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.
2013年4月30日火曜日
A Key Miscommunication
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