Team WADA 学生インターンのアンダーソンアレックス誠治（Alex Seiji Anderson）です！

この「Study with Ns. Rossi」という企画では、医療面接の練習を行っております。2024年8月25日に行った勉強会について、ご紹介させていただきます。

今回のお題はこちら、

Case:

 A 27-year-old female qualified nurse at an acute hospital fell in the lavatory without witnesses a month ago. She said she lost consciousness for a few minutes but had no visible injuries. She left the floor and went to the nearby A+E with her mother. The triage doctor indicated that they were not concerned about her condition and only prescribed painkillers. As a result, she found it difficult to focus on her daily tasks and grew tired.

She is eager to return to work after taking four weeks of sick leave.   However, she is concerned about her short-term memory loss and struggles to manage her fatigue because her symptoms have not yet improved.

Task: Provide her with an ideal diagnosis and discuss it.

事前準備

※OET SPEAKING Assessment Criteria and Level Descriptors (from September 2018) (public version)

事前にOETの評価項目を参照し、
Relationship buildingの項目
「showing empathy for feelings/predicament/emotional state」

Information givingの項目
「establishing initially what the patient already knows」
「checking whether the patient has understood information」

を目標にしました。

このcaseを見て、脳震盪が長引いているというのが第一印象でした。

脳出血かどうかを評価するために、CTを取る必要がある、、、いや、要らない、、、？

さらに、低血糖、代謝機能低下などとも鑑別するため、血液検査もオーダーしようと思いました。

実際の医療面接の流れ
Alex: I‘ｍ Dr Alex Anderson, a general practitioner at this hospital. Before we start, Could you tell me your full name and date of birth?

Sarah: My name is Sarah Smith. I’m 27.

Alex: And you are date of birth is….?

Sarah: I can’ remember…. My memory doesn’t work well after the accident.

Alex: It seems to be hard.

Sarah: It’s really weird. I’m young. That’s why I came to see you. Anything else I can’ do. It is quite embarrassing.

Alex: Ms. Smith, I’m here to be your support and I hope we can help you. Let me check how you wouldprefer to be called.

※ここのフレーズが思い出せず、wouldを３回連呼した。

Srah: Just call me Sarah. I understand you fell on the floor two days ago. Do you remember that?

Sarah: It was a really quick accident. It’s quite a bit embarrassing to say, I had a shower. While I stepped in the shower, I just slipped and realized I hit my head and tried to stand up. I also slipped again and hit my head on the floor. When I wake up, I was not sure how long I was unconscious. I thought I was at home, but apparently I wasn’t. I was at work. My colleagues popped into the shower room and helped me stand up. My colleagues contacted my mom. We went to see the triage doctors. They are not concerned  about severe conditions. I couldn’t see any head injury and cutting skin. I got a few bruises. Just a little bit achy, but doctors said it’s not necessary going to CT or MRI. They gave me painkillers and just sent me home. They said it could be post-concussion syndrome. Now, after a few weeks, they recommend to take a sick leave until I recover. I’m quite keen to return to work. I’m working as a nurse. I don’t wanna take too much for sick. Because my money just…. After the accident, I took the four-week sick leave. I ‘m really not sure how much I can do. I’m not really confident to come back to work, but I’m struggling with memory and fatigue, because even at home…..
I can do some daily things, washing clothes,  hanging the laundry. Frequently, I forget to turn off pots. My mum asked me to go shopping for particular items but I kept forgetting.

Last time, I should buy flowers, but I stayed home the whole day. When my mum came back home, she asked me ‘Have you been to the shopping?’, but I couldn’t remember. That’s why my mum is really concerned. And It’s also tiring. My symptoms don’t seem to be improving. I just need to know what to do.

Alex: Thank you very much for explaining situations and your concerns. I’d like to confirm what you said. First, you went to the emergency room, and the triage doctor said there was a possibility of concussion, right? However, your symptom doesn’t seem to be improved, like fatigue and difficulty of staying focused. And you’re also worried about finance and whether you can return to work.

Sarah: Yes.

Alex: It’s certainly understandable to get frustrated. I’d like to be your help from the bottom of my heart. To begin with, do you remember hitting a part of your body like your head on the floor?
※この質問はせず、頭を打つ前に何かの症状があったかを聞けばよかった。
「Do you have any unusual health conditions before you fell, such as dizziness？」とか
Sarah: The first one, I remember slightly. The second one, I heard a banging noise. I was not sure which side I hit.

Alex: There are possibilities of you hitting your head twice but you are not sure the second time.

Sarah: Of course, in the bathroom, I was alone. No witnesses. I felt ugly in back of my head and left side. I can’t concentrate. I don’t know what’s going on.

Alex: I’d like to figure out whether this is an acute case because you might hit your head twice. There are possible diseases here, but it’s difficult to conclude it since we don’ t have any specific data about your health. We need some tests to find out what is happening in your head and consciousness. Before that, do you feel worsening of your symptoms like headache?

