A Key Miscommunication

A CLINICAL PROBLEM-SOLVING article by Melissa Kong from Duke University Medical Center, Durham, North Carolina.
An 81-year-old woman presented to the emergency department with increasing abdominal distention, nausea, and vomiting. She also reported increasing shortness of breath and fatigue. She had a history of congestive heart failure, mitral regurgitation, hypertension, atrial fibrillation, hypothyroidism, peptic ulcer disease, and depression.
During the year before presentation, abdominal distention had developed; according to the medical records, ascites had been found. The patient had been treated for presumed congestive heart failure.
On physical examination, the patient appeared to have a long-term illness, but she was in no acute distress. A prominent systolic C-V wave was visible in the neck veins. A diastolic murmur was audible at the left upper sternal border.
Abdominal paracentesis yielded 2 liters of red, hazy serous fluid.
In this unusual case, the patient's slowly progressive symptoms were attributed to her known chronic coexisting conditions and, thus, the diagnostic evaluation was delayed. This case underscores the need to pursue further evaluation when a salient finding, in this case the diastolic murmur, appears incongruous with the presumed diagnosis.

An Unintended Consequence

A CLINICAL PROBLEM-SOLVING article by Nasia Safdar from University of Wisconsin School of Medicine, Madison.
A 79-year-old man with a 5-month history of fatigue and 20-lb weight loss presented to his local physician. The patient also reported intermittent episodes of high temperature, night sweats, and chills. He was treated with a short course of ciprofloxacin, followed by a course of levofloxacin, for a presumed sinus infection, without improvement in his symptoms.
The patient's medical history was significant for coronary artery disease, gastroesophageal reflux disease, hypothyroidism, and transitional-cell cancer of the bladder, which had been diagnosed 4 years earlier and was currently in remission.
Two weeks after completion of antimicrobial therapy, the intermittent fever, fatigue, and night sweats persisted.
An evaluation for fever of unknown origin was undertaken.
CT of the abdomen and pelvis is recommended in patients with fever of unknown origin, and the most common finding is an abscess or lymphadenopathy. In this patient, the CT study revealed an infrequent cause of fever of unknown origin — namely, a likely mycotic aneurysm of the infrarenal aorta. Infected aneurysms of the aorta are rare but potentially catastrophic.
Urgent surgical intervention was warranted for the aneurysm.
A day after the surgery, the additional history was obtained. This lead to the final diagnosis.

「膀胱内BCG注入療法後の結核性腹部大動脈瘤の1例」も御参照下さい。

Back to Basics

A CLINICAL PROBLEM-SOLVING article by Ilan Gabriely from Montefiore Medical Center, Bronx, New York.
A 41-year-old woman was brought by her husband to the emergency department with a history of 72 hours of epigastric pain, nausea, repeated vomiting, and altered mental status. Her blood calcium was found to be 18.9 mg per deciliter.
The physical examination was consistent with a hypovolemic state.
The patient's husband reported that 4 days earlier they had returned from a vacation in Central America, where the patient had consumed “a lot of alcohol.” 3 days earlier, she started having severe abdominal pain, followed by multiple episodes of vomiting.
A few months earlier, she had been told by her primary care physician that she had a mildly elevated blood calcium level of 10.9 mg per deciliter. Her physician was reported that her intact parathyroid hormone (PTH) blood level at her last examination was 33.9 pg per milliliter (normal range, 7 to 53). Medications at home included Tums as needed for abdominal pain and a multivitamin. Habitually, she had been drinking 2 to 3 shots of vodka and some wine daily.
Hypercalcemia of this degree is a medical emergency. The patient with severe hypercalcemia is invariably dehydrated, and the first line of treatment should be vigorous hydration with intravenous normal saline with close observation of blood electrolytes and renal function.
The history of a measurable PTH level in the face of elevated blood calcium suggests that the patient may have primary hyperparathyroidism. The level of hypercalcemia in this case, however, would be extremely rare with primary hyperparathyroidism.

