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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.

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(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.

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.

The physicalexamination, with a thorough neurological examination, reveals the following inMr. Bender:

Vital Signs: BP130/82, P 74, R 14, T 37C
General - tired appearing male with poor eye contact and hunched posture
HEENT - NC/AT, PERLA, EOMI, tympanic membranes white with + light reflexes,nares patent, pharynx pink, moist mucus membranes
Neck - supple, no nodes, no bruits, no thyromegaly
Heart - RRR with no murmur
Chest - CTA B/L with no rales or wheezes
Abdomen - soft, NT/ND with normoactive BS, no HSM
Neuro- CNs II-XII intact B/L, strength 5/5 UE and LE B/L, biceps and patellarreflexes 2+ B/L, sensation to light touch and pinprick intact UE and LE B/L, notremor, cerebellum intact B/L (finger to nose and heel to shin), Rombergnegative, gait straight with no assistance


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.


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."