Sarah: Headache is okay. I can’t sleep really well. Previously, I had quite a bit insomnia. But during sick-leave periods, I had pretty much nothing to do.  It might be my body not tired. That’s why I can’t sleep. Fatigue management is my concern. Once I start to work, I’d be busy. If so, I’m not sure how to cope with my current work, but of course I need to return to work because I don’ t have income now.
症状は悪化してなさそう。不眠や、経済的な不安がある。

Alex: It’s reasonable to think about financial problems. You mentioned about insomnia. Could you tell me a bit more about it? Is it due to your daily work? Or is it caused by private problems?

Sarah: I think it’s got to be when I was in school life. When I was in second- year university, my parents were divorced, so I currently live with my mum. When becoming qualified, the landlord decided selling house, so we need to move out. But of course, nowadays, renting cost is quite expensive in the centre of London, and mum can’t speak English. My mum came from India. She isn’t able to work here. But my income is not really good, because it is a junior salary. I need pay for everything of cost. In the sick leave periods, without income, It was quite difficult for us, which might lead to long-term insomnia. My mom is looking after me very well, but she can’t work and speak English. It’s quite really tricky. That’s why I have insomnia. There’s too much to think about.

家庭環境や経済状況から来る不安で、不眠になっている模様。

※このタイミングで、sleeping pills や他の薬を飲んでいるかを聞けばよかった

Alex: I understand the you are the only person of earning money in your family. I’m very proud of supporting your mum.

To deal with financial problem, I can consult to  a social worker who can offer a lot of information about specific programs about finance, so you can have opportunities to talk with them. They will definitely be your help. Getting to the point, we have to prioritise health over finance, because your health is the most fundamental element of your life. Do you understand that?
※consult a social workerであり、toはいらない。

Sarah: Yes.

Alex: The previous doctor mentioned that you need to take some break, and I agree on that. One of the possible diseases you have is concussion, but it’s not 100%. We need to take an X-ray to rule out any serious problems like hemorrhage. It’ll take only 30 minutes. Does it work for you?

※Does it work for you? はあまり良くないのかも、、
「How does that sound? 」「Would that be okay for you?」

Sarah: I’m happy to do any CT or MRI. A&E doctor said you didn’t need it because it was obviously not a head injury. My neurological observation was fine. I’m just wating for healing. But I don’t mind doing it.

Alex: It must be tough for you. The thing is, there are other possibilities like hypoglycemia, hypometabolism, or the lack of Vitamin B12. We also need to take your blood sample, which will take one hour or so. After performing these tests, we can discuss the next step, but in any cases, it’s crucial to take break. Although you have financial problems, it’s necessary. I recommend you prioritise your health. Do you understand that?

Sarah: Yes. I’m just keen to return to work. Do you think I can return to work?

Alex: There is no 100% in medicine, but speaking of this concussion, most people recover and go back to normal life. Are there any concerns you have about something we haven’t discussed?

Sarah: Probably not, but how can I manage my fatigue? It is quite affecting my daily tasks. I don’t know how I can manage.

Alex: I can see that you get upset due to a lot of problems, insomnia, fatigue, focus and other problems. We have to bread down problems and perform each test. Let’s be patient and see what will come out in the tests.

Alex: Is there anything else you are concerned about? The thing is I can give you a certificate you present to your workplace. In some hospitals, there are programs which offer financial benefits to those who can’t work.

Sarah: That’s really helpful.

Alex: I’m glad to hear that. In the case you have more sever symptoms like vomiting, don’t hesitate to call to this hospital. We’d cope with that as soon as possible.

Sarah: Thank you very much.

良かった点

Empathyが伝わっていた点。

患者がどの程度己の状態を理解しているのか、気にしていた点。
患者からの言葉をclarify & summarizeしていた点。
Fatigue, Memory loss以外に症状や心配事がないか、質問を投げかけていた点。

Financial problemについて、ソーシャルワーカーに紹介できることを提示していた点。

反省点

・Dietについて言及していない。

「”Do you have an appetite? Are you able to eat your meals as usual?」
・Drugについて尋ねていない。

「Do you take any medicines, such as sleeping pills?」

Insomniaは前々からあったが、memory lossは以前からあった？Antidepressantを飲んでいる？ Past medical history, drug historyを聞きそびれた。

・検査が全て陰性で症状が改善しなければ、精神的な側面からのアプローチも検討する必要があることを見落としていました（精神科へのreferral）。

最後に

ロッシー先生の身近にあった、sick leaveのエピソードを幾つか教えていただきました。イギリスでは福利厚生が充実しているため、sick leave期間は最大６か月も給料手当が支給されるそうです。ただ、その制度を悪用している人がいるのも事実だそう。患者さんの言葉を完全に鵜呑みにすることなく、様々な可能性を視野に入れて診察することの重要性を学びました。