n.

傷つけること、裂傷、裂創

WordNet

a torn ragged wound
the act of lacerating
state of being torn or burst open
the act of making a sudden noisy break
a personal or social separation (as between opposing factions); "they hoped to avoid a break in relations" (同)breach, break, severance, rift, falling out

PrepTutorEJDIC

〈U〉引き裂く(切り裂く)こと / 〈U〉(感情などを)ひどく傷つけること / 〈C〉裂傷,裂け目
〈U〉〈C〉(…の)破裂《+『of』+『名』》 / 〈U〉〈C〉(友好的関係などの)決裂,仲たがい / 〈C〉裂け目 / 〈C〉脱腸,ヘルニア / …‘を'破裂させる / 〈友好関係など〉‘を'断ち切る / 破裂する

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/09/08 14:58:10」(JST)

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A wound is a type of injury which happens relatively quickly in which skin is torn, cut, or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound). In pathology, it specifically refers to a sharp injury which damages the dermis of the skin.

Classification

According to level of contamination a wound can be classified as

clean wound, a wound made under sterile conditions where there are no organisms present in the wound and the wound is likely to heal without complications.
contaminated wound, where the wound is as a result of accidental injury where there are pathogenic organisms and foreign bodies in the wound.
infected wound, where the wound has pathogenic organisms present and multiplying showing clinical signs of infection, where it looks yellow, oozing pus, having pain and redness.
colonized wound, where the wound is a chronic one and there are a number of organisms present and very difficult to heal as in a bedsore.

Open

Open wounds can be classified according to the object that caused the wound. The types of open wound are:

Incisions or incised wounds, caused by a clean, sharp-edged object such as a knife, razor, or glass splinter.
Lacerations, irregular tear-like wounds caused by some blunt trauma. Lacerations and incisions may appear linear (regular) or stellate (irregular). The term laceration is commonly misused in reference to incisions.
Abrasions (grazes), superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface.
Avulsions, injuries in which a body structure is forcibly detached from its normal point of insertion. A type of amputation where the extremity is pulled off rather than cut off.
Puncture wounds, caused by an object puncturing the skin, such as a splinter, nail or needle.
Penetration wounds, caused by an object such as a knife entering and coming out from the skin.
Gunshot wounds, caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit, generally referred to as a "through-and-through."

Closed

Closed wounds have fewer categories, but are just as dangerous as open wounds. The types of closed wounds are:

Hematomas, also called a blood tumor, caused by damage to a blood vessel that in turn causes blood to collect under the skin.
- Hematomas that originate from internal blood vessel pathology are petechiae, purpura, and ecchymosis. The different classifications are based on size.
- Hematomas that originate from an external source of trauma are contusions, also commonly called bruises.
Crush injury, caused by a great or extreme amount of force applied over a long period of time.

An open wound (an avulsion)
A laceration to the leg
An infected puncture wound to the bottom of the forefoot.
A puncture wound from playing darts.
An incision: a small cut in a finger.

Pathophysiology

To heal a wound, the body undertakes a series of actions collectively known as the wound healing process.

Diagnosis

A wound may be recorded for follow-up and observing progress of healing with different techniques which consist of, but not limited to:^[1]

Photographs, with subsequent area quantification using computer processing
Wound tracings on acetate sheets
Kundin wound gauge

Management

Wound, sewn with four stitches

The overall treatment depends on the type, cause, and depth of the wound as well as whether or not other structures beyond the skin (dermis) are involved. Treatment of recent lacerations involves examining, cleaning, and closing the wound. Minor wounds, like bruises, will heal on their own, with skin discoloration usually disappearing in 1–2 weeks. Abrasions, which are wounds with intact skin (non-penetration through dermis to subcutaneous fat), usually require no active treatment except keeping the area clean, initially with soap and water. Puncture wounds may be prone to infection depending on the depth of penetration. The entry of puncture wound is left open to allow for bacteria or debris to be removed from inside.

Cleaning

Evidence to support the cleaning of wounds before closure is poor.^[2] For simple lacerations, cleaning can be accomplished using a number of different solutions, including tap water and sterile saline solution.^[2] Infection rates may be lower with the use of tap water in regions where water quality is high.^[2] Cleaning of a wound is also known as wound toilet.^[3]

Closure

If a person presents to a healthcare center within 6 hours of a laceration they are typically closed immediately after evaluating and cleaning the wound. After this point in time, however, there is a theoretical concern of increased risks of infection if closed immediately.^[4]^{[needs update]} Thus some healthcare providers may delay closure while others may be willing to immediately close up to 24 hours after the injury.^[4] A single study has found that using clean non sterile gloves is equivalent to using sterile gloves during wound closure.^[5]^[6]

If closure of a wound is decided upon a number of techniques can be used. These include bandages, a cyanoacrylate glue, staples, and sutures. Absorbable sutures have the benefit over non absorbable sutures of not requiring removal. They are often preferred in children.^[7] Buffering the pH of lidocaine makes the freezing less painful.^[8]

Adhesive glue and sutures have comparable cosmetic outcomes for minor lacerations <5 cm in adults and children.^[9] The use of adhesive glue involves considerably less time for the doctor and less pain for the person with the cut. The wound opens at a slightly higher rate but there is less redness.^[10] The risk for infections (1.1%) is the same for both. Adhesive glue should not be used in areas of high tension or repetitive movements, such as joints or the posterior trunk.^[9]

