3のためのワークブック
専門医試験対策
自習のためのチェックシート付き

中山書店

編集主幹

草場鉄周
専門編集

金井伸行

序
本書は，総合診療専門医の資格取得を目指す専攻医（後期研修医）が，研修中に習得すべき項目を演習（ワークブック）形式で学べる自習書として企画したものである．新専門医制度下において「総合診療専門医試験」が今後実施されていく予定であるが，ここでまず，本書が単なる受験対策書や専門医試験の傾向分析本でないことを強調しておきたい．
というのも，総合診療専門医に求められる臨床能力は，地域の医療現場において数多くの診療経験を積み重ね，優れた指導医の下で「省察的実践（ reflective practice ）」を地道に続けることによって，はじめて育まれるものだと考えているからである．
とはいえ，現実には，総合診療専門研修の集大成として行われる専門医試験に合格するためには，それ相応の準備が必要なこともたしかであろう．総合診療専門医試験では，専門研修のなかで身につけておくべき「総合診療」全般の基本知識・技術・態度を，筆記試
験と臨床実技試験（ CSA：Clinical Skills Assessment ）の両面で評価することが想定されている．そこで本書は，総合診療専門医試験に臨む専攻医が取り組みやすいよう，以下のような構成とした．

Ⅰ章「臨床知識ベーシックドリル」では，見開きの Q&A 形式で基本知識の総整理ができるようにした．まず，一般的な症候や疾患・病態を厳選し，各々の問診・身体診察・検査・治療のポイント等を解説した．次に，総合診療を特徴づける理論・概念を幅広く取り上げ，できるだけ具体的に解説した．なお，本章では重要語句を赤文字（赤のチェックシ
ートで消える文字色）で強調し，自習しやすいよう配慮した．
Ⅱ章「臨床実践ワークブック」では，筆記試験を想定した症例問題を，全 10 分野にわたり独自に作成し解説した．なお，専門医試験における筆記試験では，多選択肢問題が中心になると考えられているが，本章ではより高い学習効果を期待して，あえて自由記述問題として作成した．
Ⅲ章「臨床技能ワークブック」では，まず総論として CSA に役立つ概念（コミュニケー
ション，診療の構造，プロフェッショナリズム）について可能な限りわかりやすく論じた．次に，CSA で問われると想定される 6 分野でそれぞれのシナリオステーションの課題を独自に作成し，各課題へのアプローチ例をチェックリストとともに提示した．

iii

いずれの章も，日本プライマリ・ケア連合学会認定の家庭医療専門医もしくは指導医として最前線で活躍されている新進気鋭の諸先生を中心にご執筆いただいた．本書が総合診
療専門医試験に挑む専攻医の学習教材としてのみならず，各施設の指導医や一般臨床医の皆様の研修指導や生涯学習の一助となれば，この上ない喜びである．
最後に，編集主幹の草場鉄周先生，編集委員の先生方，本書の制作にご助言・ご協力くださったすべての皆様に深く感謝申し上げたい．

2017 年 4 月

医療法人社団 淀さんせん会 金井病院 理事長
関西家庭医療学センター 指導医

金井 伸行

iv

目次

Ⅰ章

臨床知識ベーシックドリル
一般的な症候アプローチ□ 心肺停止 ······································································································ 浅川麻里
□ ショック ······································································································ 浅川麻里
□ 意識障害 ······································································································ 浅川麻里
□ 呼吸困難 ······································································································ 木田盛夫
□ 全身倦怠感··································································································· 木田盛夫
□ 不眠 ·············································································································· 木田盛夫
□ 食欲不振 ······································································································ 田中久也
□ 体重減少 ······································································································ 田中久也
□ 体重増加・肥満 ··························································································· 田中久也
□ 浮腫 ··········································································································· 佐藤弘太郎□ リンパ節腫脹 ···························································································· 佐藤弘太郎□ 発疹 ··········································································································· 佐藤弘太郎□ 黄疸 ··········································································································· 関口由希公□ 発熱 ··········································································································· 関口由希公□ 頭痛 ··········································································································· 関口由希公□ めまい ········································································································ 長 哲太郎□ 失神 ············································································································ 長 哲太郎□ けいれん発作（成人） ············································································· 長 哲太郎□ 視力障害・視野狭窄 ················································································ 江口幸士郎□ 目の充血 ··································································································· 江口幸士郎□ 聴力障害 ··································································································· 江口幸士郎□ 胸痛 ·············································································································· 金井伸行
□ 動悸 ·············································································································· 平野嘉信
□ 咳・痰 ·········································································································· 平野嘉信
□ 咽頭痛 ·········································································································· 堀

