Case 4-2013

"A 50-Year-Old Man with Acute Flank Pain", a CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by Anna Greka and colleagues.
A 50-year-old man was admitted to this hospital because of left flank pain and fever.
Approximately 6 a.m. on the day of admission, pain in the left flank occurred while he was bicycling. The pain was localized, without radiation, and increased during the next 7 hours from 3 to 8 on a scale of 0 to 10, with 10 indicating the most severe pain.
At a routine annual visit 4 days before admission, the patient reported feeling well. A tetanus–diphtheria–pertussis vaccine booster was administered. During the next 4 nights, he noted mild nausea and temperatures to 38.1°C, without chills, which he attributed to the vaccination.
Fifteen years earlier, a diagnosis of Hodgkin's lymphoma had been made, and the patient had received chemotherapy as well as radiation therapy and splenectomy.
On examination, the patient was alert and oriented and appeared uncomfortable. A holosystolic soft murmur, grade 2/6, was heard at the apex, with radiation to the axilla, and a crescendo–decrescendo systolic murmur, grade 2/6, also was heard at the base, especially at the left upper sternal border.
CT of the abdomen and pelvis showed a focal wedge-shaped defect in the left inferolateral kidney.
Fever in an asplenic patient carries a specific differential diagnosis that is central to the understanding of this case. Another important feature was the presence of heart murmurs.

Lying Low

A CLINICAL PROBLEM-SOLVING article by Anand Vaidya from Brigham and Women's Hospital, Boston.
An 88-year-old woman presented to the emergency room with confusion.
Her symptoms had begun 1 year earlier, with episodes of transient confusion, dizziness, tremors, and anxiety. These episodes occurred unpredictably, were unrelated to eating or physical activity, lasted for minutes before gradual recovery, and had increased in frequency over the year. She felt well between episodes. In addition, she described spells of double vision that were of sudden onset and often independent of her other symptoms.
The patient's medical history included myocardial infarction, hypertension, hypercholesterolemia, mild chronic renal insufficiency, and benign colonic polyps.
On physical examination, the patient appeared well and was no longer confused. The vital signs and examination were unremarkable. Routine laboratory tests, echocardiographic findings and CT of the head were normal. The patient remained asymptomatic and was discharged home with a plan for outpatient follow-up.
2 months after discharge, a close friend witnessed the patient in her home, standing with a blank stare and not responding when her friend spoke to her. When confronted, the patient appeared startled; she ran, tripped, and fell to the floor, after which she was minimally responsive. She was taken to the emergency room and was asymptomatic on arrival.
An interactive medical case related to this case is available at NEJM.org. [Original Article]

The Right Angle

A CLINICAL PROBLEM-SOLVING article by Michael Reed,from University of Michigan Medical School, Ann Arbor.
A 25-year-old man presented to an ER with abdominal distention and discomfort. He had noticed his increased girth a year earlier and attributed it to beer, but it progressed after he cut back. His distention was associated with early satiety, fatigue, and exertional dyspnea.
The patient reported a history of pneumonia after spending spring break in Florida 2 years previously, and he was told at that time that he had “fluid” around his lung and heart.
On physical examination, the patient appeared to be in mild discomfort. There was no evidence of a jugular venous pulse with the head of the bed elevated to 30 degrees. His chest was clear on auscultation, and the heart sounds were regular, with no murmur, rub, or gallop. His abdomen was tense, with shifting dullness and mild, diffuse tenderness.
An electrocardiogram showed sinus rhythm with right atrial enlargement. An ultrasonographic examination of the abdomen showed marked ascites with splenomegaly and a mild increase in liver echodensity. CT of the abdomen and pelvis showed massive ascites and splenomegaly. Laboratory testing for various causes of chronic liver disease was unrevealing. Paracentesis was performed, and 3.5 liters of clear yellow fluid were aspirated.
This case illustrates an unusual cause of ascites in a young man.

A Sweet Source of Abdominal Pain

A CLINICAL IMPLICATIONS OF BASIC RESEARCH article by Shari Rogal from Brigham and Women's Hospital, Boston.
A 25-year-old woman presented to her primary care physician for evaluation of abdominal pain. Her discomfort had begun 6 months earlier and was localized to the right upper quadrant of the abdomen. She described a constant pressure unrelated to food intake that was associated with intermittent nausea and vomiting.
The patient's medical history was notable for type 1 diabetes mellitus, which had been diagnosed in childhood and was complicated by several episodes of diabetic ketoacidosis, hypothyroidism, psoriasis, and a seizure disorder, as well as juvenile rheumatoid arthritis, which was diagnosed when she was 18 months of age, after the development of arthritis in her right ankle and uveitis in both eyes.
On physical examination, the patient was a thin, anicteric woman who was not in acute distress. Laboratory studies showed that the elevated hepatic enzyme levels; the patient also had a high mean corpuscular volume, an elevated blood urea nitrogen to creatinine, and hyperglycemia. Doppler ultrasonography of the abdomen showed hepatomegaly, with no fatty infiltration or vascular abnormalities and normal echogenicity. The kidneys were normal with respect to echogenicity but were enlarged, both measuring 13.9 cm in length.
An interactive medical case related to this article is available at NEJM.org. [Original Article]

