palliative

• adj.

• 軽減/緩和する、一時的に抑える。待機的な。弁解する

• n.

• 緩和剤。弁解。酌量すべき情状。姑息な手段。待機療法

関

symptomatic

• ex.

• palliative care

　 　

WordNet

1. remedy that alleviates pain without curing (同)alleviant, alleviator
2. relating to or according to or affecting a symptom or symptoms; "symptomatic relief"; "symptomatic treatment"; "a symptomatic classification of diseases"

PrepTutorEJDIC

1. (病気などを)一時的に和らげる;(罪などを)弁解する / 〈C〉(一時的の)緩和剤;一時しのぎ
2. 徴候となる;(…の)前兆となる,(…を)示す《+of+名》

Wikipedia preview

出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/07/22 17:06:10」(JST)

wiki en

[Wiki en表示]

"Palliative Medicine" redirects here. For the journal, see Palliative Medicine (journal).

Palliative care is a multidisciplinary approach to specialised medical care for people with serious illnesses. It focuses on providing patients with relief from the symptoms, pain, physical stress, and mental stress of a serious illness—whatever the diagnosis. The goal of such therapy is to improve quality of life for both the patient and the family. Palliative care is provided by a team of physicians, nurses, and other health professionals who work together with the primary care physician and referred specialists (or, for patients who don't have those, hospital or hospice staff) to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

Physicians sometimes use the term palliative care in a sense meaning palliative therapies without curative intent, when no cure can be expected (as often happens in late-stage cancers). For example, tumor debulking can continue to reduce pain from mass effect even when it is no longer curative. A clearer usage is palliative, noncurative therapy when that is what is meant, because palliative care can be used along with curative or aggressive therapies.

Starting in 2006 in the United States, palliative medicine is now a board certified sub-speciality of internal medicine with specialised fellowships for physicians who are interested in the field. Palliative care utilises a multidisciplinary approach to patient care, relying on input from pharmacists, nurses, chaplains, social workers, psychologists and other allied health professionals in formulating a plan of care to relieve suffering in all areas of a patient's life. This multidisciplinary approach allows the palliative care team to address physical, emotional, spiritual and social concerns that arise with advanced illness.

Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease or cause. This can include treating nausea related to chemotherapy or something as simple as morphine to treat the pain of broken leg or ibuprofen to treat aching related to an influenza (flu) infection.

Although the concept of palliative care is not new, most physicians have traditionally concentrated on trying to cure patients. Treatments for the alleviation of symptoms were viewed as hazardous and seen as inviting addiction and other unwanted side effects.

The focus on a person's quality of life has increased greatly since the 1990s. In the United States today, 55% of hospitals with more than 100 beds offer a palliative-care program, and nearly one-fifth of community hospitals have palliative-care programs. A relatively recent development is the palliative-care team, a dedicated health care team that is entirely geared toward palliative treatment.

Scope of the term

Palliative care is a term derived from Latin palliare, "to cloak." It refers to specialised medical care for people with serious illnesses. It is focused on providing patients with relief from the symptoms, pain and stress of a serious illness — whatever the prognosis. The goal is to improve quality of life for both the patient and the family as they are the central system for care.

Palliative care is provided by a team of doctors, nurses and other specialists who work together with a patient's other doctors to provide an extra layer of support. It is appropriate at any age and at any stage in a serious illness and can be provided along with curative treatment.

A World Health Organisation statement describes palliative care as "an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual." More generally, however, the term "palliative care" may refer to any care that alleviates symptoms, whether or not there is hope of a cure by other means; thus, palliative treatments may be used to alleviate the side effects of curative treatments, such as relieving the nausea associated with chemotherapy.

The term "palliative care" is increasingly used with regard to diseases other than cancer such as chronic, progressive pulmonary disorders, renal disease, chronic heart failure, HIV/AIDS and progressive neurological conditions. In addition, the rapidly growing field of pediatric palliative care has clearly shown the need for services geared specifically for children with serious illness.

While palliative care may seem to offer a broad range of services, the goals of palliative treatment are concrete: relief from suffering, treatment of pain and other distressing symptoms, psychological and spiritual care, a support system to help the individual live as actively as possible and a support system to sustain and rehabilitate the individual's family.