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哲也

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□ 吐血・下血··································································································· 堀 哲也

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□ 嘔気・嘔吐··································································································· 堀 哲也
□ 腹痛 ·············································································································· 小倉和也
□ 便通異常 ······································································································ 小倉和也
□ 背部痛 ·········································································································· 松田 諭
□ 腰痛 ·············································································································· 松田 諭
□ 関節痛 ·········································································································· 松田 諭
□ 歩行障害 ······································································································ 木下賢輔

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v

□ 四肢のしびれ ······························································································· 木下賢輔
□ 乏尿・尿閉··································································································· 木下賢輔

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一般的な疾患・病態アプローチ□ 貧血 ·············································································································· 和田幹生
□ 脳血管障害··································································································· 和田幹生
□ 頭部外傷 ······································································································ 和田幹生
□ パーキンソン病・パーキンソン症候群 ···················································· 飛松正樹
□ 髄膜炎・脳炎 ······························································································· 飛松正樹
□ 皮膚感染症··································································································· 飛松正樹
□ 骨粗鬆症 ······································································································ 小嶋秀治
□ 骨折 ·············································································································· 小嶋秀治
□ 関節・靱帯の障害 ······················································································· 小嶋秀治
□ 脊柱の障害··································································································· 中島 徹
□ 心不全 ·········································································································· 中島 徹
□ 狭心症・心筋梗塞 ······················································································· 中島 徹
□ 不整脈 ·········································································································· 三浦太郎
□ 動脈疾患 ······································································································ 三浦太郎
□ 静脈・リンパ管疾患 ··················································································· 三浦太郎

□ 高血圧症 ······································································································ 堀 みき
□ 上気道感染症 ······························································································· 堀

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□ 下気道感染症 ······························································································· 堀 みき

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□ 気管支喘息··································································································· 平山陽子
□ 慢性閉塞性肺疾患 ······················································································· 平山陽子
□ 睡眠時無呼吸症候群 ··················································································· 平山陽子
□ 食道・胃・十二指腸疾患 ········································································ 福井慶太郎□ 小腸・大腸疾患 ························································································ 福井慶太郎□ 肝疾患 ······································································································· 福井慶太郎□ 膵臓疾患 ······································································································ 榎原 剛
□ 腎不全 ·········································································································· 榎原 剛
□ 尿路疾患 ······································································································ 長尾智子
□ 女性生殖器関連疾患 ··················································································· 長尾智子
□ 男性生殖器関連疾患 ··················································································· 菅野哲也
□ 甲状腺疾患··································································································· 菅野哲也
□ 糖尿病 ·········································································································· 松下公治
□ 脂質異常症··································································································· 松下公治
□ 中耳炎 ·········································································································· 成島仁人
□ 急性・慢性副鼻腔炎 ··················································································· 成島仁人
□ アレルギー性鼻炎 ······················································································· 成島仁人
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□ 気分障害 ······································································································ 細田俊樹
□ 不安障害 ······································································································ 細田俊樹
□ インフルエンザ ··························································································· 細田俊樹
□ 感染性腸炎··································································································· 宮野 馨
□ 膠原病 ·········································································································· 横田 啓
□ アナフィラキシー ······················································································· 原田昌範
□ 環境要因による疾患 ··················································································· 安藤慎吾
□ 熱傷 ·············································································································· 安藤慎吾
□ 小児けいれん性疾患 ··················································································· 平

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□ 小児ウイルス感染症 ················································································ 村井紀太郎

166□ 小児細菌感染症 ························································································ 村井紀太郎□ 小児喘息 ··································································································· 村井紀太郎

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ライフサイクルごとの健康問題への対応□ ライフサイクル総論 ··················································································· 児玉和彦
□ 乳幼児の予防接種 ······················································································· 児玉和彦
□ 乳幼児健診··································································································· 児玉和彦
□ 小児の発達・成長 ······················································································· 安来志保
□ 性感染症 ······································································································ 安来志保
□ 妊婦・授乳婦・褥婦のケア········································································ 安来志保

