SlideShare una empresa de Scribd logo
1 de 23
Descargar para leer sin conexión
Yu Funakoshi
04/Nov/10
@Gunma University
 A 58-year-old woman consults her
general practitioner (GP) with a 2-
month history of intermittent dull
central epigastric pain.
 What do you want
to ask?
 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.
 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.
 Think
 Anatomy × Pathophysiology!
101104 abdominal pain
 This patients had an
epigastric pain, so
 Stomach
 Liver
 Gallbladder
 Pancreatis
 Colon
…
 VINDICATE-P
 Vasucular
 Infection
 Neoplasm
 Degenerative
 Idiopathic, Intoxication, Iatrogenic
 Congenital
 Allergy, Auto-immune
 Trauma
 Endocrinopathy
 Psychogenic, Pregnancy
 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.
 Despite the progressive symptoms she
and her husband went on a 2-week
holiday to Scandinavia which had been
booked long before.
 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.
 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.
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
101104 abdominal pain
101104 abdominal pain
 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.
 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。
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)
101104 abdominal pain
 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
 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
 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

Más contenido relacionado

La actualidad más candente

Acute hepatitis with prolonged fever1
Acute hepatitis with prolonged fever1Acute hepatitis with prolonged fever1
Acute hepatitis with prolonged fever1Sanjeev Kumar
 
Diabetes Cases.1 Ppt
Diabetes Cases.1 PptDiabetes Cases.1 Ppt
Diabetes Cases.1 PptMiami Dade
 
Liver failure in a neonate
Liver failure in a neonateLiver failure in a neonate
Liver failure in a neonateSanjeev Kumar
 
Infantile diarrhoea and splenomegaly
Infantile diarrhoea and splenomegalyInfantile diarrhoea and splenomegaly
Infantile diarrhoea and splenomegalySanjeev Kumar
 
Neonatal Thyrotoxicosis
Neonatal Thyrotoxicosis Neonatal Thyrotoxicosis
Neonatal Thyrotoxicosis Azad Haleem
 
Premenstrual syndrome
Premenstrual syndromePremenstrual syndrome
Premenstrual syndromeAnusuyasiri
 
Sick day managment in diabetic children and adolescent
Sick day managment in diabetic children and adolescentSick day managment in diabetic children and adolescent
Sick day managment in diabetic children and adolescentImtiaz Baig
 
8. Nephrotic Syndrome & AcuteGlomerularNephritis
8. Nephrotic Syndrome & AcuteGlomerularNephritis8. Nephrotic Syndrome & AcuteGlomerularNephritis
8. Nephrotic Syndrome & AcuteGlomerularNephritisWhiteraven68
 
sick day managment CAN SAFE LIFE FOR DM1
sick day managment CAN SAFE LIFE FOR DM1sick day managment CAN SAFE LIFE FOR DM1
sick day managment CAN SAFE LIFE FOR DM1AMER ALALI
 
NR 508 Education Specialist / snaptutorial.com
NR 508 Education Specialist / snaptutorial.comNR 508 Education Specialist / snaptutorial.com
NR 508 Education Specialist / snaptutorial.comMcdonaldRyan149
 
Nr 508 Education Redefined-snaptutorial.com
Nr 508 Education Redefined-snaptutorial.comNr 508 Education Redefined-snaptutorial.com
Nr 508 Education Redefined-snaptutorial.comrobertledwes48
 
Nr 508 Education Organization -- snaptutorial.com
Nr 508   Education Organization -- snaptutorial.comNr 508   Education Organization -- snaptutorial.com
Nr 508 Education Organization -- snaptutorial.comDavisMurphyC7
 
Nr 508 Education Organization / snaptutorial.com
Nr 508  Education Organization / snaptutorial.comNr 508  Education Organization / snaptutorial.com
Nr 508 Education Organization / snaptutorial.comBaileya135
 
NR 508 Enhance teaching - snaptutorial.com
NR 508  Enhance teaching - snaptutorial.comNR 508  Enhance teaching - snaptutorial.com
NR 508 Enhance teaching - snaptutorial.comDavisMurphyA60
 
Pms management
Pms managementPms management
Pms managementFiqah Amin
 
8. a case study on typhoid fever
8. a case study on typhoid fever8. a case study on typhoid fever
8. a case study on typhoid feverDr. Ajita Sadhukhan
 
NR 508 Effective Communication - tutorialrank.com
NR 508 Effective Communication - tutorialrank.comNR 508 Effective Communication - tutorialrank.com
NR 508 Effective Communication - tutorialrank.comBartholomew49
 