Dressings

In the case of clean surgical wounds, there is no evidence that the use of topical antibiotics reduces infection rates in comparison with non-antibiotic ointment or no ointment at all.^[11] Antibiotic ointments can irritate the skin, slow healing, and greatly increase the risk of developing contact dermatitis and antibiotic resistance.^[11] Because of this, they should only be used when a person shows signs of infection and not as a preventative.^[11]

The effectiveness of dressings and creams containing silver to prevent infection or improve healing is not currently supported by evidence.^[12]

Alternative medicine

There is no good evidence that therapeutic touch is useful in healing.^[13] More than 400 species of plants are identified as potentially useful for wound healing.^[14] Only three randomized controlled trials, however, have been done for the treatment of burns.^[15]

Complications

The patient has a deep wound at the knee, and radiography is used to ensure there are no hidden bone fractures.

Bacterial infection of wound can impede the healing process and lead to life-threatening complications. Scientists at Sheffield University have identified a way of using light to rapidly detect the presence of bacteria. They are developing a portable kit in which specially designed molecules emit a light signal when bound to bacteria. Current laboratory-based detection of bacteria can take hours or even days.^[16]

Workup

Individuals who have wounds that are not healing should be investigated to find the causes. Many microbiological agents can be responsible for this. The basic workup includes evaluating the wound, its extent and severity. Cultures are usually obtained both from the wound site and blood. X rays are obtained and a tetanus shot may be administered if there is any doubt about prior vaccination ^[17]

Chronic

Non-healing wounds of the diabetic foot are considered one of the most significant complications of diabetes, representing a major worldwide medical, social, and economic burden that greatly affects patient quality of life. Almost 24 million Americans—one in every 12—are diabetic and the disease is causing widespread disability and death at an epidemic pace, according to the Centers for Disease Control and Prevention. Of those with diabetes, 6.5 million are estimated to suffer with chronic or non-healing wounds. Associated with inadequate circulation, poorly functioning veins, and immobility, non-healing wounds occur most frequently in the elderly and in people with diabetes—populations that are sharply rising as the nation ages and chronic diseases increase.

Although diabetes can ravage the body in many ways, non-healing ulcers on the feet and lower legs are common outward manifestations of the disease. Also, diabetics often suffer from nerve damage in their feet and legs, allowing small wounds or irritations to develop without awareness. Given the abnormalities of the microvasculature and other side effects of diabetes, these wounds take a long time to heal and require a specialized treatment approach for proper healing.

As many as 25% of diabetic patients will eventually develop foot ulcers, and recurrence within five years is 70%. If not aggressively treated, these wounds can lead to amputations. It is estimated that every 30 seconds a lower limb is amputated somewhere in the world because of a diabetic wound. Amputation often triggers a downward spiral of declining quality of life, frequently leading to disability and death. In fact, only about one third of diabetic amputees will live more than five years, a survival rate equivalent to that of many cancers.

Many of these lower extremity amputations can be prevented through an interdisciplinary approach to treatment involving a variety of advanced therapies and techniques, such as debridement, hyperbaric oxygen treatment therapy, dressing selection, special shoes, and patient education. When wounds persist, a specialized approach is required for healing.^[18]

History

Medieval treatment of wound with lance grittings

From the Classical Period to the Medieval Period, the body and the soul were believed to be intimately connected, based on several theories put forth by the philosopher Plato. Wounds on the body were believed to correlate with wounds to the soul and vice versa; wounds were seen as an outward sign of an inward illness. Thus, a man who was wounded physically in a serious way was said to be hindered not only physically but spiritually as well. If the soul was wounded, that wound may also eventually become physically manifest, revealing the true state of the soul.^[19] Wounds were also seen as writing on the "tablet" of the body. Wounds acquired in war, for example, told the story of a soldier in a form which all could see and understand, and the wounds of a martyr told the story of their faith.^[19]

Research

In humans and mice it has been shown that estrogen might affect the speed and quality of wound healing.^[20]

