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診察は手からはじめる

Dr須藤のビジュアル診断学 メモ1

SpPin'nitive findings

●診察は手からはじめる
「手を見ただけで20の病気が診断できる」

主訴:「内科的病気が心配」
→爪の変形
 spoon nail : 鉄欠乏性貧血
  「力が加わる指だけにおこる」 拇指・示指・中指
   けれど、かなり高度でも 感度26%

86歳女性
→ Terry's nail
肝硬変に伴う爪の所見として見つかった
 爪の付け根のピンクが大きくなる
 慢性腎不全、うっ血性心不全、2型糖尿病 肝硬変 に見られる
   腎不全で half & half nail

Beau's Line
全身疾患(重症感染症、MI)、抗癌剤
 で横の線が走る

56歳女性
 肺化膿症後遺症
 ばち指 Clubbing
   ヒポクラテスがいっている

Schamroth sigh 指をあわせると隙間がつぶれる

27歳女性 発熱&血尿
 2ヶ月前から38度台の熱。
 抗生剤を飲むと下がるけれどすぐ上がる
 そのうち貧血…、炎症反応陽性、赤血球円柱(糸球体腎炎がある)
 
 ゆびの赤い斑点が、「不思議なんですよ。これ動くんです」

petechiae, Roth斑、Osler nodes(治療経過中にでてくることある)
 Janeway病変

■心内膜炎?
56歳男性 「手がしびれる」 指先出血班
 Splinter hemorrhage 爪下線状出血班(ライトを裏から当てると出血が爪に見える)
 …そのうち腹痛がでてきた

 「一応念のために生検をしておきました」皮膚科
 →結節性多発動脈炎PN!

 …しびれるのは、血管炎の末梢神経炎だった


・64歳男性 「下痢」
 BP 98/46 P138, 皮膚がじとっと湿っている
手が白っぽい
  →真っ先にタール便

 手掌皮溝蒼白 Palmar crease paller
  貧血に特異度高い! 
  非常に強い貧血
   感度8%、特異度 98%、LR 7.9

・71男性 Palmer crease pallor
男性、閉経後女性の貧血は、消化管悪性腫瘍の可能性高い
 鉄欠乏でも高い
  両方あったらLR 20くらい!

・結膜環蒼白  一番辺縁
  Conjuctive rimpallor
 感度10、特異度99%、LR 16.7

・31歳女性 「手が黄色い」中国人留学生
  Yellow palms
... carotenemia  …他の部位に黄疸ない
甲状腺機能低下症、肝臓疾患、糖尿病
  などでもおこる

  強度の貧血でも皮膚は黄色く見える Hb 4.6とか…

Q.黄疸を見るのにもっとも適した場所は?
  鼓膜まで黄色いと、Bil 6

 「屋外の駐車場」 どんな明かりの下でみるか、が最も重要

・25歳男性 発熱
 4日前から熱と咳、黄色い
 Hb 6.3、WBC 19200、Plt 58.6
  …お母さんも貧血  遺伝性だった

・「指が白い」 31歳男性 大工
  レイノー
 氷水につけて再現した
  SLE、MCTD、強皮症
  クリオグロブリン血症、多血症、ガンマグロブリン血症
  動脈圧迫、carpal tannel syndrome
血管炎
  甲状腺機能低下症など
  20%は原疾患なし →Raynaud's disease

大工も、今は振動病なんてない、とのこと

・祈りの手 70歳男性 「手が伸びない」
  「デュピュイトラン拘縮」
  特に薬指→小指→中指
  手掌筋膜の線維性肥厚、索状に触れる
  両側に出現
  痛みは無い、いつ発症したかはわからないことが多い
  基礎疾患: DM、アルコール依存、肝障害、てんかんおよびバルビタール剤

・関節痛と膨張
 PIP、MCP関節痛、手背がむくんでいる、2ヶ月前から

 RS3PE
 RA
 PMR …近位部が痛くなるが、末梢がはれてもいい
   RS3PE・PMRどちらも少量ステロイドが劇的に効く

・「ふるえる手」 79歳男性 なんとなく体が動かない
  膵頭部癌の手術歴あり、糖尿病の治療中
  自力で起き上がるのが困難
  
  羽ばたき振戦 Asterixis(姿勢を止めていられない・固定性保持困難
           …間欠的で、規則的ではない!)
            →手だけではなく、足でもおこる。とめられない
     vs Tremor(振戦、規則的に振るえる)
 原因:肝硬変、呼吸不全(CO2がたまった)
    腎不全とか消化器疾患でも代謝性(K・Mg欠乏での筋力低下とか)でも起こる

 → このひとは、defuse typeの肝臓癌だった

・86歳女性「なんとなく意識がおかしい」
  心不全で入院していた  EF 32%、CTR 73%
  前日より話のつじつまが合わない
   …「手を止められない」
  →血液ガスとってみたら、pCO2 73.9
 
 急性のCO2貯留 基礎値から…
  10あがると、Hot hand、SBP↑、発汗
  15 羽ばたき振戦、傾眠
  30 昏睡、縮瞳
  >40 乳頭浮腫、激しい頭痛

 筋力低下でも、 Asterixis (58歳男性)


・Earlobe crease
  冠動脈疾患あると、出る
 LR +2.3 両耳に皺があると、関連が少しありそう
  (原因はよく分からない)

・Arcus sanalis 老人環
  虚血性心疾患であると言われている
   高齢者にはたくさんいるが
   若い人なら気になる!

・Campbell de Morgan spot
さくらんぼ浮腫

(おまけ) 手で見るリウマチ


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