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毎週木曜日5:30PMから30分間、Clinical Problem-Solvingを素材にクリニカル・パールを拾い集めます。

第48回:"Unfolding the Diagnosis"

 今回は、Ménétrier病。その胃襞を伸ばすが如く、診断もその背景のウイルス感染まで展開しましょうということなのでしょう。今年2月23日号のNEJM誌金沢医科大学発生発達医学部門 犀川太教授と秋田千里助教の報告があり、そのCT画像の胃は、まるで女性が身につけるシュシュのような印象的写真でした。

Word Count:2387語 (Time:  13'09'', 182 wpm)



  • Our patient presented with a clinical picture of viral infection and severe epigastric pain. Because he had ingested high doses of NSAIDs to control his fever, NSAID-induced gastritis was initially suspected as the cause of his abdominal pain. However, the finding of severe hypoalbuminemia was not easily explained by either viral infection or his NSAID use. The identification of this abnormality led to reconsideration of the working diagnosis and a shift from a “probability approach” (identifying the most likely diagnosis) to a “causal reasoning” approach (looking for clinical conditions that could underlie this finding as well as the other presenting symptoms and signs).
  • Ménétrier's disease affects men more often than women and is most common between 40 and 55 years of age. Clinical manifestations of the disease include epigastric pain, weight loss, nausea, vomiting, gastrointestinal bleeding, diarrhea, and protein-losing gastropathy. Hypoalbuminemia is present in 20 to 100% of patients, according to a different series; this feature helps distinguish Ménétrier's disease from the Zollinger–Ellison syndrome.

第47回:"Out of the Blue"

「晴天の霹靂」のBlueと有痛性青股腫(Phlegmasia cerulea dolens)のBlueを掛けたタイトルでした。

Word Count:2761語 (Time:  15'33'', 178 wpm)



  • This case highlights the importance of recognizing a rare condition (phlegmasia cerulea dolens) that requires prompt treatment to minimize the risk of morbidity and death.
  • The triad of asymmetric leg swelling, cyanosis, and pain is highly suggestive of phlegmasia cerulea dolens, a rare syndrome seen in cases of massive proximal venous thrombosis that is severe enough to cause arterial insufficiency.  
  • Phlegmasia cerulea dolens (“cerulea” is from the Latin word for “blue”) occurs in the context of complete obstruction of both superficial and deep venous return. The resultant severe venous congestion leads to increased pressure on small arterioles and to tissue ischemia, characterized by a cyanotic or dusky appearance, that may progress to frank gangrene.


 #HAKODOKU  https://ryohoku.tumblr.com/


第46回:"Making the Connection"

「時間的に離れた事象を因果関係でつなげる」という意味と意図せずに「胃と腸がつながらさった」ということを掛けたタイトルでしょうか? ひょっとして、複数の症状の組み合わせ(combination)で診断に至るということも含意しているのでしょうか?

Word Count:2988語 (Time:  15'57'', 187 wpm)



  • The combination of feculent eructation and vomiting, diarrhea, and malnutrition is the classic symptom complex.
  • The current case underscores the importance of considering late complications of bariatric surgery as causes of new symptoms in patients who have had this surgery. Although gastrocolic fistula is an uncommon complication of Roux-en-Y gastric bypass, the combination of malabsorptive diarrhea, fecal eructation, and previous marginal ulceration provided important clues that pointed to this complication.

第45回:"Spot Diagnosis"




Word Count:3170語 (Time:  11'26'', 277 wpm)




Just a Cut

第37回抄読会でとりあげた "Just a Cut" の記事にNEJM誌上での質疑応答があったので、リンクを貼っておきます。


不勉強にも、For the first ear でした。Vibrio vulnificus は鉄依存性なので、ヘプシジン低下により腸管からの鉄吸収が促進している肝硬変患者やヘモクロマトーシスや鉄剤の常用などで血清鉄が高い患者が発病しやすいのだそうです。

Susannah Cahalan at TEDxAmsWomen 2013