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Documents Documents参考サイトAlvin E. Roth Sonmezt マッチング 参考サイト Alvin E. Roth http //kuznets.fas.harvard.edu/~aroth/alroth.html http //kuznets.fas.harvard.edu/~aroth/papers/rothperansonaer.PDF Sonmezt http //www2.bc.edu/~sonmezt/ マッチング http //prof.mt.tama.hosei.ac.jp/~yutaka/matching%20(marriage).pdf
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ISSClock2 Documents STUB!! ; 書きかけです＞＜； Version "Disposable(Capsule)" because the configuration file attachments will be read automatically, Available only to launch without having to configure anything. If you change the setting does not save. How To Use for Disposable(Capsule) Version 使い捨て版(カプセル版)を打ち上げの時に見るだけなら ダブルクリックで起動するだけでOKです 使い捨て版用の説明書 Quick Start Step 1 Install インストール方法 Step 2 Open a sample file おまけの設定ファイルを読み込む Configuration 設定とか Timer Events タイマーの設定とか under construction. I m sorry. まだ書いてない。ごめんなさい＞＜； View Options 表示 OverlayWindow 半透明合成表示 Was implementation by LayeredWindow API. (http //msdn.microsoft.com/en-us/library/ms997507.aspx) コメント バグ関連はこちらのページのコメント欄にお願いします m(__)m 名前 コメント トップページ
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Hiro was in charge of the operation of the financial system for many years but was ordered to transfer abroad. As a result of confirming handover materials to successors, there was no manual for periodic inspection for the financial system which is carried out once every six months. Therefore, Hiro decided to prepare a manual. As for the inspection, only Hiro understands the work content. Therefore, Hiro has to confirm the content without review from a third party. On the other hand, the reviewer s own review tends to be subjective. How should the predecessor creates document content and ensure objectivity without review from third parties? By using a model, it becomes easier to think about what to write and how to write it when creating a document. Also, you can check objectively whether all required items are listed. Search for documents that would serve as an example and to prevent omission of necessary knowledge. Joe is in charge for the operation of estimate creation system. The system uses the same server as the financial system. Hiro decided to prepare a procedure for the manual while referring to the procedure manual for the estimate creation system. Hiro borrowed a manual from Joe and created a procedure manual. Thanks to the model, Hiro could create the manual covering all the necessary procedures. When using this pattern, it is necessary to select an appropriate similar document. It is necessary to focus on attention such as "what kind of scene do you use the document?", "Device configuration" and so on, and select the appropriate document. It is also possible to reuse similar documents You must use this pattern when the Review for the documents of handover can not be carried out for some reason . Also, a request to a Professional writer is a pattern to ensure the objectivity of the document when the review can not be made,
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Wound Management nishitarumizu 2000.9.19 I. General Principles The goal of wound management is primarily restoration of function, which requires minimizing risk of infection and repair of injured tissue with a minimum of cosmetic deformity. Be sure to maintain universal precautions. II. Significant History A. Mechanism of injury. 1.Blunt trauma. Split or crush type of injuries will swell more and tend to have more devitalized tissue and a higher risk of infection. 2.Sharp trauma. Clean edges, low cellular injury, and risk of infection. 3.Puncture wounds. 4.Bite injury. B.Contaminants. Wound contact with manure, rust, dirt, etc., will increase risk of infection. Wounds sustained in barnyards or stables are considered contaminated. Clostridium tetani is indigenous in manure. C.Time of injury. After 3 hours, the bacterial count in a wound increases dramatically.Wounds may be closed primarily up to 12-18 hours out; clean well and use clinical judgment when choosing which wounds to close. Wounds up to 24 hours old on the face may be closed after good cleaning. The blood supply in this area is much better and the risk of infection therefore much less. The risk of infection may be reduced in wounds by use of tape closures (such as Steri-Strip tape). D.Tetanus status(http //homepages.go.com/homepages/a/n/e/anealkhan/tetanus_prophylaxis.htm) E.Other medical illnesses. Diabetes, chemotherapy, steroids, peripheral vascular disease, and malnutrition may delay wound healing and increase the risk of infection. III.Physical Exam A.Vascular injury. Direct pressure is the first choice for controlling bleeding. If a fracture is involved, immobilization will help control bleeding. Do not clamp vascular structures until it is determined if it is a significant vessel needing repair. If the anatomy is suspicious for injury to major vascular structures, obtain angiogram and consider surgical consult. Capillary refill should be checked distally. Bleeding on the scalp is best controlled by suturing of the wound. For extremities, inflating a blood pressure cuff above systolic pressure assists in wound inspection and repair. However, be careful not to cause ischemic injury to the extremity. B.Neurologic injury. Check distal muscle strength and sensation. Always check sensation before administering anesthesia. For hand and finger lacerations check 2-point discrimination, which should be less than 1 cm at the fingertips. A crush injury may also decrease 2-point discrimination. This may take several months to recover. A lacerated nerve may be repaired immediately or have repair delayed. Loss of sensation may be the first sign of a developing compartment syndrome. C.Tendons. Can be evaluated by inspection, but individual muscles must also be tested for full range of motion and full strength. D.Bones. Check for open fracture or associated fractures. X-ray if any question. An open fracture is an indication for surgical debridement and repair except in the case of a distal phalanx fracture where copious irrigation and oral antibiotics are acceptable treatment if the injury can be watched carefully for infection. E.Foreign bodies. Inspect and x-ray the area. Remember that wood or low-lead glass may not show on radiograph. Wound markers can be used during radiographing, and views obtained in two planes can help localize the object for recovery. Glass may penetrate at an angle and be buried deeper than it appears to be. Ultrasonography is very sensitive at picking up foreign bodies if radiograph is questionable or there is strong clinical suspicion. IV.Repair A.Wound healing. 1.Ephithelialization occurs in 24-48 hours under optimal conditions. 