

• Causes:
• Anemia
• Psychiatric disorders

Clinical Evaluation

A thorough clinical evaluation is essential for accurate diagnosis and effective management. Key steps include:

• History Taking:
  • With or without inner ear symptoms (tinnitus, deafness)
  • Duration (seconds, minutes, days)
  • Context: triggers (e.g., position changes, head trauma)
  • Associated symptoms: nausea, visual disturbances, neurological signs
  • Past medical history: medications, atherosclerosis

                           Specific Questions and Useful Phrases:

• • General:
    • “Can you describe what you mean by dizziness?”
    • “When did you first notice the dizziness?”
    • “How long does each episode last?”
  • Vertigo:

• • • “Do you feel like you or the room is spinning?”

• “Do these episodes happen when you change positions, like turning over in bed?”
• “Have you noticed any ringing in your ears or hearing loss?”
• Presyncope:

• • • “Did you feel like you were going to faint or pass out?”

• “Do you experience this feeling when you stand up quickly?”
• “Have you ever lost consciousness during these episodes?”
• Disequilibrium:

• • • “Do you feel unsteady on your feet or like you might fall?”

• • • “Is it difficult to walk in a straight line?”
    • “Have you noticed any numbness or tingling in your feet or legs?”
  • Lightheadedness:
    • “Do you feel lightheaded, like you might faint?”
    • “Do you feel like your head is swimming or foggy?”
    • “Does this feeling come on suddenly or gradually?”

• Examination:

1. Physical Examination:

• • • Vital Signs: Blood pressure, heart rate, respiratory rate, SpO2

1. 1. • Chest and Heart Examination: Look for signs of cardiovascular issues
      • Jugular Venous Distension (JVD): Assess for heart failure
      • Neurological Examination: Check for nystagmus, perform finger-to-nose and knee-heel tests
      • Other Examinations: ENT, digital rectal exam if indicated
2. Diagnostic Tests:

• • • Electrocardiogram (EKG): To rule out cardiac causes
    • Laboratory Tests: Hemoglobin, hematocrit, BUN/creatinine, electrolytes
    • Imaging: Chest X-ray (CXR) if indicated
    • Audiometry: For hearing loss associated with vestibular disorders
    • Imaging (MRI/CT): If central causes are suspected

Management Strategies

Management of dizziness depends on the underlying cause:

• Vertigo:
• BPPV: Canalith repositioning maneuvers (e.g., Epley maneuver)
• Meniere’s Disease: Dietary modifications (low salt), diuretics, vestibular rehabilitation
• Vestibular Neuritis: Corticosteroids and vestibular exercises
• Presyncope:
• Orthostatic Hypotension: Increase fluid and salt intake, compression stockings, and medications (e.g., fludrocortisone)
• Cardiac Causes: Specific treatment for arrhythmias or structural heart disease
• Disequilibrium:
• Neurological Disorders: Physical therapy and treatment of the underlying condition
• Musculoskeletal Issues: Strengthening exercises and addressing joint instability
• Non-specific Dizziness:
• Anxiety or Depression: Cognitive-behavioral therapy (CBT), relaxation techniques, and selective serotonin reuptake inhibitors (SSRIs)

🚩Red Flags and Critical Conditions

It's crucial to rule out serious conditions such as:

• Cerebellar/brain stem infarction or hemorrhage
• Wallenberg syndrome
• Cardiovascular causes
• Severe anemia or hypovolemia

Use the San Francisco Syncope Rule: 

to predict the risk for serious outcomes in patients presenting with syncope or presyncope. 

Criteria include: CHESS

• Congestive heart failure
• Hematocrit under 30% (severe anemia)
• EKG abnormalities (e.g., bradycardia, sick sinus syndrome, paroxysmal supraventricular tachycardia/ventricular tachycardia)
• Shortness of breath
• Systolic blood pressure less than 90 mmHg

1. Baloh RW. Dizziness. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 409.
2. Strupp M, Magnusson M. Diagnostic approach to dizziness. Neurol Clin. 2005 May;23(2):387-405, vi. doi: 10.1016/j.ncl.2004.10.002.
3. Tusa RJ, Furman JM. Dizziness. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC, eds. Bradley's Neurology in Clinical Practice. 7th ed. Philadelphia, PA: Elsevier; 2016:chap 44.
4. Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE. Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ. 2011 Nov 22;183(9):E571-92. doi: 10.1503/cmaj.100174.
5. Edlow JA. Diagnosing dizziness: we are teaching the wrong approach. Ann Neurol. 2013 Nov;74(5):742-50. doi: 10.1002/ana.24096

問診と身体診察を極めよう、OSCEに向けて：動悸 / Unleash your Mastery - The art of hystory taking and physical examination: Palpitations

Hello everyone!