Notes

• ketoacidosis: アクセントのない音節のtは無気音になり、タ行かダ行か判別が難しくなります。
• psoriasis: 形容詞形のpsoriaticとともにアクセントの位置に注意。
• uveitis: 内科ではあまり使わない用語にも注意が必要です。
• anicteric: 字面では了解可能だが、アクセントの位置に注意。

CPS要約のテキスト解析(1)

20回分のAudiosummaryのClinical Problem-Solving部分のテキストを解析した。用いたのは、Mac OS X 用のコンコーダンサー"CasualConc"で、対照のテキストには欧米では9歳頃から読まれるという「星の王子さま」の英語版を使用した。χ２乗値を計算して降順にソートすると、上位10語は、patient、article、clinical、pain、woman、year、problem、chest、examination、solveだった。そのうちpatient、chestについてメモしておく。

patient

• 旧来の症例報告では患者を主体とすることは少なかったが、近年「患者中心の医療」の観念の浸透故か、患者が主語となる文章が多くなってきた。
• 個々の患者を扱う"case report"で使用される語なので基本的に単数形。従って"-s"が付いて聞こえるのは、属格形で、後続するのは名詞となる。（多症例を扱う臨床試験の論文では基本的に複数形で現れる。）
• 述語は、受動態(was pp)、report、appear、undergoなどが多い。（日本語では、患者が「訴える」というところで、"report"が使われる。say、tellなどの日常語は使われない。）

chest

• 同意語であるthorax[θɔ'ːræks]、thoracic[θəræ'sik]はあまり使われない。（雑誌名の"Chest"と"Thorax"の例に見るように、米語と英語で差がある可能性はある。）
• chest pain、chest wall、CT of the chest、chest X-ray、chest radiographの形で使われることが多い。
• 蛇足だが、胸を意味するギリシア語には、"στήθος"と"θώρακας"があり、現代も使われている。それぞれGoogle画像検索すると、ニュアンスの違いが分かる。前者の画像検索は場所を考えたほうがよい。英語の"breast"と"chest"にそうとうする

今後も20回分のスクリプトを追加するたびに解析を加えていく予定です。

A Recurrent Problem

A CLINICAL PROBLEM-SOLVING article by Holenarasipur Vikram, from the Mayo Clinic, Phoenix, Arizona.
A 50-year-old woman from Texas had nasal stuffiness, postnasal drip, myalgias, cough, and hoarseness in early winter. She attributed her symptoms to “cedar fever,” a common environmental allergic reaction in Texas, which she had every winter for 3 to 6 weeks.
Six weeks later, her nonproductive cough and hoarseness persisted. She had no fever, chills, night sweats, pain, weight loss, nausea, vomiting, or rash.
Within the past 3 years, she had traveled to nearly every state in the contiguous United States as part of her marketing job and she had recently traveled to Arizona.
CT of the chest revealed a 10-mm spiculated nodule in the medial segment of the left upper lobe.
Flexible videolaryngoscopy which can be reviewed at NEJM.org revealed normal-appearing vocal cords without any lesions, atrophy, or inflammation. However, abduction and adduction of the left vocal cord was severely diminished, confirming paralysis.
On repeat CT of the chest 3 weeks later, the nodule in the left upper lobe had increased to 22 mm. A new 6-mm superior mediastinal lymph node and three new lung nodules were identified in the left apex, left lower lobe, and right lower lobe. [Original Article]

Notes

• abduction: 外転、拉致、アブダクション
• the contiguous United States: 地続きのアメリカ合衆国◆アラスカとハワイを除く48州で構成される、アメリカ本土を指す。