TumsというOTC薬の使用を聞き出せるかどうかが、分かれ道。

A Joint Venture

A CLINICAL PROBLEM-SOLVING article by Abraham Schwarzberg from Massachusetts General Hospital, Boston.
A 59-year-old woman presented with new-onset oligoarthritis and extreme fatigue. 6 weeks earlier, she noted a gradual onset of pain and swelling in her right knee. Two weeks before presenting for care, she began to experience pain in her left knee, followed by an onset of pain and swelling in her left ankle and left wrist. The pain in her joints worsened with movement. In the previous 2 weeks, she had noted fatigue and progressive dyspnea on exertion.
On physical examination, the patient appeared fatigued. The left wrist joint was swollen, with a limited range of motion. Both knees were swollen, warm, erythematous, and painful on palpation. There was periarticular swelling, a reduced range of motion, and pain in her left ankle.
The erythrocyte sedimentation rate and serum ferritin level were strikingly high.
A bone marrow biopsy was warranted.
A few days after admission, the patient's body temperature rose to 39.1°C, and a rash appeared bilaterally on her anterior shins. The rash was erythematous, nonblanching, palpable, nontender, and nonpruritic.
The core-biopsy specimen was nondiagnostic but contained a population of intermediate-size, immature mononuclear cells.
In this case, the joint aspiration provided important additional information.

タイトルのJOINTは、関節と結合を掛けたのでしょう。中年期以降の突発する「関節炎と貧血」の組み合わせは、背景に重篤な疾患を考えましょう、とのこと。

A Gut Feeling

A CLINICAL PROBLEM-SOLVING article by Eddy Fan from University of Toronto, Canada.
A 72-year-old man presented with a 3-month history of watery diarrhea. This condition was associated with intermittent fevers, abdominal pain, and weight loss of 15 lb.
The patient was originally from the Philippines and had immigrated to Canada 8 years earlier. His most recent visit to the Philippines was approximately 9 months before presentation.
Specimens from random colonic biopsies were consistent with nonspecific chronic inflammation with marked eosinophilia. A biopsy of the terminal ileum captured fragments of an adult helminth embedded within the mucosa. The pathology report stated the fragment had features suggestive of a cestode scolex, but the exact species could not be determined.
Because of the low likelihood that infection with a cestode was causing the patient's symptoms and the lack of confirmatory stool testing for an active cestode infection, no antimicrobial therapy was initiated. The patient's symptoms improved. But four weeks later, his diarrhea worsened with associated episodes of first presyncope, then hypotension, for which he was admitted to the hospital.
An important component of clinical problem solving is the concept of “context specificity”; successful clinical reasoning is strongly related to having the appropriate context knowledge. In this case, lack of “context specificity” led to the failure to correctly identify the helminth on initial pathological examination. The discussion also suggests having an effective internet search might have helped with a difficult diagnosis in patient with life-threatning diarrheal illness.

「フィリピン毛細線虫(Capillaria philippinensis)感染」ということだが、ここまで来ると、ネット検索に頼るしかない。コメンテーターも“Philippines” 、“endemic”、 “parasite”、“chronic diarrhea”でググっている。

Beware of First Impressions

A CLINICAL PROBLEM-SOLVING article by Oluwaseun Falade from Johns Hopkins Bayview Medical Center, Baltimore.
A 64-year-old Filipino man presented to a Baltimore hospital with a 4-month history of worsening midback pain, progressive leg weakness, and intermittent bladder and bowel incontinence. He had no fever or pulmonary symptoms. MRI of the thoracic spine revealed hypointense T1-weighted and hyperintense T2-weighted bone marrow signal involving vertebral bodies T2, T3, and T4 findings that were consistent with osteomyelitis; vertebral compression fractures; an epidural fluid collection; and spinal cord compression.
Multiple blood cultures were negative. Because the spine was considered unstable, he underwent T2, T3, and T4 vertebrectomy with fusion from C3 to T8. Pathological studies of the operative specimen revealed granulation and chronic inflammation. No organisms were identified with the use of routine or special stains.
A purified protein derivative (PPD) test was positive, with 12 cm of induration. A chest radiograph did not show cavitary disease or other findings suggestive of pulmonary tuberculosis. On the basis of the clinical presentation and the results of the PPD test, a presumptive diagnosis of vertebral tuberculosis was made, and a regimen of ethambutol, isoniazid, pyrazinamide, and rifampin was started.
The patient then returned to the Philippines. There, despite reporting adherence to his antituberculosis regimen, he began to have high temperatures and drenching night sweats, and he lost 30 lb.