□ 生活習慣病予防 ························································································· 小宮山 学□ 感染症予防································································································· 小宮山 学□ 虐待（小児・高齢者）の発見およびその対処法 ··································· 小宮山 学□ プライマリ・ケアにおける自殺予防 ························································ 吉本 尚
□ ニコチン依存症（喫煙）への対応 ···························································· 吉本 尚
□ アルコール使用障害への対応···································································· 吉本 尚
□ がんスクリーニング・がん予防 ····························································· 朝倉健太郎□ 認知症スクリーニング ············································································ 朝倉健太郎□ 認知症診療の基本 ···················································································· 朝倉健太郎□ 高齢者症候群（誤嚥） ·························································· 武末真希子，吉田 伸□ 高齢者症候群（尿失禁） ························································· 生田奈央，吉田

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伸

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□ 高齢者症候群（転倒） ····························································· 赤岩 喬，吉田 伸

214□ 高齢者症候群（褥瘡） ··············································································· 太田 浩
□ 高齢者総合機能評価（CGA） ·································································· 太田 浩
□ リハビリテーションの基本········································································ 太田 浩
□ 成人・高齢者の予防接種 ··········································································· 宮﨑 景
□ アドバンス・ケア・プランニング（ACP） ············································ 宮﨑 景
□ 緩和ケアの基本 ··························································································· 古川倫也
□ 栄養管理の基本 ··························································································· 古川倫也

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vii

多様な診療の場に基づく医療□ 訪問診療と往診 ··························································································· 富塚太郎
□ 多職種協働（IPW） ··················································································· 富塚太郎
□ 地域包括ケアシステム ··············································································· 富塚太郎
□ 成年後見制度・日常生活自立支援事業 ···················································· 森屋淳子
□ 施設入居者の診療 ······················································································· 森屋淳子
□ 学校保健 ······································································································ 池尻好聰
□ 産業保健 ······································································································ 池尻好聰
□ スポーツ医学 ······························································································· 池尻好聰
□ へき地・離島医療 ······················································································· 安藤高志
□ 成人・高齢者健診 ······················································································· 安藤高志
□ 海外渡航者への対応 ··················································································· 安藤高志
□ 日本在住外国人医療 ··················································································· 渡邉力也
□ 病院における総合診療医の役割 ································································ 渡邉力也
□ 災害時の継続診療・被災者へのケア ························································ 渡邉力也

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ジェネラリストアプローチ①□ プライマリ・ケアの定義とその概念 ························································ 藤谷直明
□ 生物心理社会モデル ··················································································· 藤谷直明
□ 患者中心の医療の方法 ··············································································· 北山 周
□ 家族志向性アプローチ ··············································································· 北山 周
□ 地域志向性アプローチ ··············································································· 松井善典
□ 患者‐医師関係 ··························································································· 松井善典
□ ケアの継続性 ······························································································· 松井善典
□ ケアの包括性 ······························································································· 杉谷真季
□ 複雑な問題に関するケア ··········································································· 杉谷真季
□ 慢性疾患モデル ··························································································· 杉谷真季
□ ポリファーマシー ···················································································· 森下真理子□ ケアの移行時の対応 ················································································ 森下真理子□ ケアの近接性・アクセス ········································································ 森下真理子□ ケアの協調性 ······························································································· 西川武彦
□ ケアの責任性・文脈性 ··············································································· 西川武彦
□ 情報提供と病病・病診・診診連携 ···························································· 西川武彦
□ 介護保険における医師の役割···································································· 今江章宏
□ 地域診断と地域への介入 ··········································································· 今江章宏
□ 臓器別専門医へのコンサルテーション ···················································· 今江章宏

viii

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ジェネラリストアプローチ②□ EBM（Evidence-Based Medicine） Step 1：疑問の定式化 ··········· 青木拓也
□ EBM Step 2：エビデンスの収集 ····························································· 青木拓也
□ EBM Step 3：批判的吟味 ········································································ 松島和樹
□ EBM Step 4：情報の患者への適用 ························································· 松島和樹
□ 検査の解釈（感度・特異度・尤度比） ···················································· 茂木恒俊
□ NBM（Narrative-Based Medicine） ··················································· 茂木恒俊
□ Shared decision making ········································································ 茂木恒俊
□ 患者教育と行動変容 ··················································································· 八藤英典
□ 診療の質評価と改善 ··················································································· 八藤英典