Comparison with hospice

See also: Hospice care in the United States

In the United States, a distinction should be made between palliative care and hospice care. Hospice services and palliative care programs share similar goals of providing symptom relief and pain management. Palliative care services can be offered to any patient without restriction to disease or prognosis, and can be appropriate for anyone with a serious, complex illness, whether they are expected to recover fully, to live with chronic illness for an extended time, or to experience disease progression.

Hospice is a type of care involving palliation without curative intent. Usually, it is used for people with no further options for curing their disease or in people who have decided not to pursue further options that are arduous, likely to cause more symptoms, and not likely to succeed. Hospice care under the Medicare Hospice Benefit requires that two physicians certify that a patient has less than six months to live if the disease follows its usual course. This does not mean, though, that if a patient is still living after six months in hospice he or she will be discharged from the service.

The philosophy and multi-disciplinary team approach are similar with hospice and palliative care, and indeed the training programs and many organizations provide both. The biggest difference between hospice and palliative care is the patient: where they are in their illness especially related to prognosis and their goals/wishes regarding curative treatment.

Outside the United States there is generally no such division of terminology or funding, and all such care with a primarily palliative focus, whether or not for patients with terminal illness, is usually referred to as palliative care.

Outside the United States the term hospice usually refers to a building or institution which specialises in palliative care, rather than to a particular stage of care progression. Such institutions may predominantly specialise in providing care in an end-of-life setting; but they may also be available for patients with other specific palliative care needs.

History

Palliative care began in the hospice movement and is now widely used outside of traditional hospice care. Hospices were originally places of rest for travellers in the 4th century. In the 19th century a religious order established hospices for the dying in Ireland and London. The modern hospice is a relatively recent concept that originated and gained momentum in the United Kingdom after the founding of St. Christopher's Hospice in 1967. It was founded by Dame Cicely Saunders, widely regarded as the founder of the modern hospice movement.

The hospice movement has grown dramatically in recent years. In the UK in 2005 there were just under 1,700 hospice services consisting of 220 inpatient units for adults with 3,156 beds, 33 inpatient units for children with 255 beds, 358 home care services, 104 hospice at home services, 263 day care services and 293 hospital teams. These services together helped over 250,000 patients in 2003 & 2004. Funding varies from 100% funding by the National Health Service to almost 100% funding by charities, but the service is always free to patients.

Hospice in the United States has grown from a volunteer-led movement to a significant part of the health care system. In 2005 more than 1.2 million persons and their families received hospice care. Hospice is the only Medicare benefit that includes pharmaceuticals, medical equipment, twenty-four-hour/seven-day-a-week access to care and support for loved ones following a death. Most hospice care is delivered at home. Hospice care is also available to people in home-like hospice residences, nursing homes, assisted living facilities, veterans' facilities, hospitals and prisons.

The first United States hospital-based palliative care programs began in the late 1980s at a handful of institutions such as the Cleveland Clinic and Medical College of Wisconsin. Since then there has been a dramatic increase in hospital-based palliative care programs, now numbering more than 1,400. 80% of US hospitals with more than 300 beds have a program.

A 2009 study regarding the availability of palliative care in 120 US cancer center hospitals reported the following: Only 23% of the centers have beds that are dedicated to palliative care; 37% offer inpatient hospice; 75% have a median time of referral to palliative care to the time of death of 30 to 120 days; research programs, palliative care fellowships, and mandatory rotations for oncology fellows were uncommon.

The results of a 2010 study in The New England Journal of Medicine showed that lung cancer patients receiving early palliative care experienced less depression, increased quality of life and survived 2.7 months longer than those receiving standard oncologic care.

Hospital palliative care programs today care for non-terminal patients as well as hospice patients. The Patient Protection and Affordable Care Act currently being debated by United States House of Representatives and Senate would seek to expand palliative care in the U.S.

In 2011 The Joint Commission (an independent, not-for-profit organisation who accredits and certifies thousands of health care organisations and programs in the United States) began an Advanced Certification Program for Palliative Care that recognizes hospital inpatient programs. In order to obtain this certification, a hospital must show superior patient and family-centred care and enhancement of the quality of life for patients with serious illness.