References

^ Thomas, AC; Wysocki, AB (February 1990). "The healing wound: a comparison of three clinically useful methods of measurement.". Decubitus 3 (1): 18–20, 24–5. PMID 2322408. Retrieved 15 June 2013.
^ ^a ^b ^c Fernandez, R; Griffiths, R (Feb 15, 2012). Fernandez, Ritin, ed. "Water for wound cleansing". Cochrane database of systematic reviews (Online) 2: CD003861. doi:10.1002/14651858.CD003861.pub3. PMID 22336796.
^ Simple wound management on patient.info website, viewed 2012-01-08
^ ^a ^b Eliya, MC; Banda, GW (Sep 7, 2011). Eliya, Martha C, ed. "Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury". Cochrane database of systematic reviews (Online) 9 (9): CD008574. doi:10.1002/14651858.CD008574.pub2. PMID 21901725.
^ Perelman, VS; Francis, GJ; Rutledge, T; Foote, J; Martino, F; Dranitsaris, G (March 2004). "Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial". Annals of Emergency Medicine 43 (3): 362–70. doi:10.1016/j.annemergmed.2003.09.008. PMID 14985664.
^ van den Broek, PJ (2011). "[Sterile gloves are necessary in minor surgery]". Nederlands tijdschrift voor geneeskunde 155 (18): A3341. PMID 21466736.
^ "BestBets: Absorbable sutures in pediatric lacerations".
^ Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R (2010). Tzortzopoulou, Aikaterini, ed. "Adjusting the pH of lidocaine for reducing pain on injection". Cochrane Database Syst Rev 12 (12): CD006581. doi:10.1002/14651858.CD006581.pub2. PMID 21154371.
^ ^a ^b Cals, JW; de Bont EGPM (2012). ". Minor incised traumatic laceration". BMJ 345: e6824. doi:10.1136/bmj.e6824. PMID 23092899.
^ Farion, K et al. (2002). Farion, Ken J, ed. "Tissue adhesives for traumatic lacerations in children and adults". Cochrane Database Syst Rev (3): CD003326. doi:10.1002/14651858.CD003326. PMID 12137689.
^ ^a ^b ^c American Academy of Dermatology (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Academy of Dermatology), retrieved 5 December 2013 , which cites
- Sheth, V. M.; Weitzul, S. (2008). "Postoperative topical antimicrobial use". Dermatitis : contact, atopic, occupational, drug 19 (4): 181–189. PMID 18674453.
^ D'Amico G, Pagliaro L, Pietrosi G, Tarantino I (2010). d'Amico, Gennaro, ed. "Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients". Cochrane Database Syst Rev 3 (3): CD002233. doi:10.1002/14651858.CD002233.pub2. PMID 20238318.
^ O'Mathúna, DP; Ashford, RL (Jul 29, 2014). "Therapeutic touch for healing acute wounds.". The Cochrane database of systematic reviews 7: CD002766. doi:10.1002/14651858.CD002766.pub3. PMID 25069726.
^ Ghosh, PK; Gaba, A (2013). "Phyto-extracts in wound healing.". Journal of pharmacy & pharmaceutical sciences : a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques 16 (5): 760–820. PMID 24393557.
^ Bahramsoltani, R; Farzaei, MH; Rahimi, R (September 2014). "Medicinal plants and their natural components as future drugs for the treatment of burn wounds: an integrative review.". Archives of dermatological research 306 (7): 601–17. doi:10.1007/s00403-014-1474-6. PMID 24895176.
^ "Light to detect wound infection" (web). UK scientists have identified a way of using light to rapidly detect the presence of bacteria. bodat. BBC News. 11 March 2007. Retrieved 2008-03-17.
^ Work Up eMedicine General Surgery. Retrieved on 2010-01-27
^ "The Clinical Case for Use of Hyperbaric Oxygen Therapy in the Treatment of Diabetic Wounds," Diversified Clinical Services, copyright 2009
^ ^a ^b Reichardt, Paul F. (1984). "Gawain and the image of the wound". PMLA 99 (2): 154–161. doi:10.2307/462158. JSTOR 462158.
^ Desiree May Oh, MD, Tania J. Phillips, MD (2006). "Sex Hormones and Wound Healing". Wounds.

External links

US based wound healing society
Association for the Advancement of Wound Care AAWC
European Wound Management Association - EWMA works to promote the advancement of education and research.

UpToDate Contents

全文を閲覧するには購読必要です。 To read the full text you will need to subscribe.

1. 縫合糸による皮膚創傷部の閉鎖 closure of skin wounds with sutures
2. 口唇裂傷の評価およびマネージメント assessment and management of lip lacerations
3. 耳介（耳）裂傷の評価およびマネージメント assessment and management of auricle ear lacerations
4. 口腔内裂傷の評価およびマネージメント assessment and management of intra oral lacerations
5. 顔面裂傷の評価およびマネージメント assessment and management of facial lacerations

English Journal

Use of topical bovine thrombin in an anti-coagulated rat model of hepatic injury.

Schmiedt CW, Köhler R, Brainard BM.SourceDepartment of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, 501 DW Brooks Dr., Athens, GA 30602, United States. Electronic address: cws@uga.edu.
Research in veterinary science.Res Vet Sci.2012 Dec;93(3):1498-503. doi: 10.1016/j.rvsc.2012.04.012. Epub 2012 May 23.
The need for surgical hemostasis in patients treated with anticoagulant medications is a concern. This study assessed a bovine-derived topical hemostat (FastAct, FA) using a partial hepatectomy hemorrhage model in anticoagulated rats. Ninety rats were randomly assigned to receive preoperative hepari
PMID 22633173

The impact of wound age on the infection rate of simple lacerations repaired in the emergency department.

Zehtabchi S, Tan A, Yadav K, Badawy A, Lucchesi M.SourceDepartments of Emergency Medicine, State University of New York, Downstate Medical Center, Brooklyn, NY, USA. Electronic address: Shahriar.zehtabchi@downstate.edu.
Injury.Injury.2012 Nov;43(11):1793-8. doi: 10.1016/j.injury.2012.02.018. Epub 2012 Mar 15.
BACKGROUND: The influence of wound age on the risk of infection in simple lacerations repaired in the emergency department (ED) has not been well studied. It has traditionally been taught that there is a "golden period" beyond which lacerations are at higher risk of infection and therefore should no
PMID 22424703

Investigation of the force associated with the formation of lacerations and skull fractures.