A Sleeping Giant

A CLINICAL PROBLEM-SOLVING article by Alanna Morris from Brigham and Women's Hospital, Boston.
A 71-year-old woman presented to her primary care doctor with abdominal pain and night sweats. Four weeks earlier, a headache, left maxillary sinus pressure, and intermittent night sweats had developed. Amoxicillin was prescribed for presumed sinusitis. Although her symptoms initially abated, after 1 week of treatment, new, diffuse abdominal pain developed, which was dull in character and persisted throughout the day. In addition, she had loose stools and anorexia; and worsening of her night sweats. During the 2 weeks before she saw her physician, she lost 4.5 kg (10 lb) in body weight and her headache recurred.
The patient was referred to the emergency room for further evaluation. She appeared to be in mild distress. She was febrile and tachycardic. Laboratory results were consistent with a systemic inflammatory response, possibly of rheumatologic origin.
The patient remained ill, with fever and abdominal pain. CT of the abdomen revealed abnormal intimal thickening of the thoracic and abdominal aorta that extended into the superior mesenteric artery and the proximal left common iliac artery. An MRI scan of the chest and upper abdomen confirmed diffuse intimal thickening and enhancement in the wall of the thoracic and abdominal aorta.
An interactive medical case related to this article is available at NEJM.org. [Original Article]

Case 3-2013 "Tuberculous peritonitis"

"A 72-Year-Old Woman with Abdominal Pain and Distention after Peritoneal Dialysis", a CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by David Steele and colleagues.
A 72-year-old woman from Southeast Asia with end-stage renal disease was admitted to the hospital because of nausea, vomiting, and abdominal pain and distention. She had been receiving peritoneal dialysis, reportedly had had multiple episodes of peritonitis, and had recently switched to hemodialysis. During the next few weeks, nausea and vomiting developed and were associated with an unspecified loss of weight. Seventeen days before admission, the patient was evaluated for removal of the peritoneal catheter and for creation of an arteriovenous fistula. While the patient was awaiting surgery, abdominal discomfort and constipation developed, nausea worsened, and the frequency of vomiting increased. On current examination, the patient was drowsy but easily aroused, and she answered questions slowly.
Patients with peritonitis occurring in the context of peritoneal dialysis usually present with the onset of systemic and abdominal symptoms. This patient had had pain and systemic symptoms for several weeks. She was no longer receiving peritoneal dialysis. The physicians were not able to determine the location of the pain. The white-cell count was normal in the peripheral blood but was elevated in the peritoneal fluid. Although these findings are suggestive of peritonitis, they could be due to either an infectious or a noninfectious cause. [Original Article]

Looking at the Whole Picture

A CLINICAL PROBLEM-SOLVING article by Carol Donagh, Galway University Hospital, Ireland.
A 50-year-old woman presented with rapidly progressive shortness of breath. Five months earlier, she had received a diagnosis of invasive breast carcinoma and had undergone mastectomy. Her fifth cycle of chemotherapy was completed 10 days before presentation.
On examination, an arterial blood gas analysis showed a pH of 7.47, a partial pressure of oxygen of 49 mm Hg, and a partial pressure of carbon dioxide of 31 mm Hg. A chest radiograph showed no focal abnormality. A transthoracic echocardiogram revealed normal biventricular function, normal valves, and an estimated pulmonary-artery pressure of 22 mm Hg.
This degree of hypoxemia in a patient with a clear lung examination and a normal chest X-ray increases physician's suspicion that she has a pulmonary embolism of thrombotic, septic, or cancerous origin is most likely, given the underlying breast cancer, potential hypercoagulability, and presence of an infusion port.
CT pulmonary angiography showed no filling defects in the pulmonary artery, and the lung parenchyma appeared normal. On the fifth hospital day, after a brief mobilization from her bed to a chair, the oxygen saturation decreased to 78% while the patient was breathing ambient air. The nurses noted that the patient's hypoxemia was substantially worse when she was lying on her left side. [Original Articles]

A Problem in Gestation

A CLINICAL PROBLEM-SOLVING article by Bindu Chamarthi from Brigham and Women's Hospital, Boston.
A 39-year-old woman (gravida 2, para 0) presented to her obstetrician at 32 weeks' gestation with a 2-day history of low back pain. The pain was abrupt in onset and constant. She reported no fever, dysuria, vaginal discharge or bleeding. Preterm labor was ruled out, and she was advised to rest and take acetaminophen as needed.
The patient returned to her obstetrician the next day with worsening pain located in the middle-to-lower back, now with radiation to the upper abdomen. She reported an episode of vomiting that morning. She was referred to the emergency room for further evaluation.
The abdominal examination showed a gravid uterus and epigastric tenderness without rebound or guarding. There was no palpable mass or hepatosplenomegaly and no tenderness at the costovertebral angle.
The patient was transferred to a tertiary-care hospital with a diagnosis of acute pancreatitis.
Pancreatitis is uncommon in pregnancy, and when it does occur, the cause is most often of biliary origin. Plasma triglyceride levels are increased by a factor of two to four during pregnancy, a change that is inconsequential in most pregnant women but that may result, in the presence of an underlying lipid disorder, in severe hypertriglyceridemia, precipitating pancreatitis; however, the triglyceride level is normal in this patient.
An interactive medical case related to this article is available at NEJM.org. [Original Article]