2.Collagen formation. Peaks at day 7. Wound has 15% to 20% of full strength at 3 weeks, 60% full strength at 4 months. The wound is then completely sealed. 3.Scar formation. Requires 6 to 12 months for a mature scar. The smallest scar will be formed when the wound is not under tension. Scars should not be revised until 12 months have passed. Contractures can develop when a scar intersects perpendicularly to a joint crease. B.Wound preparation. Hand washing, face masks are recommended. C.ANESTHESIA 1.In general, pain control should be provided before extensive wound preparation. 2.Local. Use 27- or 30-gauge needle and infiltrate slowly and through the open wound edge avoiding the intact skin. This decreases the pain of infiltration. The addition of bicarbonate to lidocaine before infiltration has been shown to significantly decrease the pain of injection (9 ml of lidocaine and 1 ml of bicarbonate) and warming lidocaine to body temperature may help as well. a.Lidocaine (0.5% to 2%) most frequently used with onset 2 to 5 minutes, duration 60 minutes. Can use 3 to 5 mg/kg with not more than 300 mg total (in adults). Avoid using lidocaine with epinephrine on distal extremities such as the ears, fingers, toes, and penis. b.Mepivacaine (Carbocaine) has onset 3 to 5 minutes, duration of 90 to 120 minutes. c.Bupivacaine (Marcaine) has onset 5 to 10 minutes, duration of hours; longest lasting of the local anesthetics. Intravenous administration may cause serious arrhythmias. d.For "caine" allergies, use diphenhydramine diluted to 1%. Mix 5% diphenhydramine 1 4 ml with normal saline to make a 1% solution. Onset of anesthesia takes longer and does not last so long as with lidocaine. Stronger solutions may cause tissue necrosis. 3. Regional anesthesia. Especially good for fingers, hands, feet, toes, mouth, and face. See Chapter 17 for common blocks. HEMOSTASIS Control of bleeding is necessary for both hemodynamic stability and for proper evaluation of a wound. Direct pressure, epinephrine, bipolar electrocautery, tourniquet. FOREIGN -BODY REMOVAL Avoid the temptation to initially explore wounds with a finger in search of foreign body. Plain radiography , US, CT HAIR REMOVAL Shaving the area with a razor damage the hair follicle, allowing bacterial invasion, and is associated with a ten fold increase in infection rate when compared with clipping. Hair should be as completely as possible with clipping 1to 2 mm above the skin with scissors. Never shave eyebrows because they are needed for alignment of the wound and may not grow back. IRRIGATION Irrigation pressures of 5 to 8 psi are recommended, which is achieved using a 19-guage needle with either 35-ml or 65-ml syringe. Fluid (saline) volume 60ml /cm of wound length. 200ml- 1000ml. There is no added benefit to the addition of an antiseptic ( such as povidone-iodine or hydrogen peroxide) . All detergents cause tissue and fibroblast toxicity. DEBRIDEMENT Not only removes foreign matters, bacteria, and devitalized tissue,but also creates a sharp wound edge that is easier to repair. Using aseptic technique, devitalized tissue should be removed; avoid taking healthy tissue. High-pressure irrigation is the most effective means of cleansing a wound. Scrubbing does not cleanse the wound as well and using any disinfectant in the wound damages healthy cells needed for healing. SKIN DISINFECTION Can be performed with povidone-iodine solution or chlorhexidine. Avoid getting these solutions in the wound because they impede wound healing. D.Wound closure. 1.Avoid primary closure of infected and inflamed wounds, dirty wounds, human and animal bites, neglected and severe crush wounds,and puncture wounds. 2.Tape closure (with Steri-Strips or others). Strips carry a lower risk of infection than suturing does and may be a consideration for higher-risk wounds. 3.Open wound care. Saline wet to dry dressings with gauze will keep the tissue moist and help debride, Gentle washing of the wound 2 to 3 times per day will remove bacterially contaminated secretions (showers are appropriate for this). Avoid iodine dressings because they damage healthy tissue and will slow granulation. When clean granulation tissue is apparent, secondary closure may be considered or can change to dry, sterile, packing material. 4.Suturing. Sutures are of two types (1)absorbable and (2)nonabsorbable. Precision-point cutting needles, and small-sized suture (5-0 or 6-0) should be chosen for skin when a cosmetic closure is important as on the face. Conventional cutting needle is used for routine skin closure. 4-0 or 3-0 nylon may be used on extremities. Noncutting needle should be used for subcutaneous tissue. Extensor tendons are slow healing and should have permanent suture of small size chosen (such as polypropylene). Depending on your practice situation, a surgical consultation should be considered. The majority of subcutaneous or dermal suturing may be performed with an intermediate-duration absorbable suture. However, some wounds require permanent sutures (such as stainless steel wires in sternotomy). 5.Staples. Can be used on the scalp and abdomen with good result. However, avoid use on face, hand, or other areas where structures such as tendons and nerves may become incorporated into the staples. 6.Dressings. Maintaining a moist environment for the first 24h-48 h facilitate healing. Dressing absorbs exudate, protect contamination, and prevention of premature removal. Consider antibiotic petroratum-based ointment on face and torso. Antibiotic ointment should be avoided on distal extremities for more than 24 to 48 hours because it may lead to maceration and delayed wound healing. Immobilize if motion of a joint is going to increase skin tension. Keep the wound for 24 hours, after which time most wounds do not require a dressing. 7.Antibiotics. There is no medical indication for using prophylactic antibiotics in routine, noncontaminated, skin wounds. a.Consider antibiotic use for patients prone to endocarditis, patients with hip prostheses, lymphedema, contaminated foot wound in diabetics, or others with peripheral vascular disease. b.See Chapter 1 for antibiotic choices for bite wounds. V.Follow-Up Care A.Risk of infection highest 24 to 48 hours, and so all wounds should be rechecked at 48h. B.Washing and Grooming Within 8 to 24h after closure, wounds in highly vascular areas can be washed. Other areas can be washed after 12- 24h without increased an adverse outcome. However, immersion or soaking should be avoided. C.General guidelines for suture removal. Face, 3 to 5 days with tape reinforcement after suture removal. Scalp, 7 to 10 days; trunk, 7 to 10 days; arms, 7 to 10 days; legs, 10 to 14 days; joints, dorsal surface, 14 days. Increase length for diabetics or steroid-dependent patients who may require several weeks to heal.