Sharkey EJ, Cassidy M, Brady J, Gilchrist MD, Nicdaeid N.SourceCentre for Forensic Science, WestCHEM, Department of Pure and Applied Chemistry, University of Strathclyde, Glasgow, UK.
International journal of legal medicine.Int J Legal Med.2012 Nov;126(6):835-44. doi: 10.1007/s00414-011-0608-z. Epub 2011 Aug 6.
Post-mortem examination is often relied upon in order to determine whether a suspicious death was natural, accidental, suicidal or homicidal. However, in many cases the mechanism by which a single injury has been inflicted cannot be determined with certainty based on pathological examination alone.
PMID 21822684

Japanese Journal

Unanticipated adverse event of endoscopic submucosal dissection: Rectal perforation associated with injury of the cecum wall, Report of a case

To Kazuo,Takeshita Hiroaki,Wakata Kouki,Tominaga Tetsuro,Kunizaki Masaki,Abo Takafumi,Hidaka Shigekazu,Nanashima Atsushi,Sawai Terumitsu,Nagayasu Takeshi,Oka Tadayuki
Acta medica Nagasakiensia 59(3), 103-106, 2015-03
… The perforated site was resected, and the laceration of the cecum was repaired by extracorporeal suture. …
NAID 120005593512

ラテラルウインドウテクニックとオステオトームテクニックを用いた二期的上顎洞底挙上術の一症例 : コーンビームCTでの評価を加えて

山本英一,南部聡,松﨑紘一,上林毅,和田義行,藤沢隆一,田村正人
北海道歯学雑誌 35(2), 164-172, 2015-03
… On the other hand, the Lateral Window Technique can be applied is broad cases, but it inevitably requires a wide sinus membrane elevation with limited laceration. …
NAID 120005572456

マイコプラズマ肺炎による咳嗽が誘因となったと思われる伝染性単核球症の脾破裂の1例

岡田倫明,清地秀典,永岡智之,中川祐輔,山内達雄,石田直樹,今井良典,中村太郎,岡田憲三,梶原伸介
日本消化器外科学会雑誌 48(4), 350-356, 2015
　症例は20歳の男性で，抗生剤抵抗性の発熱，咽頭痛，激しい乾性咳が2週間継続し，突然の左側腹部痛を主訴に当院救急受診した．採血にて肝機能異常，リンパ球優位の白血球上昇，異型リンパ球の出現，EBV-VCA-IgM抗体の陽性，EBNA抗体陰性を認めた．また，CTにて脾腫，脾損傷，腹腔内出血を認めた．Epstein-Barr virus感染による伝染性単核球症（infectious mononucleo …
NAID 130005065291

胃-膵断裂部の内瘻化を試みた小児外傷性膵損傷（IIIb 型）の2例

洲尾昌伍,横井暁子,中尾真 [他],尾藤祐子,荒井洋志,福澤宏明,西島栄治
日本小児外科学会雑誌 51(2), 234-239, 2015
外傷性膵損傷のうち，主膵管損傷を伴うIIIb 型の治療方針に関してはいまだ標準的治療が確立されているとは言えず，治療法はそれぞれの施設の方針で異なっている．今回，膵断裂部-胃内瘻化にて，ドレナージ治療，さらに尾側膵温存を試みた2 症例を経験したので報告する．症例は14 歳男児と7 歳男児．いずれも日本外傷学会分類IIIb 型と診断し，保存的治療を試みたが改善せず，急性期の初回手術で膵断裂部のドレナ …
NAID 130005065238

Related Pictures

★リンクテーブル★

リンク元	「100Cases 84」「100Cases 16」「100Cases 52」「rupture」「裂創」

「100Cases 84」

Wound
	Wounded man
Classification and external resources
Specialty	Emergency medicine
ICD-10	T14.0-T14.1
ICD-9-CM	872-893
MeSH	D014947

　　[★]

☆case84　嘔吐

■症例

32歳　男性

主訴：

現病歴：2 amにからり酔っぱらって救急部に受診。11.45 pmに気分が悪くなり2度嘔吐。嘔吐物は最初は苦く感じられ、それは食べ物と2Lのビールであった。1時間程度後に、何度か猛烈に吐き気を催した。1 amに鮮赤血を吐いた(bright red blood)。患者が言うには最初は少量だったが、2回目にはかなり多い量であった。服用薬なし。時々マリファナを吸う。タバコ1日10本、アルコール2-3 unit/week

既往歴：特記なし

家族歴：特記なし

生活歴：

・身体診断

酔っぱらっているように見える。口の周りに乾燥した血液の付着を認める。脈拍：102/分。(臥位(lying))血圧：134/80 mmHg。立位でも血圧の変化は認められない。心血管系、呼吸器系に異常を認めず。腹部：上腹部(心窩部)にわずかに圧痛。

・検査

(血液生化学)

異常なし

■解説

(第1パラグラフ)

　もっともな診断は、下部食道もしくは胃上部における吐血を引き起こす粘膜の裂傷である(Mallory-Weiss lesion/Mallory-Weiss tear/Mallory-Weiss laceration)。激しい嘔吐やむかつきによる機械的な外傷で生じる。本症例では、なれない大量飲酒によって生じた。

