※上記の広告は60日以上更新のないWIKIに表示されています。更新することで広告が下部へ移動します。

1.low back pain の原因

  1.Vascular

  2.Infection

  3.Trauma/Toxins

  4.Allergic/Collagen Vascular

  5.Metabolic

  6.Iatrogenic

  7.Neoplasm

  8.Congenital

  9.Drug

10. Endocrine

11. Musculoskeletal

12. Other

     1.Abdominal Aortic Aneurysm

        * A. Pelvic infection -Prostatitis

        *Pyelonephritis

        * SpinalTuberculosis

        * HerpesZoster

        * SinalAbscess?spinalabscess??

        *Osteomyelitis

    2. Fractures-compressionFX(fracture)

     3. PolymyalgiaRheumatica(リウマチ性多発(性)筋痛)

        * A.Osteomalacia

        *Osteoporosis

        *Hyperparathyroidism

        * Paget'sDZ

     4.Osteoporosis 2o Steroid use over replacement thyroidhormone

     5.Osteosarcoma

     Metastatic CA

     Multiple Myeloma

     Spinal Tumors

     6.Musculoskeletal

        *Osteoarthritis

        * Ankylosingspondylitis

       * Rheumotoidarthritis

        * CompressionFX

        * Lumbosacralstrain

        * Discherniation/rupture

        * SpinalStenosis

     7.Kidney Stone

2.更なる問診

 OPQRST

3.degenerative jointdisease(変形性関節疾患)

4.なにか他に悩みがあるかも

5.診断への仮説

脊柱管の物理的な狭窄:変形性関節症、椎間板ヘルニア、急性腰痛症(ぎっくり腰)、骨粗しょう症で圧迫骨折、リウマチ性多発筋痛症

 頻度は低い:脊柱管狭窄症、多発性骨髄腫、骨軟化症、骨メタ

6.身体診察

股関節、腹腔内、足の神経筋に対する評価。

7.診察から分かること

神経根圧迫(-)

血圧のコントロール悪い

Afで疲労感

前立腺癌?

8.診断

背部痛:変形性関節症、急性腰痛症、骨粗しょう症、骨メタ

高血圧

Af

前立腺癌

9.

前立腺癌の確定診断?超音波、PSA(カルシウム、ALP)biopsy

腰椎に対する評価?XpCT


10.「告知」

雰囲気、理解させること

# Practice in your head before you go into theroom.

# Take enough time.

# Be sure of the facts.

# Know your patient.

# Create an atmosphere of intimacy:


  * use thepatient's name while talking

  *concentrate on good eye contact

  * speaksoftly and calmly


# Be direct but gentle.

# Be hopeful but not dishonest about theprognosis.

# Explore therapeutic options only if the patient wantsto.

# Remember: Patients (and families) "shut down" when theyhear certain words (cancer, tumor, going to die, aids, multiple sclerosis,paralyzed, can't have children, might not live, nothing more to do, etc.). Theywill appear attentive to what you say, but in actuality they will not haveheard another word after the word they dreaded most to hear. But you may notrealize it.

# It is important to repeat what you have already said indifferent ways and at different times - slowly and patiently. Don't besurprised when they haven't grasped information that appears very clear to youor if they distort things you have said. You're probably dealing with "shutdown".

# Terminate the conversation gently if the patient appearstoo confused or upset by the news you have just given.

# Promise to come back later in the day or the evening totalk more about it. Try very hard to keep your promise.

# Don't be afraid of your own fears of death anddying.

# Don't be afraid to cry with a patient. This is a sign ofyour humanity as a person and not a weakness as aprofessional.

# Once you have given the bad new, don't abandon thepatient.

# Every time you give bad news, ask yourself afterward ifyou could have done it better so that next time you can.

# Seek out those who do it well, observe their style andadopt what you like into your own style.

# Giving bad news is a special form of communication. Youcan be very bright, very hard working and even very caring - and still do a badjob of communicating. Learn how to be a better communicator. It will paydividends for you, your patients, your families, and yourcolleagues.


http://www.aafp.org/afp/20000315/1779.html