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Insomnia 2000.11.14 nishitarumizu Up to one third of patients seen in the primary care setting experience occasional difficulties in sleeping, and up to 10 percent of patients have chronic sleep problems. Although insomnia is rarely the chief reason for an office visit, its detection may be enhanced by incorporating sleep-related questions into the general review of patient systems. Sleep disturbance is a reliable predictor of psychologic ill health, physical ill health, or both. Thus a report of disturbed sleep signals the need for further evaluation. Natural History of Sleep With aging, the total amount of sleep shortens. Delta sleep (stages 3 and 4 sleep), the deepest and most refreshing kind of sleep, diminishes markedly with age. In contrast, early stage 1 sleep, the lightest sleep, increases with age. These features help explain why sleep in old age becomes more fragmented, with more brief awakenings. There is little decline in REM sleep throughout a person s lifetime. Even though sleep is shorter in duration, shallower and more fragmented in the elderly, poor sleep is not an inevitable consequence of aging, and elderly persons do not necessarily require less sleep than younger persons. Also, constant daytime drowsiness or early-morning awakening should not be considered normal changes of aging. Epidemiology and Prevalence In a survey of office-based physicians in the United States, patients with insomnia had also been diagnosed with comorbid depression (30% of total), other mental diseases (20%) and organic disorders (19%); thus, only 31% of the sample were determined to have primary insomnia. A population-based survey using a structured DSM-III-based diagnostic questionnaire, 811 (10.2%) of the 7954 respondents complained of insomnia, and of those, 328 (40.4%) had a comorbid psychiatric disorder - most met the criteria for either anxiety or depression. For those with insomnia that persisted over a 12-month period, compared with those without insomnia, the risk of developing new major depression (odds ratio [OR] 39.8; 95% confidence interval [CI] 19.8-80.0), anxiety disorder (OR 25.6) or alcohol dependence (OR 3.4) was much higher. Evaluation of Insomnia A wide range of disorders should be considered in the search for an underlying cause of chronic insomnia. (Table 1) The etiology of primary insomnia relates in part to psychologic conditioning processes. Most cases of insomnia develop initially in response to a medical or psychosocial stressor. As sleeplessness persists, the patient begins to associate the bed with wakefulness and heightened arousal rather than sleep. The patient may fall asleep easily outside the bedroom (i.e., when watching television or reading in the living room) but feel wide awake in bed. It is important to note that once this conditioning process has occurred, the patient s insomnia may persist long after the original psychosocial or medical stressor has been resolved. TABLE 1 Common Causes of Insomnia Nonprescription drugs Alcohol (promotes sleep onset, but tends to shorten total sleep time) Caffeine "Diet pills" (e.g., those including pseudoephedrine, phenylpropanolamine) Nicotine Prescription drugs Beta-adrenergic blockers Thyroid preparations Corticosteroids Selective serotonin reuptake inhibitors Monoamine oxidase inhibitors Methyldopa (Aldomet) Phenytoin (Dilantin) Methylphenidate (Ritalin) Theophylline Albuterol Quinidine Pemoline Phenylephrine Medical conditions Primary sleep disorders (sleep apnea, periodic limb movement disorder, nocturnal myoclonus,restless legs syndrome) Pain from any source or cause Drug or alcohol intoxication or withdrawal Thyrotoxicosis Dyspnea from any cause (CHF, COPD) Menopause (hot flush) Gastroesophageal reflux Urinary incontinence (BPH) Psychologic causes Depression Anxiety , Panic disorder Life stressors Bedtime worrying Mania or hypomania Environmental causes Bedroom too hot or too cold Noise Eating, exercise, caffeine or alcohol use before bedtime Jet lag Shift work Daytime napping Treatment Management of chronic insomnia begins with attempts to identify and treat any underlying causes. There may be more than one cause of insomnia, but the causes may be difficult to identify. Drug therapy may be beneficial for short-term improvement, while behavioral intervention provides more sustained effects. Long-term use of many psychotropic or sedative-hypnotic drugs can cause adverse reactions and may actually impair sleep. Behavioral intervention combined with pharmacologic agents may be more effective than either approach alone. Psychologic and Behavioral Treatment of Insomnia Sleep diary Having the patient keep a sleep diary for two weeks may be helpful. Depending on the findings in the sleep diary, a discussion of sleep hygiene may be beneficial Cognitive Therapy. Cognitive therapy involves identifying dysfunctional beliefs and attitudes about sleep and replacing them with more adaptive substitutes. For example, patients who believe that sleeping eight hours per night is absolutely necessary to function during the day are asked to question the evidence and their own experience to see if this is true for them. Patients who are convinced that insomnia is destroying their ability to enjoy life are encouraged to develop more adaptive coping skills and to cease viewing themselves as victims. These attitudinal changes often help minimize the anticipatory anxiety and arousal that interfere with sleep. Stimulus Control Therapy The purpose of stimulus control therapy is to re-establish the connection between the bed and sleep by prohibiting the patient from engaging in non-sleep activities while in bed. This treatment is easily administered by the family physician and has demonstrated efficacy. 1. Go to bed only when sleepy. 2. Do not use the bed for any activities other than sleep (or sex). Do not read, watch television or eat. 3. If you don t fall asleep in about 20 minutes, leave the bedroom. Return to bed when you are sleepy. 4. Repeat step 3 as many times as needed until sleep occurs within 20 minutes of returning to bed. 5. Get up at the same time each day regardless of how much you slept. 