Case#17
1.
12歳までに3回あったてんかん発作と交通事故�
脳に器質的異常はないか.
主訴は疲労と不眠.体重減少もあるとのこと.患者の動作は緩慢.
妻は非常に患者である夫のことを非常に心配しており,癌ではないかと恐れている
(ややヒステリックか).
2.
体重減少はいつからでどの程度か.
動悸や息切れ,呼吸困難感,咳嗽
(夜間)はないか.
サプリメントなどの服用はないか.
排尿に問題はないか.
急に意識が消失したり,物を落としたりするようなことはないか.
物忘れがひどくなったと感じたり他人から指摘されたりしたことはあるか.
疲労感が強くなったのはいつからか.日内変動はあるか.
不眠の型:入眠困難,途中覚醒,悪夢,日中に突然眠くなることはあるか.いびきはかくか.
職場の労働環境.換気などに問題はないか.
仕事上でなにか問題はないか.ストレッサーになるような状況は.人間関係はうまくいっているか.
家庭内や親戚関係などに悩み事はあるか.
DSM-IVの大うつ病エピソード.
FacultyComments
At this point
youshould inquire into the patient's sleep patterns, as well as
associatedsymptoms. Also inquire into the patient's appetite, and if he
intended to loseweight.
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Your HPI reveals
Mr.Bender has had difficulty sleeping for most of his adult life, but over
thepast 4 weeks has been having more trouble falling asleep and has been
wakingup three to
fourtimes per night.
Hedenies difficulty breathing, coughing or nocturia when he awakens
atnight.
He describes
adecreased appetite over the past "couple of weeks" and his weight
hasunintentionally dropped from 205 pounds (93kg) to 190 pounds (86kg). You
notehis height is 5' 11" (180cm). |
3,
4,5.
大うつ病エピソード Major
DepressiveEpisode
以下の症状のうち5つ(またはそれ以上)が同じ2週間の間に存在,病前の機能からの変化を起している;これらの症状のうち少なくとも1つは,
(1)または
(2).
(1) *Sad/
Depressedmood
抑うつ気分
(2) Interest
loss(anhedonia)
興味、喜びの減退
(3)
Appetite体重減少/体重増加,食欲の減退/増加
(4)
Sleepdisturbance
不眠/睡眠過多。
(5)
Psychomotoragitation or retardation精神運動性の焦燥または制止
(6)
Energydecrease
易疲労性,気力の減退
(7)Guilt無価値観,罪責感
(8)Concentration
思考力・集中力の減退,決断困難
(9)
Suicidalideation
死についての反復思考,反復的な自殺念慮,自殺企図,または自殺計画
FacultyComments
The nine symptoms
ofdepression should be thoroughly assessed at this time, which can be
recalledusing the pneumonic *SIG E CAPS.
6.気分障害の分類;
うつ病性障害
大うつ病性障害:大うつ病エピソード
(+),躁病・混合性・軽躁病エピソード
().
気分変調性障害 =抑うつ神経症.最近2年間に大うつ病エピソード()
双極性障害
双極I型障害:大うつ病エピソード
(+),躁病エピソード
(+).
双極II型障害:大うつ病エピソード
(+),軽躁病エピソード
(+),躁病・混合性エピソード
().
気分循環性障害:軽躁病症状と抑うつ症状の期間が多数存在.大うつ病エピソード
().
7.大うつ病性障害
8.
FacultyComments
All patients
withsymptoms of depression must be asked, "Are you having any thoughts of
harmingyourself (suicidal ideation)?"
If the response
is"no", the patient should be asked, "If you would have thoughts of
harmingyourself, what would you do?" A patient may agree to contact a friend or
familymember if suicidal thoughts begin -- that friend or family member can
thenassist the patient in getting to his or her physician's office or the
nearestEmergency Room for evaluation. A person could also agree to call their
localCrisis Intervention number if suicidal thoughts begin -- a Crisis
Interventionworker can help arrange for an ambulance to transport the patient
to thenearest ER for evaluation.
