ChatGPTと臨床推論のフォーマット

ChatGPT and autoimmunity – A new weapon in the battlefield of knowledge
Autoimmun Rev .2023 May 19;22(8):103360.

ChatGPT and autoimmunity - A new weapon in the battlefield of knowledge - PubMed

Autoimmun Rev のChatGPTの記事で具体的な症例相談の仕方が書いてありました。

やり方
Please provide me with clinical support for the following patient presentation:

具体的な症例相談。

そして、鑑別を聞く。

Based on this patient's presentation, what is your initial differential diagnosis? And what subsequent steps should we take to diagnose and manage this patient?

有効なところとLimitation

論文に載っていた具体的なやりとりです。

質問① 58歳女性のワクチン5日後の構音障害、嚥下障害の患者さん
Please provide me with clinical support for the following patient presentation: A 58-year-old Asian female with dysarthria and dysphagia was firstly admitted to the otolaryngology department. A fiberoptic laryngoscope was arranged to observe the pathophysiological changes of the pharynx and larynx, and the results revealed that there was no pathophysiological change.

Subsequently, the patient was admitted to the department of neurology and underwent a thorough neurological examination. The muscular strength of the patient's upper and lower extremities was normal, and the deep tendon reflex of both sides was also normal.

The patient's medical history was hypertension and cholesterol gallstone disease without smoking and alcohol consumption. The patient had been vaccinated against chickenpox many years ago, and received a trivalent inactivated influenza vaccination (Site and method of inoculation: intramuscular injection of deltoid muscle of left upper arm; Dosage: 0.5 mL; Manufacturer: Hualan Biological Vaccine Co., LTD) 10 days before being admitted, and the symptoms of dysarthria and dysphagia occurred on the fifth day after vaccination.

Based on this patient's presentation, what is your initial differential diagnosis? And what subsequent steps should we take to diagnose and manage this patient?

人種をしっかり入れること、最後に、鑑別診断と各疾患ごとのその後のマネージメントの仕方について聞いています。ワクチンは、日本製などかなり詳細にデータを提供しています。

ChatGPTの返事は
ChatGPT: I am not a doctor, but based on the patient's presentation, I can suggest some possible differential diagnoses and subsequent steps that may be taken. However, it is essential to consult with a healthcare professional for a definitive diagnosis and appropriate management.

Initial differential diagnosis:　鑑別診断

• 1.Guillain-Barré Syndrome (GBS) or a variant, such as Miller Fisher Syndrome

• 2.Transient ischemic attack (TIA) or cerebrovascular accident (CVA)

• 3.Myasthenia gravis

• 4.Bulbar palsy or other cranial nerve involvement

• 5.Inflammatory or autoimmune process related to vaccination

Subsequent steps for diagnosis and management: 診断のためにすべきこと

• a)Obtain a detailed history, focusing on the onset and progression of symptoms, prior infections, and any family history of neurological disorders.

• b)Perform a comprehensive neurological examination, including testing for cranial nerve function, muscle strength, reflexes, coordination, and sensation.

• c)Conduct laboratory tests such as complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and electrolyte levels to assess for inflammation or other abnormalities.

• d)Consider conducting nerve conduction studies and electromyography (EMG) to evaluate peripheral nerve and muscle function.

• e)Perform neuroimaging studies, such as MRI or CT of the brain, to rule out structural abnormalities or vascular events.

• f)If myasthenia gravis is suspected, consider testing for anti-acetylcholine receptor (AChR) antibodies and/or the edrophonium test.

• g)If an autoimmune or inflammatory process is suspected, consider a lumbar puncture for cerebrospinal fluid (CSF) analysis.

鑑別診断とそれぞれのto doをまとめてくれている。

これを受けてさらに追加の情報を与えて、確定診断できるか聞いています。

質問① 続けて打つ): Chest computed tomography (CT) revealed that there was no thymus abnormality. Other possible intracranial lesions, such as hemorrhage, infarction, and tumor, were excluded by craniocerebral magnetic resonance imaging (MRI). Repeated nerve stimulation (RNS) did not indicate a significant reduction in the compound muscle action potentials (CMAP) of the orbicularis oculi, deltoid, quadriceps femoris, and intercostal muscles. Other immunological and thyroid function tests were negative. The patient had severe dysarthria and mild dysphagia, her quantitative MG score was 4 (1 for swallowing and 3 for speech), and the patient's neurological symptoms varied. The serum AChR antibody titer was 0.67 nmol/L (normal range below 0.2 nmol/L). The patient's dysarthria and dysphagia temporarily improved with the pyridostigmine test.
CT、MRIは異常がなくAChR抗体上昇していました。

Can we make a definitive diagnosis?　確定診断できますか？

ChatGPT: I am not a doctor, but based on the information provided, it appears that the patient's clinical presentation and positive response to the pyridostigmine test, as well as the elevated serum AChR antibody titer, suggest a possible diagnosis of myasthenia gravis (MG). Myasthenia gravis is an autoimmune disorder characterized by weakness and rapid fatigue of voluntary muscles, which can involve dysarthria and dysphagia.

MGっぽいですね、とここはまーそうでしょう。
さらに、MGのマネジメントについて詳細に書いてくれています。きれいなフォーマット。

質問③ (Continued): Taking this patient's presentation into perspective, summarize the latest research that has been done linking Myasthenia gravis (MG) to influenza vaccine.

この症例に関連した最近のリサーチをまとめてほしい（2021年までしかありませんが）
ChatGPT:A few case reports have described the development of MG following influenza vaccination, but these reports do not establish a definitive causal link. It is essential to consider that the occurrence of MG in temporal proximity to vaccination could be coincidental or due to other underlying factors.

A 2011 study published in the journal “Vaccine” investigated the risk of autoimmune neuromuscular disorders following vaccination and found no increased risk of developing MG after receiving the influenza vaccine. This study suggested that the benefits of vaccination in preventing severe influenza infections outweigh the potential risk of triggering autoimmune neuromuscular disorders, including MG.

ChatGPTの鑑別診断リストからの、症例の迫り方は、詳細な病歴聴取、身体診察、そして検査と画像と非常に教育的ですね。どうにかして教育に落とし込んで運用していきたいですね。教育の自動化。人間がやれることは、コーチング、勇気づけ、など。