6. Do not nap during the day or sleep in locations other than bed. Sleep Restriction Therapy Poor sleepers often increase their time in bed in an effort to provide more opportunity for sleep, a strategy that is more likely to result in fragmented and poor-quality sleep. Sleep restriction therapy consists of curtailing the amount of time spent in bed to increase the percentage of time spent asleep. This improves the patient s sleep efficiency (time asleep/time in bed). For example, a person who reports staying in bed for eight hours but sleeping an average of five hours per night would initially be told to decrease the time spent in bed to five hours. The allowable time in bed per night is increased 15 to 30 minutes as sleep efficiency improves. Adjustments are made over a period of weeks until an optimal sleep duration is achieved. To minimize daytime sleepiness, time in bed should not be reduced to less than five hours per night. Sleep restriction therapy is modified in older adults by allowing a short afternoon nap. Sleep Hygiene Education Sleep hygiene education consists of a set of instructions regarding environment and lifestyle factors that affect sleep. Sleep hygiene is not effective as the sole intervention for insomnia but is recommended as an adjunct to other forms of therapy. 1. Decrease or eliminate the use of caffeine, especially after noon. 2. Do not use tobacco or alcohol near bedtime. 3. Avoid heavy meals close to bedtime. However, a light snack at bedtime may promote sleep. 4. Regular exercise in the late afternoon may deepen sleep. Vigorous exercise within three to four hours of bedtime may interfere with sleep. 5. Establish a regular schedule for going to bed and getting up. Avoid daytime naps. 6. Keep the bedroom at a comfortable temperature and minimize light and noise. 7. Do not use the bed as a place to worry (especially about not sleeping). If necessary, write down your worries and concerns before you go to bed and place the list on your dresser to examine the next morning. 8. Use the bedroom only for sleep (and sex). Don t read, watch television, eat or do other activities in bed. 9. Get regular exposure to outdoor sunlight, especially in the late afternoon. Relaxation Therapy. Of several relaxation methods, none has been shown to be more efficacious than the others. Progressive muscle relaxation, autogenic training and electromyographic biofeedback seek to reduce somatic arousal (e.g., muscle tension), whereas attention-focusing procedures such as imagery training and meditation are intended to lower presleep cognitive arousal. Abdominal breathing may be used as a component of various relaxation techniques, or it may be used alone. Phototherapy Advanced sleep-phase syndrome may be corrected through exposure to bright light for two hours during the evening, which may shift the body s circadian timing mechanism and delay the onset of sleep until a typical bedtime. In contrast, delayed sleep-phase syndrome may be treated by exposure to bright light in the morning. Pharmacologic Treatment Benzodiazepine The primary indication for hypnotic medication is short-term management of insomnia--either as the sole treatment modality or as adjunctive therapy until the underlying problem is controlled. The most common medications used to promote sleep are benzodiazepine receptor agonists. Differences between the compounds ability to induce and maintain sleep are based on rate of absorption and elimination. The most common side effects of these medications are anterograde amnesia and, for long-acting drugs, residual daytime drowsiness and vertigo, dysarthria, and ataxia and they often have additive effects when used in conjunction with other central nervous system depressants, such as alcohol. Currently an estimated 10 to 15 percent of patients who use hypnotic medications use them regularly for more than one year, although little safety or efficacy data are available to guide their use beyond two to three months. While selected patients may benefit from chronic use of these medications, there are no clear indications showing which patients might benefit from chronic therapy. In patients who need to be alert because of occupational or societal demands, short-acting medications are preferred. However, patients with insomnia and high levels of daytime anxiety may benefit more from long-acting medications. It is important to remember that, with age, the volume of distribution increases and the rate of metabolism slows for most of these medications. Hypnotic medications are contraindicated in pregnant women, patients with untreated obstructive sleep apnea, patients with a history of substance abuse and patients who might need to awaken and function during their normal sleep period. Finally, patients with hepatic, renal or pulmonary disease must be monitored more carefully than otherwise healthy patients with insomnia. Antidepressants It is very common for sedating antidepressants to be prescribed for insomnia, often in low dosages, but little scientific evidence supports the efficacy or safety of this approach in the treatment of most types of insomnia. When prescribed for patients with major depression, sedating antidepressants improve insomnia, and sleep symptoms often improve more quickly than other symptoms of depression. When administered concurrently with "alerting" antidepressants, low dosages of sedating antidepressants such as trazodone again improve insomnia. However, in nondepressed patients, the data to recommend use of antidepressants are minimal. Antidepressants have a range of adverse effects including anticholinergic effects, cardiac toxicity, orthostatic hypotension and sexual dysfunction (selective serotonin reuptake inhibitors [SSRIs]). Tricyclic antidepressants and SSRIs can exacerbate restless legs syndrome and periodic limb movement disorder in some patients.. Antihistamines. Few recent studies have assessed the efficacy of antihistamines in the treatment of insomnia, but older studies demonstrated subjective and objective improvements during short-term treatment. The long-term efficacy of antihistamines in the management of insomnia has not been demonstrated. Adverse effects associated with antihistamines include daytime sedation, cognitive impairment and anticholinergic effects. Tolerance and discontinuation effects have been noted. Finally, a variety of herbal preparations (e.g., valerian root, herbal teas), so-called nutritional substances (e.g., l-tryptophan) and over-the-counter drugs are promoted, especially in the lay press. In general, little scientific evidence supports the efficacy or safety of these products. Melatonin Melatonin is a hormone secreted by the pineal gland and is purported to have sleep-inducing properties. Although the