In general,
patientswho are free of suicidal ideation do not require inpatient
hospitalizationBASED ON their self-harm risk. (Note that other factors may
supporthospitalization, such as poor physical health secondary to depression,
or apsychotic depression.)
If the patient
iscurrently having self-harm thoughts, the severity of suicidal ideation must
beevaluated. Does the patient have intent to harm himself / herself? Is there
aspecific plan of self-harm? Is there a past history of self-harm? Does
thepatient have guns in the home? In patients with suicidal ideation and a
planof action, inpatient psychiatric hospitalization is likely
required.Immediate consultation with an inpatient psychiatrist at the local
hospitalshould be the next step.
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Mr. Bender
statesthat when he was in his 20's he had thought about how things would be if
he"fell asleep and never woke up." However, he clearly states that he has not
hadthose thoughts since that time, presently has no thoughts of harming
himself,presently has no plan of harming himself and will tell his wife or call
thelocal Crisis Intervention number if suicidal ideation begins. You give both
Mr.and Mrs. Bender the number for the local CrisisInterventionCenter. |
9.必ず記録すべき
Faculty
Comments:Absolutely -- it is critical to document the findings with regard to
suicidalideation. This part of your note may read as follows: "patient denies
suicidalideation and will tell wife or call Crisis Intervention if self-harm
thoughtsbegin; both the patient and his wife given the number for local
CrisisIntervention in DauphinCounty(For other
counties,refer to the blue pages of the phone book). It is a good idea to
include theactual phone number that you give the patient, in the
medicalrecord.
仙台いのちの電話: 022-718-4343http://www6.ocn.ne.jp/~sen/
10.
FacultyComments
Up to 15% ofpatients
with severe MDD (i.e., needing to be hospitalized) die from suicide.The risk of
suicide in MDD is 30 times greater than the risk of suicide in thegeneral
population.
11.
FacultyComments
Past
PsychiatricHistory and Family Psychiatric History should be obtained when a
diagnosis ofMDD is considered in a patient. Our discussion with Mr. Bender
reveals thefollowing (see case).
12.抑うつ神経症,統合失調症,身体状態に伴ううつ状態などの鑑別が必要.
13.気分障害には遺伝素因も関与している.
14.
身体疾患:内分泌疾患(Cushing症候群,甲状腺機能低下症,糖尿病,など),自己免疫疾患,悪性腫瘍
Parkinsonism,脳血管障害.
薬の副作用:高用量のレセルピン,高用量のグルココルチコイド,レボドパ,アナボリックステロイド,コカインまたはアンフェタミン離脱,インターフェロン,経口避妊薬,カルバマゼピン,フェノバルビタール,アルコール.
精神疾患:適応障害,死別反応,統合失調症,人格障害.
FacultyComments
Metabolic
disorders:hypothyroidism, hyperthyroidism (particularly in the elderly),
Cushing'ssyndrome
Drug
induced:sedatives, hypnotics, antipsychotics, antiepileptics, antiparkinsonian
drugs,antineoplastics, corticosteroids and cardiac medications such as
reserpine andB-blockers
Drug abuse:
alcoholand sedative abuse, cocaine and stimulant withdrawal
Neurologicdisorders:
stroke, Parkinson's disease, Huntingdon's disease, dementingillnesses, multiple
sclerosis, subdural hematoma, brain tumors (particularlyfrontal), epilepsy,
closed head injuries
Other: HIV (highrisk
patients), pancreatic cancer, mononucleosis, systemic
lupuserythematosus
When considering
thediagnosis of a MDD, particularly in light of the items included in
thedifferential diagnosis, a physical exam should be performed.
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The
physicalexamination, with a thorough neurological examination, reveals the
following inMr. Bender:
Vital Signs:
BP130/82, P 74, R 14, T 37C |
15.