結核と思ったときには、「類鼻疽(melioidosis)」も考慮しましょうってことです。日本も人口減少を補うため、海外からの移民を受け入れることを免れないでしょうから。

Collateral Damage

A CLINICAL PROBLEM-SOLVING article by Daniel Clayburgh from University of Chicago.
A 50-year-old white man presented to the emergency room with an 18-hour history of severe right-sided abdominal and flank pain.
One week earlier, he was hospitalized and diagnosed with widespread deep-vein thrombosis in the left leg. His only known risk factor was an airline flight from Rome to Chicago 1 month earlier. The results of an extensive hypercoagulability workup were normal.
Anticoagulation was initiated with enoxaparin with a transition to warfarin, and he was discharged home 4 days before this admission. On presentation, he was still taking both enoxaparin and warfarin. He awoke early in the morning with severe right-sided abdominal and flank pain.
In the last few hours before presentation his urine had changed to a dark tea color.
This patient's most recent hospitalization was for a classic presentation of a deep-vein thrombus; however, the recent airline flight may be a red herring, since immobility sitting on an airplane several weeks earlier seems unlikely to have contributed to the development of deep-vein thrombosis.
Although this patient's presentation suggested the possible need for surgical intervention, a thorough and methodical investigation coupled with the patience of the patient, who was medically stable, ultimately yielded a diagnosis that was managed with conservative treatment, avoiding unnecessary invasive intervention.

「重複下大静脈の１例」などを参照すると、１％程度の発生率で、多くはないが極端に稀ではない奇形であることを認識しておく必要がある。右胸心が１万人に１人、奇静脈葉が0.4%程度と言われているので、それらよりは多い頻度であるということを知っておいたほうがいいでしょう。

【本】診断のゲシュタルトとデギュスタシオン

サン・ジョルディの善き日に診断学の素晴らしい本を手にした。表紙は編者の肖像を加工したものであろうか？私自身は編者にお会いしたことがなく、ゲシュタルトを把握しておらず断言は出来ないが、分かる人には分かるのであろう。本書の内容を的確に示唆している。
コモンであるがゆえに誤診されやすい疾患やレアであるゆえに誤診を通じて学ばれる疾患、織り交ぜて、分かる人が暗黙知にスポットライトを当ててくれた本である。ぐだぐだ説明するよりも取り扱っている疾患の一覧がこの本の秀逸性を物語ってくれていると思うので、目次から抜粋する。

片頭痛、パニック障害、うつ状態・うつ病、副鼻腔炎、良性発作性頭位めまい症、急性喉頭蓋炎、慢性閉塞性肺疾患、肺血栓塞栓症、モンドール病、急性心筋梗塞、大動脈弁狭窄症、感染性心内膜炎、タコツボ型心筋症、虫垂炎、総胆管結石、急性膵炎、閉鎖孔ヘルニア、大腸憩室炎、肝硬変、輸入脚症候群、菊池病、多発性骨髄腫、好酸球性血管浮腫、Spontaneous retroperitoneal hemorrhage(SRH)、偽痛風、Crowned dens syndrome(CDS)、慢性髄膜炎、リウマチ性多発筋痛症、RS3PE、側頭動脈炎、副腎不全、甲状腺中毒症、シェーグレン症候群、脊椎関節症（炎）、皮膚筋炎、キャンピロバクター腸炎、つつが虫病、パルボウイルス感染症、Lemierre 症候群、腸アニサキス症、成人スティル（スチル）病

このリストの疾患で痛い目に遭っていない医師は、セネカの「過つは人の常、繰り返すは悪魔の業」という言葉に倣うと、神か悪魔かであろう。編者自身、発売前からブログでこの本の発刊を示唆しており、発売後も同ブログで「はじめに」を引用し、その出来に自信を覗かせている。神と悪魔のdégustationを待ちたい一冊である。

Variations on a Theme

A CLINICAL PROBLEM-SOLVING article by Zachary Goldberger from Veterans Affairs Puget Sound Health Care System, Seattle, Washington
A 57-year-old man presented to the emergency department with a 2-week history of progressive dyspnea with exertion, edema of the upper and lower legs, a nonproductive cough, and scant hemoptysis. He also reported the occasional passage of bright red blood from his rectum and intermittent nausea and vomiting during the previous 4 days.
The patient's medical history included hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux with Barrett's esophagus. He was a heavy smoker and he had worked with paint solvents approximately 2 weeks before coming to the hospital but reported no previous exposure to hydrocarbons.
On admission, the patient had tachypnea and his oxygen saturation was mildly depressed. There was conjunctival pallor and dried blood in the oropharynx. Crackles were heard at both lung bases. The cardiac examination revealed an early systolic murmur, grade 1 out of 6. A rectal examination revealed external hemorrhoids.
This seemingly unrelated array of symptoms cannot be readily explained by a single diagnosis, but their simultaneous development tempts the clinician to find a unifying cause.
This case of multiorgan disease has classic themes with interesting variations. A good clinical history with rigorous analysis enabled the discussant to deduce combined diagnoses.