La actualidad más candente (20)

Acute hepatitis with prolonged fever1
Acute hepatitis with prolonged fever1Acute hepatitis with prolonged fever1
Acute hepatitis with prolonged fever1
 
Diabetes Cases.1 Ppt
Diabetes Cases.1 PptDiabetes Cases.1 Ppt
Diabetes Cases.1 Ppt
 
Liver failure in a neonate
Liver failure in a neonateLiver failure in a neonate
Liver failure in a neonate
 
Infantile diarrhoea and splenomegaly
Infantile diarrhoea and splenomegalyInfantile diarrhoea and splenomegaly
Infantile diarrhoea and splenomegaly
 
Neonatal Thyrotoxicosis
Neonatal Thyrotoxicosis Neonatal Thyrotoxicosis
Neonatal Thyrotoxicosis
 
Premenstrual syndrome
Premenstrual syndromePremenstrual syndrome
Premenstrual syndrome
 
Sick day managment in diabetic children and adolescent
Sick day managment in diabetic children and adolescentSick day managment in diabetic children and adolescent
Sick day managment in diabetic children and adolescent
 
10. asthma
10. asthma10. asthma
10. asthma
 
8. Nephrotic Syndrome & AcuteGlomerularNephritis
8. Nephrotic Syndrome & AcuteGlomerularNephritis8. Nephrotic Syndrome & AcuteGlomerularNephritis
8. Nephrotic Syndrome & AcuteGlomerularNephritis
 
sick day managment CAN SAFE LIFE FOR DM1
sick day managment CAN SAFE LIFE FOR DM1sick day managment CAN SAFE LIFE FOR DM1
sick day managment CAN SAFE LIFE FOR DM1
 
NR 508 Education Specialist / snaptutorial.com
NR 508 Education Specialist / snaptutorial.comNR 508 Education Specialist / snaptutorial.com
NR 508 Education Specialist / snaptutorial.com
 
Nr 508 Education Redefined-snaptutorial.com
Nr 508 Education Redefined-snaptutorial.comNr 508 Education Redefined-snaptutorial.com
Nr 508 Education Redefined-snaptutorial.com
 
Nr 508 Education Organization -- snaptutorial.com
Nr 508   Education Organization -- snaptutorial.comNr 508   Education Organization -- snaptutorial.com
Nr 508 Education Organization -- snaptutorial.com
 
Phenylketonuria
PhenylketonuriaPhenylketonuria
Phenylketonuria
 
Phenylketonuria
PhenylketonuriaPhenylketonuria
Phenylketonuria
 
Nr 508 Education Organization / snaptutorial.com
Nr 508  Education Organization / snaptutorial.comNr 508  Education Organization / snaptutorial.com
Nr 508 Education Organization / snaptutorial.com
 
NR 508 Enhance teaching - snaptutorial.com
NR 508  Enhance teaching - snaptutorial.comNR 508  Enhance teaching - snaptutorial.com
NR 508 Enhance teaching - snaptutorial.com
 
Pms management
Pms managementPms management
Pms management
 
8. a case study on typhoid fever
8. a case study on typhoid fever8. a case study on typhoid fever
8. a case study on typhoid fever
 
NR 508 Effective Communication - tutorialrank.com
NR 508 Effective Communication - tutorialrank.comNR 508 Effective Communication - tutorialrank.com
NR 508 Effective Communication - tutorialrank.com
 

Destacado

一類感染症講座受講の手引き
一類感染症講座受講の手引き一類感染症講座受講の手引き
一類感染症講座受講の手引きSatoshi Kutsuna
 
入院患者の下痢へアプローチ
入院患者の下痢へアプローチ入院患者の下痢へアプローチ
入院患者の下痢へアプローチSentaro Iwabuchi
 
NCGM感染症ベーシックレビューコース2014受講の手引き
NCGM感染症ベーシックレビューコース2014受講の手引きNCGM感染症ベーシックレビューコース2014受講の手引き
NCGM感染症ベーシックレビューコース2014受講の手引きSatoshi Kutsuna
 
NCGM感染症ベーシックレビューコース2015
NCGM感染症ベーシックレビューコース2015NCGM感染症ベーシックレビューコース2015
NCGM感染症ベーシックレビューコース2015Satoshi Kutsuna
 