effectiveness of melatonin remains controversial, it has received attention in the treatment of insomnia caused by circadian schedule changes (i.e., jet lag, shift work). In these circumstances, melatonin successfully hastens adaptation to the new circadian schedule. No systematic long-term studies of the use of melatonin have been reported. Its ingestion in pharmacologic dosages has the potential to induce undesirable side effects, such as sleep disruption, daytime fatigue, headache, dizziness and increased irritability. よく用いられる催眠薬 薬物 半減期（時間） 利点および欠点 投与量*（mg） ベンゾジアゼピン類 ハルシオン 1.5-3 入眠障害に有用；高用量では前向性健忘を誘発する 0.125-0.25 リスミー 10 1-2 レンドルミン 6-9.5 緩徐に吸収；熟眠障害に有用 0.25-0.5 デパス 6 抗不安作用あり 1-3 ワイパックス 10-20 中程度の長さの鎮静 1-4 ユーロジン 16-18 投与量の範囲ではほとんど残留効果がない 0-2 ベンザリン† 25-35 日中の若干の鎮静を許容できるなら頻回覚醒に有用 2.5-10 セルシン† 30-56 薬物およびその活性代謝産物の排出が遅いため蓄積する 2.5-10 ドラール 39 長期使用は推奨されない；早朝覚醒に有用なことがある 7.5-15 インスミン† 40-100 日中の若干の鎮静を許容できるなら頻回覚醒に有用 15-30 メンドン† 55-70 不安を伴う不眠に有用 7.5-22.5 抗うつ薬‡ アミトリプチリン 16 就寝時に全量を用いるとうつ病および早朝覚醒の患者の 不眠が改善されることがある；抗コリン作用が強い 50-100 その他 抱水クロラール 4-10 中程度の長さの鎮静；消化管作用および残留効果 500-1000 一般用催眠薬 ジフェンヒドラミン§，大部分に軽度の鎮静がみられるが，鎮静作用は3-4日の使用後には 消失する；強い抗コリン作用（口内乾燥，視力障害，尿閉，便秘）は， 高齢者および緑内障，良性前立腺肥大，痴呆の患者で特に問題となる. *高齢患者に対する初回量は，しばしば最小量の1/2で十分である。 †加齢に伴って半減期が延長するため，高齢者への投薬は避けるべきである。 ‡うつ病がなければ抗うつ薬を用いるべきではない。 §抗コリン作用が強いため，高齢者への投薬は 避けるべきである。 Reference Insomnia Assessment and Management in Primary Care http //home.org/afp/990600ap/3029.html Chronic Insomnia A Practical Review Am Fam Physician 1999;60 1431-42 The diagnosis and management of insomnia in clinical practice a practical evidence-based approach CMAJ 2000;162(2) 216-20 Behavioral Medicine In Primary Care A Practical Guide
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1 2 3 4ルーン魔法について 5\n人間に魔法を与えたのは神でした。\n\n人間は呪文を唱え、魔法使いとなりました。\nパワーを伝達するために彼らはルーンを造り、その中に魔法を格納しました。\nしかし彼らは他の者からこの知識を隠すことを決めました。 6その結果、Masterは話しました \n人の時代となるが戦争によって荒廃するだろう。 \n魔法の力はみなで使用することはできない！\n\nしたがって、魔法から人類を保護することを決めた。 \n彼らは防護のシンボルを使用してルーンストーンを封印した。 \nそして彼らは封印を破るためにひるような知識を弟子たちにだけ渡しました。 7\nクリスタルの魔力は他のいかなる器のものよりもはるかに大きいです。\n\nA それがルーンに付けられている同じように単一のスペルをクリスタルに付けることができます。 \n今までのところ、私たちは、首尾よく3つの異なったスペルを組み込みました \n\nThe fireball \nThe frost spell \nThe magic bullet 8クリスタル魔法について 9クリスタルについて造詣を深めることで、魔法使いは、クリスタル固有のスペルを強化するのに彼自身の経験を使用できます。\nスペルは、魔法使いがクリスタルに関して知ればしるほど、彼の経験が大きければ大きいほど、よりいっそう強力になります。\nしたがって、魔法使いなら最大の力を解放するためにクリスタルに注目することは十分に努力の価値があります。 10賢明なファイターは彼の心を使用するでしょう。 11賢明なファイターは武器としてスタッフを選ぶでしょう。\n賢明なファイターはクリスタル魔法を学ぶでしょう。\n賢明なファイターは、魔法とスタッフの両方を使用することを選ぶでしょう。\n魔法と戦闘を結合するのは激しくて困難な研究を必要とします。\n勇敢な戦士は炎の道を選ぶでしょう、燃え上がる炎が長い集中の後に破壊的な威力を放つので。 12用心深いファイターは氷の道を選ぶでしょう、冷たい吐息で敵を凍らせるために。\n\n怒り狂っているファイターはスタッフの打撃とともに、敵に純粋な魔法の弾丸シャワーを浴びさせることを選ぶでしょう。\n\n真の戦闘マスターだけがひとつ以上の道を歩めるでしょう。 13Test 14Table 15Text 16賢明なファイターは武器としてスタッフを選ぶでしょう。\n賢明なファイターはクリスタル魔法を学ぶでしょう。\n賢明なファイターは、魔法とスタッフの両方を使用することを選ぶでしょう。\n魔法と戦闘を結合するのは激しくて困難な研究を必要とします。\n勇敢な戦士は炎の道を選ぶでしょう、燃え上がる炎が長い集中の後に破壊的な威力を放つので。 17 18 19許可リスト 20\n火山砦をでるまでの許可 \n\nKarlsen (recruit, smith)\nTucker (recruit)\nHarlok (recruit, cook)\nEnzo (novice)\nAsh (novice)\nCaspar (novice)\nTaylor (novice)\n\nPallas 21実験に必要なもの 22\n6 healing plants \n4 mana plants\n\nはあなたが火山のふもとで植物を見つけることができる。\nぶらぶらせずにそれらの植物を持ってきてください、すぐに!\n\nAbrax 23スクロールの材料 24\n各巻き物のために、あなたはスペルに関連しているルーン、および空白の羊皮紙を必要とします。\n\nIllusion The tusk of a boar\nLight healing A healing herb\nTelekinesis A portion of wing dust\nNautilus A nautilus shell \nLight 10 gold pieces \nJoke A pearl 25Ingredients 26Pirate grog 27Ashbeast potion 28Grave moth potion 29Nautilus potion 30Ingredients 31\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 hero s crown\n- 1 pixie hat\n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。\n 32Ingredients 33\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 3 healing herbs \n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をすくい取ってください、そして、空の小瓶にそれを注いでください。\n 34Weak healing potion 35Healing potion 36\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 2 healing plants\n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、空の小瓶にそれを注いでください。 37Strong healing potion 38\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 healing root\n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。\n 39\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 hero s crown\n- 10 mushrooms\n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。\n 40\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 3 mana mushrooms\n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をすくい取ってください、そして、空の小瓶にそれを注いでください。 41Weak mana potion 42Mana potion 43\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 2 mana plants\n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、空の小瓶にそれを注いでください。 44Strong mana potion 45\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 mana root\n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。 46\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 hero s crown\n- 10 berries\n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。 47Ingredients 48Speed potion 49Ingredients 50Strength potion 51\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 hero s crown\n- 1 ogreroot\n\nEquipment needed Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。 52Potion of dexterity 53Potion of health 54Potion of magic 55Ingredients 56Hearty soup 57Ingredients 58High proof rum 59Hunter s fry-up 60Ingredients \n3 pieces of raw meat\n1 mushroom\n1 portion of potatoes\n1 bag of spices\n\nEquipment needed \nStove or campfire\nFrying pan\n\nじゃがいもで、肉にこげ目をつけてください。\nその時、スパイスときのこは加えます。\n弱火でじっくり料理してください。 61Hunter s fry-up 62Ingredients \n3 pieces of raw meat\n1 mushroom\n1 portion of potatoes\n1 bag of spices\n\nEquipment needed \nStove or campfire\nFrying pan\n\nじゃがいもで、肉にこげ目をつけてください。\nその時、スパイスときのこは加えます。\n弱火でじっくり料理してください。 63Meat-stuffed bread 64\nIngredients \n3 pieces of raw meat\n1 bread\n1 portion of onions\n1 bag of spices\n\nEquipment needed \nStove or campfire\nFrying pan\n\nきめ細かく肉とたまねぎをさいのめに切ってください、そして、スパイスの中に混入してください。\nC慎重にパンのかたまりを深く切ってください、そして、それをすくい出してください\n詰め物をパンに挟んでうまく包んでください。\n弱火でじっくり料理してください。\n 65Plaice melt 66\nIngredients \n3 raw plaice\n1 cheese\n1 portion of potatoes\n1 bag of spices\n\nEquipment needed \nStove or campfire\nFrying pan\n\nじゃがいもを切って炒めてください。\nじゃがいもがいったん完了している後、plaiceとスパイスを加えてください。\nチーズですべてを覆ってください、そして、チーズが溶けるまで、中火で料理してください。\n\nEnjoy!. 67Fish soup 68\nIngredients \n1 portion of onions\n1 portion of water\n1 herring\n\nEquipment needed \nKettle\nLadle\n\nたまねぎと魚をさいのめに切ってkettleに入れてください、そして、水を加えてください。\n絶えずかき混ぜて、弱火の上で液体を半分減少させてください。 