It's Not All in Your Head

A CLINICAL PROBLEM-SOLVING article by Kathryn Towns from University of Toronto, Ontario, Canada.
A 63-year-old man presented to the emergency department with shaking chills and drenching sweats of 4 days' duration. He reported no weight loss, arthralgias, headache, visual changes, or new skin eruptions, but he had progressively worsening bilateral anterior thigh pain of 10 days' duration.
Approximately 6 months earlier, he had had similar symptoms, in addition to myalgias and fatigue. The onset of these symptoms coincided with the initiation of minocycline for the treatment of rosacea. The minocycline was stopped, and the influenza-like symptoms resolved.
The patient's medical history was notable for benign prostatic hypertrophy, a single episode of atrial fibrillation that was successfully managed with cardioversion to sinus rhythm, gastroesophageal reflux disease, and rosacea.
On physical examination, his temperature was 39.2°C. The abdomen was soft, with mild tenderness in the right upper quadrant on deep palpation. The alkaline phosphatase level was 429 U per liter (normal range, 35 to 125). Fractionation of alkaline phosphatase indicated isoenzymes of hepatic origin.
The patient was admitted to the hospital for further evaluation. MRI of the thighs bilaterally revealed diffuse, symmetric soft-tissue, interfascial, and muscle edema. A T2-weighted image showed multiple, small, punctate foci of high signal intensity scattered within the spleen.
Over the next week, the fevers persisted. The alkaline phosphatase level increased further, to 962 U per liter. All medications were discontinued. Extensive testing has failed to yield a diagnosis. A liver biopsy was performed. [Original Article]

A Bird's-Eye View of Fever

A CLINICAL PROBLEM-SOLVING article by Alfred Ian Lee, from Brigham and Women's Hospital, Boston.
A 78-year-old man presented with a 4-month history of worsening fatigue, generalized weakness, and anorexia, and reported an unintentional weight loss of about 25 lb.
He reported subjective fevers, chills, drenching night sweats, dry mouth, a nonproductive cough, dyspnea with minimal exertion, and nausea with occasional emesis. He became light-headed on standing and had become largely bedridden in the preceding month.
The patient reported the development of escalating pain, erythema, and blurred vision in his right eye, without antecedent trauma, 18 months earlier; 1 month before the onset of these symptoms, he had traveled to the Great Smoky Mountains, after which he sustained a brief febrile illness. Ophthalmologic evaluation showed vitritis in one eye.
Vitreous fluid showed a polymorphous cellular infiltrate. CT of the chest revealed mild basilar lung atelectasis and nodules measuring 1.6 cm in diameter on both adrenal glands.
The constellation of symptoms of this patient points to the presence of a disseminated infectious, inflammatory, or malignant process. The antecedent travel to the Great Smoky Mountains is of particular interest. An interactive medical case associated with this article is available at NEJM.org. [Original Article]

A Hidden Solution

A CLINICAL PROBLEM-SOLVING article by Pornpoj Pramyothin from Boston Medical Center and Boston University School of Medicine.
A 51-year-old woman presented to her local emergency room with a 6-month history of intermittent palpitations, which had worsened that day. She described her pulse as fast (it was approximately 140 beats per minute) but regular. She also reported recent worsening fatigue, heat intolerance, and an 18-kg (40-lb) weight loss despite a good appetite.
The patient had had a spinal cord injury at T12 from a car accident at the age of 21 years. The injury resulted in paraplegia with associated fecal and urinary incontinence, for which she underwent a colostomy and a urinary diversion with a Koch pouch (a continent ileal reservoir) that required self-catheterization several times daily.
On physical examination, her pulse was 99 beats per minute, and her blood pressure was normal. An electrocardiogram revealed sinus tachycardia. Ultrasonography of the thyroid gland showed that it was slightly enlarged but diffusely hypoechoic, findings suggestive of autoimmune thyroid disease. The iodine-123 uptake at 24 hours was 1.8% (normal range, 15 to 30).
The patient reported no ingestion of exogenous thyroid hormone, thyroid extract, or other dietary supplements that may have contained iodine. [Original Article]

Notes

• iodine [a'iəda`in]