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□ リスクマネジメントと患者安全 ································································ 八藤英典

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文献リスト ···································································································································

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Ⅱ章

臨床実践ワークブック□ 公衆衛生・EBM ········································································· 金子

Ⅲ章

惇

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□ コミュニケーション··································································· 松田聡介

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□ 日常病 ·························································································· 山梨啓友347

□ 女性・男性医療，周産期医療 ················································ 増山由紀子

353□ 小児・思春期医療 ······································································ 町野亜古

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□ 高齢者医療 ·················································································· 神廣憲記

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□ メンタルヘルス ·········································································· 上野暢一364

□ 急性疾患・救急医療··································································· 小淵岳恒

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□ 整形疾患 ··················································································· 村田亜紀子

373□ 緩和医療 ······················································································ 小西徹夫

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臨床技能ワークブック
総論□ コミュニケーション··································································· 髙栁宏史386

□ 診療の構造 ·················································································· 孫

大輔

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□ プロフェッショナリズム ··························································· 宮田靖志

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ix

各論
□ 日常病ステーション··································································· 加藤光樹

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□ 患者教育ステーション······························································· 三澤美和

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□ 高齢者ステーション··································································· 中村琢弥413

□ 心理社会ステーション······························································· 吉本清巳

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□ 小児ステーション ······································································ 佐古篤謙

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□ 救急ステーション ······································································ 北村

大427

索引 ···············································································································································

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本文中の重要語句は添付の赤色チェックシートで隠すことができます．自習の際に工夫してお使いくださいxⅠ 臨床知識ベーシックドリル

胸痛
問題 胸痛をきたす緊急疾患を 4 つあげよ．

問題 胸痛をきたすその他の疾患を臓器カテゴリー別にあげよ．

問題 急性の胸痛患者に対して来院から 10 分以内にすべきことを述べよ．

問題 胸痛患者の医療面接で聴取すべき項目を述べよ．

問題 急性大動脈解離を強く疑わせる病歴・身体所見について説明せよ．

問題 緊張性気胸を疑うべき病歴・身体所見と治療法について説明せよ．

46

一般的な症候アプローチ
胸痛

解答・解説
金井伸行
急性冠症候群，肺血栓塞栓症，大動脈解離，緊張性気胸．
胸痛をきたすこれら 4 つの緊急疾患を “4 killer chest pains” という．なお，急性冠症候群には，急性心筋梗塞と不安定狭心症が含まれる．
●心血管疾患：心外膜炎，心筋炎，大動脈弁狭窄症．
●肺疾患：自然気胸，胸膜炎，肺炎．
●消化器疾患：食道破裂，胃食道逆流症，消化性潰瘍，胆嚢炎，胆石発作，膵炎．
●胸壁疾患：帯状疱疹，肋骨骨折，肋軟骨炎，肋間神経痛．
●精神疾患：パニック障害，うつ病．など
まず，A（気道）B（呼吸）C（循環）とバイタルサインをすみやかに確認する．続いて，来院 10 分以
内に 12 誘導心電図検査を実施する．
初期の医療面接に手間取って心電図検査が遅れると，急性冠症候群を見逃し生命予後を悪化させる恐れがあると心得ておきたい．「受診から 10 分以内」ではなく「来院から 10 分以内」に実施すべきであり，受付事務や看護師等によるトリアージも重要になる．
①痛みの詳細，②随伴症状，③患者背景，の 3 点を聴取する．
①痛みの詳細では，発症様式，経時的変化，性質，程度，部位，放散の有無，持続時間，増悪・軽快
因子について聞く．
②確認すべき随伴症状には，呼吸困難，咳嗽，喀血，動悸，嘔気・嘔吐，胸やけ，冷汗がある．
③患者背景としては，虚血性心疾患のリスク因子（☞狭心症・心筋梗塞〔 p.96〕）の確認が特に重要である．
急性大動脈解離は，引き裂かれるような突然発症の痛みを特徴とし，それが背部に放散したり，解離の経路に沿って移動したりすることもある．また，リスク因子には，高齢者，男性，高血圧が含まれる．
身体診察で脈の欠如や左右差（収縮期血圧 20 mmHg 以上の差）があれば，その可能性が非常に高くなる．
突然発症の胸痛と進行する呼吸困難があり，身体診察で頻脈，頻呼吸，低血圧，気管偏位，頸静脈怒張といった所見を呈する場合は，緊張性気胸を疑う．
治療は，胸部 X 線撮影を待つことなく，患側の胸壁（鎖骨中線上第 2 肋間）を 18 G より太いサーフロ
ー針で穿刺し，緊急脱気を行う．
※急性冠症候群は，ここでは詳細を取り上げなかった．☞狭心症・心筋梗塞（ p.96）