Mitoten_pneumonia_20150724
Mitoten_pneumonia_20150724Mitoten_pneumonia_20150724
Mitoten_pneumonia_20150724Sentaro Iwabuchi
 
レビューコース2016案内
レビューコース2016案内レビューコース2016案内
レビューコース2016案内Satoshi Kutsuna
 
ジカ熱を知り、ジカ熱に備えよう!
ジカ熱を知り、ジカ熱に備えよう!ジカ熱を知り、ジカ熱に備えよう!
ジカ熱を知り、ジカ熱に備えよう!Satoshi Kutsuna
 
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値についてER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について小滝 和也
 
医療安全・医療裁判・医療をめぐる法律
医療安全・医療裁判・医療をめぐる法律医療安全・医療裁判・医療をめぐる法律
医療安全・医療裁判・医療をめぐる法律k-kajiwara
 
医療に纏わる法律・制度 Q&A
医療に纏わる法律・制度 Q&A医療に纏わる法律・制度 Q&A
医療に纏わる法律・制度 Q&Ak-kajiwara
 
IDATEN冬セミナー2016_中心静脈カテーテル関連感染
IDATEN冬セミナー2016_中心静脈カテーテル関連感染IDATEN冬セミナー2016_中心静脈カテーテル関連感染
IDATEN冬セミナー2016_中心静脈カテーテル関連感染Sentaro Iwabuchi
 
ジャーナルの批判的吟味と委託研究について
ジャーナルの批判的吟味と委託研究についてジャーナルの批判的吟味と委託研究について
ジャーナルの批判的吟味と委託研究についてk-kajiwara
 
症候別レクチャー:腹痛
症候別レクチャー:腹痛症候別レクチャー:腹痛
症候別レクチャー:腹痛小滝 和也
 
胸部X線写真の診かた
胸部X線写真の診かた胸部X線写真の診かた
胸部X線写真の診かたk-kajiwara
 
角が立ちにくい紹介状の言い回し
角が立ちにくい紹介状の言い回し角が立ちにくい紹介状の言い回し
角が立ちにくい紹介状の言い回しk-kajiwara
 
カテコラミンの勉強会
カテコラミンの勉強会カテコラミンの勉強会
カテコラミンの勉強会小滝 和也
 

Destacado (20)

一類感染症講座受講の手引き
一類感染症講座受講の手引き一類感染症講座受講の手引き
一類感染症講座受講の手引き
 
入院患者の下痢へアプローチ
入院患者の下痢へアプローチ入院患者の下痢へアプローチ
入院患者の下痢へアプローチ
 
NCGM感染症ベーシックレビューコース2014受講の手引き
NCGM感染症ベーシックレビューコース2014受講の手引きNCGM感染症ベーシックレビューコース2014受講の手引き
NCGM感染症ベーシックレビューコース2014受講の手引き
 
NCGM感染症ベーシックレビューコース2015
NCGM感染症ベーシックレビューコース2015NCGM感染症ベーシックレビューコース2015
NCGM感染症ベーシックレビューコース2015
 
Mitoten_pneumonia_20150724
Mitoten_pneumonia_20150724Mitoten_pneumonia_20150724
Mitoten_pneumonia_20150724
 
20130217 st lukes fuo lecture
20130217 st lukes fuo lecture20130217 st lukes fuo lecture
20130217 st lukes fuo lecture
 
レビューコース2016案内
レビューコース2016案内レビューコース2016案内
レビューコース2016案内
 
ジカ熱を知り、ジカ熱に備えよう!
ジカ熱を知り、ジカ熱に備えよう!ジカ熱を知り、ジカ熱に備えよう!
ジカ熱を知り、ジカ熱に備えよう!
 
Non specific findings to diagnosis of arthralgia
Non specific findings to diagnosis of arthralgiaNon specific findings to diagnosis of arthralgia
Non specific findings to diagnosis of arthralgia
 
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値についてER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について
ER査読会:肺塞栓症を除外するための 年齢調整された d dimerカットオフ値について
 
医療安全・医療裁判・医療をめぐる法律
医療安全・医療裁判・医療をめぐる法律医療安全・医療裁判・医療をめぐる法律
医療安全・医療裁判・医療をめぐる法律
 
疾患を意識した関節所見の取り方
疾患を意識した関節所見の取り方疾患を意識した関節所見の取り方
疾患を意識した関節所見の取り方
 
ステロイド(と、免疫抑制剤)の使い方 2015 update
ステロイド(と、免疫抑制剤)の使い方 2015 updateステロイド(と、免疫抑制剤)の使い方 2015 update
ステロイド(と、免疫抑制剤)の使い方 2015 update
 