タイトルは、「主題による変奏曲」の意味。

【本】みんなはどう診るこの症状

表紙が、まるで「色彩を持たない多崎つくると、彼の巡礼の年」にそっくりのこの本、日本版簡易Clinical Problem-Solvingといった内容。研修医、指導医に遍く目を通していただきたい一冊です。その理由を3つ挙げると、

1. 記載が簡潔であること：あたり前のことだが、読まないと身にならない。症例呈示も簡潔で各科の医師の思考が箇条書きで記されており、当直の合間にでも読みやすい。
2. 複数分野の専門医の思考が記載されていること：科の異なる複数医師の思考が対比できることで、正解・不正解という短絡思考から免れることができる。
3. Clinical Pearlがまとまっていること：あんまり診断過程には興味がなくて、手っ取り早く自分の日常診療を見直すには、ここだけ読んでも充分有用。

本家のClinical Problem-Solvingは、読むだけでも骨が折れるし、日常のカンファレンスに導入するにも、あそこまでの症例呈示を準備するのには腰が重くなる。「この程度のカンファレンスでも充分ためになるよ」という実践の書としても、嬉しい一冊です。

Fool's Gold

A CLINICAL PROBLEM-SOLVING article by Nicholas Leeper from Stanford University School of Medicine, California.
A 20-year-old man presented to the emergency department after a syncopal episode. During the previous 2 weeks, he had had persistent low-grade fever, anorexia, rhinorrhea, and headache. On the morning of admission, he felt weak and then collapsed while walking into a room; he had no other antecedent symptoms. Once he regained consciousness, he reported having dyspnea. In the emergency department, the patient remained hypotensive and dyspneic. Electrocardiography showed a right bundle-branch block with right-axis deviation, a finding that had not been present 8 months earlier.
Two years earlier, the patient had received the diagnosis of stage IV pre–T-cell lymphoblastic lymphoma. Despite a complete remission after induction and consolidation chemotherapy, he had a recurrence within the year.
After the patient's initial presentation with hypotension, syncope, and ECG evidence of right heart strain, the treating physicians pursued the diagnosis of pulmonary embolism. The patient's long-term use of corticosteroids also prompted consideration of sepsis and adrenal insufficiency. In the process of the evaluation, he was found to have cardiomyopathy. A comparison with previous imaging revealed that there had been rapid progression of ventricular-wall thickening; this was immediately recognized to be pathologic and to point to an infiltrative process. Although a recurrence of the patient's cancer was high on the list of suspected diagnoses, the “gold standard” test — endomyocardial biopsy of the right ventricle — was normal.

"Fool's Gold"は、もともと「黄鉄鋼(Pyrite)」の意味で、金と似ていることから比喩的に「見掛け倒し」の意味でも使われる。本ケースでは、"Golden Standard"が見掛け倒しであるという意味が込められている。

Taken Out of Context

A CLINICAL PROBLEM-SOLVING article by Michael Thomas from University of Michigan in Ann Arbor.
A 25-year-old woman with a history of depression, mitral-valve prolapse, and migraine presented with a 3-day history of fever, arthralgia, and severe generalized headache that was not characteristic of her previous migraines. On examination, the patient was afebrile , with a pulse rate of 120 beats per minute and a blood pressure of 98/41 mm Hg. She was somnolent but easily arousable. The neurologic examination was normal. Laboratory study showed a normocytic anemia and severe thrombocytopenia. A peripheral-blood smear revealed few platelets and some schistocytes. Thrombotic thrombocytopenic purpura was suspected. Plasma exchange and corticosteroid therapy were initiated with improvement of her symptoms and hematologic abnormalities However, five days after discharge, the patient returned because of a recurrent headache and emesis and a falling platelet count to 23,000 per cubic millimeter. Blood cultures now showed β-hemolytic group C streptococcus. A transesophageal echocardiogram revealed ruptured chordae tendineae of the mitral-valve leaflet, possible leaflet perforation, a thickened posterior leaflet, and severe regurgitation. This suggests infective endocarditis, not thrombotic thrombocytopenic purpura, as the unifying diagnosis. This case discussion examines have clinical presentation prompted the incorrect diagnosis and asks as the correct diagnosis should be made earlier.

