Speed Input & Rational Output

　日々、地方の現場で臨床業務に明け暮れる大多数の医師にとって、外国人の患者と接したり、国際学会に参加したりする機会は乏しい。従って、英語はオンライン文献から情報を入手するための道具であり、英語を文字情報として理解出来れば事足りてきた。しかし、近年、一流ジャーナルのポッドキャストやMOOCs(Massive Open Online Courses：大規模公開オンライン授業)の普及により、音声英語の理解が医師卒後教育の機会に格差をもたらす可能性が生じてきている。さらには、医師の根本的な技能である診断という認知作業の定式化の分野では、英語圏を中心に新たな概念が創出されてきている。また、決断という認知作業においては、感情と思考の連携が弱い分、母国語よりも外国語で行ったほうがバイアスが少ない可能性も示唆されている。

　そこで、今後、医師の卒後教育の為に特化した英語コースのパッケージ化の試行錯誤を本ブログで公開していきたい。ESP (English for Specific Purposes)の概念をさらに推し進めると同時に、従来の論文の読解、執筆を目指したものを離れ、日常診療に即したものを志向する。よって、入力系の対象は「症例報告」、出力系は「診断の思考過程」に限定する。これには、NEJM誌の"Cabot Case"や"Clinical Problem-Solving"、Journal of Hospital Medicine誌の"Clinical Care Conundrums"の連載が、打って付けである。具体的には、これらの素材を元に、ポッドキャスト該当部分を聴き取り、卓越した臨床家の思考過程をなぞり、自分なりの思考過程を英語で呟くことができることを目標としたい。スローガンは、"Speed Input"と"Rational Output"である。

　その辺を意識して、明日からClinical Problem-Solvingのディクテーションを再開の予定。

Reference

• Keysar B, Hayakawa SL, An SG. "The foreign-language effect: thinking in a foreign tongue reduces decision biases".  Psychol Sci. 2012 Jun;23(6):661-8.

優先順位付けされた鑑別診断の覚え書き

Simple Problem List
Processed Problem List
Patient Illness Script

• Epidemiology
• Time Course
• Syndrome Statement
• Other History

Case Summary
Tiered (Prioritized) Differential Diagnoses

• Tier I (very likely,  > 90%, odds: > 9)　喩えると、馬、本命馬。
•          (likely, 67 - 90%, odds: 2 - 9)
• Tier IE (Emergent severe consequencies if missed)　喩えると、ブラックスワン、ケンタウロス、地雷…
• Tier II (uncertain, 34 - 66%, odds: 0.5 - 2)　喩えると、鹿、対抗馬。
• Tier III (unlikely, 10 - 33%, odds: 0.11 - 0.5)　喩えると、シマウマ、穴馬。
•           (very unlikely, < 10%, odds: < 0.11)

References

• Schmidt HG. "A cognitive perspective on medical expertise: theory and implication". Acad Med. 1990 Oct;65(10):611-21. 
• Miller, GA. "The magical number seven, plus or minus two: Some limits on our capacity for processing information". Psychological Review 1956 63 (2): 81–97
• 医療における頻度を表す言葉と確率の接点

The Writing on the Wall

A CLINICAL PROBLEM-SOLVING article by Brian Wolpin from Brigham and Women's Hospital, Boston.
A 52-year-old man presented to the emergency department with abdominal discomfort. 5 weeks earlier, nonradiating discomfort developed in the epigastric region. The patient's pain became more localized to the periumbilical area and was accompanied by early satiety and multiple episodes of vomiting. He had no fever, diarrhea, tenesmus, melena, or hematochezia.
The medical history included mild intermittent asthma that was diagnosed 20 years earlier, obstructive sleep apnea, hypertension, dyslipidemia, type 2 diabetes mellitus, hypothyroidism, and gout. A diagnosis of chronic idiopathic angioedema–urticaria was established 11 years earlier.
Palpation of the abdomen revealed mild, diffuse tenderness without rebound, guarding, or organomegaly. Laboratory findings revealed eosinophilia.
In this patient, who has gastrointestinal discomfort and a history of asthma, has traveled internationally, and has angioedema, several disorders associated with eosinophilia warrant consideration.
 An Interactive Medical Case related to this article is available at NEJM.org. With this online feature, you, user can direct investigation, select treatment and compare your performance with that of others. [Original Article]

