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。