69Novices stew 70\nIngredients \n1 portion of potatoes\n2 pieces of raw meat\n1 bottle of wine\n\nEquipment needed \nKettle\nLadle\n\nすべてのワインが蒸発するまで、kettleで肉と半分のワインを弱火の上に料理してください。\nその時、じゃがいもとワインの残りは加えます。\nじゃがいもが煮えるまで絶えずかき混ぜてください。\n\nEnjoy! 71Meat stew 72\nIngredients\n1 portion of potatoes\n1 portion of onions\n2 pieces of raw meat\n\nEquipment needed \nKettle\nLadle\n\n肉とたまねぎをふらいぱんでいためさいの目に切ったじゃがいもも加えます。\nじゃがいもが煮えるまで中火で煮てください。\n\nEnjoy! 73Hearty meat stew 74\nIngredients\n1 portion of potatoes\n1 portion of onions\n5 pieces of raw meat\n\nEquipment needed \nKettle\nLadle\n\n肉とたまねぎをふらいぱんでいためさいの目に切ったじゃがいもも加えます。\nじゃがいもが煮えるまで中火で煮てください。\n\nEnjoy! 75Hotpot 76\nIngredients\n1 portion of potatoes\n1 portion of onions\n10 pieces of raw meat\n\nEquipment needed \nKettle\nLadle\n\n肉とたまねぎをふらいぱんでいためさいの目に切ったじゃがいもも加えます。\nじゃがいもが煮えるまで中火で煮てください。\n\nEnjoy! 77\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 1 hero s crown\n- 1 pixie hat\n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、次に、それを蒸留してください。\n空の小瓶に蒸留液を注ぎ込んでください。 78\nIngredients \n\n- 1 empty vial\n- 1 bottle of wine\n- 3 healing herbs \n\nEquipment needed \n\n- Alchemy table\n\n材料をよく混ぜ、ワインを沸騰させてください。\n煎じ薬をすくい取ってください、そして、空の小瓶にそれを注いでください。 79Traveller s potion 80\nIngredients \n\n- 1 empty vial\n- 1 waterskin\n- 5 wanderlust\n\nEquipment needed \n\n- Alchemy table\n\n植物を水につけ沸騰させてください。\n煎じ薬をフィルターにかけてください、そして、空の小瓶にそれを注いでください。 81Note 82私はまだ集める必要がある 83\nRhobart\nObel \nLuis \nHawkins \nEnrico\nDwight\nDoug\nDanny\nOscar 84Needy people 85 86My dear Pallas, 87 88\nGuttersの以下の人々にhealing potion を与えてくださいので、彼らの傷を癒すことができます。 \n\nElias\nCole\nFinn\nJosh\nMartha\n\n 89h 90h 91h 92h 93h 94 95\n\n墓は現在mutineersの名前を示す十字が出現しています。 1個の墓がAshandorで一度Korganに襲われた年取った大酒飲みの名がついています。\n\n彼はこの今日をまだ誇りに思っているでしょうか? だれが知っていますか? 96\n\n1つのchestだけが危険を全く引き起こしません。 どれがそうであるのか知ることができれば私のマスターキーはあなたのものだ。 \n\n正直なところ、Tarrasについてお詫び致します。 彼は善人でした。 97\n\nだれも私の金をいじくり回すことができないのを確実にするために、現在または将来において、私の宝物箱を開こうとする現場にいるだれがも死ぬいくつかの致命的な罠を設置します。\n\nこれは以前 Barnabas s trademark trick でした。確かに 彼は彼の犠牲者と同じ運命になるなど夢にも思いませんでした、しぬまでは。- 98\n\n私は墓の6つの宝物箱を埋めました。 しかし、それらの1つだけが私の貴重な所有物を収めています。 \n\nFergoldが最も重かったです。 彼は2頭の猪の重さと同じくらいだと思いました。chestの余地がほとんどありませんでした。 99Mutiny 1 1001 101\n\nBulbaはそれらの最後でした. 結局、私は、6個の墓を掘らなければなりませんでした。 \n\n\n5つはmutineersのために。 \n\nそして一つは宝のために。\n\n 1021 1031 1041 1051 106The mutineers 1 107The mutineers 2 108The mutineers 3 109The mutineers 4 110The mutineers 5 111My last resort 112誤りを決してしなかっただれかを私に見せてください。 しかし、私の誤りが私の破滅をするだろうように見えます。\nああ、黒魔術によって他の支配者のコントロールを獲得する私の試みは部分的にうまくいっただけです。幽霊が致命的な捧げ物を要求しているので。私は、彼らが、私に支払って欲しい物が私を滅ぼすと感じることができます。\n私はvassal(隷属の) rings を取り戻して、もう一度、それらに加わらなければなりません。\nさもなければ、彼らの呪いは永遠に私を悩ますでしょう。 113Fincherの地図 114世界地図 115sfdsadofjsdl\n 116Pattyの地図 117武器 118鎧 119錬金術 120魔法 121Miscellaneous 122文書 123ハーバータウン 124火山砦 125Bandit camp 126世界 127全て
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Depression nishitarumizu 2000.9.1 Overview Lifetime risk 7% to 12% for men, 20% to 25% for women. As many as two-thirds of the people suffering from depression do not realize that they have a treatable illness and do not seek treatment. Clinical depression commonly occurs concurrently with other medical illnesses and worsens the prognosis for these illnesses. Tip-offs for depression in a primary care setting May include fatigue, somatic complaints (such as headache, backache, chest pain, dyspepsia, and limb pain), anxiety symptoms, depressed mood, or insomnia. Risk factors female (especially post partum), history of depressive illness in first-degree relatives, prior episodes of major depression, prior suicide attempts, age 40 years, medical comorbidity, decreased social support, stressful life events, and current substance or alcohol abuse. Symptoms can be divided into 1. Emotional. Dysphoria, irritability, anhedonia, withdrawal. 2. Cognitive. Self-criticism, sense of worthlessness or guilt, hopelessness, poor concentration, memory impairment, delusions or hallucinations. 3. Vegetative. Fatigue, decreased energy, insomnia, hypersomnia, anorexia, psychomotor retardation or agitation, impaired libido. Diagnosis Depression is often difficult to diagnose because it can manifest in many different forms. Depression is a holistic disorder, affecting body, feelings, thoughts and behaviors. In addition to Depressed mood or Anhedonia ( loss of interest or pleasure ), five or more of the following symptoms have been present during the same two week period ESCAP-GS E nergy decreased S leep disturbance (classically , early awakening ; or may sleep longer than usually) C oncentration disturbance A ppetite disturbance (increased or decreased; with or without weight loss) P sychomotor changes G uilt (self-deplication, feelings of worthlessness) S uicidal thinking Depressed mood is neither necessary nor sufficient for a diagnosis of depression. Barriers to diagnosis Patient Barriers Somatic Presentations Stigma Clinician barriers Pandora’s Box Normal feature At least 50% of depressed patients are either undetected or are not adequately treated by primary care providers. Evaluation History May use Beck Depression Scale , Zung Depression Scale, or Geriatric Depression Scale to screen for high-risk patients. If depressive symptoms are present, determine a. Time course and severity. b. Any prior episodes and level of recovery. c. Any history of manic or hypomanic episodes. d. If other major psychiatric disorders are present. e. Any suicidal ideation, plan, or intent. Examination Evaluate for possible related medical conditions anemia, hypothyroidism, chronic infection, substance abuse, or medication side effects (oral contraceptives,antihypertensives, etc.). Causes of organic depressions Type Specific Cause Drugs corticosteroids,contraceptives,reserpine, antibiotics alpha-methyldopa,anticholinestherase, cimetidine ranitidine, indomethacin, phenothiazines, thallium mercury, cyclosporine, vincristine, vinblastine Drug withdrawal amphetamine, cocaine Infection Tertiary syphillis, influenza, AIDS, viral pneumoniae Viral hepatitis, infectious mononucleosis, Tb Endocrine Hypothyroidism, apathetic hyperthyroidism, Hyperparathyroidism, postpartum and menses-related, Cushing’s disease, adrenal insufficiency Collagen SLE, RA, vasculitis Neurologic MS, Parkinson’s disease, head trauma Complex partial seizures, CNS tumors, stroke, Early dementia, sleep apnea Nutritional Vitamine deficiencies (B12, C, folate, niacin, thiamine) Neoplastic Pancreatic cancer, disseminated carccinomatosis Others Renal Failure,Liver Failure, Alcohol/Substance Abuse Lab tests Screen for medical causes