A Bloody Mystery

A CLINICAL PROBLEM-SOLVING article by Adam Cuker from Brigham and Women's Hospital, Boston.
A 62-year-old woman presented to the urgent care clinic with persistent gingival bleeding after periodontal scaling of her lower-right second molar. The patient recalled a similar episode approximately 6 months earlier, also after a periodontal procedure.
A critical first step in narrowing the diagnostic possibilities is to determine whether this patient's hemostatic disorder is hereditary or acquired. The fact that she had undergone significant hemostatic challenges in the past, which includes childbirth and orthopedic surgery, without bleeding complications suggests that the current presentation can be attributed to an acquired bleeding diathesis. The pattern of bleeding also provides important clues. Mucocutaneous bleeding, as is seen in this case, is typical of disorders of primary hemostasis, including thrombocytopenia, qualitative platelet disorders, and von Willebrand's disease.
An Interactive Medical Case associated with this article is available at NEJM.org.[Original Article]

A Crisis in Late Pregnancy

A CLINICAL PROBLEM-SOLVING article by Akshay Desai from Brigham and Women's Hospital, Boston.
A 31-year-old woman in the 37th week of an uncomplicated pregnancy presented to the emergency department with sudden onset of severe bitemporal headache and shortness of breath. Her medical history was notable for hypothyroidism and pernicious anemia (both treated).
The patient was in apparent respiratory distress and reported that she felt like she was “drowning.” Her pulse was 120 beats per minute, blood pressure was 180/110 mm Hg, respiratory rate was 32 breaths per minute, and oxygen saturation was 70% while she was breathing ambient air. She was unable to lie flat without having more difficulty breathing. Funduscopic examination was normal. Cardiovascular examination revealed tachycardia, a summation gallop, and a grade 2/6 apical holosystolic murmur.
Shortness of breath in the third trimester of pregnancy has a broad differential diagnosis. Her physical examination suggests biventricular heart failure. Although malignant hypertension could account for the headache and heart failure, her funduscopic examination does not reveal papilledema or hemorrhages. This severe hypertension alone would not be expected to precipitate acute heart failure in a young person. This case highlights the critical importance of a broad differential diagnosis and careful attention to all the diagnostic clues in a complex clinical presentation.
An Interactive Medical Case related to this article is available at NEJM.org.[Original Article]

Diagnostic Strategiesに関する覚書

ケースバイケースで下記の手法を使い分けるが、診断に熟練するに従い、より下方の手法を使用する比率が上がっていく。

• Backward Thinking (Hypothesis Testing)：主訴の鑑別診断リストを逐一チェックしていく。時間、医療費、能力のリソースを使い過ぎるきらいがある。
• Published Lists: 教科書のリスト
• Personal Lists: 経験や施設の傾向を加味したリスト
• Category Chase: I VINDICATE-Pなどに代表される疾患範疇からリストを作る。
• Forward Thinking：病歴や身体所見から患者像を鮮明にして鑑別診断を絞る。
• Problem Representation: Processing by semantic qualifiers (lay language → medical terminology)
• Duration, Distribution, Qualitative: ex acute oligoarthritis, chronic hemiplegia
• Pattern Recognition：Gestalt診断、俗にいう一発診断。自動化されたForward Thinking