こんにちは～

Today marks the inaugural edition of our series on studying medical history taking and physical examination!

And what better way to kick things off than by delving into the topic of "Palpitations"!

今日は

問診と身体診察を勉強していくシリーズの記念すべき第一弾！！

テーマは「動機/palpitations」についてです

For those who haven't read the introductory explanation about this series yet, be sure to check it out before diving into today's topic.

このシリーズについての説明は

総論で行っているので、まだ読んでいない方はぜひ読んでからがおすすめです！

poohmedical.hatenablog.com

Today,

I've delved into a common phenomenon encountered in clinical practice – palpitations!

さて

今日は、臨床の現場でよく遭遇する動機について勉強しました！

I'm here to share a summary of what we've learned,

but I'm also eager to hear your thoughts, questions, and anything else you'd like to share.

まとめをみなさんに共有するので

気になることとか、質問とかあったらどしどしよろしくお願いします～

While I've provided the basic summary in English,

If you're interested in seeing a Japanese version too,

Just drop us a line, and I'll be happy to share it with you!!

基本まとめは英語で行っていますが、

もし日本語版もみたい！

という声があれば、公開するのでぜひ教えてください～

--------------------------------------------------------------------------------------------------

[Palpitations]

Definition: "Awareness of one’s own heartbeats"

Introduction to Palpitations:

Palpitations are a common symptom that many patients experience, often described as a sensation of the heart pounding, fluttering, or beating irregularly. While palpitations are often benign, they can sometimes indicate serious cardiac conditions, making proper evaluation essential.

Approach to Palpitations

Chief Complaints (℅):

• “I have palpitations.”
• “My heart is pounding/fluttering/flip-flopping.”
• “My heart is skipping beats.” (*Note: "My heart skips a beat" often refers to excitement, amazement, or shock.)

Specifics: Quality (rhythms) and Timing (provoking factors/situations)

Quality: “Could you tap out your heartbeats on the desk?”

                → Irregular heartbeat: atrial fibrillation (AF)

                     Regular heartbeat: others

 Timing: vItMIn cd

             I: infection

           M: metabolics (hypoglycemia, hyperthyroidism, anemia) 

             I: iatrogenic (medication: anti-arrhythmias, stimulants: caffeine, drugs)

• psychiatric: panic, stress, somatization disorder
• postural: postural tachycardia (autonomic dysfunction: DM, MAS)hycardia (autonomic dysfunction: diabetes mellitus, MAS)

⇒Remember that palpitations can be caused by non-cardiac factors, including stress, anxiety, and certain medications or substances.

<History Taking>

1. Red Flag Symptoms:

• Severe shortness of breath (SOB) / fatigue
• Syncope / pre-syncope

• Chest pain

• Sweating

1. Exact Nature of Palpitations:

• Rate, rhythm, missed beat, extra beat, duration, onset/offset, precipitants, frequency

1. Factors Increasing Likelihood of Cardiac Cause:

• Onset during sleep or at work
• Prior cardiac disease

1. Additional History Questions:

• Onset: "When did you first notice the palpitations?"
• Duration: "How long do the palpitations last?"
• Frequency: "How often do you experience them?"
• Triggers: "Do any specific activities or situations trigger your palpitations?"
• Relieving factors: "Does anything make them better or worse?"

<Physical Examination>

• Vital signs (heart rate, blood pressure, respiratory rate)
• Inspection (skin, mucous membranes for pallor or cyanosis)
• Palpation (pulse, precordial area for heaves or thrills)
• Auscultation (heart sounds, murmurs, extra heart sounds)

<Diagnostic Workup>

• Electrocardiogram (ECG)
• Holter monitoring or event recorder
• Blood tests (complete blood count, thyroid function tests, electrolyte levels)
• Echocardiography
• Stress testing

<Management Strategies>

1. Lifestyle modifications (reducing caffeine, alcohol, and stress)

• Pharmacological treatments (beta-blockers, anti-arrhythmic medications)
• Referral to a specialist (cardiologist, electrophysiologist)

1. Patient Education:

• Encourage patients to keep a diary of their symptoms, noting the frequency, duration, and possible triggers.
• Advise patients on when to seek immediate medical attention (e.g., if they experience chest pain, severe shortness of breath, or syncope).

