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「救急外来でのキケンな一言」

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「救急外来でのキケンな一言」

「軽症例でも、時間の許す限り詳細に、時系列で、自分の頭に再現フィルムが浮かんでくるくらい病歴聴取すること」
それが重症を見落とさないコツ。検査をたくさんしたって、見落としは防げない
たくさんの病歴に触れることで、一定の流れがわかり、「いつもとちがう」が分かるようになる。『臨床医の勘』

・失敗をみんなで共有すべし

・有害な施設の伝統、はけっこう多い!

・家に帰せないのは…
慢性疾患の急性増悪
独居の高齢者、歩けないめまい、など、更なるアクシデントが予想される群
「この患者さん、それほど重症ではないと思うのですが、帰宅して自宅で一晩過ごすには心配が残るんです」と相談できるべし!

・教えられ上手な後輩を目指せ!
自分の給料の8割は八つ当たり料

・脳幹反射診療ばかりやっていると、医者としての大脳皮質、の萎縮が進行して回復不能に…

・専門家へのコンサルテーション。合併症(血流・神経障害等)を評価せずのまるなげは問題。専門家は専門の評価からはじめ、全身からはじめられない…

・胃腸炎と診断するためには、嘔気・嘔吐・下痢 の3つがそろっていることが必要

・浣腸後の腹痛増強は危険…

・強い腹痛があって、便意はあるのに便がでないとき、
AAA破裂や子宮外妊娠などが怖い…

・高齢者、高血圧患者のはじめての尿管結石はAAAを!
・Af、動脈硬化などの尿管結石は造影CTを
・初回の尿管結石は、アメリカでもCTをとる
・AAAの12%は初回、憩室炎と誤診。5%は下半身の神経症状、5%は下肢の動脈閉塞、萎縮

・高齢者の腹痛の10%は血管疾患
高齢者は自覚症状に乏しい、検査増えてもしょうがない 「痛がらない!」
「血管→穿孔→ねじれる→詰まる」の順に考える

・精巣捻転 →パンツをおろせ!

・気管異物は無気肺をみろ

・発熱+咽頭痛のRed Flag
成人の高熱
時間単位で咽頭痛が進行
こもる声
唾を飲み込めない
咳が軽度またはない
偏側の扁桃炎

→急性喉頭蓋炎、後咽頭膿瘍、扁桃周囲膿瘍
 Toxic Shock Syndrome(最近の手術歴、皮疹、ショック症状をチェック!)

・発熱のハイリスク
3ヶ月未満の乳児、高齢者、免疫不全

・緑内障の瞳孔チェック

・痙攣は回復が遅い(5分以上)、舌をかむことも特異的
失神は数分以内に完全に回復する

・過呼吸 ペーパーバッグ法は、CO2上昇せず酸素濃度は落ちる
→もはや推奨されない
なんで過換気なのか、原因を探すことたいせつ
「ぞうさん」とか歌うのが効果的

・酔っ払いが階段の下で寝ていたら、転落を考えろ

・タバコ。 小児でも半分以上たべなければ症状でない。液体飲んでだとしても1時間以内に強い嘔吐がでてはいちゃう
4時間待ってもOKならだいじょうぶ。洗浄はかわいそうなだけ

胃洗浄の有効性は不明
活性炭は比較的有効かもしれない、が、誤嚥すると致命的な肺炎に
コーラ割りはそこそこのめるらしい
マグコロールPとか、下剤もまぜる

・小児に1錠でも致命的なのは…
カルシウム拮抗薬、βブロッカー、SU剤、三環系抗うつ薬、テオフィリン、クロルプロマジン、ニトロ・ニコチン経皮パッチ、樟脳

・ボーダーの自殺率は高い! 10%と一般人口の50倍

・高齢者の、最近元気ない
心血管障害、感染症、慢性硬膜下血腫

・若い女性の立ちくらみは、子宮外妊娠の否定を!

・単純型熱性痙攣に該当しない項目
生後6ヶ月未満、6歳以上
接続時間>15分
同じ日に2回以上の反復、年5回以上  「車内での再発はやばい!」
体温38度未満での痙攣
偏側性、痙攣後の麻痺
精神運動発達障害

熱性痙攣の再発予防に、抗痙攣薬や解熱剤投与が経験的に行われているが、エビデンスはない

・FASTは繰り返すこと(4時間)で感度が上がる

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