Painful Purple Toes

A CLINICAL PROBLEM-SOLVING article by Jennifer Johnson from Brigham and Women's Hospital, Boston.
A 57-year-old man presented to the emergency department with painful purple toes. He had first noted a painful discoloration of his left great toe 2 weeks earlier. The pain and discoloration progressed to involve the left second and third toes. During the 3 weeks preceding presentation, the patient also had intermittent blurry vision, intermittent chest pain, fatigue, anorexia, drenching night sweats, and a weight loss of 6.8 kg (15 lb). His roommate commented that the patient had also been slightly confused.
The patient had a history of hypertension, anxiety, chronic back pain, and gastroesophageal reflux disease. While in the Marine Corps in Vietnam, he had malaria and injuries to the hip and skull. Since serving in Vietnam he had also had post-traumatic stress disorder. Two years before presentation, a screening colonoscopy detected benign polyps. His medications included alprazolam, oxycodone with acetaminophen, and esomeprazole. The patient worked for the U.S. Postal Service and was living with a friend. He reported smoking half a pack of cigarettes daily for 30 years, weekly alcohol use, and rare but ongoing intranasal cocaine use, but no intravenous drug use. He was divorced and had not recently been sexually active. There was no family history of cancer, autoimmune diseases, diabetes, or clotting disorders.
An Interactive Medical Case associated with this article is available at NEJM.org. Direct the investigation, select the treatment and compare your performance with that of others. [Original Article]

Stalking the Diagnosis

A CLINICAL PROBLEM-SOLVING article by Bindu Chamarthi from Brigham and Women's Hospital, Boston.
A 58-year-old woman presented to her primary care physician after several days of dizziness, anorexia, dry mouth, increased thirst, and frequent urination. She had also had a fever and reported that food would “get stuck” when she was swallowing. Her history was notable for cutaneous lupus, hyperlipidemia, osteoporosis, and primary hypothyroidism, which had been diagnosed a year earlier. The patient was given a prescription for ciprofloxacin for a urinary tract infection and was advised to drink plenty of fluids. On a follow-up visit 3 days later, her fever had resolved, but she reported continued weakness and dizziness despite drinking a lot of fluids. She was referred to the emergency department, where she received normal saline and supplemental potassium, and her symptoms abated. One week later, she returned to the emergency department with continued weakness, frequent urination, intermittent vomiting, dysphagia, and increased thirst and fluid intake. Her course was complicated by hypotension, dehydration and hyponatremia.
A review of symptoms revealed difficulty swallowing and occasional emesis of solid foods because of a feeling of “sandlike” dryness in her mouth; she also had an involuntary weight loss of 10 lb over the past month. Physical examination revealed a nontender left cervical lymph node, 2 cm in diameter.
An Interactive Medical Case associated with this article is available at NEJM.org. [Original Article]

Under Pressure

A CLINICAL PROBLEM-SOLVING article by Michael Detsky from University of Toronto, Canada.
A 25-year-old woman presented with dyspnea. She described a 2-year history of progressive shortness of breath on exertion. One year earlier she was able to walk on flat ground for approximately 5 minutes or walk up one flight of stairs. Within the previous 3 days, her condition had deteriorated to the point that she was unable to leave her bedroom without having dyspnea. The patient reported a nonproductive cough, palpitations, and pain on the left side of the chest that worsened with inspiration. Her medical history included unprovoked deep-vein thrombosis in the right leg. Her only current medication was warfarin.
On physical examination, the patient appeared to be in moderate respiratory distress. Her heart rate was 94 beats per minute and regular; her blood pressure was 110/64 mm Hg with no pulsus paradoxus. Respiratory examination revealed equal bilateral breath sounds, with no wheezes or crackles. A cardiovascular examination revealed a jugular venous pressure 10 cm above the sternal angle, with a positive Kussmaul's sign. There was a left-sided parasternal heave. The patient had a normal S1 sound and a loud, split S2, with no S3 or S4 sounds and no murmurs. There was no peripheral edema.
This case underscores the range of potential causes of pulmonary hypertension. [Original Article]