Breathless

A CLINICAL PROBLEM-SOLVING article by Michael Gavin from Brigham and Women's Hospital, Boston.
A 50-year-old woman presented with fatigue and shortness of breath. Dyspnea after moderate exertion had developed gradually, along with profound malaise and a nonproductive cough. In the 48 hours before admission, her shortness of breath had worsened.
At 47 years of age, the patient had received a diagnosis of high-grade invasive ductal carcinoma of the left breast, clinical stage 2. After participating in a clinical trial, the patient underwent complete mastectomy of the left breast, with no residual carcinoma detected on analysis of the tissue sample, followed by irradiation of the chest wall.
Approximately 1 year before the current admission, a new mammographic density was detected on examination of the patient's right breast. Analysis of the biopsy specimen revealed triple-negative invasive ductal carcinoma. A right mastectomy was performed.And the patient underwent postoperative chemotherapy. A course of radiation to the right chest wall and locoregional lymph nodes, with clinical resolution of the chest-wall nodules, was completed 3 days before the current admission.
At the time of admission, on physical examination, the patient appeared ill and was breathless after speaking a few words. She had hypoxemia and normal breath sounds. An electrocardiogram showed sinus tachycardia.
The history and examination suggested relatively rapid development of a pulmonary vascular process with concomitant right heart failure.
An interactive medical case related to this article is available at NEJM.org. [Original Article]

Case 2-2013 "Cholesteatoma"

"A 20-Year-Old Man with Recurrent Ear Pain, Fever, and Headache", a CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by Konstantina Stankovic and colleagues.
A 20-year-old man was transferred to this hospital because of recurrent ear pain for 8 months despite antibiotics.
8 months earlier pain developed in the right ear; a diagnosis of otitis media was made. During the next 7 months, pain recurred intermittently, despite antibiotics and antimicrobial therapy. Two weeks before admission, headache developed and gradually increased in severity. Four days before admission, he awoke at night with a severe occipital headache and stiff neck, with photophobia, phonophobia, fever, chills, and dizziness. Imaging showed opacification of the middle ears and mastoid air cells and erosion of the right temporal bone.
Mastoiditis, meningitis, proteus and peptostreptococcus bacteremia, and extensive venous sinus thrombosis developed. This patient's symptoms and signs are consistent with an infectious cause. His history and the bacteria identified in his blood are consistent with chronic otitis media, as opposed to recurrent acute otitis media. How can we explain the development of severe chronic otitis media that ultimately led to multiple intracranial complications in this man? The differential diagnosis includes an acquired cholesteatoma, a congenital cholesteatoma, and granulation tissue without a cholesteatoma.

Worth a Second Look

A CLINICAL PROBLEM-SOLVING article by Tyler Berzin from Brigham and Women's Hospital, Boston.
A 72-year-old man presented to his primary care physician for evaluation of fatigue and weight loss. Over the prior 8 months, the patient had lost 16 kg from a baseline weight of 82 kg. During the same period, he began having up to 10 loose stools per day, which he described as voluminous and watery. The loose stools improved with fasting, and the urge to defecate did not awaken him from sleep. There was no history of blood in the stool, fever, chills, or rash.
The patient also reported a poor appetite, with early satiety and a reduced ability to taste foods.
On physical examination, the patient appeared thin and tired. The extremities were warm and well perfused, with 3+ soft, pitting edema of the legs bilaterally. The neurologic examination was notable for diminished sensation of pinprick and vibration in the distal lower extremities bilaterally as well as the absence of ankle reflexes.
The patient had deficiencies in iron, vitamin D, and zinc. Upper endoscopy revealed enlarged folds extending from the stomach to the beginning of the jejunum, with multiple nonbleeding erosions.
The patient preferred symptom management over additional diagnostic testing, and for the next several months, he was followed closely by a nutritionist and a gastroenterologist. His weight stabilized but did not increase, and his diarrhea improved only marginally. Follow-up evaluation by his gastroenterologist revealed new, patchy alopecia with depigmentation of the remaining scalp hairs, as well as onycholysis and yellow discoloration of his nails.[Original Article]

A Startling Decline

A CLINICAL PROBLEM-SOLVING article by Mikael Rinne from Brigham and Women's Hospital, Boston.
An 89-year-old man was brought to the emergency room by his wife and son for an evaluation of changes in cognition and personality. Six months earlier, he began to require help managing finances and operating his computer. He had poor memory for recent events, had difficulty expressing himself, and had become increasingly irritable. He also exhibited unusual behaviors, such as eating a banana peel, pouring milk onto the table, and undressing immediately after getting dressed. He began to have difficulty walking and occasional urinary and fecal incontinence. During the course of several months, he became unable to dress, bathe, use the toilet, or walk independently.
This patient presents with progressive neurologic decline predominantly affecting his thinking and behavior. This pervasive impairment of cognitive function, including memory, language, and personality, is characteristic of dementia, defined as a progressive deterioration in cognition, behavior, or both, without impaired consciousness, that is severe enough to interfere with activities of daily living. In patients presenting with dementia, a variety of causes should be considered, including neurodegenerative, vascular, infectious, or inflammatory disease; neoplasia; toxic or metabolic disorders; hydrocephalus; and psychiatric disorders.
An interactive medical case related to this article is available at NEJM.org.
[Original Article]