(第2パラグラフ)

患者の話から出血量を見積もるのは難しい。吐血はびっくりするような出来事であり、吐血の量を多く見積もりがちである。ヘモグロ分派性状であり、急性の出血では吐血量を見積もる手がかりにならない。急性期にヘモグロ分が低ければ慢性の出血をほのめかす。著しい失血の最初のサインは頻脈と起立時の血圧低下であることがある。本症例の彼の脈波速いが、これは不安と関連しているのかもしれない。

(第3パラグラフ)

吐血の他の原因は胃炎か消化性潰瘍である。何度か血液を含まない胃内容物のむかつきと嘔吐の話はマロリーワイス症候群に特徴的である。この疾患は普通介入を必要としない良性の病態である。確定診断は上部消化管内視鏡を必要とするが、典型的な症例ではいつも必要になるわけではない。時に、出血がもりひどかったり、壁の解離が粘膜より深いこともあり、穿孔につながる。

(第4パラグラフ)

この症例の管理は注意深い観察、嘔吐で失われた体液を戻すための静脈内輸液である。出血が激しい場合には血液型検査のために採血するが、輸血は必ずしも必要ない。彼は生徒大とH2 blockerで治療された。嘔吐は収まりそれ以上の出血も見られなかった。彼は将来のパーティでは通院しすぎないように決めた。

■管理(内科診断学第2版医学書院)

①本疾患の大多数は安静、絶食、制酸薬・粘膜保護薬の投与で保存的に治療できる。

②輸血が必要なほどの貧血は稀である。

③内視鏡検査時に出血している症例に対しては内視鏡的止血術を行う。

④クリッピング法(図4-89) [図] 、純エタノール局注法、アルゴンプラズマ凝固(APC)法などさまざまあるが、いずれの方法でも良好な止血成績を得られる。

■鑑別診断 (内科診断学第2版医学書院 p.843)

・特発性食道破裂(ブールハーフェ症候群)

・逆流性食道炎

・食道静脈瘤破裂

・出血性胃潰瘍

・急性胃粘膜病変(AGML)

■KEYPOINT

・吐血の前の血液を伴わない激しい嘔吐とむかつきの既往は、上部消化管の裂傷を示唆する。

・患者は血液の量を見積もるのが困難と分かるので、吐血で失われた失血の程度は多糸かでないし、消化管の中にとどまっている血液の量は分からない。

・アルコールは救急入院の約1/4と直接の連関があるという研究がある。

□マロリーワイス症候群(内科診断学第2版医学書院)

　嘔吐などにより腹腔内圧が急激に上昇して噴門部近傍に裂創が発生し、これを出血源として顕出血をきたしたもの。30-50歳代の男性に多く、全消化管出血例の約3-15%を占める。アルコール多飲が原因となることが多いが、ほかに妊娠悪阻、乗り物酔い、脳腫瘍や髄膜炎、医原性のものとしては上部消化管内視鏡検査や心肺蘇生術など、原因となるものは種々である。 ②嘔吐などにより急激に腹圧が上昇すると、急激に胃内圧が上昇し、これにより食道胃接合部近傍に裂創が生じる。

□吐血 hematemesis (内科診断学第2版医学書院)

　コーヒー残渣用の吐血　melanemesis

　鮮血の吐血　hematoemesis

□急性胃粘膜病変 acute gastric mucosal lesion AGML

急性胃炎の劇症型であり、急速に起こる腹痛(時に、吐血、下血)をきたし、潰瘍・びらん・出血が混在した病態を呈する。

病因はアルコール、薬物(アスピリン、ステロイド)、薬品、ストレス、食物(激辛食品など)、アニサキス、中枢神経系障害、熱傷、外科手術

■glossary

inebriate

vt. (人)を酔わせる(make drunk)。～を有頂天にする

adj. 酔っぱらいの、大酒飲みの

n. 酔っぱらい、大酒飲み

pint n. (液体の単位)1パイント = 1/2クオート＝(米)28.8753 inch cube = 0.473 liter = (英) 0.568 liter = 約500cc

retch

vi. むかつく、吐き気を催す、無理に吐こうとする

vt. 吐く

n. むかつく。ヒック(吐き気を催すときの音)

lager n. ラガー(ビール)(貯蔵ビール；日本の普通のビール)

violently adj. 激しく、猛烈に

drunk adj. (pred)酔って。(fig)酔いしれて

epigastrium n. 上腹部、心窩部

blood grouping 血液型判定、血液型検査

indulge

vt. ～にふけらせる。気ままにさせる、(子どもを)甘やかす。(欲求などを)思いのままに満たす。喜ばせる、楽しませる。

vi. (快楽・趣味などに)ふける、身を任す(in)。(略式)たらふく食べる、痛飲する。(～に)従事する。(好ましくないことに)かかわる(in)

□Hematemesis and Melena(Differential Diagnosis in Primary Care 4th)

・吐血か喀血を見分けたい場合はnitrazine paperを使って判定

・身体開口部(body orifice)からの出血を鑑別するとき解剖学的なアプローチがよい。

(食道)