of depression (if suspected by Hx or Pex) Complete blood count (CBC) Electrolytes, including calcium, phosphate, magnesium BUN and Creatinine Calcium Serum toxicology screen TSH level CT or MRI of brain Electrocardiogram (ECG), Electroencephalogram (EEG) Physical Psychomotor retardation or agitation, such as slowed speech, sighs, and long pauses Slowed body movements, even to the extent of motionlessness or catatonia Pacing, handwringing and pulling on hair Preoccupation Lack of eye contact Tearfulness Self-deprecatory manner Memory loss, poor concentration and poor abstract reasoning Consultations Psychiatry should be consulted after a screening evaluation is complete and all acute medical complications are addressed. Treatment Treatment is effective in at least 70% of cases. Communicating with depressed patients Empathy Presenting the diagnosis “These symptoms indicate to me that you are suffering from depression.” It can be helpful to then add a couple of additional symptoms not mentioned by the patient. It is helpful to explain depression as a common biological disorder. Drawing a picture of a synapse and neurotransmitters may be helpful. Depression is a curable illness. Counseling by the physician SPEAK approach Schedule Pleasurable activities Exercise Assertiveness Kind thoughts about onself Psychotherapy cognitive therapy behavioral therapy Medication Most antidepressants believed to be equally effective in equivalent therapeutic doses. Expect a 2- to 6- week latent period before the full effect is seen at therapeutic doses. To prevent relapse, continue medication for at least 4 to 9 months after patient becomes asymptomatic. For recurrent depression, consider chronic prophylactic therapy. If at 6 weeks a patient shows no response or a poor response to an adequate dose of antidepressant medication , treatment should be changed. Tricyclic antidepressants (TCAs). Choose between them based on patient s sedation requirements and ability to tolerate orthostatic hypotension, weight gain, and anticholinergic adverse effects TCAs are usually given QHS to take advantage of sedating effects. All TCAs may cause slowing of cardiac conduction. May be fatal in overdoses around 2000 mg or more in adults. A therapeutic trial usually is considered 100 mg/day of amitriptyline or its equivalent for at least 3 weeks. Note Nortriptyline (Pamelor) has a "therapeutic window" plasma level of 50 to 150 ng/ml for optimal efficacy. It has the lowest risk for orthostatic hypotension of all TCAs making it a safe choice in the geriatric patient. Selective serotonin reuptake inhibitors (SSRIs) Much safer in overdose than TCAs. Expensive in contrast to generic TCAs. Initial dose often an effective dose. May need to start at lower doses in the elderly of others sensitive to side effects. Side effects vary and may include nausea, anorexia, insomnia or mild sedation, sweating, headache, tremor, sexual dysfunction, and nervousness. Fluvoxamine is contraindicated with astemizole and terfenadine. All SSRIs contraindicated with MAOIs. If switching from a SSRI to a MAOI, need a drug-free period of 14 days for paroxetine, sertraline or fluvoxamine or 5 weeks for fluoxetine. Monoamine oxidase inhibitors (MAOIs) Sometimes used in depression refractory to the other treatments. Consider consulting psychiatrist before starting because of the serious adverse effect potential. St. John’s wort For short-term treatment of mild acute depression. Equally effective. Induction of the cytochrome P450 system. Psychostimulants Methylphenidate(Ritalin) They take effect very quickly( 24h) Provide a relatively quick test of whether antidepressants are likely to be effective. Electroconvulsive therapy. ECT is the most effective, rapid method of treating severe major depressive disorder (MDD). Indicated for patients with poor response to medications, poor tolerance of usual antidepressants, severe vegetative symptoms, or psychotic features. The decision to administer ECT should be made by a psychiatrist. Figure. Adverse effects of selective serotonin reuptake inhibitors (striped bars) and tricyclic antidepressants (white bars). REFERENCE Pharmacologic Treatment of Acute Major Depression and Dysthymia Ann Intern Med. 2000; 132 738-742 Behavioral Medicine in Primary Care A Practical Guide 1st.ed. Assessing and Managing Depression in the Terminally ill Patients. Ann Intern Med. 2000; 132 209-218 http //www.wellbutrin-sr.com/eval/zung.htm http //www.vh.org/Providers/ClinRef/FPHandbook/Chapter15/01-15.html#Box%2015-1 http //www.emedicine.com/emerg/index.shtml
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Confused Elderly Patient 09/29/2000 Nakahara Initial Approach Yet not all cognitive problems in the elderly are due to dementia. Only after delirium and psychiatric disorders have been ruled out can dementia be diagnosed in an elderly patient with cognitive impairment. Because delirium is associated with an increased risk in mortality, it should always be considered first when a physician confronts a patient with cognitive impairment. DDD（Delirium, Depression, Dementia）を鑑別する。 Delirium 認知の変化を伴う意識障害（注意を集中・維持する能力の低下。短期間で出現し、変動がある。 チューブや点滴を取ろうとするなどのagitationや、活動減少 型（日中うとうと）がある。短期記憶や見当識も傷害される。環境変化（入院当日や術後）、ストレスなどがリスクになる！ Common Causes of Delirium Metabolic disorders Electrolyte abnormalities Acid-base disturbances Hypoxia Hypercarbia Hypoglycemia or hyperglycemia Azotemia Infections Decreased cardiac output Dehydration Acute blood loss Acute myocardial infarction Congestive heart failure Stroke (small cortical) Medications Intoxication (alcohol and/or other substances) Hypothermia or hyperthermia Acute psychoses Transfer to unfamiliar surroundings Miscellaneous Fecal impaction Urinary retention Risk R/O Electrolyte, Dehydration, Infection Urinary retention. Drug（全ての。NSAIDやH2-Blockerでも） Dementia Hearing or Visual disorder Delirium and dementia may coexist. Dementia is a known risk factor for delirium. As many as 22 percent of community-dwelling elderly persons with dementia have coexisting delirium. At any one time, 15 percent of hospitalized patients over the age of 70 years are delirious. In this situation, treatment of the delirium often improves the patient s cognitive and/or functional abilities Depression Check DSM-Ⅳ Criteria 2wk depressed mood+5/8 “SIGECAPS” Dementia Memory impairment and at least one of the following Aphasia Apraxia Agnosia Impaired executive functioning (e.g., planning, organizing, abstracting) Significant impairment in social functioning.