Keeping an Open Mind

A CLINICAL PROBLEM-SOLVING article by Nasia Safdar from University of Wisconsin–Madison School of Medicine.
A 67-year-old man presented with a 3-month history of fatigue and fever. He had undergone heart transplantation 6 years earlier for idiopathic cardiomyopathy. During the previous several weeks, the patient had been seen by his regular physicians and was initially prescribed oral amoxicillin followed by levofloxacin for nasal stuffiness due to presumed sinusitis, with no change in his fever. Evaluation during this time included a complete blood count, liver-function tests, and routine serum chemical analyses. Results were normal. Serum polymerase-chain-reaction assays for CMV and Epstein–Barr virus were negative. A serum cryptococcal-antigen test was negative. Chest radiography revealed no infiltrate. A CT of the head showed mild hydrocephalus but no focal lesions.
His fever persisted and profound apathy developed. His treating physicians diagnosed depression.
How can clinicians avoid mistakenly ruling out a disease when a highly sensitive test is negative? It is important to remember that no test is 100% sensitive and that technical problems and factors specific to the organism or patient may result in a false negative test. This case highlights another important question: When should we begin treatment for a disease that is suspected but not yet verified?

PDCA要約

P: A 67-year-old man presented with a 3-month history of fatigue and fever.
D: This patient has a prolonged fever without focal symptoms years after a heart transplant.
C: When the diagnosis is elusive, repeating studies or using different diagnostic methods may be necessary. These approaches avoid the cognitive error of “blind obedience,” in which a negative test result inhibits further consideration of a diagnosis despite a high pretest probability of the disease.
A: Cryptococcal meningitis

Needle in a Haystack

A CLINICAL PROBLEM-SOLVING article by Roger Kapoor from Stanford University School of Medicine, California.
A 50-year-old woman reported multiple loose bowel movements associated with mild, cramping abdominal pain. 2 months earlier, her bowel habits changed from one formed stool per day to frequent loose stools of moderate volume. The abdominal pain was variable in intensity and was slightly relieved with defecation.
The patient received a diagnosis of the irritable bowel syndrome, and diphenoxylate–atropine and belladonna–phenobarbital were prescribed. She noted some improvement with this regimen, but she reported tenesmus, and her diarrhea became watery.
Her diarrhea persisted, and occasional nausea, vomiting, fever, and chills had developed.
Six months later, she reported that she was awakened during the night several times each week by fecal incontinence or the need to defecate.
Repeat measurements of potassium showed hypokalemia. Ten months after her initial presentation, the patient had lost a total of 27 lb.
In clinical problem-solving, physicians must continue to evaluate old and new data in order to vigorously evaluate the likelihood of the leading diagnosis. The discussant recognized that in this patient the hypokalemia, nocturnal diarrhea, weight loss, and persistence of watery diarrhea despite medical management were inconsistent with a diagnosis of the irritable bowel syndrome. The patient's partial response to symptomatic treatment appeared to provide the clinicians caring for her with false reassurance and created a sense of premature closure.

瑠璃も針も照らせば光るって諺があります。しつこく光を当て続ければの話で、早期閉鎖してしまうと、診断は闇の中になってしまいます。以前紹介したPDCA(Presenter-Discussant-Commentator-Answer)形式での要約。

P: A 50-year-old woman reported multiple loose bowel movements associated with mild, cramping abdominal pain.
D: Diarrhea is a common symptom with many possible causes.
C: Earlier recognition of secretory diarrhea in our patient would have focused attention on a narrower list of potential causes, allowing the needle — in this case, VIPoma — to be found in the haystack of possibilities.
A: VIPoma 

When Past Is Prologue

A CLINICAL PROBLEM-SOLVING article by Nihar Desai from Brigham and Women's Hospital, Boston.
A 36-year-old man presented to the emergency department with a 2-week history of lower-extremity edema, progressive fatigue, and exertional dyspnea.
The patient's medical history was notable for a fall from a roof 10 months before this presentation. He had traumatic head injury with multiple cranial fractures, including a basal skull fracture, and underwent bifrontal craniotomies. After an extensive rehabilitation period, he achieved almost full functional recovery. Eight months before this presentation, dyslipidemia was diagnosed.
Atorvastatin was started but then discontinued because of myalgias and elevated levels of creatine kinase and aspartate aminotransferase. One month later, his symptoms had improved, but the creatine kinase level had risen to 1200 U per liter. The thyrotropin level was 0.32 mIU per liter.
On examination, the patient appeared chronically ill and in mild respiratory distress.
Rales, S3 gallop, and elevated jugular venous pressure indicate severe left ventricular dysfunction with volume overload. The constellation of hypotension, narrow pulse pressure, and cool extremities is consistent with what has been described as the “cold and wet” classification of acute heart failure, which is a type of cardiogenic shock.
In this case, the first priority is to stabilize the patient. As the patient is being medically stabilized, ongoing investigations of the underlying disease process should continue to focus on possible causes of both his clinically evident cardiomyopathy and a skeletal myopathy.