Differential Diagnosis (DDx) of Palpitations

Arrhythmias:

1. Tachycardia/Tachyarrhythmia:

• Supraventricular tachycardia (SVT):
• Sinus tachycardia: Most common
• Consider: Psychiatric disorders (panic disorder, somatization disorder)
• Intoxication (medications, stimulants)
• Metabolic disorders (hypoglycemia, hyperthyroidism)
• Atrial fibrillation (AF): Irregularly irregular atrial rhythm
• Atrial flutter (AFL): Regularly irregular atrial rhythm
• Paroxysmal supraventricular tachycardia (PSVT)
• Atrioventricular reentrant tachycardia (AVRT): WPW syndrome
• Atrioventricular nodal reentrant tachycardia (AVNRT)
• Jugular vein pulse (JVP): Frog sign (due to simultaneous contraction of atria and ventricles)
• Ventricular tachycardia (VT): Adams-Stokes syndrome
• Monomorphic ventricular tachycardia (MVT)
• Polymorphic ventricular tachycardia (PVT): Torsades de pointes
• Ventricular fibrillation (VF)

1. Bradycardia/Bradyarrhythmia:

• Sick sinus syndrome (SSS)
• Atrioventricular (AV) block: Adams-Stokes syndrome
• First-degree
• Second-degree: Mobitz type 1 (Wenckebach) and Mobitz type 2
• Third-degree

1. Premature Contractions:

• Premature atrial contraction (PAC)
• Premature ventricular contraction (PVC)

Tips and Clinical Pearls:

1. Thorough History Taking:
• Ask the patient to describe the palpitations in detail: onset, duration, frequency, and associated symptoms.
• Inquire about the patient’s medical history, including any known heart conditions, recent illnesses, and medication use.
• Explore lifestyle factors such as caffeine, alcohol, and drug use.
2. Identifying Red Flags:
• Be alert for symptoms that may indicate a serious underlying condition, such as syncope, severe chest pain, or shortness of breath.
• Assess for risk factors of cardiac disease, including family history, hypertension, diabetes, and smoking.
3. Characterizing the Palpitations:
• Ask the patient to tap out the rhythm of their palpitations. This can help differentiate between regular and irregular rhythms.
• Determine if the palpitations are episodic or persistent and if there are any identifiable triggers.
4. Physical Examination:
• Perform a thorough cardiovascular examination, including checking vital signs, palpating pulses, and auscultating the heart for murmurs or abnormal rhythms.
• Look for signs of hyperthyroidism (e.g., tremors, goiter) or anemia (e.g., pallor).
5. Electrocardiogram (ECG):
• Obtain an ECG to identify arrhythmias or other cardiac abnormalities.
• Consider a Holter monitor or event recorder if the palpitations are intermittent and not captured during the initial ECG.
6. Laboratory Tests:
• Order blood tests to check for conditions that can cause palpitations, such as anemia (CBC), electrolyte imbalances, and thyroid dysfunction (TSH, T4).
7. Patient Education:
• Explain to the patient the potential benign and serious causes of palpitations.
• Advise on lifestyle modifications, such as reducing caffeine and alcohol intake and managing stress.
8. Referral to Specialist:
• Refer to a cardiologist if there is evidence of a significant arrhythmia or if the diagnosis remains unclear despite initial workup.
• Consider referral to an endocrinologist if hyperthyroidism is suspected or confirmed.
9. Reassurance and Follow-Up:
• Reassure the patient if initial evaluation suggests a benign cause.
• Schedule follow-up appointments to monitor symptoms and response to any interventions.

Harrison's Principles of Internal Medicine:

The American College of Cardiology (ACC) and the American Heart Association (AHA) Guidelines:

European Society of Cardiology (ESC) Guidelines:

UpToDate:

Mayo Clinic:

Journal Articles and Reviews:

問診と身体診察を極めよう、OSCEに向けて：総論 / Unleash your Mastery: The art of hystory taking and physical examination: Overview

こんにちは～、

いつも読んでくださりありがとうございます

Greetings, dear readers,

Gratitude flows your way for your consistent support.

医学生は実習に出る前と、実習が一段落した時に

OSCE (Objected Structured Clinical Examination)という試験を受けないといけません

Before medical students embark on their clinical rotations, and once they've navigated through them, there looms the formidable OSCE (Objective Structured Clinical Examination)

簡単に説明すると、

皆さんが病院に行ったときに受ける問診と診察の能力を客観的に図る試験です

In essence,

it's a meticulous evaluation of one's prowess in eliciting patient histories and conducting physical examinations

—an experience akin to a hospital visit, distilled into an exam format.