（これも必須項目） Significant decline from previous level of functioning Deficits that do not occur exclusively during the course of delirium ・Memory impairment 生理的物忘れとは違う。痴呆による物忘れは、体験した全体が抜け落ち自覚が無く高度で進行性である。日常生活に支障を及ぼす。 （例）最近よく人の名前を忘れたり、物を置き忘れたりするが実生活に支障は無い。 →老化による生理的物忘れ 体験の一部を思い出せない。後になって思い出す。物忘れを自覚している。生活に支障が無い ・Aphasia Have any difficulties with finding the right word to say? Substitute an incorrect word, such as "chair" for "table"? Break off in midsentence or lose his or her train of thought? Stutter or repeat words over and over? ・Apraxia Dressing or bathing alone? Using a brush or comb? Feeding himself or herself? If the answer to any of the above is yes, follow up with Do you think it s a physical problem, or is it because he or she is having trouble figuring out how to do it? ・Agnosia Familiar people or places? Familiar objects or personal items? Mental Status Examination The Mini-Mental State Examination (MMSE) is the most widely used method for grading cognitive status. A score of less than 24 is considered abnormal, but this score should be adjusted to account for the educational bias associated with the instrument. An abnormal score on the MMSE is not diagnostic of dementia or delirium, but it does reflect the severity of cognitive impairment. スクリーニングとして有用だが、病歴や問診にもとづく患者の全体像を無視して痴呆の有無を判断しない。検査を受けている患者の態度としては、あっけらかんととして他人事のようであり,でまかせな応答をするのがアルツハイマー病らしさである。悲壮感があったり，回答に時間がかかるのは脳血管性痴呆、うつ病の方が多い。 Medication Review Polypharmacy and adverse drug reactions are major causes of confusion in the elderly. Since many commonly used drugs can cause delirium. （例）一ヶ月くらい前から物忘れがひどくてボーっとしている。転倒歴はない。CTでは異常ないといわれた 内科と整形外科に通っている。お薬は10種類以上飲んでいます。 →慢性薬物中毒。 精神安定剤や、抗うつ剤、睡眠薬などに注意。複数の医療機関を受診している場合にはレビューを忘れない。 Medications Associated with Confusion in the Elderly Analgesics (narcotic and nonnarcotic) Antihistamines Antihypertensives Antimicrobials Antiparkinsonian drugs Cardiovascular drugs Hypoglycemics Psychotropic drugs Anxiolytics Antidepressants Antipsychotics Hypnotics Miscellaneous Cimetidine (Tagamet) Steroids Xanthines History 患者および家族（または親しい友人）の両方からの病歴聴取が必要となる。認知障害が最初に現れた時期、病初期の行動異常を正確に把握する。階段状の進行は脳血管性痴呆に特徴的だが、アルツハイマー型痴呆でも身体合併症（肺炎、骨折etc）により急激な変化が階段状に見えることもある。 身体的病歴を見直す→認知障害の症候に関与する外科手術（胃切除術など）、内科疾患（高血圧やSLE）、輸血歴、重金属曝露、頭部外傷歴。アルコールや薬物、市販薬など。 Physical Examination the physician should focus the physical examination on the cardiovascular, neurologic and psychiatric systems. Note that the physical examination is frequently normal in patients with early DAT. The physical evaluation should include an assessment of the patient s level of arousal and orientation. Patients who lack alertness or have a clouded consciousness are more likely to have delirium than dementia. Focal neurologic changes are signs of an underlying neurologic disorder. Unfortunately, focal changes are not associated exclusively with delirium or dementia. Treatable Dementia Dementia can be classified as reversible or irreversible. Potentially reversible causes include thyroid dysfunction, deficiencies of vitamins such as B12 and folate, infections such as neurosyphilis, metabolic abnormalities such as uremia, and normal-pressure hydrocephalus. (例)3週間前より元気がなく失禁がみられる。一ヶ月前に玄関で転んだ。もともと大酒のみ→慢性硬膜下血腫 (例)記銘力の低下、見当識障害、妄想あり。TSH高値→甲状腺機能低下の仮性痴呆。甲状腺製剤で消失。 Laboratory Tests Test Possible underlying causes that can be detected Urinalysis Urinary tract infection, diabetes Electrolytes Electrolyte imbalance Serum, calcium Hypercalcemia, hypocalcemia BUN, creatinine Uremia Liver enzymes Hepatic dysfunction, encephalopathy Thyroid hormones Hyperthyroidism, hypothyroidism Serum B12 VB12 deficiency VDRL Neurosyphilis CBC, Chemi, Renal/Liver, TSH, B12(Folate), VDRL Electroencephalograms (EEGs) can be used to detect patterns characteristic of delirium, especially when a previous EEG is available for comparison. Electroencephalograms (EEGs) in patients with Alzheimer s disease may be normal or show diffuse slowing and are not obtained in the routine evaluation of dementia. However, an EEG may be helpful when seizure or Creutzfeldt-Jakob disease is suspected (in the latter, an EEG shows both diffuse slowing and periodic complexes). Lumbar puncture is not needed in the evaluation of most patients with dementia. However, spinal fluid examination may be indicated in those with specific clinical and laboratory findings Acute or subacute onset ( 8 wk) Evidence of immunosuppression Fever or presence of meningeal signs Atypical presentation of dementia (eg, severe headaches, seizures, cranial neuropathies) Clinical findings suggestive of normal-pressure hydrocephalus Positive serum fluorescent treponemal antibody absorption test Abnormalities on computed tomographic or magnetic resonance imaging brain scan (eg, meningeal enhancement) Diagnostic imaging Computed tomography (CT) or magnetic resonance imaging (MRI) of the brain has become a routine part of the workup of suspected dementia. Yet the value of these expensive tests in the evaluation of dementia continues to be questioned. In actual practice, both families and physicians often are not satisfied that a "thorough" workup has been done unless an imaging test has been performed. However, CT or MRI should not be considered a substitute for thorough history taking and physical examination. As a general rule, imaging should be performed in most patients with dementia. However, it may not be warranted in patients in whom the medical history reveals no significant findings, the results of physical and neurologic examination are normal, and the onset and progression of cognitive decline are consistent with Alzheimer s disease. Imaging may be helpful in diagnosis of atypical dementias, meningitis, hydrocephalus, tumor, stroke, focal lesions or atrophy, and hematomas. CT or MRI is particularly recommended in patients with an atypical presentation, rapid deterioration, incontinence, focal neurologic signs, past history of head injury, or systemic diseases that prominently affect the brain (eg, HIV infection, systemic lupus erythematosus). Apolipoprotein E the recommendation is that apo E genotyping should be limited to use in patients with cognitive deficits who are members of autosomal-dominant families with a history of early-onset DAT MGH総合病院精神医学マニュアル Diagnostic Approach to the Confused Elderly Patient - March 15, 1998 - American Academy of Family Physicians Initial evaluation of suspected dementia asking the right questions. Postgrad Med 1999 106(5) 72-83
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