医療に纏わる法律・制度 Q&A
医療に纏わる法律・制度 Q&A医療に纏わる法律・制度 Q&A
医療に纏わる法律・制度 Q&A
 
IDATEN冬セミナー2016_中心静脈カテーテル関連感染
IDATEN冬セミナー2016_中心静脈カテーテル関連感染IDATEN冬セミナー2016_中心静脈カテーテル関連感染
IDATEN冬セミナー2016_中心静脈カテーテル関連感染
 
ジャーナルの批判的吟味と委託研究について
ジャーナルの批判的吟味と委託研究についてジャーナルの批判的吟味と委託研究について
ジャーナルの批判的吟味と委託研究について
 
症候別レクチャー:腹痛
症候別レクチャー:腹痛症候別レクチャー:腹痛
症候別レクチャー:腹痛
 
胸部X線写真の診かた
胸部X線写真の診かた胸部X線写真の診かた
胸部X線写真の診かた
 
角が立ちにくい紹介状の言い回し
角が立ちにくい紹介状の言い回し角が立ちにくい紹介状の言い回し
角が立ちにくい紹介状の言い回し
 
カテコラミンの勉強会
カテコラミンの勉強会カテコラミンの勉強会
カテコラミンの勉強会
 

Similar a 101104 abdominal pain

1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf
1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf
1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdfdeepaarora22
 
Take home-exam (1)
Take home-exam (1)Take home-exam (1)
Take home-exam (1)TarekWaleed1
 
A case of recurrent hypoglycemia.pptx
A case of recurrent hypoglycemia.pptxA case of recurrent hypoglycemia.pptx
A case of recurrent hypoglycemia.pptxsarathchandran951352
 
A young woman with lupus
A young woman with lupusA young woman with lupus
A young woman with lupusEnida Xhaferi
 
Case Studies Clinical pharmacy
Case Studies Clinical pharmacyCase Studies Clinical pharmacy
Case Studies Clinical pharmacyQurat Ul Ain
 
Giant cell arteritis,polymyalgia rheumatica
Giant cell arteritis,polymyalgia  rheumaticaGiant cell arteritis,polymyalgia  rheumatica
Giant cell arteritis,polymyalgia rheumaticaDoha Rasheedy
 
acutepancreatitis-231026214130-e9413a87.pdf
acutepancreatitis-231026214130-e9413a87.pdfacutepancreatitis-231026214130-e9413a87.pdf
acutepancreatitis-231026214130-e9413a87.pdfmarvinbreyes
 
Acute Pancreatitis .pptx
Acute Pancreatitis .pptxAcute Pancreatitis .pptx
Acute Pancreatitis .pptxSandra Gboneme
 
Comprehensive Health History Discussion Paper.docx
Comprehensive Health History Discussion Paper.docxComprehensive Health History Discussion Paper.docx
Comprehensive Health History Discussion Paper.docx4934bk
 
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docx
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxClinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docx
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxbartholomeocoombs
 
Case presentation: Chronic pancreatitis
Case presentation: Chronic pancreatitisCase presentation: Chronic pancreatitis
Case presentation: Chronic pancreatitisBSMMU
 
Case summary : Pancreatitis
Case summary : PancreatitisCase summary : Pancreatitis
Case summary : PancreatitisDr Nazeera
 
an Approach to Dyspepsia
an Approach to Dyspepsiaan Approach to Dyspepsia
an Approach to DyspepsiaAhmed Almumtin
 
Biliary_Disorders_Cases[1].pptx
Biliary_Disorders_Cases[1].pptxBiliary_Disorders_Cases[1].pptx
Biliary_Disorders_Cases[1].pptxDakaneMaalim
 
Seminar nada pdf.pdf
Seminar nada pdf.pdfSeminar nada pdf.pdf
Seminar nada pdf.pdfNadaSAlotibi
 
A case study on Pangastritis with pancreatitis
A case study on Pangastritis with pancreatitis A case study on Pangastritis with pancreatitis
A case study on Pangastritis with pancreatitis martinshaji
 
Nursing information helps you to collect history of patient which is helpful
Nursing information helps you to collect history of patient which is helpfulNursing information helps you to collect history of patient which is helpful
Nursing information helps you to collect history of patient which is helpfulYashaswiniV20
 

Similar a 101104 abdominal pain (20)