・静脈瘤、逆流性食道炎、癌腫、マロリーワイス症候群。

・外来異物も忘れるな。

・先天性まれな病因として異所性胃粘膜によるバレット食道炎と潰瘍もある。

・大動脈瘤、縦隔腫瘍、肺癌が食道を潰瘍化させ出血させることもある。

(胃)

・炎症：胃炎と胃潰瘍。アスピリンとアルコールも良くある原因

・幽門部静脈瘤で出血するかもしれない

・出血がひどく、他の原因が見つからなければ血液疾患を検索する。

(診断への道)

・吐血の確固たる証拠がある時、内視鏡をつかえる状況にあれば問診とか検査で無駄な時間を使わずに内視鏡で診断＆治療をやってしまえ。

・血液型検査、血液のクロスマッチ？して輸血の準備、凝固能検査など鑑別に必要な検査をやりなさい。内視鏡検査の準備をしている間に、アルコール、アスピリン、そのほかの薬品の服用、潰瘍の既往、食道疾患既往を聴け

・ひどい出血や最近の急な吐血の既往がなければ(内視鏡を使わずに？)伝統的なアプローチでも良い

・吐血の前に血液を伴わない嘔吐があればマロリーワイス症候群の診断の助けとなる。

「100Cases 16」

　　[★]

☆case16　膝の痛み

■glossary

indigestion 消化障害、消化不良

■症例

80歳　男性

主訴：左膝の痛みと腫脹

現病歴：左膝の痛みを2日前から認めた。膝は発熱・腫脹しており、動かすと疼痛を生じる。時々胸焼けと消化不良が見られる。6ヶ月前のhealth checkで、高血圧(172/102mmHg)と血中クレアチニンが高い(正常高値)こと以外は正常といわれた。その4週間数回血圧を測定したが、高値が継続したため、2.5mg bendrofluamethizide(UK)/ベンドロフルメチアジド bendroflumethiazide(US)で治療を開始した。最近の血圧は138/84 mmHgであった。

喫煙歴：なし。

飲酒歴：一週間に平均4unit。

既往歴：股関節に中程度(mild)の変形性関節症

家族歴：特記なし

服薬歴：アセトアミノフェン(股関節の疼痛に対して)

身体所見 examination

　血圧 142/86mmHg。体温37.5℃。脈拍88/分。grade 2 hypertensive retinopathy(高血圧症性網膜症)。心血管系、呼吸器系に検査場異常なし。手にDIPにヘバーデン結節なし。

　左膝が発熱し腫脹している。関節内に液、patellar tap陽性。90℃以上膝関節を屈曲させると痛みを生じる。右の膝関節は正常に見える。

検査　 investigation

　生化学：白血球増多、ESR 上昇、尿素高値、グルコース高値

　単純X線：関節間隙やや狭小。それ以外に異常は認めない。

■problem list

　#1 左膝の痛み

　#2 胸焼け

　#3 消化不良

　#4 高血圧

　#5 クレアチニン正常高値

　#6 股関節の変形性リウマチ

　#7 高血圧性網膜症

■考え方

　・関節痛の鑑別診断を考える。

　・VINDICATEで考えてみてもよいでしょう。

　・関節痛の頻度としては　外傷＞慢性疾患(OAなど)＞膠原病＞脊椎疾患＞悪性腫瘍

■関節痛の鑑別疾患

DIF 282

V Vascular 血友病 hemophilia, 壊血病 scurvy, 無菌性骨壊死 aseptic bone necrosis (Osgood-Schlatter diseaseとか)

I Inflammatory 淋疾 gonorrhea, ライム病 lyme disease, 黄色ブドウ球菌 Staphylococcus, 連鎖球菌 Streptococcus, 結核 tuberculosis, 梅毒 syphilis, 風疹 rubella, 単純ヘルペス herpes simplex, HIV human immunodeficiency virus, サイトメガロウイルス cytomegalovirus

N Neoplastic disorders 骨原性肉腫 osteogenic sarcoma, 巨細胞腫 giant cell tumors

D Degenerative disorders degenerative joint disease or 変形性関節症 osteoarthritis

I Intoxication 痛風 gout (uric acid), 偽痛風 pseudogout (calcium pyrophosphate), ループス症候群 lupus syndrome of hydralazine (Apresoline) and procainamide, gout syndrome of diuretics

C Congenital and acquired malformations bring to mind the joint deformities of tabes dorsalis and syringomyelia and congenital dislocation of the hip. Alkaptonuria is also considered here.

A Autoimmune indicates (多い)関節リウマチ RA (可能性)血清病 serum sickness, 全身性エリテマトーデス lupus erythematosus, リウマチ熱 rheumatic fever, ライター症候群 Reiter syndrome, 潰瘍性大腸炎 ulcerative colitis, クローン病=限局性回腸炎 regional ileitis, 乾癬性関節炎 psoriatic arthritis (老人であり得る)リウマチ性多発筋痛症 polymyalgia rheumatica

T Trauma 外傷性滑膜炎 traumatic synovitis, tear or rupture of the collateral or cruciate ligaments, 亜脱臼 subluxation or laceration of the meniscus (semilunar cartilage), 脱臼 dislocation of the joint or patella, a 捻挫　 sprain of the joint, and fracture of the bones of the joint.