47

Ⅰ 臨床知識ベーシックドリル

問題 禁煙外来を利用できるのはどのような人か述べよ．

問題 禁煙外来での診療のスケジュールと流れについて説明せよ．

問題 禁煙補助薬とその作用，副作用を述べよ．

問題 禁煙外来の設置基準をあげよ．

アルコール使用障害への対応
問題 ほどほどの飲酒について，g（グラム），ドリンク，単位といった呼び方も含めて説明せよ．

196

ライフサイクルごとの健康問題への対応
ニコチン依存症（喫煙）への対応 / アルコール使用障害への対応

解答・解説
準備期，行動期の患者が対象で，①直ちに禁煙することを宣言できる，②ニコチン依存症に関するスクリーニングテスト（ TDS ）で 5 点/10 点以上，
③ 1 日の喫煙本数×喫煙年数（ブリンクマン指数）が 200 以上，の 3 点を満たす必要がある．さらに，ニコチン依存症の病名で，「禁煙治療のための標準手順書」にのっとった禁煙治療プログラムについて説明を受け，文書による同意が必要となる．
なお，2016 年 4 月より，未成年を含めた 35 歳未満の患者は，①，②の 2 点のみで禁煙外来を利用できるようになった．
標準的な禁煙治療プログラムは 12 週間提供され，初診，2 週間後，4 週間後，8 週間後，12 週間後の合計 5 回の治療を行い，ニコチン依存症管理料を算定する．算定要件は，①「禁煙治療のための標準手順書」に沿った禁煙治療を行うこと，②禁煙の成功率を所属厚生局へ報告すること，である．
再治療に関しては，使用薬剤にかかわらず初回算定日より 1 年を超えた日からでないと行えない．
2017 年春現在，利用できる禁煙補助薬は，ニコチンガム，ニコチンパッチ，バレニクリン（チャンピックス® ）である．ニコチンガム，ニコチンパッチは市販され，バレニクリンは保険収載されている．
ニコチン補充療法は 1.6 倍ほど，バレニクリンは 2.2 倍程度，禁煙しやすくなることが示されている．
副作用として，ニコチン補充療法は不眠，頭痛，嘔気，接触皮膚炎など，バレニクリンは嘔気，不眠，異常な夢，頭痛などがみられる．ニコチン補充療法は能書上，妊娠時には禁忌である．
①禁煙治療を行っていることを医療機関内に掲示している．
②禁煙治療の経験を有する医師が 1 名以上勤務している．
③禁煙治療の専任看護職員を 1 名以上配置している．
④呼気一酸化炭素（ CO ）濃度測定器を備えている．
⑤医療機関の敷地内禁煙を実施している．
これらの施設基準を満たした後，特掲診察料の施設基準に係る届出書を所属厚生局に提出する．

吉本

尚

日本では，節度ある適度な飲酒として「1 日，純アルコール（以下，略）男性 20 g，女性 10 g 以下」，
生活習慣病のリスクを高める飲酒量として「1 日，男性 40 g 以上，女性 20 g 以上」と定められた．また，10 g を 1 ドリンク，20 g を 1 単位（＝ 2 ドリンク）と呼ぶ．20 g の目安は，ビール 500 mL，日本
酒 1 合（180 mL ），焼酎 25% 100 mL，缶チューハイ 7% 350 mL，ワイン グラス 2 杯程度，である．
一般的には節度ある適度な飲酒をめざすのがよい．また，非飲酒者に飲酒は勧めない．