The first pan-European centre devoted to improving patient palliative care and end-of-life care was established in Trondheim, Norway in 2009. The centre is based at NTNU's Faculty of Medicine and at St. Olav's Hospital/Trondheim University Hospital and coordinates efforts between groups and individual researchers across Europe, specifically Scotland, England, Italy, Denmark, Germany and Switzerland, along with the USA, Canada and Australia.

Indications

Immediate palliative care is indicated for patients with any serious illness and who have physical, psychological, social, or spiritual distress as a result of the treatment they are seeking or receiving. Palliative care increases comfort by lessening pain, controlling symptoms, and lessening stress for the patient and family, and should not be delayed when it is indicated. Evidence shows that end-of-life communication interventions decrease utilization (such as length of stay), particularly in the intensive care unit setting, and that palliative care interventions (mostly in the outpatient setting) are effective for improving patient and caregiver perceptions of care.

Palliative care is not reserved for patients in end-of-life care and can increase quality of life and lengthen the patient's life. If palliative care is indicated for a person in an emergency department, then that care should begin in the emergency department immediately and with referral to additional palliative care services. Emergency care physicians have a unique and critical position to begin discussions with patients and caregivers about palliative care and hospice services as they see persons in difficult times of life.

In some cases, medical specialty professional organizations recommend that patients and physicians respond to an illness only with palliative care and not with a therapy directed at the disease. The following items are indications named by the American Society of Clinical Oncology as characteristics of a patient who should receive palliative care but not any cancer-directed therapy.

1. patient has low performance status, corresponding with limited ability to care for oneself
2. patient received no benefit from prior evidence-based treatments
3. patient is ineligible to participate in any appropriate clinical trial
4. the physician sees no strong evidence that treatment would be effective

These characteristics may be generally applicable to other disease conditions besides cancer.

Practice

Assessment of symptoms

A method for the assessment of symptoms in patients admitted to palliative care is the Edmonton Symptoms Assessment Scale (ESAS), in which there are eight visual analog scales (VAS) of 0 to 10, indicating the levels of pain, activity, nausea, depression, anxiety, drowsiness, appetite and sensation of well-being, sometimes with the addition of shortness of breath. On the scales, 0 means that the symptom is absent and 10 that it is of worst possible severity. It is completed either by the patient alone, by the patient with nurse's assistance, or by the nurses or relatives.

Symptom management

Further information: Symptom management in end-of-life-care

Medications used for palliative patients are used differently from standard medications, based on established practices with varying degrees of evidence. Examples include the use of antipsychotic medications to treat nausea, anticonvulsants to treat pain, and morphine to treat dyspnea. Routes of administration may differ from acute or chronic care, as many patients lose the ability to swallow. A common alternative route of administration is subcutaneous, as it is less traumatic and less difficult to maintain than intravenous medications. Other routes of administration include sublingual, intramuscular and transdermal. Medications are often managed at home by family or nursing support.

Dealing with distress

An elderly cat with chronic renal failure receives Lactated Ringer's solution, a form of hydration, during her final days.

See also: Distress in cancer caregiving

The key to effective palliative care is to provide a safe way for the individual to address their physical and psychological distress, that is to say their total suffering, a concept first thought up by Cicely Saunders, and now widely used, for instance by authors like Twycross or Woodruff. Dealing with total suffering involves a broad range of concerns, starting with treating physical symptoms such as pain, nausea and breathlessness. The palliative care teams have become very skilful in prescribing drugs for physical symptoms, and have been instrumental in showing how drugs such as morphine can be used safely while maintaining a patient's full faculties and function. However, when a patient exhibits a physiological symptom, there are often psychological, social or spiritual symptoms as well. The interdisciplinary team, which often includes a registered nurse, a licensed mental health professional, a licensed social worker or a counselor and spiritual support such as a chaplain, can play a role in helping the patient and family cope globally with these symptoms, rather than depending on the medical/pharmacological interventions alone. Usually, a palliative care patient's concerns are pain, fears about the future, loss of independence, worries about their family and feeling like a burden. While some patients will want to discuss psychological or spiritual concerns and some will not, it is fundamentally important to assess each individual and their partners' and families' need for this type of support. Denying an individual and their support system an opportunity to explore psychological or spiritual concerns is just as harmful as forcing them to deal with issues they either don't have or choose not to deal with. There are five principal methods for addressing patient anxiety in palliative care settings. They are counseling, visualisation, cognitive methods, drug therapy and relaxation therapy. Palliative pets can play a role in this last category. (Pets as such may also receive palliative care at the end of their lives.) For animal lovers approaching the end of life, contact with the familiar positive interactions with pets helps to normalise the hospice environment and reduce anxiety. Even for patients whose cognitive abilities have been hampered by illnesses such as Alzheimer's disease, clinical research has shown that the presence of a therapy dog enhanced nonverbal communication as shown by increases in looks, smiles, tactile contact and physical warmth.