1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf
1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf
1.1 LOCATION Inpatient, Hospital PATIENT Elaine Snow PHYSICIAN An.pdf
 
Take home-exam (1)
Take home-exam (1)Take home-exam (1)
Take home-exam (1)
 
A case of recurrent hypoglycemia.pptx
A case of recurrent hypoglycemia.pptxA case of recurrent hypoglycemia.pptx
A case of recurrent hypoglycemia.pptx
 
A young woman with lupus
A young woman with lupusA young woman with lupus
A young woman with lupus
 
Case Studies Clinical pharmacy
Case Studies Clinical pharmacyCase Studies Clinical pharmacy
Case Studies Clinical pharmacy
 
Case History: Guillain-Barré Syndrome
Case History: Guillain-Barré SyndromeCase History: Guillain-Barré Syndrome
Case History: Guillain-Barré Syndrome
 
Giant cell arteritis,polymyalgia rheumatica
Giant cell arteritis,polymyalgia  rheumaticaGiant cell arteritis,polymyalgia  rheumatica
Giant cell arteritis,polymyalgia rheumatica
 
acutepancreatitis-231026214130-e9413a87.pdf
acutepancreatitis-231026214130-e9413a87.pdfacutepancreatitis-231026214130-e9413a87.pdf
acutepancreatitis-231026214130-e9413a87.pdf
 
Acute Pancreatitis .pptx
Acute Pancreatitis .pptxAcute Pancreatitis .pptx
Acute Pancreatitis .pptx
 
sle depression case
sle depression casesle depression case
sle depression case
 
Comprehensive Health History Discussion Paper.docx
Comprehensive Health History Discussion Paper.docxComprehensive Health History Discussion Paper.docx
Comprehensive Health History Discussion Paper.docx
 
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docx
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docxClinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docx
Clinical ScenarioREASON FOR CONSULTATION Desaturation to 64.docx
 
Case presentation: Chronic pancreatitis
Case presentation: Chronic pancreatitisCase presentation: Chronic pancreatitis
Case presentation: Chronic pancreatitis
 
Case summary : Pancreatitis
Case summary : PancreatitisCase summary : Pancreatitis
Case summary : Pancreatitis
 
an Approach to Dyspepsia
an Approach to Dyspepsiaan Approach to Dyspepsia
an Approach to Dyspepsia
 
Biliary_Disorders_Cases[1].pptx
Biliary_Disorders_Cases[1].pptxBiliary_Disorders_Cases[1].pptx
Biliary_Disorders_Cases[1].pptx
 
Seminar nada pdf.pdf
Seminar nada pdf.pdfSeminar nada pdf.pdf
Seminar nada pdf.pdf
 
Diabetis & brain
Diabetis & brainDiabetis & brain
Diabetis & brain
 
A case study on Pangastritis with pancreatitis
A case study on Pangastritis with pancreatitis A case study on Pangastritis with pancreatitis
A case study on Pangastritis with pancreatitis
 
Nursing information helps you to collect history of patient which is helpful
Nursing information helps you to collect history of patient which is helpfulNursing information helps you to collect history of patient which is helpful
Nursing information helps you to collect history of patient which is helpful
 

Último

ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptxWINCY THIRUMURUGAN
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .Mohamed Rizk Khodair
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project reportNARMADAPETROLEUMGAS
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communicationskatiequigley33
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptPradnya Wadekar
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentsaileshpanda05
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.kishan singh tomar
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...Shubhanshu Gaurav
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxMAsifAhmad
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfHongBiThi1
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfHongBiThi1
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfDolisha Warbi
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfMedicoseAcademics
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdfHongBiThi1
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxNaveenkumar267201
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.whalesdesign
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectiondrhanifmohdali
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaSujoy Dasgupta
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsMedicoseAcademics
 

Último (20)

ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptxANATOMICAL FAETURES OF BONES  FOR NURSING STUDENTS .pptx
ANATOMICAL FAETURES OF BONES FOR NURSING STUDENTS .pptx
 
Neurological history taking (2024) .
Neurological  history  taking  (2024)  .Neurological  history  taking  (2024)  .
Neurological history taking (2024) .
 
blood bank management system project report
blood bank management system project reportblood bank management system project report
blood bank management system project report
 
Using Data Visualization in Public Health Communications
Using Data Visualization in Public Health CommunicationsUsing Data Visualization in Public Health Communications
Using Data Visualization in Public Health Communications
 
Unit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.pptUnit I herbs as raw materials, biodynamic agriculture.ppt
Unit I herbs as raw materials, biodynamic agriculture.ppt
 
CPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing studentCPR.nursingoutlook.pdf , Bsc nursing student
CPR.nursingoutlook.pdf , Bsc nursing student
 
Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.Different drug regularity bodies in different countries.
Different drug regularity bodies in different countries.
 
