第35回："D Is for Delay"

Diarrhea, Dermatitis, Dementia, Deathの４つのDで要約される疾患だが、Deathの前に診断のDelayがあるでしょうということをタイトルは指摘しています。診断のDelayはある意味、裕福な社会の副作用かもしれません。同シリーズの "Remembering the ABC's" でも指摘されていますが。

Word Count：2735語 (Time:  17'36'', 155 wpm)

参加人数：５名

クリニカル・パール：

• The absence of impaired vibration sense or proprioception makes diseases of the large, myelinated nerve fibers or dorsal column less likely.
• The absence of hyperreflexia, increased tone, sensory level, and distal motor weakness argues against a compressive myelopathy.
• Testing for cryoglobulinemia involves challenging logistics in terms of handling and processing the sample, so a false negative result is possible.
• The dermatitis of pellagra involves sun-exposed skin in a bilateral and symmetric pattern.
• One of the hallmark clinical signs is an eruption on the front of the neck extending into the region of cervical dermatomes C3 and C4, simulating a necklace (Casal's necklace).
• The classic symptoms and signs of niacin deficiency typically evolve at different intervals over time, rather than appearing simultaneously, making it harder for the clinician to see the pattern and apply diagnostic parsimony.
• However, once there is diagnostic momentum (the tendency for a particular diagnosis to become established over time across multiple providers without adequate evidence or verification), reframing the situation in each new encounter becomes more challenging, and previous solutions (in this case, antibiotic treatment for recurrent episodes of presumed cellulitis) become engrained.
• Patients with pellagra should also receive a high-protein diet and B-complex vitamins, since they frequently are malnourished and have other vitamin deficiencies.

感想：

• 徘徊の英語表現は、wanderingとか、walking aloneとか言う。さらに無目的性を強調したければ、aimlessを加える。
• ビタミンB3、C3領域の皮疹、D3の症状。