タイトルは、シェークスピアの戯曲「テンペスト」アントーニオのセリフ"Whereof what's past is prologue, what to come In yours and my discharge."(Act II Scene I)
から。

A Question Well Put

A CLINICAL PROBLEM-SOLVING article by Brendan Reilly from Weill Cornell Medical Center, New York.
A 51-year-old woman with a history of hypertension and depression reported progressively worsening pain in the left thigh over a period of several months, which had made her unable to walk for the past week. She reported having undergone hip surgery 6 months earlier to repair a “stress fracture” of her painful left leg.
At that time, a bone survey revealed generalized osteopenia, confirmed by dual-energy x-ray absorptiometry.
Postoperatively, the patient was treated with vitamin D2 weekly for 3 months and monthly thereafter, as well as physical therapy. She recovered from her surgery and was able to resume walking, but her pain continued.
Physical examination was unremarkable except for severe pain with any movement of the patient's left thigh and tenderness to palpation of both upper arms, several ribs bilaterally, and her lower spine.
Radiographs showed generalized osteopenia, multiple rib fractures, and transverse lytic lesions in the left femur and pubic ramus.
The serum phosphorus level was 1.1 mg per deciliter (normal range, 2.5 to 4.5). The serum level of 1,25-dihydroxyvitamin D was 15 pg per milliliter (normal range, 15 to 60).
Hypophosphatemia, most often caused by renal phosphate wasting, is a potent stimulus of the production of 1,25-dihydroxyvitamin D. Thus, the low-normal serum level of 1,25-dihydroxyvitamin D is surprising. Combined with severe hypophosphatemia, it suggests rare disorders that cause both renal phosphate wasting and down-regulation of 25-hydroxyvitamin D-1α-hydroxylase.

タイトルは、John Deweyの"A question well put is half resolved." から。答えの、hemangiopericytoma-like tumorは、hemangiopericytoma自体、非常に珍しい疾患で私も知らなかった。日本語訳も、血管外皮腫、血管周皮細胞腫、血管外皮細胞腫、血管周皮腫と様々で、定まっていない。

Reference

• Thomas O. Carpenter, M.D. Oncogenic Osteomalacia — A Complex Dance of Factors N Engl J Med 2003; 348:1705-1708

A Red Flag

A CLINICAL PROBLEM-SOLVING article by Reza Fazel from Emory University, Atlanta, Georgia.
A 64-year-old man was brought to the emergency department because of sudden-onset blurred vision in both eyes and diplopia, as well as a frontal headache that had begun earlier that day. On presentation, he was noted to have an altered mental status. His visual symptoms spontaneously resolved shortly after his arrival at the emergency department.
On physical examination, the patient was lethargic, was oriented to person and place but not to time, and had difficulty with word finding.
The hemoglobin level was 11.8 g per deciliter; the platelet count 234,000 per cubic millimeter, and the white-cell count 10,300 per cubic millimeter with  59% eosinophils.
Chest radiography revealed bilateral apical opacities.
This illness is distinguished by its multisystem involvement and the marked eosinophilia.
Complicated cases with multisystem manifestations often force clinicians to consider numerous diagnostic possibilities that span the major categories of disease, including infections, cancer, autoimmune disorders, and metabolic derangements. On occasion, the initial evaluation reveals a distinctive finding, or clinical red flag, that allows the clinician to transform a broad question (What is causing this multisystem illness?) into a more circumscribed problem (What explains this marked eosinophilia?).