FacultyComments
Standard
laboratoryevaluation for MDD includes checking for thyroid dysfunction via a
TSH andT4 level. Other laboratory studies may be considered in light of
additionalfindings during the HPI or on physical exam. Aside from a TSH and T4,
Mr.Bender requires no additional blood work at this time for evaluation of
hisdepressive symptoms.
While a diagnosis
oflung cancer is unlikely in this patient (normal chest exam, negative
pulmonaryROS and explanation of weight loss due to MDD), a chest x-ray may
beconsidered.
Both the patient
andhis wife are quite concerned with lung cancer, and a negative CXR may
helpalleviate their fear. More importantly, however, the patient should
becounseled regarding smoking cessation at this and all subsequent clinic
visits.With this heightened fear of cancer, this may be a great opportunity for
thepatient to achieve smoking cessation
16.うつ病の障害有病率は女性で10-25%,男性で5-12%.
FacultyComments
The
lifetimeprevalence of MDD for women has been found to be about 21%. Women are
morelikely than men to develop depression. Women are at increased risk for
mooddisorders at times of hormonal fluctuation: when premenstrual, postpartum,
andperimenopausal, and with infertility. Postpartum depression
ischaracterized by symptoms lasting for 2 weeks and occurring within 4 weeks
ofdelivery. Interestingly, pregnancy does not confer protection
againstdepression, as some might assume.
The
lifetimeprevalence of MDD for men appears to be as high as 13%. Overall the
prevalencein the general population is about 17%
17.家族歴,女性であること,結婚,妊娠,出産,月経,過労,職場異動,停年退職,遊学,精神的打撃,経済問題,近親者の病気・死,家庭内葛藤,転居.
18.抗うつ薬,睡眠薬の処方.十分な休養が必要であることを説明し,ストレス誘因を避けるよう忠告,場合によっては休職をすすめる.患者家族に適切な対応法を説明.
19.FacultyComments
The goal oftreatment
of MDD is to bring the patient to remission. Remission is the returnto
functional normality, not just feeling better. When evaluated with anassessment
tool, such as the Zung Questionnaire in the office or the HamiltonDepression
Rating Scale (i.e., Ham-D Scale) in clinical trials, the patient nolonger meets
the defined criteria for major depression.
In general,
responseto an antidepressant is defined as at least a 50 % improvement, but
notcomplete relief of symptoms. Remission involves a full restoration of
dailyfunctioning (e.g., resumption of hobbies), and the patient can no longer
bedistinguished from the non-depressed patient. This level of improvement,
forduration of 2 months, is required to meet the definition of remission.
Ifremission is reached within three months of MDD onset, studies show
thatpatients are three times LESS likely to go on to have a relapse or
recurrence,for up to two years. Therefore, there is an argument to treat
effectively toreach remission, as well as to treat early on in the course of
theillness.
In general,
responserates for any given antidepressant can be expected to reach 60-70%,
whileremission rates for an individual antidepressant range from 35-45 %. As
such,achieving remission may require using maximal doses of a medication,
oraugmenting one antidepressant with a second one.
20.
支持的精神療法:基本は信頼関係.症状・病気の説明,治療法,見通し,経過,予後などを丁寧に説明.治療の段階に応じて生活の仕方や社会復帰の方法について助言.休業する場合はその期間を明示する.
認知療法:認知の歪みを患者に気づかせ,柔軟な思考法を身に付けさせる.軽症例では単独で効果があり,特に予防に有効とされる.
力動的精神療法:精神分析に基づいた精神療法.
21.ノルアドレナリン,セロトニン,ドパミン
22.
SSRI,SNRI,
三環系.
23.1-2週間ごとに外来診察を行い状態を確認,薬の種類や用量を必要があれば変更・調節し,副作用にも対処する.自殺念慮について以後も確認し注意していく.
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Mr. Bender and
hiswife seem agreeable to the treatment plan. You also offer Mr. and Mrs.
Benderreassurance that it is unlikely he has lung cancer, reminding him of the
needto quit smoking to prevent lung cancer in the future. On their way out of
theexamination room, Mr. Bender shakes your hand and says,
"Thanksdoc." |
