3. A 72-year-old man is brought to the emergency room
after fainting while in church.
72歳男性。教会で気を失ってERに運び込まれた。
He had stood up to sing a hymn and then fell to the floor.
立って賛美歌を歌っていたところ、床に倒れた。
His wife, who witnessed the episode, reports that he was
unconscious for approximately 5 minutes.
妻は気を失っていたのは5分くらいだと言った。
When he awakened, he was groggy for another minute or two,
then seemed himself.
意識が戻ってから1,2分間ふらふらしていたが、やがて元に戻った。
No abnormal movements were noted.
異常な動きはみられなかった。
History①
5. A Alcohol 急性アルコール中毒、ウェルニッケ脳症
I Insulin 低血糖、DKA、非ケトン性高浸透圧性昏睡
U Uremia 尿毒症
E Encephalopathy 肝性脳症、高血圧性脳症
Electrolytes Na, K, Ca, Mg
Endocrinopathy 甲状腺クリーゼ、副甲状腺クリーゼ、急性副腎不全
O Opiate, Overdose 薬物中毒(オピオイド含む)
Oxygen 低酸素血症、高二酸化炭素血症、一酸化炭素中毒
T Trauma 脳挫傷、頭蓋内出血(急性/慢性硬膜下、急性硬膜外)
Temperature 低体温、高体温
Tumor 脳腫瘍、腫瘍随伴症候群
I Infection 中枢神経系感染症(髄膜炎、脳炎、脳膿瘍)、敗血症
P Psychogenic 転換性障害(ヒステリー)
Porphyria ポルフィリア
S Seizure けいれん
Stroke, SAH SAH、脳出血、脳梗塞(脳幹もしくは広範囲)
Shock 循環不全 「UCSFに学ぶできる内科医への近道」より
6. This has never happened to him before,
このような症状は今まで起きたことがなかったが
but his wife does report that for the last several months he has
had to curtail activities, such as mowing the lawn,
妻が言うには、ここ数ヶ月草刈りのような作業を減らす必要が
あった。
because he becomes weak and feels lightheaded.
元気が無かったりふらふらしたりしたからだ。
His only medical history is osteoarthritis of his knees, for which
he takes acetaminophen.
膝の変形性関節症の既往があり、アセトアミノフェンを服用して
いる。
History②
7. On examination, he is alert, talkative, and smiling.
意識清明で会話可能。笑顔を浮かべている。
He is afebrile, his heart rate is regular at 35 bpm, and his blood
pressure is 118/72 mm Hg, which remains unchanged on
standing.
発熱なし。心拍数35bpm、整。血圧118/72mmHgで、起立しても
変わらず。
He has contusions on his face, left arm, and chest wall, but no
lacerations.
顔面と左腕、胸部に打撲があるが、裂傷はなし。
His chest is clear to auscultation, and his heart rhythm is regular
but bradycardic with a nondisplaced apical impulse.
胸部聴診清。心拍整だが徐脈。心尖拍動の位置正常。
He has no focal deficits.
局所神経障害なし。
Physical Examination
8. Laboratory examination shows normal blood counts, renal
function, and serum electrolyte levels, and negative cardiac
enzymes.
血算正常。腎機能正常。電解質正常。心筋逸脱酵素陰性。
His ECG (electrocardiogram) is shown below.
心電図は次スライドで。
Laboratory Examination
14. ➤ What is the most likely diagnosis?
➤ What is your next step?
15. Most likely diagnosis:
Syncope as a consequence of third-degree AV block.
診断:Ⅲ度房室ブロックによる失神
Next step:
Placement of temporary transcutaneous or transvenous
pacemaker and evaluation for placement of a permanent
pacemaker.
次の一手:一時ペースメーカーの設置
植込み型ペースメーカー設置の検討