Kiss of Death

A CLINICAL PROBLEM-SOLVING article by Brian Graham from University of Colorado Health Sciences Center, Denver.
A 23-year-old South African man presented to an emergency department with a 2-day history of fever, mild dyspnea, headache, nausea, and myalgias. His symptoms had begun 5 days after he had traveled to Colorado to ski with friends. He was thought to have a viral illness, was treated with intravenous fluids, and was discharged with a prescription for acetaminophen–hydrocodone. After 2 days, his symptoms worsened and he returned to the emergency department. A chest radiograph was clear, and he was treated with intravenous fluids and ibuprofen, again without relief. The following day, he returned to the emergency department with vomiting, dyspnea, and photophobia. He was admitted to the hospital for further evaluation and treatment. He was sexually active and had had more than 15 sexual partners in his lifetime. He had traveled extensively the preceding year and had recently driven across South Africa in an uncovered vehicle.
In this patient, disease acquired in Africa as well as more “routine” causes of infection must be considered.
He remained episodically febrile. On day 5 of the patient's hospitalization, the antibiotic regimen was broadened. Liver-function values continued to increase. The patient's mental status declined. He had a generalized tonic–clonic seizure. He was transferred to a tertiary care hospital for further evaluation and possible liver transplantation. Patient's friends revealed that he had left a nightclub with a female companion several days before he became ill.

"kiss of death" というのは、最後の晩餐後、ゲッセマネの祈りを終えたキリストにユダが売り渡す合図のとしての接吻をすることに由来するそうです。「一見ためになるようで実は破滅をもたらすもの」とか、「ありがたくない方面からの（計略的な）候補者支持」、「命取りになるもの」、「災いの元」、「致命傷」などの比喩として使われるようです。
一方、"kiss of life" という表現もあり、イギリス英語で「口移しの人工呼吸」のことで、アメリカ英語のmouth-to-mouth resuscitationのことです。

A Fragile Balance

A CLINICAL PROBLEM-SOLVING article by Asaf Bitton from Brigham and Women's Hospital, Harvard Medical School, Boston.
A 31-year-old man presented to the emergency department with pain in the left shoulder. He had tripped over the shoulder strap of his backpack earlier in the day and noted immediate severe pain around his left shoulder, without paresthesias or neck pain. Physical examination revealed bony point tenderness over the humeral head. Shoulder x-rays revealed an impacted fracture of the left humerus and evidence of osteopenia. His medical history was notable for multiple fractures of the femur, elbow, and wrist, without previous evaluation.
Plain x-rays are not sensitive for bone loss; the fact that osteopenia was detected on such imaging suggests considerable bone loss, and a formal assessment of bone mineral density is warranted. When osteopenia is suspected in a male patient who is younger than 50 years, a careful history taking is essential. The key components should include questions about fractures and the circumstances in which they occurred, growth and pubertal development in childhood, medication use, a thorough review of systems to screen for systemic diseases, and a family history of fractures or systemic diseases. The initial laboratory evaluation should include an assessment for secondary causes of bone loss in young men, with tests of thyroid, parathyroid, renal, and gonadal function, as well as vitamin D levels.

The Essential Element

久々にディクテーションの復活。

A CLINICAL PROBLEM-SOLVING article by Nathan Houchens from University of Michigan Medical School, Ann Harbor
A 21-year-old female college student presented with a 10-day history of progressive fatigue, weakness, light-headedness, exertional dyspnea, and dark-colored urine, followed by an episode of syncope without injury.
On physical examination, the temperature was 38.1°C (100.6°F). There was scleral icterus. Auscultation of the heart revealed regular tachycardia without extraneous sounds.
Laboratory analysis revealed profound anemia, leukocytosis, reticulocytosis, elevated bilirubin and aminotransferase levels, coagulopathy, and hypoalbuminemia.
Three units of packed erythrocytes were transfused, and the hemoglobin level increased from 3.9 g per deciliter to 7.8 g.
However, the patient continued to require multiple erythrocyte transfusions for refractory anemia.
A peripheral-blood smear obtained after the transfusion revealed immature granulocytes and nucleated erythrocytes, marked anisopoikilocytosis, and numerous spherocytes and echinospherocytes.
In this case, although several test results appear to be consistent with hemolysis, the pattern of the aminotransferase levels — that is, the level of alanine aminotransferase being greater than that of aspartate aminotransferase — along with the elevated bilirubin level and coagulopathy continue to suggest an underlying hepatic disorder.

タイトルは、「（診断過程における）必須の要素」と「必須元素」を掛けた、上手い洒落。Discussantのパートのテキストを、Word Cloudsを作ってくれる"Wordle"というオンラインサービスに流し込んでみたのが、下図。

臨床推論のムーブ 暫定版"GESTALT"

Generate a hypothesis. (inductive phase)
例）

• This patient's age, sex and presentation suggest a pathologic process with organ involvement.
• The first things that come to mind are the usual causes of respiratory distress, such as pneumonia, congestive heart failure, or a pulmonary embolus.

