Thinking outside the Box

A CLINICAL PROBLEM-SOLVING article by Ramin Farzaneh-Far from Brigham and Women's Hospital, Boston and colleagues.
A 35-year-old man with advanced AIDS presented to the emergency department after a witnessed syncopal event. He had light-headedness after walking from the bathroom. While speaking to his partner, he suddenly became unresponsive and lost motor tone, and his breathing appeared shallow and labored, prompting his partner to call 911. The man regained consciousness after approximately two minutes and had no recollection of the event. There was no evidence of tonic–clonic seizure activity or postictal confusion. He reported no chest pain, cough, palpitations, pleurisy, vertigo, shortness of breath, fevers, chills, nausea or vomiting, or incontinence.
A detailed history from an eyewitness is invaluable in evaluating a patient with syncope and distinguishing true syncope from seizure. Although this patient's history of HIV infection puts him at risk for several conditions that might result in seizure, the absence of observed sustained tonic–clonic movements, confusion or drowsiness after the syncopal event, and urinary incontinence argue against this diagnosis.
This case highlights the effect of the ability to “think outside the box” is critical to avoid missing this diagnosis, particularly in patients whose underlying diseases may otherwise suggest alternative explanations for presenting symptoms.

重要視されていても正確な診断が困難なのが肺塞栓症。 エコーの所見を2つほどメモ。

• McConnell's sign(hypokinesis of the right ventricular free wall with sparing of the right ventricular apex in the presence of preserved left ventricular systolic function) : sensitivity 77%, specificity 94% 
• 60/60 sign (Pulmonary ejection acceleration time in RVOT of 60ms in the presence of tricuspid insufficiency oressure gradient 60mmHg): sensitivity 26%, specificity 89%