More Than Meets the Ear

A CLINICAL PROBLEM-SOLVING article by Spyridon Marinopoulos from Johns Hopkins University School of Medicine, Baltimore.
A 62-year-old man presented with a “clogged” sensation and a 6-week history of diminished hearing in his right ear. Audiometry confirmed a mixed, but principally conductive, hearing loss in the right ear. Serous otitis media was diagnosed and treated with intranasal corticosteroids. His symptoms recurred 5 months later, and a right myringotomy was performed. He continued to report slightly “muffled” hearing.
Otolaryngoscopy revealed no obstructing lesions. Six months later, in late May, the patient reported stiffness and pain in his right shoulder after he had been working outside in the yard.
The patient was advised to take nonsteroidal antiinflammatory drugs and noted improvement, but the following week he reported a sore left shoulder and a tender right knee. He also had lower back pain and bilateral heel sensitivity. Over the next 2 days, his ankles became swollen and painful, and he reported fatigue, a low-grade fever, night sweats, and a decreased appetite. On further questioning, the patient described his heel sensitivity as “numbness.”
It remains a challenge for clinicians confronting one specific problem or symptom to determine whether it is part of a more complex clinical entity. In this case, the diagnosis eluded the treating physicians until a set of musculoskeletal symptoms developed that at first seemed unrelated to the patient's initial presentation with hearing loss. [Original Article]

Illness Scriptに関する覚書

Core Components of Illness Script

• Predisposing conditions (Epidemiology)
• Demographics: Age, Gender, Ethnicity
• Risk factors: 
• Exposures: Travel, Occupation, Pet, Activities, Close contact
• Progression (Time course)
• Duration
• hyperacute = hourly
• acute = daily
• subacute = weekly
• chronic = monthly
• Pattern
• Constant
• Episodic
• Presentation
• key feature (discriminating feature, must-have feature)
• differentiating feature (defining feature)
• Pathophysiology (Mechanism)

References

• Mandin, H. Developing a "clinical presentation" curriculum at the University of Calgary Acad Med March 1995 
• Bowen, JL. Educational Strategies to Promote Clinical Diagnostic Reasoning N Engl J Med 2006; 355:2217-2225

Recommended Readings

• CMDT2013
• the Merck Manual
• Up To Date Patient Information, Beyond the Basics
• the Medecins Sans Frontieres Clinical Guidelines：国境なき医師団のマニュアルで、他に仏語、西語版がある。

The Beat Goes On

A CLINICAL PROBLEM-SOLVING article by Kathryn Britton from Brigham and Women's Hospital, Boston.
A 45-year-old man presented at a hospital after having a syncopal event while watching a baseball game. The syncopal event was preceded by the sudden onset of light-headedness. He awoke after several seconds, without confusion. He reported having nausea and diaphoresis but had no chest pain before or after the event. An emergency-medical-services team obtained an electrocardiogram that revealed monomorphic, wide-complex tachycardia at a rate of 240 beats per minute; the blood pressure was 110/50 mm Hg. The team administered amiodarone, without effect. On arrival at the hospital, his systolic pressure was 70 mm Hg. Electrocardioversion was performed, with successful restoration of sinus rhythm. Pertinent electrocardiographic findings noted before cardioversion included QS complexes across the precordium and right-axis deviation. Analysis of these findings and the postcardioversion tracing supported the diagnosis of ventricular tachycardia.
After the patient's condition was stabilized, further history was obtained. The patient reported receiving a diagnosis of cardiomyopathy 6 months earlier. An echocardiogram revealed normal left ventricular wall thickness, an ejection fraction of 40%, and inferior-wall hypokinesis.
In the absence of structural heart disease, monomorphic ventricular tachycardia has a benign prognosis. In contrast, when ventricular tachycardia is coupled with underlying cardiac disease, it is associated with an increased risk of death.
Direct investigation and select treatment for this patient with An Interactive Medical Case at NEJM.org. [Original Article]