Skin Deep

A CLINICAL PROBLEM-SOLVING article by Nasia Safdar from the University of Wisconsin–Madison School of Medicine.
A 56-year-old woman with symptoms of carpal tunnel syndrome for 6 months presented to a referral clinic with nodular lesions on her right forearm and hand and an increase in numbness and tingling in her right hand.
During the previous 3 months, the patient had several appointments with an orthopedic surgeon for carpal tunnel syndrome. The surgeon performed an incision and drainage on one of the forearm lesions, and serosanguineous fluid was noted. Over the next 2 weeks, new lesions formed on the dorsum of her hand and on the palmar side at the base of the middle finger. A carpal-tunnel–release procedure was then performed on the right side. Pathological assessment of biopsy specimens obtained during the procedure revealed granulomas with central necrosis and predominant neutrophilic infiltration. Gram's stain and special stains were negative for bacteria, mycobacteria, and fungi.
She had annual tuberculin skin tests at her job at a medical clinic; after 13 years of negative tests, her most recent test 3 weeks earlier was positive, with 11 mm of induration; a chest radiograph was negative. The patient lived in the midwestern United States. She recalled injuring her thumb on a thorn on a separate occasion approximately 4 months before the nodular lesions appeared.
On current physical examination, the volar aspect of her right arm had a 6-cm surgical incision, with a violaceous area surrounding it.
In this case, the positive tuberculin test provided an important clue.
[Original Article]

Whistling in the Dark

A CLINICAL PROBLEM-SOLVING article by Daniel Solomon from Brigham and Women's Hospital, Boston.
A 38-year-old woman presented  with shortness of breath, fever, and cough productive of yellow sputum soon after the birth of her third child. She received a course of antibiotics for a presumed respiratory tract infection, and her symptoms resolved. Soon thereafter, however, she returned to her physician with an intermittent, nonproductive cough, wheezing, and shortness of breath. She was unable to identify any specific exposures that might have provoked these symptoms, although she noted that her symptoms tended to worsen at night. She reported no fever, orthopnea, leg swelling, or aspiration with swallowing, but she had a history of episodic retrosternal burning that was consistent with gastroesophageal reflux.
The patient's other active medical problems included depression and seasonal allergic rhinitis. She had smoked cigarettes for approximately 10 years and quit 10 years before presentation.  Her examination was notable for her body-mass index, which was 45.4, and loud, diffuse expiratory wheezing in both lungs.
A presumptive diagnosis of asthma was made. However, confirmatory evidence was lacking.
During the ensuing 5 years, the patient required hospitalization as often as once yearly for episodes of severe shortness of breath and wheezing.
After a move from Florida to New Hampshire, her symptoms worsened. During the next 3 years, she required hospitalization every 3 to 4 months for respiratory distress.
An interactive medical case related to this article is available at NEJM.org [Original Article]

The Wolf at the Door

A CLINICAL PROBLEM-SOLVING article by Benjamin Uttenthal, from Royal Free and University College Medical School, London in United Kingdom.
A 29-year-old man presented with a 1-week history of fever, night sweats, reduced appetite, and left upper abdominal pain exacerbated by inspiration.
Eight years previously, the patient had an episode of fever, with raised inflammatory markers that persisted for 12 weeks. He underwent evaluation for cancer and infection, including tuberculosis, but no cause was identified. Joint pains subsequently developed, and he had a positive antinuclear antibody test, at a low titer; he was treated with oral glucocorticoids over a period of 2 months, with resolution of his symptoms.
It was unclear whether the patient's present illness represents a relapse of his prior condition or was unrelated.
Current clinical examination confirmed a temperature of 38.2°C, but the patient appeared well. Laboratory results showed pancytopenia with a low reticulocyte count which indicated a low bone marrow output. The activated partial-thromboplastin time was markedly raised, and failed to normalize with the addition of normal plasma.
The patient was treated with intravenous amoxicillin and clavulanate but continued to have spiking fevers daily, with peak temperatures of more than 38.5°C. Over the next 2 days, headaches, confusion, and muscle cramps developed, as well as proteinuria, and he was transferred to a tertiary care hospital. Laboratory results revealed a very high ferritin level.