197

Ⅰ 臨床知識ベーシックドリル

問題 危険な飲酒および有害な飲酒について説明せよ．

問題 アルコール依存症について説明せよ．

問題 プライマリ・ケア医に必要なアルコール使用障害へのアプローチについて説明せよ．

問題 アルコール使用障害に対する効果的なスクリーニングツールについて説明せよ．

問題 アルコール使用障害への簡易介入と動機づけ面接について説明せよ．

問題 アルコール治療の専門家へ紹介を考えるのはどのような場合か．他機関との連携を含めて説
明せよ．

198

ライフサイクルごとの健康問題への対応
アルコール使用障害への対応

解答・解説
危険な飲酒とは，飲酒者や他者に対する有害事象の危険が高まるアルコール摂取パターンであり，世界保健機構（ WHO ）が提唱する概念で，①過剰な習慣飲酒，②一時的多量飲酒，③飲んではいけない状況下での飲酒，の 3 つがある．
一方，有害な飲酒は，ICD‑10（国際疾病分類第 10 版）で，飲酒により精神的・身体的な問題が生じている状況であるとされる．飲酒に関連する疾患は 200 以上あるとされており，高血圧，心房細動，低血糖や高血糖，ミオパチー，うつ病を含めた気分障害，不安障害などさまざまである．
アルコール依存症とは，大切にしていた家族，仕事，自分の健康などよりも，飲酒をはるかに優先させるような状態で，飲酒のコントロールができない状況である．日本では ICD‑10 の診断基準がよく用いられ，①強い飲酒欲求，②飲酒量・時間の管理困難，③離脱症状，④耐性，⑤他の楽しみ・興味を犠牲にして飲酒，⑥有害性にかかわらず飲酒，の 6 項目中 3 項目が 1 か月以上続けばアルコール依存症と診断される．
アプローチには，①スクリーニング，②簡易介入，③紹介・連携，が必要とされる．これらを効果的かつ簡便に行うことができるように配慮された枠組みが，SBIRT（ Screening, Brief Intervention,
and Referral to Treatment：エスバート）であり，飲酒量，医療機関利用，社会的コストを減少させることが示されている．
AUDIT（ Alchol Use Disorders Identiﬁcation Test ）や CAGE が一般的に用いられる．さまざまなツールが開発されているが，AUDIT は現在プライマリ・ケアで使用できるスクリーニングツールとしては最も有用と考えられており，10 個の質問で危険 / 有害な飲酒と依存症の発見の両方に有効である．CAGE は 4 つの質問で依存症の発見に有効だが，危険 / 有害な飲酒の発見が苦手という欠点がある．
簡易介入は，5〜15 分で介入を行う方法で，依存症になる前の危険 / 有害な飲酒をしている人に効果がある．行動科学的な介入が望ましく，特に動機づけ面接に効果があるとされている．
動機づけ面接では，前熟考期・熟考期の場合には動機づけを，準備期，行動期，維持期には患者が望む行動の支援を行う．そして，OARS（開かれた質問 Open question，承認・賞賛 Aﬃrm，反映的傾
聴 Reflective listening，要約 Summary ）の 4 つの技術を用いて，行動を変える決断の言葉（ Change talk ）を引き出す．
AUDIT で 20 点以上，もしくは ICD‑10 で 3 項目以上，精神疾患をもっておりアルコールが症状に影響を与えていると考えられる場合，確定診断と治療を受けるために専門家への紹介が望ましい．アルコール専門機関の情報は，所属県の精神保健福祉センターに問い合わせるとよい．本人が紹介を嫌がった場合，家族の関わり方を変えることでアルコール依存症の本人の症状を軽減したり，治療への動機づけを高めたりする方法があるため，家族だけの受診が可能か，紹介先に問い合わせるとよい．

199

中山書店の出版物に関する情報は，小社サポートページを御覧ください．
https://www.nakayamashoten.jp/support.html

総合診療専門医シリーズ
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3総合診 療 専門医のためのワークブック
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専門医試験対策2017 年 6 月 1 日

初版第 1 刷発行 ©

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のぶゆき

〔検印省略〕

編集主幹 ─ 草場鉄周
専門編集 ─ 金井伸行
発行者 ── 平田

直発行所 ── 株式会社中山書店〒112 ─ 0006 東京都文京区小日向 4 ─ 2 ─ 6
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本文デザイン─ 株式会社 SunFuerza
装丁─── ビーコム
印刷・製本─ 三報社印刷株式会社

PublishedbyNakayamaShotenCo.,Ltd.
ISBN978 4 521 74190 1

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PrintedinJapan

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