All in the Family

A CLINICAL PROBLEM-SOLVING article by Joshua Easter from Children's Hospital of Boston.
A 34-year-old woman presented to a community hospital with aphasia. Her husband reported that her condition had been normal until 2 hours earlier, when her arms and legs suddenly shook for several seconds. Immediately afterward, she was unable to speak or to move her limbs on the right side. There was no incontinence or tongue biting.
On physical examination, the patient was afebrile and had a regular pulse. Her gaze deviated to the left. She was mute and followed spoken commands intermittently. On neurologic examination, the patient was aphasic and had right homonymous hemianopia. She had a facial droop on the right side, complete paralysis of the right arm, and partial paralysis of the right leg. Strength was normal on the left side. Her reflexes were absent on the right side and normal on the left. Plantar responses were extensor on the right side and flexor on the left. Approximately 3½ hours after the onset of symptoms, a CT scan of the head revealed a hyperdense left middle cerebral artery.
The abrupt onset of a focal neurologic deficit is a true emergency. When an ischemic stroke occurs in a young patient without the traditional vascular risk factors, alternative causes must be considered. [Original Article]

A Rash Hypothesis

A CLINICAL PROBLEM-SOLVING article by Anne Liu from Brigham and Women's Hospital, Boston.
A 40-year-old woman presented with diarrhea, reporting to her physician that she had been having loose stools for 2 years, progressing over the previous 6 months to 15 large-volume, watery stools daily, including nocturnal stools. She had also been vomiting over the previous 2 months.
The patient had had a mild rash since infancy, characterized by fixed pink patches on her trunk and limbs that became red and pruritic when scratched or exposed to sun and heat. She reported that in adulthood the patches had become smaller and more diffuse, and over the previous year the itching had become more intense. She also had long-standing facial flushing, brought on by exertion or strong emotion. Aspirin caused flushing and stomach irritation. She did not drink alcohol because even a few sips brought on nausea and abdominal pain.
On examination, the abdomen was distended, with active bowel sounds, and was soft and nontender, without a fluid wave. As measured by percussion, the liver span was 18 cm, with a firm inferior edge.
Chronic diarrhea associated with weight loss requires a search for underlying disease. In this case, the differential diagnosis was guided by recognition of the relevance of the long-standing rash and flushing.
An Interactive Medical Case related to this Clinical Problem-Solving article is available at NEJM.org. Learn interactively. Get immediate feedback and compare your performance with that of others. [Original Article]

Thinking Inside the Box

A CLINICAL PROBLEM-SOLVING article by Peter Jessel from University of Michigan Medical School, Ann Arbor.
A 62-year-old woman presented to a community hospital with nausea, vomiting, diarrhea, and fever, all of 1 week's duration.
Her medical history included psoriasis and psoriatic arthritis, hypertension, hyperlipidemia, possible fibromyalgia, and degenerative lumbar disk disease. Her medications included the tumor necrosis factor (TNF) inhibitor infliximab (500 mg intravenously every 8 weeks), methotrexate, folic acid, atenolol, diltiazem, hydrochlorothiazide, aspirin, simvastatin, and gabapentin, as well as oxycodone for chronic pain.
Chest radiography revealed a small pleural effusion on the right side, with no infiltrate. Two sets of blood cultures were negative. CT of the chest, abdomen, and pelvis revealed a hazy infiltrate in the left midlung and small, bilateral pleural effusions.
The patient's fever persisted despite ceftriaxone therapy. On the 13th hospital day, the patient reported chest tightness. Cardiac catheterization revealed nonobstructive coronary artery disease. A transthoracic echocardiogram revealed an ejection fraction of 15% and a mobile, multilobulated soft-tissue mass, 7 mm by 25 mm, attached to the midpoint of the interventricular septum in the left ventricle.
This case demonstrates the need for extraordinary vigilance should patients who are being treated with TNF inhibitors present with symptoms suggestive of infection. However, this patient's unusual presentation and the negative results on initial blood cultures hindered a timely diagnosis. [Original Article]

タイトルは、添付文書の枠組みされた警告文"boxed warning"と型通りの考え方をすること"think inside the box "を掛けたものとなっている。