Drenching Night Sweat（盗汗） の鑑別診断

• Abscess
• Brucellosis
• HIV
• Lymphoma
• Malaria
• Malignancy
• Menopause
• Subacute bacterial endocarditis
• Tuberculosis

At a Loss

A CLINICAL PROBLEM-SOLVING article by Joseph Merola, from Brigham and Women's Hospital, Boston.
A 31-year-old woman who had been unable to eat or drink for the preceding week was admitted to the hospital. For the preceding 8 months she had had nausea, vomiting, and abdominal discomfort and several episodes of crampy epigastric pain with vomiting and intermittent chills and sweats, but no documented fevers. She also had loose, pale stools occasionally, but these episodes did not represent a notable change from her baseline. Gradually increasing fatigue, loss of appetite, and a recent weight loss of several kilograms were also reported.
The patient's medical history included hypertension, obesity, and migraine headaches. She had undergone Roux-en-Y gastric bypass 5 years before presentation and subsequently lost approximately 45 kg (100 lb). Her weight had been stable for the past few years; her body-mass index was 33.
The increase in the number and severity of symptoms during the previous 8 months suggests a serious disorder, and the gastric bypass surgery raises important issues for consideration. The differential diagnosis at this point is broad and includes disorders of the gastrointestinal tract, liver, and pancreas as well as complications related to the patient's abdominal surgeries. An interactive Medical Case related to this article is available at NEJM.org.  [Original Article]

"At a loss"ってのは、confusionとweight lossを掛けたのだろうけど、日本人にとっては、米国の度量衡のほうが、at a lossです。1lb. = 0.45359237kg、1in. = 0.0254m (1ft = 12in)なので、ポンドとインチで計算したBMIは、703.06958を掛けてやる必要があります。

本題は、Wernicke脳症で、その背景としては、Alcoholism、Bariatric Surgery、Carcinoid Syndrome、Crohn's disease、Chronic gastritisなどに留意が必要である。

Case 1-2013 "Rabies"

10:55| "A 63-Year-Old Man with Paresthesias and Difficulty Swallowing", a CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITAL by David Greer and colleagues.
A 63-year-old man was admitted to this hospital because of paresthesias, difficulty drinking liquids, and anxiety.
4 days before admission, aching developed in the left elbow, which improved with ibuprofen. The next day, right-elbow discomfort occurred, and he had decreased appetite. Two days before admission, he noted difficulty forming words, mild light-headedness, and mild recurrent pain in both elbows. An attempt to drink a glass of water precipitated a gagging sensation. He stopped drinking liquids and became increasingly anxious. One day before admission, he was unable to shower because of increased anxiety and noted intermittent decreased fluency in his speech and pruritus at the nape of his neck. He had no history of animal bites; however, bats had been seen in his home.
On examination, the patient was intermittently very anxious and hyperventilating. When given a cup of water or juice, he gagged as the cup neared his mouth and coughed while attempting to drink.
The approach to a patient with an altered sensorium involves a careful history taking, with particular attention to the time course. There are several considerations in the formulation of the differential diagnosis. These include tetanus, diphtheria, botulism, delirium tremens, drug intoxication or reaction, and rabies. [Original Article]

今回は、aerophobia、hydrophobia...風水恐いと言えば、1956年以降国内で発症がない割に、巷に知られ、恐れられている病気。

Breathtaking Journey

A CLINICAL PROBLEM-SOLVING article by David Rhee, from Brigham and Women's Hospital, Boston.
A 48-year-old man came to the emergency department in early August with a 3-day history of influenza-like symptoms and profound dyspnea on exertion, which had started 3 days after his return to Boston from a vacation in California. On his return flight, subjective fevers, headache, myalgias, and nausea developed, and the patient had one episode of vomiting. Over the next 2 days, a nonproductive cough and profound exertional dyspnea developed. The patient said that he did not have a rash, neck stiffness, visual changes, diarrhea, dysuria, or joint pain.
Three weeks before admission, the patient hiked and camped in the Catskill Mountains for 9 days. On the first night, he slept on the floor of a lean-to, where he observed mice. Two weeks before admission, he removed an attached tick. Then he flew to California and spent 4 days hiking and camping in the San Joaquin Valley.
The evaluation of illness in a returning traveler should include determination of whether events on the trip are causally associated with the illness. A thorough review of the patient's itinerary and activities on the trip is critical for identifying human, animal, or environmental exposures that might explain the patient's presentation. Because potential pathogens associated with travel have different incubation periods, establishing the temporal sequence of events is essential. In this case the relevant documented exposures, in addition to those involving domestic air travel, include tick, mouse, and possibly mosquito and dust exposure. [Original Article]