E Endcrine 先端肥大症 acromegaly, 閉経 menopause, 糖尿病 diabetes mellitus

■答え

　骨格筋系-関節炎-単関節炎-急性単関節炎

　痛風　尿酸　→　発熱、ESR↑、白血球↑

　偽痛風　ピロリン酸カルシウム

　高齢女性でチアジド系利尿薬の使用により痛風が誘発されやすい。特に腎機能低下、糖尿病の人はこのリスクが高まる。

■(BSTからの知識「)循環器領域での利尿薬

・心不全の治療において、循環血漿量を減らし、心臓の前負荷を軽減する。

・利尿薬は高尿酸血症を起こす。(けど、心不全の治療において高尿酸血症になったからといって痛風を発症している患者はみたことない)

・電解質異常を起こしやすいので、血液生化学の検査でモニタして注意する。たとえば低Kで不整脈のリスクが高まる。

・チアジド系の利尿薬は血糖を上げるし、尿酸を上げる

・長期の使用で腎機能を低下させる

■initial plan

　Dx 1. 関節液の吸引：関節液の一般検査、生化学検査、培養検査、

　　　　・白血球が増加していれば急性炎症性であることを示す。

　　　　・偏光顕微鏡で関節液を検鏡する。

　　　　　・尿酸の結晶：針状結晶。negatively birefringent

　　　　　・ピロリン酸カルシウムの結晶：positively birefringent

　Tx 1. 関節液の吸引：炎症が軽度改善

　　 2. NSAIDによる疼痛管理

　　 3. PPI：NSAID 潰瘍を予防するため

　　 4. ACE inhibitorの導入

「100Cases 52」

　　[★]

☆case52　全身性の筋力低下

■glossary

筋力低下、筋無力、筋脱力 muscle weakness, muscular weakness

denture 義歯

leg 脚、下肢

bruising 打撲、打撲傷

hair follicle 毛包

edentulous adj. 歯のない。歯を失った、全歯欠損の

■症例

82歳、男性

主訴：筋力低下と全身の倦怠感

現病歴：(以前から続く)筋痛。関節痛(特に肘、手首、膝)。3週間前に転倒して足を打ち、足に局所的な痛みがある。喫煙歴なし。飲酒歴なし。服用薬なし。

既往歴：12年前に心筋梗塞になった。心筋梗塞のβブロッカーを処方されていたが、過去6年間は処方薬を持ってなかった。20年前に胆嚢摘出術。

家族歴：

社会歴：労働者として働いていた。63歳に退職。2階のアパート(in a second-floor flat)に単身で住んでいる。妻は5年前に死亡。息子が一人おり、アイルランドに在住している。息子とは3年間会っていない。

・診察 examination

　肢帯周辺の筋肉に圧痛。肘、手首、肘周辺にも圧痛。口には異常がないが舌がかなり平坦化。歯はなく、義歯は無くしている。循環器系、呼吸器系、消化器系に異常なし。下肢では右脚の脛の前面に(superficial laceration)が認められる。このlacerationは血かにじみ出ており治癒していない。下肢には出血斑が認められる部分がある。腕や脚に打撲傷がみとめられる広い範囲がある。彼が言うには、この打撲傷はどんな外傷とも関係がないとのことである。

・検査 investigation

　ヘモグロビン低値、MCV 低値

■答え

(第一パラグラフ)

・dietary historyは重要なhistoryの中でも重要な部分。

・特に今回のような症例では重要。

・今回の症例では、多くの特徴が栄養的な問題を示している。

　・家族の援助が無く、5年間widowerである。

　・2階のアパートに独りで住んでいる。get outが困難である。

　・義歯を無くしており、食べるのが痕案である。

(第二パラグラフ)

・凝固異常に関係しうる点状出血の皮疹(petechial rash)が見られるが、血小板数は正常。

・毛包の周りに分布しているかどうかを見るために皮疹を注意深く診察することが重要。　←　どういうこと？

・多くの特徴が壊血病を示唆。

・体内のビタミンC ストックは2-3ヶ月。

・壊血病の特徴：皮疹、筋肉と関節の痛みと圧痛、創傷治癒の遅延、小球性貧血

・全歯欠損している患者では、古典的な壊血病の特徴である歯肉出血はないであろう(would not be present)

(第三パラグラフ)

・血清中のビタミンCレベルは正常な患者で広い範囲にあるので、測定は難しい。

・この患者ではアスコルビン酸を経口的にビタミンCレベルを正常に戻すことで(replacement)することで、2週間で症状が消えた。

・この状況で(in this situation)、他の栄養の欠乏を探したり、退院後再発しない状況を保証するための手続きをすることが重要である。

■KEY POINTS

・特に老人では栄養歴は臨床的評価に入れるべき

・ビタミン不足はあらゆる栄養吸収不良の問題がない場合、貧しい食生活を送っている患者に起こる。

「rupture」

　　[★]

n.

破裂、破断、破壊。(医)破裂、断裂。(医)ヘルニア
決裂、断絶。仲違い、不和(between, with)

vt.

