第2581号 2004年4月19日

英語で発信!臨床症例提示 -今こそ世界の潮流に乗ろう-

Oral Case Presentation

[第3回]Keep up the good work!



 今回は,Contentsの第一峰HPI=history of present illnessとDeliveryの第一歩Paceに焦点を当てます。症例提示は情報が一回限りの形で流れ,文書のように再読できません。不明な内容が積み重なれば,聴者は関心を失います。HPIを初聴で理解できるように構造化し,Paceを聴者の最大多数に対して最適化することが学習目標です。


 ID&CCを一息に述べた後,「HPI」と宣言します。現病歴はじまりの合図です。以後,見出しが変わるごとに,「Family history」,「Physical exam」などのようにcrispyに見出しを宣言します。些細な工夫ですが,症例提示の構造が明確になり,聴者の思考を休眠させない刺激効果があります。



■Contents Index [HPI]


 患者が自由に語ったことを漫然と接合するだけでは,よい症例提示は誕生しません。症状が千差万別であっても,私たちがそれを測るために持ち合わせている座標軸は有限で,臨床の現場では表1の10座標が実践的です。痛みの把握に著効しますが,年齢を問わずあらゆる症状に適用可能で,副作用がまったくありません。練習1を経て,Chloride PPsを自家薬籠中の物としてください。

表1 症状把握の特効薬Chloride PPs
Characterization/QualityCan you describe what it feels like?
LocationCan you show me where you feel it?
OnsetWhen did the symptom begin?
RadiationDoes it radiate or move?
IntensityHow bad is it?
Duration/FrequencyHow long did it last? How often did you get it?
Events leading up to the symptomWhat were you doing at the time?
Provoking(aggravating)factorsDoes anything make the symptom worse?
Palliative(alleviating)factorsDoes anything make the symptom better?
Symptoms associated with the eventDo you have any other symptoms?

Pain Scale

 痛みのIntensityを表現する際,Pain Scaleが有用な場合があります。痛みという主観的体験を本人に数値化してもらう方法ですが,数値そのものに絶対的な意味はなく,あくまで,経時的評価における使用が基本です。最も親切な尋ね方である「Can you rate the pain on a scale of 1 to 10 with “1" being barely noticeable and “10" being the worst in your life?」を覚えておくと,さまざまな場面で応用できます。

1)表1のmnemonic(記憶術)“Chloride PPs”を暗記します。
2)Text box [Sample1]に進み,Chloride PPsの各項目について,模擬情報を創作してください。
3)Text box [Sample 2]を音読し,Chloride PPsの10成分を抽出・分析してください。

■Delivery Index [Pace]


 表2に,症例提示の速度表を掲げました。100-120words/min.(以下,wpmと略)はかなりゆっくり。Voice of America Special Englishの速度でもあり,英語圏に参加するための「資格速度」です。120-150wpmはリラックスした心地よい調子。重要事項の議論は,ここで勝負します。150-180wpmは,放送局のAnchorpersonの報道速度。症例提示の最適速度でもあります。しかし,弾む議論に速度制限はないので,180-230wpmで会話が進むこともしばしばであることを知っておきましょう。

表2 話す速度の目安(単位:words/min.)





2)固有速度による症例呈示を行ない,native speakerからfeedbackを受けましょう。


 Text boxで紹介できる英文の量は限られています。欠乏補填のために,Diane L. Elliot and Linn Goldberg. “The history and physical examination casebook"(Lippincott-Raven, Philadelphia, 1997)をお勧めします。最近改訂されていない難点がありますが,通読・精読・音読により,安定した基礎体力を獲得することができます。Keep up the good work!

Text Box
Phil Collins [Based on the PBL tutorial(HCP9/Unit1.15)in the UH/JABSOM MD Program.]

【Sample 1】

A 40 year-old man has been coming to our emergency department because of abdominal pain. After completing an interview, our working diagnosis is right nephrolithiasis. Focusing on the character of the pain, what kind of details would you expect to have obtained from the patient?
◆The patient might have the pain characterized by….
(Ch) Initially sharp and colicky, but gradually became diffused and constant.
(L) Localized in the right flank.
(O)&(D) Began suddenly three hours ago and has been increasing since.
(R) While initially beginning in the right flank, the pain soon began radiating to the area of his right groin.
(I) The worst pain the patient has ever felt in his life.He refused to rate the pain by using the pain scale,because it was really severe for him.
(E) The patient worked in his house yard at the time.He couldn't relate the pain to any particular events.
(P)&(P) Walking makes the pain worse and nothing really makes it better.
(S) Associated with nausea and vomiting. The patient denied fever, chills, dysuria, and hematuria. He passed a stool on the day and did not have diarrhea, hematochezia, and melena. He has had three similar episodes in the past year, but they were not nearly as severe and resolved spontaneously.

【Sample 2】

A 61 year-old Japanese-Korean male, retired fiscal officer presented to our emergency department with right upper quadrant abdominal pain.
The patient had been well until eight hours earlier, when he suddenly experienced stabbing pain during dinner. The pain was initially localized in his right upper quadrant, followed by some radiation to his right flank and back. He rated the initial pain as being a 10 on a scale of 1-10. But the severity fluctuated between “worst" and “tolerable." The pain has not been alleviated in any position and aggravated by moving, coughing, and deep breathing. He noted diaphoresis and nausea.

Four hours before, the patient spiked a fever with chills. He once vomited before coming to our hospital. Hematemesis, melena, or change in bowel habits were not noted. He denied chest pain, shortness of breath, and palpitations.

Two years before, an abdominal ultrasonographic examination in a regular check-up incidentally revealed multiple gallstones without thickening of the gallbladder wall. But the patient had never had abdominal pain or jaundice. He has had an eight-year history of hypertension and hyperlipidemia, but he had not seen his physician regularly. He had no history of trauma, surgery, or hospitalization. He had had a 60-pack-year history of smoking and drunk approximately 7 glasses of beer per week for ten years.

E-mail: nakaya@deardoctor.ac