OSCEには大きく分けて、

実習が始まる前に受けるOSCEをpre-CC (clinical clerkship) OSCE

実習が終わり、国試を受ける前にあるのがpost-CC OSCE

があります

This OSCE journey unfolds in two significant chapters:

First:

the Pre-CC (Clinical Clerkship) OSCE, a rite of passage before the clinical odyssey commences.

Second:

the Post-CC OSCE, marking the culmination of rotations and a prerequisite before facing the national licensing examination.

pre-CC OSCEに受かることで晴れてSD (student doctor)の称号が与えられて

一歩お医者さんに近づいていきます

A successful Pre-CC OSCE bestows upon the aspirant the coveted mantle of "student doctor," propelling them closer to the zenith of their medical journey

またpost-CC OSCEに合格しないと、

国試を受けることすら出来ない、、、

However, faltering at the Post-CC OSCE gate bars entry to the national exam arena—a pivotal juncture in every medical student's path

と避けては通れない、

医学生にとっての鬼門のような試験です

Indeed, the OSCE stands as an unavoidable, formidable milestone—a crucible where aspirations are tested, and futures shaped.

なので、

このシリーズで、問診と身体診察を極めていきましょう

Hence:

join me in this series as we delve deep into the artistry of history taking and physical examination.

医学生じゃない人も、

なんでこんなこと聞いてくるの？そんな診察必要？

なんて疑問が解消されるはずです！！！

一緒に楽しんでいってくださいね～

Even for those outside the medical realm, it promises enlightenment on the relevance and intricacies of clinical assessments

Together, let's revel in this enlightening expedition

さて、

前段はこの辺にしまして

総論としての内容に入っていきましょう

Now, let's embark on this journey by delving into the thematic overview.

OSCEでは37症候と呼ばれる

代表的な症状に対して、問診と診察の記述を評価されます

In the OSCE,

candidates are evaluated on their ability to elicit patient history and perform physical examinations for 37 common symptoms

37症候はこんな感じです

・発熱 (fever/pyrexia)

・全身倦怠感 (malaise/TATT: tired all the time)

・食思不振 (anorexia)

・体重減少／増加 (weight loss/gain)

・ショック (shock)

・心停止 (Cardiac arrest/CPA)

・意識障害／失神 (confusion/presyncope/syncope)

・けいれん (convulsion/seizure)

・めまい (dizziness/vertigo)

・脱水 (dehydration)

・浮腫 (edema/swelling)

・発疹 (skin rash)

・咳／痰 (cough/sputum/phlegm)

・血痰／喀血 (bloody sputum/hemoptysis)

・呼吸困難 (dysnea/SOB: shortness of breath)

・胸痛 (chest pain)

・動機 (palpitation)

・胸水 (pleural fluid)

・嚥下困難／障害 (dysphagia/dysarthria)

・腹痛 (stomachache)

・悪心／嘔吐 (nausea/vomitting)

・吐血／下血 (hematemesis/melena)

・便秘／下痢 (constipation/diarrhea)

・黄疸 (jaundice)

・腹部膨隆／腫瘤 (fluactuation/tumor)

・貧血 (anemia)

・リンパ節腫脹 (LAD: lymphadenopathy)

・尿量／排尿の障害 (polyuria/oligouria/anuria)

・血尿／タンパク尿 (hematuria/proteinuria)

・月経不順 (irregular menstruation/period)

・不安／抑うつ (anxiety/depression)

・物忘れ (forgetfulness/dementia)

・頭痛 (headache)

・運動麻痺／筋力低下 (paralysis/muscle weakness)

・腰背部痛 (back pain)

・関節痛／腫脹 (arthralgia/joint pain/joint swelling)

・外傷／熱傷 (trauma/burn)

毎回の記事では

その１つ１つを取り上げて、まとめていきます

順番は私の気分になりますが、、、

よく聞かれるもの、出会うものからまとめていくと思います

In each article,

I will address each one individually and summarize them.

The order will depend on my mood, but...

I think I'll start by summarizing the ones that are frequently asked about or encountered.

それぞれの疾患について掘り下げる

というよりかは、鑑別を挙げることに焦点を置いて行っていくので

詳しく知りたい方は、また教えてください

Rather than delving deeply into each disease,

I will focus on listing differential diagnoses,

So if you want more detailed information, please let me know again

別の記事にして、共有していきます

私の勉強にもなるので、ぜひぜひ遠慮せずに～

I'll make it into a separate article and share it.

It'll also be beneficial for my studies, so please don't hesitate to share!

ということで、

これから長丁場になると思いますが

時々覗いていってくださいね

I expect it'll be a long journey ahead,

but please drop by from time to time.

おつかれさまでした～

Good job, and take care!