Explore the worst case scenario.
例）

• ... are among the “must not miss” diagnoses and should be ruled out.
• ... are not compelling possibilities with this history, but they should be kept in mind.

Sharpen the hypothesis.
例）

• The finding narrowed the broad differential diagnosis.
• The finding leads me to broaden my differential diagnosis.

Tweak the probability
例）

• The presence of ... reduces the likelihood of ...
• The absence of ... raises the possibility of ...

Ask for further information (Proposal of further investigation, Question ... )
例）

• I would also check for the presence of antineutrophil cytoplasmic antibodies and consider a sural-nerve biopsy.
• To look for other possible sources of sepsis, I would order an abdominal CT scan and an echocardiogram.

List some hypotheses in order of priority.
例）

• My three major considerations at this point are ...
• The three most likely diagnoses at this point are ...

TEST the hypothesis (deductive phase) - Timeline review, Explain the findings?, Simple adequately?, Theory-based?
例）

• Because her diagnosis continues to elude me, I would also carefully review her previous test results to try to discover something that is obvious only with hindsight.
• Rheumatoid arthritis could explain subacute symmetric arthralgias in a young woman, but severe pulmonary or cardiac manifestations early in the disease course would be unusual.
• Occam's razor is an issue here — that is, will one diagnosis explain all the findings?
• The pathological findings are consistent with the presence of arteriopathy, venulopathy, and secondary hemorrhagic infarcts; nothing suggests necrotizing vasculitis

SIROメソッドのゴール

目標：

• NEJMのポッドキャストでClinical Problem-Solvingの聴き取りができる。
• 上記素材を聴き取り、臨床推論を呟くことができる。
• 以上２点を３ヶ月で可能とするメソッドを開発する。

素材と方法：

• オリジナル記事から臨床推論部分を抽出、テキスト素材を準備する。済
• ポッドキャストからCPS部分を切り出し、音声素材を準備する。済
• 音声素材のスクリプトを作成。５月中
• 音声素材を10段変速に編集。６月中
• 臨床推論部分をOCHA（Observe, Classify, Hypothesize and Apply）アプローチでジャンル分析。
• ムーブを同定する。
• ムーブ毎の例文集を作成し、mp3化。(Rational Output)６月中

予定成果：

• 10段変速音声とそのスクリプト
• 頻出語のコロケーションの可視化。
• １ムーブにつき10例程度の例文集
• パーソナルユースの電子本作成(Sigil)

参考：

• "Advances in Medical Discourse Analysis: Oral and Written Contexts" Maurizio Gotti,Françoise Salager-Meyer から Philippa Mungra "Macrostructure and Rhetorical Moves in Secondary Research Articles: The Meta-Analysis and the Systematic Analysis"

Introduction section (move 1, 2, 3) 

Move 1: Establishing a territory e.g. centrality claim
Move 2: Establishing a niche e.g. indicating a gap and raising a question
Move 3: Occupying a niche e.g. introducing the aim or identifying the purpose of present study

Methods section (move 4, 5) 

Move 4: Search strategy for selection of studies

• Step 1: Identification and justification of RAs or RCTs , with inclusion and exclusion criteria of selection

• Step 2: Dealing with aberrations or disagreements between researchers

• Step 3: Defining extraction of parameters or subgroups to be compared

Move 5: Procedures used in data synthesis

• Step 1: Extraction of data from roster of publications and researcher blinding for quality control 

• Step 2: Data synthesis, statistical modeling and software used

Results section (move 6)

• Step 1: Data descriptions of tables (Present in MAs, absent in SRs)

• Step 2: Synthetic comment in each result or groups of results

• Step 3:  Generalizing comments from the data tables 

Conclusions section (move 7, 8, 9) 

Move 7: Evaluating the findings and/or claim, indicating whether the findings are concordance with other authors

• Step 1: Restating the purpose of the study and the hypothesis expected

• Step 2: Making a claim supported by data from move 6-3

• Step 3: Indicating limitation to the claim

Move 8: Clinical applications and recommendations
Move 9: Limitations of study and problem areas for further study

Clinical Problem-Solvingを考えるための12文献

と、銘打ってはみましたが、単に右本からの孫引きであります。ですから、概要を知るためには、右本を購入して第一章「内科的診断能力を鍛える」を読むのが手っ取り早いです、日本語でもありますし。ただ、概要で物足りないという方のために（実のところ、後で読む自分の為に）リンク集をこさえてみた訳です。

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