Hard to Conceive

A CLINICAL PROBLEM-SOLVING article by Julie Levison from Brigham and Women's Hospital, Boston.
A 31-year-old woman reported to her primary care physician that she and her husband had been unable to conceive a child since abstaining from all contraception 18 months earlier. One year before presentation, she had been evaluated by her physician for abdominal pain in the left lower quadrant. She reported having received BCG vaccination against tuberculosis as an infant. She was born and raised in Kathmandu, Nepal, and had moved to the United States 4 years earlier with her husband. As part of the immigration process, she underwent screening for latent tuberculosis infection and received a “borderline positive” result on a tuberculin skin test with a purified protein derivative. She was told that this result was due to her BCG vaccination and did not receive treatment for latent tuberculosis infection.
The patient and her husband had no apparent current or past medical conditions that explained their infertility. and they were seen by an obstetrical–gynecologic fertility specialist.
A hysterosalpingogram revealed a normal uterus and endometrial cavity without synechiae. Both fallopian tubes filled with contrast medium and were of normal caliber. However, there was no distal spill of contrast medium from either fallopian tube.
After the two unsuccessful cycles of IVF, an endometrial biopsy was performed. An Interactive Medical Case related to this article is available at NEJM.org. [Original Article]

The Search Is On

A CLINICAL PROBLEM-SOLVING article by Molly Perencevich from Brigham and Women's Hospital, Boston.
An 81-year-old man presented to the emergency department with hematochezia and hematemesis, which began after he was awakened by an urgent need to move his bowels. initially, he had diarrhea with brown stool. Soon afterward, he again had urgency, and this time red blood filled the toilet bowl. He later vomited a small amount of blood. He did not have abdominal pain, black stools, dysphagia, or odynophagia. The patient's medical history included unstable angina treated 3 months earlier with placement of a drug-eluting coronary stent.
On physical examination the patient appeared fatigued. While he was supine, the heart rate 55 beats per minute, the blood pressure 122/60 mm Hg. When he stood up, the heart rate increased to 83 beats per minute and the blood pressure was 118/62 mm Hg.
No cause of the gastrointestinal bleeding was apparent on upper endoscopy. CT showed the prior aortoiliac repair but no evidence of an aortoenteric fistula or graft infection. The patient no longer appeared to be bleeding when the CT was performed; however, approximately 24 hours later, he had an episode of hematochezia and hematemesis.
In this case, given the patient's recurrent hematemesis and the results of the evaluation so far, the source of the bleeding seemed most likely in the proximal small bowel. [Original Article]

A Heavy Heart

A CLINICAL PROBLEM-SOLVING article by Amy Miller from Brigham and Women's Hospital, Boston.
A 73-year-old man presented with a 6-month history of progressive, symmetric edema that began in the lower extremities and extended to involve his thighs, scrotum, and arms. He had dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea, as well as chest pressure on mild exertion. Despite anorexia and early satiety, he gained 16 kg (35 lb) and noted new abdominal distention.
The medical history included rheumatic heart disease, requiring mitral-valve replacement with a St. Jude mechanical valve 19 years earlier, as well as hypertension, atrial fibrillation, and benign prostatic hypertrophy.
On physical examination The jugular venous pressure was markedly elevated. There was dullness on percussion over the right lung base, with no breath sounds. The apex beat was not palpable, and there was no right ventricular heave. Auscultation revealed an irregular rhythm with a crisp, mechanical S1 and a 2/6 holosystolic murmur at the apex and lower left sternal border, with no radiation. The liver was enlarged and was pulsatile. Pitting edema involved the legs, scrotum, sacrum, and abdominal wall, and there was mild arm edema.
An electrocardiogram revealed atrial fibrillation with a slow ventricular response, low voltage in the limb leads, rightward axis, poor R-wave progression with clockwise rotation, and diffuse nonspecific T-wave changes.
The physical examination indicates elevated right-sided cardiac filling pressures. The degree of low voltage in this case is striking and suggests extensive infiltrative or fibrotic replacement of the myocardium.