Acceptance

Physicians practicing palliative care do not always receive support from patients, family members, healthcare professionals or their social peers for their work to reduce suffering and follow patients' wishes for end-of-life care. More than half of physicians in one survey reported that a patient's family members, another physician or another health care professional had characterised their work as being "euthanasia, murder or killing" during the last five years. A quarter of them had received similar comments from their own friends or family member, or from a patient.

Society

Costs and funding

Families of persons who get a referral to palliative care during a hospitalisation incur less costs than similar patients who do not get a palliative care referral.

Funding for hospice and palliative care services varies. In Great Britain and many other countries all palliative care is offered free to the patient and their family, either through the National Health Service (as in the UK) or through charities working in partnership with the local health services. Palliative care services in the US are paid by philanthropy, fee-for service mechanisms, or from direct hospital support while hospice care is provided as Medicare benefit; similar hospice benefits are offered by Medicaid and most private health insurers. Under the Medicare Hospice Benefit (MHB) a patient signs off their Medicare Part B (acute hospital payment) and enrols in the MHB through Medicare Part B with direct care provided by a Medicare certified hospice agency. Under terms of the MHB the Hospice agency is responsible for the Plan of Care and may not bill the patient for services. The hospice agency, together with the patient's primary physician, is responsible for determining the Plan of Care. All costs related to the terminal illness are paid from a per diem rate (~US $126/day) that the hospice agency receives from Medicare - this includes all drugs and equipment, nursing, social service, chaplain visits and other services deemed appropriate by the hospice agency; Medicare does not pay for custodial care. Patients may elect to withdraw from the MHB and return to Medicare Part A and later re-enrol in hospice.

Certification and training for services

In most countries hospice and palliative care is provided by an interdisciplinary team consisting of physicians, pharmacists, registered nurses, nursing assistants, social workers, hospice chaplains, physiotherapists, occupational therapists, complementary therapists, volunteers and, most important, the family. The team's focus is to optimise the patient's comfort. Additional members of the team are likely to include certified nursing assistants or home health care aides, volunteers from the community (largely untrained but some being skilled medical personnel), and housekeepers. In the United States, the physician subspeciality of hospice and palliative medicine was established in 2006, to provide expertise in the care of patients with life-limiting, advanced disease and catastrophic injury; the relief of distressing symptoms; the coordination of interdisciplinary patient and family-centred care in diverse settings; the use of specialised care systems including hospice; the management of the imminently dying patient; and legal and ethical decision making in end-of-life care.

Caregivers, both family and volunteers, are crucial to the palliative care system. Caregivers and patients often form lasting friendships over the course of care. As a consequence caregivers may find themselves under severe emotional and physical strain. Opportunities for caregiver respite are some of the services hospices provide to promote caregiver well-being. Respite may last a few hours up to several days (the latter being done usually by placing the patient in a nursing home or in-patient hospice unit for several days).

In the US, board certification for physicians in palliative care was through the American Board of Hospice and Palliative Medicine; recently this was changed to be done through any of 11 different speciality boards through an American Board of Medical Specialties-approved procedure. Additionally, board certification is available to osteopathic physicians (D.O.) in the United States through four medical speciality boards through an American Osteopathic Association Bureau of Osteopathic Specialists-approved procedure. More than 50 fellowship programs provide one to two years of speciality training following a primary residency. In Britain palliative care has been a full speciality of medicine since 1989 and training is governed by the same regulations through the Royal College of Physicians as with any other medical speciality.

In India Tata Memorial Centre, Mumbai has started a MD course in palliative medicine for the first time in the country since 2012.