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
FDMA FLAP - The first dorsal metacarpal artery (FDMA) flap is used mainly for...
 
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptxDNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
DNA nucleotides Blast in NCBI and Phylogeny using MEGA Xi.pptx
 
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdfSGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
SGK RỐI LOẠN TOAN KIỀM ĐHYHN RẤT HAY VÀ ĐẶC SẮC.pdf
 
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdfSGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
SGK RỐI LOẠN KALI MÁU CỰC KỲ QUAN TRỌNG.pdf
 
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
How to master Steroid (glucocorticoids) prescription, different scenarios, ca...
 
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdfCONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
CONNECTIVE TISSUE (ANATOMY AND PHYSIOLOGY).pdf
 
Red Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdfRed Blood Cells_anemia & polycythemia.pdf
Red Blood Cells_anemia & polycythemia.pdf
 
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdfSGK ĐIỆN GIẬT ĐHYHN        RẤT LÀ HAY TUYỆT VỜI.pdf
SGK ĐIỆN GIẬT ĐHYHN RẤT LÀ HAY TUYỆT VỜI.pdf
 
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptxBreast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
Breast cancer -ONCO IN MEDICAL AND SURGICAL NURSING.pptx
 
MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.MedMatch: Your Health, Our Mission. Pitch deck.
MedMatch: Your Health, Our Mission. Pitch deck.
 
AORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissectionAORTIC DISSECTION and management of aortic dissection
AORTIC DISSECTION and management of aortic dissection
 
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy DasguptaMale Infertility Panel Discussion by Dr Sujoy Dasgupta
Male Infertility Panel Discussion by Dr Sujoy Dasgupta
 
AUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functionsAUTONOMIC NERVOUS SYSTEM organization and functions
AUTONOMIC NERVOUS SYSTEM organization and functions
 

101104 abdominal pain

  • 2.  A 58-year-old woman consults her general practitioner (GP) with a 2- month history of intermittent dull central epigastric pain.
  • 3.  What do you want to ask?
  • 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.  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.  Think  Anatomy × Pathophysiology!
  • 8.  This patients had an epigastric pain, so  Stomach  Liver  Gallbladder  Pancreatis  Colon …
  • 9.  VINDICATE-P  Vasucular  Infection  Neoplasm  Degenerative  Idiopathic, Intoxication, Iatrogenic  Congenital  Allergy, Auto-immune  Trauma  Endocrinopathy  Psychogenic, Pregnancy
  • 10.  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.
  • 11.  Despite the progressive symptoms she and her husband went on a 2-week holiday to Scandinavia which had been booked long before.
  • 12.  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.
  • 13.  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.
  • 14. 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
  • 17.  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.
  • 19. 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)
  • 21.  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
  • 22.  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
  • 23.  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

Notas del editor

  1. vindicate=立証する
  2. Obstructive Jaundice secondary to to the pancreatic carcinoma.
  3. プロスタグランジンはこれらの疼痛物質の作用を高める。 一方、特に表皮下神経叢に分布するC繊維の痛覚神経終末版が軽度、かつ持続的に刺激されると、それは「疼痛」ではなく「かゆみ」として脳に認識される。
  4. 1次痛first pain(somatic pain)= fast pain, 2次痛second pain(visceral pain)=slow pain, 関連痛 referred pain または放散痛 radiating pain
  5. Appendisitis の例 虫垂炎は腸管中の細菌が虫垂の管腔内で繁殖して起きる感染症。増悪すると管腔の内側から外側へ次第に波及していく。 まず細菌が繁殖し管腔内圧が上昇すると、「関連痛」である上腹部あるいは細部鈍痛として最初に認識される。 次に感染が成立して炎症が内膜に及ぶと、「内臓痛」である右下腹部の鈍痛として認識される。 内臓痛の段階であれば、抗生剤での治療も可能だが、体性痛となり、反跳圧痛が出現していれば手術による治療が適当である。 やがて感染が虫垂の外膜から壁側腹膜まで達すると、それが「体性痛」として右下腹部の鋭い疼痛として認識され、身体所見では反跳痛として観察される。