USMLE STEP2 CS Case 14 (Headache) 英語プレゼン例

First Aid for the USMLE STEP 2 CS Clinical Skills 6th Editionの、Case 14: 35-Year-Old Woman With Headacheを基にプレゼン例を書いてみました。今回は、ちょっと解説も加えてみました。

Opening Statement

Patient is a 35 year old female with positive family history of migraines, comes in with 2 week history of right sided unilateral headache associated with photophobia, phonophobia, nausea and vomiting.

→　主訴と随伴症状を一文に落とし込んですぐ診断がわかるようにする。また、主訴の頭痛に"unilateral"を加えて、偏頭痛感を増させる。

History of Presenting Complaint

The patient's headache started two weeks ago, and has been worsening since. The pain is located on the right temporal region, sharp and pounding in quality, and does not radiate anywhere. Pain score is 9 out of 10.

Her headache is associated with photophobia, phonophobia, and the patient had one episode of non-bloody non-bilious vomiting yesterday. The pain is also exacerbated by recent stress at work.

→　増悪因子を述べるときに"Her headache is exacerbated by light and sound"という言い方でもいいが、photophobia（羞明）とphonophobia（音声恐怖）は偏頭痛のバズワードなので"Her headache is associated with photophobia and phonophobia"という言い方にした。

The pain is relieved by rest, going to a dark and quiet room, sleep and aspirin.

→　寛解：relieved by, alleviated by、増悪：exacerbated by, aggravated by

Otherwise there are no red flags such as fever, nuchal rigidity, limb weakness, morning headaches; the headache does not wake the patient from sleep and the patient does not report it as the worst headache of her life.

→　Red flag: 危険な症状

→　その他陰性所見・除外診断の述べ方："otherwise the patient doesn't have any symptoms such as..." または "otherwise the patient is asymptomatic"

The patient's last menstrual period was 2 weeks ago.

Regarding past medical history, the patient recently had an episode of sinusitis 4 months ago and took amoxicillin. The patient had tubal ligation 8 years ago. Patient currently takes aspirin for her headache. Otherwise no drug allergies.

Family history wise, patient's father died of brain tumor at age 65, and the patient's mother has migraines.

→　「〜に関しましては」の言い方は　"Regarding ~" または "~ wise"

The patient does not smoke, drink, or use illicit drugs.

The patient works as an engineer and lives with her husband and three children.

Physical Examination

On general inspection, the patient appears to be in severe pain. The vitals are stable. Neurological exam was grossly normal; cranial nerves II - XII are intact, motor strength is 5 out of 5 throughout, with normal reflexes. Remaining physical exam is also grossly normal; the neck is supple, heart sounds S1/S2 no murmurs, breath sounds are clear. 

Summary

In summary, patient is a 35 year old female with positive family history of migraines, comes in with 2 week history of right sided unilateral headache associated with photophobia, phonophobia, nausea and vomiting. Her neurological exam was grossly normal apart from the fact that the patient seems to be in distress due to pain.

Differentials

With that my first differential is migraines, due to the nature of her pain and positive family history of migraines.

→　"With that~" ≒ 以上をもって、というわけで

My second differential is tension headache mainly because the pain is exacerbated by stress.

For my third differential, I'd like to rule out any intracranial mass lesion due to her positive family history of brain tumor and the fact that she has had one episode of vomiting.

→　"I'd like to rule out": 〜を除外したい

Investigations

Investigations wise, I'd like to perform funduscopy to look for any papilledema that may suggest raised intracranial pressure, and I may consider doing a head CT scan.