Regional variation in services

See also: Hospice care in the United States

Because palliative care sees an increasingly wide range of conditions in patients at varying stages of their illness it follows that palliative care teams offer a range of care. This may range from managing the physical symptoms in patients receiving treatment for cancer, to treating depression in patients with advanced disease, to the care of patients in their last days and hours. Much of the work involves helping patients with complex or severe physical, psychological, social and spiritual problems. In the UK over half of patients are improved sufficiently to return home. Most hospice organisations offer grief counseling to the patient's partner or family should he die.

In the United States hospice and palliative care represent two different aspects of care with similar philosophy, but with different payment systems and location of services. Palliative care services are most often provided in acute care hospitals organised around an interdisciplinary consultation service with or without an acute inpatient palliative care ward. Palliative care may also be provided in the dying person's home as a "bridge" program between traditional US home care services and hospice care or provided in long-term care facilities. In contrast over 80% of hospice care in the US is provided in a patient's home with the remainder provided to patients residing in long-term care facilities or in free standing hospice residential facilities. In the UK hospice is seen as one part of the speciality of palliative care and no differentiation is made between 'hospice' and 'palliative care'. The goal of palliative care and hospice are both entirely based on comfort of the patient and not on curative treatments. This allows the patient to live the last of their days comfortably and surrounded by their family and friends rather than in an Intensive Care Unit (ICU). Some of the major reasons people don’t have knowledge of these options are the reluctance of doctors to have difficult EOL discussions with patients, language/cultural barriers, and the lack of universal protocol regarding documentation of a person’s EOL wishes. Even though most doctors would choose to not be on life-support, ventilators, feeding tubes, etc. they still find themselves not discussing alternatives to patients for many reasons. Some cultures prefer to not avoid talking openly about death because they feel it is disrespectful, and poor translation of words like “hospice” have entirely different meanings in languages like Spanish, which makes hospice and palliative care less accessible to people of their culture. If more states required Physician Orders for Life-Sustaining Treatment (POLST), it would provide a more comfortable atmosphere for physicians to openly have EOL discussions with patients and their families. More education on communication barriers cross-culturally regarding topics of EOL care is needed and would be mandated if POLST was required for every person suffering from terminal illness. Millions of dollars annually would be saved from reduced stays in the ICU and more people would spend their last days in the manner they choose.

In the UK palliative care services offer inpatient care, home care, day care and outpatient services, and work in close partnership with mainstream services. Hospices often house a full range of services and professionals for both paediatric and adult patients.

In the US palliative care services can be offered to any patient without restriction to disease or prognosis. Hospice care under the Medicare Hospice Benefit, however, requires that two physicians certify that a patient has less than six months to live if the disease follows its usual course. This does not mean, though, that if a patient is still living after six months in hospice he or she will be discharged from the service. Such restrictions do not exist in other countries such as the United Kingdom.

See also

• Children's hospice
• Elderly care
• Elisabeth Kübler-Ross
• End-of-life care
• Florence Wald
• Hospice
• Medical ethics
• Palliative sedation
• Robert Twycross

References

External links

• Family Caregiver's Guide to Hospice and Palliative Care
• Palliative Care Nursing at DMOZ
• NCPC The UK National Council for Palliative Care
• All Ireland Institute of Hospice and Palliative Care
• The Children and Young People Palliative Hub

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. 緩和ケアにおける疼痛以外の一般的症状マネージメントの概要 overview of managing common non pain symptoms in palliative care
• 2. 緩和ケア：人生最後の数時間 palliative care the last hours and days of life
• 3. 苦痛緩和のための鎮静 palliative sedation
• 4. 緩和ケアにおける症状の評価へのアプローチ approach to symptom assessment in palliative care
• 5. 緩和ケア：疲労、脱力および無力症の概要 palliative care overview of fatigue weakness and asthenia

English Journal

• Paclitaxel-eluting nanofiber-covered self-expanding nonvascular stent for palliative chemotherapy of gastrointestinal cancer and its related stenosis.