Bitter Pills

A CLINICAL PROBLEM-SOLVING article by Yonatan Grad from Brigham and Women's Hospital, Boston.
A 60-year-old man presented to an urgent care clinic with fatigue of 1 month's duration and increasing frequency of urination, nighttime urination, and increasing thirst over the previous week. He had earlier been told that he had prediabetes and was now concerned that his symptoms reflected progression to diabetes mellitus.
The patient's medical history was notable for anxiety, depression, hypercholesterolemia, seasonal allergies, hypogonadism, and gastroesophageal reflux disease. Three months earlier, he had an upper respiratory tract infection that was treated with a 5-day course of azithromycin. His regular medications included full-strength aspirin (taken for its cardioprotective effect), diazepam, venlafaxine, atorvastatin, omeprazole, budesonide, St. John's wort, and testosterone gel. The patient drank two cups of coffee daily and two shots of whisky (also taken because of the patient's belief in its cardioprotective effect) each evening.
A normal blood glucose level and the absence of glycosuria indicated that the patient's presenting symptoms were not due to diabetes mellitus and elevated level of blood urea nitrogen and elevated creatinine level indicated recent kidney injury. The chain of events in this case underscores the aphorism that medications can at times be thought of as poisons with beneficial side effects. In this case, as in many others, the treatment for one disease is the cause of another.
An Interactive Medical Case related to this article is available at NEJM.org. [Original Article]

Notes

• glycosuria [glàikousjúəriə]
• underscore = accentuate, bring out, italicize, stress, underline, emphasize

In Search of . . .

A CLINICAL PROBLEM-SOLVING by Kyle Brizendine from University of Alabama School of Medicine, Birmingham.
A 61-year-old man was admitted with a week-long history of nausea, vomiting, nocturia, and polyuria. During the previous 6 months, he had noted progressive fatigue and a weight loss of about 7 kg (15 lb).
On physical examination the patient had orthostatic hypotension. The cardiovascular examination revealed a nonradiating, early systolic murmur.
The serum creatinine level was 3.9 mg per deciliter. The serum calcium level was 17.1 mg per deciliter (normal range, 8.8 to 10.4 mg per deciliter. Serum calcium and creatinine levels had been normal 8 weeks earlier. The serum parathyroid hormone (PTH) concentration was 9.05 pg per milliliter (normal range, 15 to 65) and the PTHrP concentration was less than 2.5 pmol per liter (normal value, <4.7).
A chest radiograph showed calcified granulomas in the right lung and calcified right hilar lymph nodes on the right side.
From 1976 to 1982, Leonard Nimoy  hosted a weekly television show called “In Search of . . .” which attempted to determine the underlying causes of various phenomena. Like Nimoy, physicians frequently find themselves searching for the answer that underlies certain observations. In this clinical problem-solving exercise, two puzzles needed to be solved. The first involved determining why the patient had nausea, vomiting, and polyuria. The answer was simple: hypercalcemia. The second puzzle entailed elucidating the underlying reason for the hypercalcemia. [Original Article]

