The administration of calcitriol is also indicated to increase phosphate levels through several mechanisms. This approach was successful in our patient, with resolution of her pain, muscle weakness and wasting, and electrolyte abnormalities and amelioration of the bone loss caused by urinary electrolyte wasting.
Phosphate redistribution into bone occurs in the “hungry bone” syndrome, in which the decrease in parathyroid hormone levels after parathyroidectomy for primary hyperparathyroidism leads to the rapid deposition of calcium and phosphate (in the form of hydroxyapatite) into undermineralized bone within an expanded remodeling space.
Her HBV infection increases her risk of polyarteritis nodosa, which could explain the fatigue, weight loss, weakness, and abdominal pain.
The clinical manifestations of hypophosphatemia are rarely apparent until phosphate levels fall below 1 mg per deciliter. Common symptoms and signs include fatigue, proximal myopathy, dysphagia, ileus, and impaired cardiac contractility. There may be involvement of the central nervous system, which can result in irritability, delirium, or coma. Hemolysis and impaired granulocyte function have also been described. Finally, chronically low serum phosphate levels lead to a reduction in bone-mineral deposition, which can lead to rickets in childhood and osteomalacia in adulthood. Rickets is associated with stunted linear growth and bone deformities. In adulthood, bone deformities are rare, but widespread bone pain may occur. Gait abnormalities attributable to pain with weight-bearing ambulation are common.

2017-04-05

Chicago Med I-1 "Derailed"

YouTube ChicagoMed

昨日から放映が始まった "Chicago Med"、"ER" 後、なかなか気に入る医療ドラマが現れなかったが、今回は期待が持てそう。時代的には、ERのグリーン先生のお嬢さんがメディカル・スクール４年生のサラ・リースといったところか。（もちろん別ドラマ、別人なのだが）

動画とは関係ないが、１話目で感動したのが、精神科部長ダニエル・チャールズが、地下鉄脱線事故で命を落とした婚約者の臓器提供を説得したシーン。ラティーノである彼女を納得させるために、フェデリコ・ガルシア・ロルカの戯曲「血の婚礼」の木樵のセリフを引いた。

Leñador 1: ¡Ay muerte mala! ¡Deja para el amor la verde rama!

あぁ、不幸な死よ！　愛に緑の枝を接げよ！

来週からの楽しみが、増えました。

2017-03-23

第49回："Histology Rings True"

抄読会

今回は、"ring true"という熟語と"fibirin ring granuloma"という組織パターン名を掛けたタイトルでした。その意味を汲めば、「実質臓器が語る真実」という訳にでもなりましょうか。

Word Count：2927語 (Time: 10'16'', 285 wpm)

参加人数：4名＋1名（文書参加）

引用箇所：

Jaundice and dark urine raise suspicion for cholestasis, which can be intrahepatic (caused by infection or lymphoma, for example) or extrahepatic (caused by choledocholithiasis, for example). Given the patient’s fever, the first priority is to rule out obstruction of the biliary tree and cholangitis. Jaundice and dark urine (hemoglobinuria) also occur in cases of acute intravascular hemolysis, such as autoimmune hemolytic anemia, malaria, or Clostridium perfringens bacteremia.
Fibrin-ring granulomas are characterized by granulomatous inflammation with a central fat vacuole and surrounding ring of fibrin. They are suggestive but not pathognomonic of Q fever; in one series, 10 of 23 patients (43%) with fibrin-ring granulomas were shown to have this infection. Fibrin-ring granulomas have also been described in visceral leishmaniasis, toxoplasmosis, EBV hepatitis, and allopurinol hypersensitivity.
ANA has been reported in 12 to 35% of patients with Q fever, and anti–smooth muscle antibodies have been reported in 30 to 65%. Rheumatoid factor, antineutrophil cytoplasmic antibodies, and anti–double-stranded DNA antibodies have also been reported in some patients.

2017-03-09

第48回："Unfolding the Diagnosis"

抄読会

　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誌に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)

参加人数：5名

引用箇所：

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.

2017-02-23

第47回："Out of the Blue"

抄読会

「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)

参加人数：4名

引用箇所：

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.

音声配信を実験的にはじめました。

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

2017-02-10

第46回："Making the Connection"

抄読会

「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)

参加人数：5名

引用箇所：

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.

函館稜北病院総合診療科抄読会Ｂ面

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。

今後の抄読会

第50回："Wasting Away"

Chicago Med I-1 "Derailed"

第49回："Histology Rings True"

第48回："Unfolding the Diagnosis"

第47回："Out of the Blue"

第46回："Making the Connection"