• Kim SY1, Kim M, Kim MK, Lee H, Lee DK, Lee DH, Yang SG.
• Biomedical microdevices.Biomed Microdevices.2014 Dec;16(6):897-904. doi: 10.1007/s10544-014-9894-9.
• Self-expanding non-vascular metal stents (SEMS) is now a choice of treatment for tumor-induced obstructive symptoms of gastrointestinal tract. But in-growing tumor causes re-stenosis. Here, we studied a paclitaxel-eluting nanofiber-covered stent for palliative chemotherapy of gastrointestinal cancer
• PMID 25135441

• End-of-life matters in chronic renal failure.

• Berman N.
• Current opinion in supportive and palliative care.Curr Opin Support Palliat Care.2014 Dec;8(4):371-7. doi: 10.1097/SPC.0000000000000097.
• PURPOSE OF REVIEW: The population considered eligible for dialysis has expanded dramatically over the past 4 decades, so that a significant proportion of patients receiving renal replacement therapy are elderly, frail and infirm. These patients have an extremely limited life expectancy and suffer fr
• PMID 25343175

• End-of-life matters in chronic heart failure patients.

• Sobanski P1, Jaarsma T, Krajnik M.
• Current opinion in supportive and palliative care.Curr Opin Support Palliat Care.2014 Dec;8(4):364-70. doi: 10.1097/SPC.0000000000000094.
• PURPOSE OF REVIEW: Until recently, concepts of care for people with heart failure had rarely included preparation for unavoidable imminent death or caring for the dying.The purpose of this review is to provide an update on current end-of-life issues specific to heart failure patients.RECENT FINDINGS
• PMID 25319275

• Opioids prescription for symptoms relief and the impact on respiratory function: updated evidence.

• López-Saca JM1, Centeno C.
• Current opinion in supportive and palliative care.Curr Opin Support Palliat Care.2014 Dec;8(4):383-90. doi: 10.1097/SPC.0000000000000098.
• PURPOSE OF REVIEW: Opioids are used for treating dyspnea and other symptoms in oncological and nononcological patients. The relief of respiratory fatigue and anxiety that these opioids offer is well known. One of the scarcely frequent, but very much feared, side-effects is respiratory depression. Th
• PMID 25319272

Japanese Journal

• リエゾンと緩和(51)高カルシウム(Ca)血症による末期がん患者のせん妄に対する治療について : ゾレドロン酸が有効であった症例を通じて

• 塩田 勝利,西嶋 康一
• 精神科 20(6), 662-668, 2012-06
• NAID 40019315641

• 緩和ケアチームとの地域連携 : 在宅のOTの立場から (特集 緩和ケア病棟で求められるOTの役割と活動)

• 佐治 暢,佐山 順子
• 作業療法ジャーナル 46(6), 583-587, 2012-06
• NAID 40019262525

• 緩和ケア病棟との連携から生まれる支援 : 一般病院のOTの立場から (特集 緩和ケア病棟で求められるOTの役割と活動)

• 島？ 寛将
• 作業療法ジャーナル 46(6), 578-582, 2012-06
• NAID 40019262520

Related Links

• Palliative | Define Palliative at Dictionary.com

Palliative definition, serving to palliate. See more. Dictionary.com Word of the Day Translate Games Blog Thesaurus.com Apps Favorites Log Out Log In follow Dictionary.com Dictionary.com Thesaurus.com My Account Log Out ...

• What is Palliative Care? - Palliative Medicine & Treatment ...

Palliative care is medical care that relieves pain, symptoms and stress caused by serious illnesses, improving patients' quality of life. ... What Is Palliative Care? Palliative care (pronounced pal-lee-uh-tiv) is specialized medical care ...

• Palliative - definition of palliative by The Free Dictionary

pal·li·a·tive (păl′ē-ā′tĭv, -ē-ə-tĭv) adj. 1. Tending or serving to palliate. 2. Alleviating the symptoms of a disease or disorder, especially one that is terminal, when a cure is not available. n. One that palliates, especially a palliative drug or ...