破る、裂く、破裂させる。断裂させる、決裂させる。仲たがいさせる
(医)～にヘルニアを起こさせる。

関: abolish、break、breakdown、burst、destroy、destruction、dismantle、disrupt、disruptant、disruption、explode、explosion、laceration、lesion、subversion、subvert

「裂創」

　　[★]

英: laceration, lacerated wound
ラ: vulnus lacerum, vulnus scissum
同: 裂傷、裂開創 grapping wound
関: 伸展創 traction wounds

[1] Thomas, AC; Wysocki, AB (February 1990). "The healing wound: a comparison of three clinically useful methods of measurement.". Decubitus 3 (1): 18–20, 24–5. PMID 2322408. Retrieved 15 June 2013.

[Cochrane2012-2] Fernandez, R; Griffiths, R (Feb 15, 2012). Fernandez, Ritin, ed. "Water for wound cleansing". Cochrane database of systematic reviews (Online) 2: CD003861. doi:10.1002/14651858.CD003861.pub3. PMID 22336796.

[3] Simple wound management on patient.info website, viewed 2012-01-08

[Wound11-4] Eliya, MC; Banda, GW (Sep 7, 2011). Eliya, Martha C, ed. "Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury". Cochrane database of systematic reviews (Online) 9 (9): CD008574. doi:10.1002/14651858.CD008574.pub2. PMID 21901725.

[5] Perelman, VS; Francis, GJ; Rutledge, T; Foote, J; Martino, F; Dranitsaris, G (March 2004). "Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial". Annals of Emergency Medicine 43 (3): 362–70. doi:10.1016/j.annemergmed.2003.09.008. PMID 14985664.

[6] van den Broek, PJ (2011). "[Sterile gloves are necessary in minor surgery]". Nederlands tijdschrift voor geneeskunde 155 (18): A3341. PMID 21466736.

[7] "BestBets: Absorbable sutures in pediatric lacerations".

[8] Cepeda MS, Tzortzopoulou A, Thackrey M, Hudcova J, Arora Gandhi P, Schumann R (2010). Tzortzopoulou, Aikaterini, ed. "Adjusting the pH of lidocaine for reducing pain on injection". Cochrane Database Syst Rev 12 (12): CD006581. doi:10.1002/14651858.CD006581.pub2. PMID 21154371.

[Cals-9] Cals, JW; de Bont EGPM (2012). ". Minor incised traumatic laceration". BMJ 345: e6824. doi:10.1136/bmj.e6824. PMID 23092899.

[10] Farion, K et al. (2002). Farion, Ken J, ed. "Tissue adhesives for traumatic lacerations in children and adults". Cochrane Database Syst Rev (3): CD003326. doi:10.1002/14651858.CD003326. PMID 12137689.

[AADfive-11] American Academy of Dermatology (February 2013), "Five Things Physicians and Patients Should Question", Choosing Wisely: an initiative of the ABIM Foundation (American Academy of Dermatology), retrieved 5 December 2013 , which cites

Sheth, V. M.; Weitzul, S. (2008). "Postoperative topical antimicrobial use". Dermatitis : contact, atopic, occupational, drug 19 (4): 181–189. PMID 18674453.

[12] Sheth, V. M.; Weitzul, S. (2008). "Postoperative topical antimicrobial use". Dermatitis : contact, atopic, occupational, drug 19 (4): 181–189. PMID 18674453.

[12] D'Amico G, Pagliaro L, Pietrosi G, Tarantino I (2010). d'Amico, Gennaro, ed. "Emergency sclerotherapy versus vasoactive drugs for bleeding oesophageal varices in cirrhotic patients". Cochrane Database Syst Rev 3 (3): CD002233. doi:10.1002/14651858.CD002233.pub2. PMID 20238318.

[13] O'Mathúna, DP; Ashford, RL (Jul 29, 2014). "Therapeutic touch for healing acute wounds.". The Cochrane database of systematic reviews 7: CD002766. doi:10.1002/14651858.CD002766.pub3. PMID 25069726.

[14] Ghosh, PK; Gaba, A (2013). "Phyto-extracts in wound healing.". Journal of pharmacy & pharmaceutical sciences : a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques 16 (5): 760–820. PMID 24393557.

[15] Bahramsoltani, R; Farzaei, MH; Rahimi, R (September 2014). "Medicinal plants and their natural components as future drugs for the treatment of burn wounds: an integrative review.". Archives of dermatological research 306 (7): 601–17. doi:10.1007/s00403-014-1474-6. PMID 24895176.

[Sheffield-16] "Light to detect wound infection" (web). UK scientists have identified a way of using light to rapidly detect the presence of bacteria. bodat. BBC News. 11 March 2007. Retrieved 2008-03-17.

[17] Work Up eMedicine General Surgery. Retrieved on 2010-01-27

[18] "The Clinical Case for Use of Hyperbaric Oxygen Therapy in the Treatment of Diabetic Wounds," Diversified Clinical Services, copyright 2009

[Gawain-19] Reichardt, Paul F. (1984). "Gawain and the image of the wound". PMLA 99 (2): 154–161. doi:10.2307/462158. JSTOR 462158.

[20] Desiree May Oh, MD, Tania J. Phillips, MD (2006). "Sex Hormones and Wound Healing". Wounds.

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「100Cases 84」

「100Cases 16」

「100Cases 52」

「rupture」

「裂創」