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< NEDO、ナノテク、健康影響 | メイン | 今日（6/29）は、何の日。 >
2008.06.28 21:30 |  診療  |  その他（医療関連）  |  ミチバ  | 推薦数 : 2

鑑別診断に職業・環境性疾患を

・医学書院医学大辞典には鑑別診断は以下のように説明されています．

鑑別診断［differential diagnosis] 　ある症候の原因となっている疾患を，類似した他の疾患と識別すること．具体的には，症状や検査結果など患者から得られた全ての臨床情報をもとにして，そのような症状を示す可能性のある疾患の中で，一番よく一致する疾患を選別する作業をいう．症状の経過から正確な診断が下しにくい場合には仮の診断を設定し，鑑別すべき疾患を除外していく．教科書には，鑑別診断のため多くの疾患が記載された表が掲載されている．しかし正しい診断に到達するためには，有病率や各症状の発現頻度も含めた膨大な知識が必要であり，表やアルゴリズムを用いれば鑑別が簡単に行えるわけではない．診断法には，他に系統的診断法がある．

・日常診療では、どのような症候･疾患でも必ず鑑別疾患を挙げるクセをつけたいものです。是非、臨床の先生方は、以下のような思考をして欲しい。

①頻度の高い疾患をあげる

②緊急性・重篤な疾患（放置してはいけないもの）をあげる

③職業・環境性の疾患を挙げる。

④疾患は一つとは限らない：合併しているものを考える。

 ・是非、臨床医は③を挙がることができるようになって欲しいと思います。そうすれば、アスベストの悲劇は少なくなると思うのです。

・少し例示。

熱、頭痛を主訴に来た場合。当然鑑別診断のトップは感冒。緊急性・重篤なものは、髄膜炎。職業･環境性なら金属熱や熱中症。合併症（感冒なら）として、心筋炎といったものを挙げましょう。

腹痛なら、トップに胃腸炎。重篤・緊急なものなら、心筋梗塞や腹部大動脈瘤。職業・環境性なら鉛中毒。合併症というか、二つの疾患として胃潰瘍とすい臓癌（実際、私、経験しました）

・意識障害なら、脳卒中、脳腫瘍。職業・環境性として酸欠や何らかのガス・化学物質中毒。「合併症」として、くも膜下出血と神経原性肺水腫。

・クボタショック３周年を迎えるに当たって、ぜひ、鑑別診断に職業・環境性因子/疾患を取り上げるように臨床医学がなって欲しい。ex.

内科学会雑誌の毎月に疾患の特集では、必ず職業・環境因子を取り上げる　

研修医の各科ローテートのとき、かならず職業環境因子を教える　

ex.　感染症科：職業感染

　　　消化器科：職業性肝障害（有機溶剤　　中毒）

　　　腎臓病科：金属による障害

　　　呼吸器科：いっぱい

　　　循環器科：職業性心筋障害

　　　血液科：有機溶剤や鉛中毒

　　　神経内科：重金属による神経障害

　　　　　　　　・・・・・

産業衛生学会が「これだけは知っておきたい職業・環境疾患」といったパンフレットを作る　　　　　　　　　　　　　　　　　　　　　　　　　　　　　

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