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101104 abdominal pain

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101104 abdominal pain

  1. 1. Yu Funakoshi 04/Nov/10 @Gunma University
  2. 2.  A 58-year-old woman consults her general practitioner (GP) with a 2- month history of intermittent dull central epigastric pain.
  3. 3.  What do you want to ask?
  4. 4.  It has no clear relationship to eating and no radiation.  Her appetite is normal, she has no nausea or vomiting and she has not lost weight.  Her bowl habit is normal and unchanged.
  5. 5.  There is no relevant past or family medical history.  She has never smoked, and drinks alcohol very rarely.  She has worked all her life as an infant school teacher.
  6. 6.  Think  Anatomy × Pathophysiology!
  7. 7.  This patients had an epigastric pain, so  Stomach  Liver  Gallbladder  Pancreatis  Colon …
  8. 8.  VINDICATE-P  Vasucular  Infection  Neoplasm  Degenerative  Idiopathic, Intoxication, Iatrogenic  Congenital  Allergy, Auto-immune  Trauma  Endocrinopathy  Psychogenic, Pregnancy
  9. 9.  An H2 antagonist was prescribed and follow-up advised if her symptoms did not resolve.  There was slight relief at first, but after 1 month the pain became more frequent and severe, and the patient noticed that it was relieved by sitting forward. It had also begun to radiate through to the back.
  10. 10.  Despite the progressive symptoms she and her husband went on a 2-week holiday to Scandinavia which had been booked long before.
  11. 11.  During the second week her husband remarked that her eyes had become slightly yellow, and a few days later she noticed that her urine had become dark and her stools pale.  On return from holiday she was referred to a gastroenterologist.
  12. 12.  She was found to have yellow sclerae with a slight yellow tinge to the skin.  There was no lymphadenopathy and her back was normal. As before her heart, chest, and abdomen were normal.
  13. 13. Actual Predicted Total bilirubin 97 mmol/L 3-17 mmol/L Alkaline phosphatase 1007 IU/L 30-300 IU/L Alanine aminotransferase 38 IU/L 5-35 IU/L Gamma-glutamil transpeptidase 499 IU/L 11-51 IU/L
  14. 14.  Carsinoma of the pancreas can present with non-specific symptoms in its early stages.  It is an important cause of obstructive jaundice.  Patients who have had a partial removal of the pancreas are at risk of diabetes.
  15. 15.  疼痛とは、  痛覚神経終末板(いわゆる痛覚レセプター)が、 セロトニンやブラジキニンなどの疼痛物質により刺 激されて脳が認識する知覚。
  16. 16. 1次痛(体性痛) 2次痛(内臓痛) 性質 鋭い 鈍い 局在 高い 低い 神経線維 Aδ C 神経経路 新脊髄視床路 旧脊髄視床路 修飾 なし あり (Aβ繊維と心理的 刺激)
  17. 17.  Chest pain radiating to left arm?  Ischemic heart disease  Upper abdominal pain radiating to left shoulder?  Acute pancreatitis  Right upper abdominal pain radiating right shoulder?  Acute cholecystitis
  18. 18.  痛みを見たら  解剖と病態を組み合わせて鑑別診断を考える!  VINDICATE-Pのようなmnemonicsが便利!  急性疼痛の分類を覚えよう!  関連痛  体性痛  内臓痛
  19. 19.  100 Cases in Clinical Medicine, 2nd edition, Rees, Hodder Arnold  (Case69を引用しました)  ハリソン内科学、第3版、福井次矢、黒川清監修、 メディカルサイエンスインターナショナル  問題解決型 救急初期診療、第1版、田中和豊、 医学書院

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