Notes

• pico /ˈpaɪ.ko/, /ˈpi.ko/

A Crazy Cause of Dyspnea

A CLINICAL PROBLEM-SOLVING article by Amy Miller from Brigham and Women's Hospital, Boston.
An 18-year-old black woman with a history of asthma presented with fever, ear pain, and dull discomfort on the right side of her chest. On examination, her temperature was 38.8°C, and her right tympanic membrane was inflamed. Radiography revealed air-space opacities in both lower lobes. Azithromycin was prescribed. Her symptoms resolved within 24 hours. Several months later, the patient returned, reporting a nonproductive cough and dyspnea on exertion. Initially, the dyspnea occurred only with coughing, but it slowly progressed to the point of limiting her functional capacity, despite the use of inhaled albuterol. She was given a spacer and peak-flow meter, began using a fluticasone–salmeterol inhaler, and was given a prescription for loratadine. Over the next 2 months, symptoms progressed to the extent that the patient noted considerable dyspnea while walking and occasional dyspnea while talking. She continued to have episodes of nonproductive cough and had occasional night sweats. She had lost about 1.5 kg since her initial presentation.
A chest radiograph revealed the presence of extensive pulmonary opacities, with the most severe in the left perihilar region, and diffuse bilateral involvement sparing the apexes.
In this case, the persistence of symptoms after multiple courses of antibiotics suggested a cause other than community-acquired pneumonia and demanded a broadened differential diagnosis and more aggressive evaluation.
An Interactive Medical Case related to this article is available at NEJM.org. [Original Article]

Notes

• apexes /éɪpəsìːz，ˈæp‐/
• albuterol /̀ælbj́utɚɔl/

Avoiding a Rash Diagnosis

A CLINICAL PROBLEM-SOLVING article by Julie Reznicek from Vanderbilt University Medical Center, Nashville, Tennessee.
A 74-year-old man presented to the emergency department with confusion and lethargy. 2 weeks earlier, his wife noted a decrease in his activity level in association with an unsteady gait and multiple falls. He lived in an urban area in central Tennessee. He was active outdoors and reported feeding a stray kitten daily. On admission, the patient's temperature was 39.3°C. Multiple nonblanching, erythematous, macular lesions were present from the knees to the ankles bilaterally, sparing the soles of the feet.
The differential diagnosis for delirium in an elderly patient is broad. Patients with infectious conditions, such as pneumonia, and those with noninfectious conditions, such as myocardial infarction, may present with delirium and often have no localizing symptoms or fever. Primary neurologic processes that are consistent with this presentation include subdural hematoma, subarachnoid hemorrhage, stroke, and meningoencephalitis. Given his outdoor activities, tickborne diseases and arboviruses need to be considered.
The patient was admitted to the medical intensive care unit, and empirical treatment was begun for bacterial meningitis, HSV encephalitis, and rickettsial infections. He remained febrile, and his level of consciousness declined during the next 6 hours.

Severe Fever with Thrombocytopenia Syndrome virus

"Fever with Thrombocytopenia Associated with a Novel Bunyavirus in China" by Xue-Jie Yu from Chinese Center for Disease Control and Prevention, Beijing.
In 2009, a mysterious illness associated with fever, thrombocytopenia, gastrointestinal symptoms, and leukocytopenia was seen in rural areas in central China, with an initial case fatality rate of 30%.
These investigators isolated a novel virus, designated severe fever with thrombocytopenia syndrome bunyavirus, from patients who presented with fever, thrombocytopenia, leukocytopenia, and multiorgan dysfunction. RNA sequence analysis revealed that the virus was a newly identified member of the genus phlebovirus in the Bunyaviridae family. Electron-microscopical examination revealed virions with the morphologic characteristics of a bunyavirus. The presence of the virus was confirmed in 171 patients with this syndrome from six provinces by detection of viral RNA, specific antibodies to the virus in blood, or both. Serologic assays showed a virus-specific immune response in all 35 pairs of serum samples collected from patients during the acute and convalescent phases of the illness.
A novel phlebovirus was identified in patients with a life-threatening illness associated with fever and thrombocytopenia in China.
In editorial, Heinz Feldmann from National Institutes of Health, Hamilton, Montana, writes that contrary to predictions of the mid-20th century, infectious diseases are on the rise, threatening human and animal health on both local and global scales.
In developing countries that have the largest burden of infectious diseases, strategies for rapid communication of case clusters and outbreaks need to be implemented. The response has to be secure and safe but also rapid and targeted, with the primary goal of immediately supporting public health while providing the best treatment for the affected patient. Early detection and immediate response will save lives and may prevent the next epidemic or pandemic. [Original Article]

参考：＜速報＞　国内で初めて診断された重症熱性血小板減少症候群患者