Related Pictures

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★リンクテーブル★

リンク元	「100Cases 39」「医療面接」「symptomatic」「対症」
拡張検索	「palliative treatment」「palliative therapy」

「100Cases 39」

　　[★]

erratic adj. adj. 軌道の定まらない。一貫性のない、不安定な、不規則な

bowel motion 腸運動、排便

fit adj. adj. 体調がよい、健康で

emaciated adj.

glisten vi. ぴかぴか光る

dislodge

palliative

erythema multiforme 多形紅斑

dermatitis herpetiformis 疱疹状皮膚炎

itch 痒み

itching

celiac disease セリアック病

herpes gestationis 妊娠性疱疹

皮膚の水疱

83歳　男性

主訴：皮膚と口内における多数の水疱

現病歴：水疱は2日前より出現。水疱は破れやすく、赤色の有痛性病変が残る。3ヶ月前から5kg体重が減少しており、食欲が減退している。患者は体調の不調を自覚してた。排便習慣が不規則になり、排便にいくらか血液を認めた。

既往歴：生来、健康であり、既往なし。

生活歴：一人住まい

嗜好歴：喫煙・飲酒無し

服薬歴：処方薬なし。マルチビタミンタブレットは体調の不調を感じてから薬局で購入している。これ以外て薬を購入していない。

身体所見　examination

全身：emaciateで調子悪そうである

皮膚：全身の皮膚に水疱

口内：びらん(sore)あり　sore→有痛性のびらん・潰瘍

脈拍：102/min、irregularly irregular →　不規則な不整脈　→ ( )

血圧：160/78 mmHg

上記以外、心臓、呼吸器系に異常を認めない。

腹部触診：6cmの硬い結節を肝の辺縁に触知。可動性のある硬性の腫瘤を左腸骨窩に触知。

直腸診：鮮血色の血液と糞便の混合物が認められる

検査　examination

低値：Hb, MCV,Alb

高値：AlP

Q1. まず皮膚病変の診断をつけろ。

Q2. 次に皮膚病変と患者の病態を関連づけてみろ。

A. 尋常性天疱瘡

特徴：表皮内水疱、弛緩性水疱、ニコルスキー現象、口内びらん、

・病因：癌腫、リンパ腫、胸腺腫、全身性エリテマトーデス、特定の薬物(ペニシラミン、カプトプリル)などによる

治療：ステロイド、免疫抑制薬

鑑別疾患

・水疱性類天疱瘡：緊満性水疱、水疱は尋常性天疱瘡に比べて破れにくく大型になりやすい。

・多形性紅斑：中心に水疱を伴った的形病変(target-shaped lesion with central blisters)。よく全身紅皮症と粘膜潰瘍と伴う(スティーブン・ジョンソン症候群)。病因は単純ヘルペスウイルス、薬剤(スルフォナミド)、悪性腫瘍。

・疱疹状皮膚炎：肘、膝、顔面に小水疱病変(vesicular lesion)が形成される。vesicleはblister(<0.5cm)より小さく、ひっかくことで破裂する。非常にかゆい。セリアック病に合併することがある

・その他の疾患

　・糖尿病

　・妊娠性疱疹

　・家族性水疱疾患

まとめ

・悪性腫瘍に合併しうる(→腫瘍の存在下で皮膚病変が出現したのであれば腫瘍随伴性天疱瘡と診断されるべき)、

・天疱瘡は気づかないうちに体液を喪失し、あるいは水疱からの感染の結果としての敗血症が生命を脅かす。

「医療面接」

　　[★]

英

medical interview

関

問診

問診のテクニック

OPQRS

• onset
• palliative/provocation
• quality/quantity
• region/radiate
• symptom(associated)
• time course

感情面への配慮

• 反映：患者から受け取った気持ちを、医師が代弁すること 。患者の言葉を分かりやすく言い直したり、確認したりする事。
• 正当化
• 肯定
• 個人的支援
• 協力関係
• 尊重
• 探索

問診における態度

• 共感的態度・理解的態度
• 支持的態度
• 支援的態度
• 評価的態度
• 解釈的態度
• 調査的態度
• 逃避的態度

「symptomatic」

　　[★]

• adj.

• 症候性の、徴候の、症候の、対症の

Management of children with MDS is symptomatic.

関

indication、manifestation、palliative、sign、stigma、stigmata、symptom、syndromic

　 　

「対症」

　　[★]

英

symptomatic、palliative

関

症候、症候性、徴候

「palliative treatment」

　　[★]

• 対症療法、緩和療法、姑息療法

関

palliative care、palliative therapy、symptomatic treatment

「palliative therapy」

　　[★]

• 対症療法、緩和療法

関

palliative care、palliative treatment、symptomatic treatment