該当記事は、"Health care providers should be aware of the association between mouse exposure and cardiopulmonary illness in wilderness travelers to facilitate early diagnosis of the hantavirus pulmonary syndrome and initiation of supportive therapy."で締め括られている。もともと朝鮮戦争で出血熱が発生し、後に韓国の医師により漢灘江（한탄강）の鼠からこのウイルスが同定され、名前もそこに由来することやアメリカ合衆国では南西部のfour corners地域のwhite-footed mouseに保有率が高く、そこのウイルスは、米墨戦争における割譲地故にSin Nombre virus（名前なしウイルス）とスペイン語で名付けられていることを知っておくと、記憶に残りやすいかも。NOW@NEJMも参照。

The Eyes Have It

A CLINICAL PROBLEM-SOLVING article by Miten Vasa, from University of California, Irvine.
A 69-year-old man presented to the emergency room 2 hours after he awakened with slurred speech. The patient reported a single episode of sharp, self-limited, periumbilical pain after dinner the previous night, and he had awoken that morning with slurred speech, difficulty chewing, blurry vision in both eyes, generalized weakness, and unsteady gait. He reported drinking one pint of vodka daily, smoking one pack of cigarettes daily for the past 30 years, and smoking “crack” cocaine three times a week, most recently about 24 hours before presentation. On physical examination, the patient appeared in no acute distress. The blood pressure 203/93 mm Hg. Speech was decreased in volume, dysarthric, and almost unintelligible. The dysarthria was most pronounced when he was asked to repeat guttural sounds. There was bilateral rotary nystagmus. Because he reported difficulty chewing, a swallow evaluation was performed later that evening, during which he was unable to transfer soft food from his oropharynx. On the second hospital day, his pupils reacted sluggishly to light and nystagmus was no longer present.
In the early afternoon, before a scheduled MRI and MRA evaluation of the head and neck, the patient was unresponsive, with his eyes closed. He was no longer breathing spontaneously and was intubated. [Original Article]

「神は細部に宿る。"Der liebe Gott steckt in Detail."」の格言に違わず、眼は多くを語る。メンタリズムで有名になった神経言語学プログラミングの分野でも重要視されている。
本症例では、食餌性ボツリヌス症の症状で有名な"Dozen D's"（Dry mouth, Diplopia, Dilated pupils, Droopy eyelids, Droopy face, Diminished gag reflex, Dysphagia, Dysarthria, Dysphonia, Difficulty in lifting head, Descending paralysis, Dyspnea from diaphragmatic paralysis)の１２項目のうち３項目が眼に関する所見で、いずれも感度が上位に位置していることが眼目。

Reference

• "Descending Paralysis Ascending the Path to Diagnosis" Case Studies in Toxicology

An Intricate Interplay

A CLINICAL PROBLEM-SOLVING article by Richard Moseley, from the Veterans Affairs Ann Arbor Healthcare System, Michigan
A 55-year-old man presented with sinus congestion, headaches, chills, mild nausea, fatigue, and a “foggy” sensation that had lasted approximately 1 week. He reported darker urine than usual and had noticed that his eyes were turning yellow. The patient's medical history was notable for hypertension and hyperlipidemia. He consumed one to two alcoholic drinks per night. His medications included baby aspirin, atenolol, hydrochlorothiazide, lovastatin, fexofenadine, fish oil, acidophilus, vitamin D, and calcium carbonate. Three and a half years previously, at routine physical examination, the patient was noted to have mildly elevated liver-enzyme levels. At the time of the patient's current presentation, the examination was notable for scleral icterus and a soft, nontender abdomen with the liver edge palpable less than one finger breadth below the costal margin. Laboratory results which were returned late on a Friday afternoon showed markedly elevated aminotransferase levels, with more modest elevations of the alkaline phosphatase and bilirubin levels. The patient was advised to come to the emergency department that evening for further evaluation. In contrast to the broad differential diagnosis for elevations in serum aminotransferase levels that are less than 5 times the upper limit of the normal range, the causes of severe aminotransferase elevations (>20 times the upper limit of the normal range) are more limited. [Original Article]

A Complex Cause of Pleuritic Chest Pain

A CLINICAL PROBLEM-SOLVING article by Lindsay King from Brigham and Women's Hospital, Boston.
A 33-year-old man presented to the emergency department with pain in the right side of his chest that started 5 days earlier. It originated near his right shoulder blade and radiated throughout his right chest. The pain was worse with deep inspiration and when he was lying down. He also noted mild swelling of his lower legs during the past several weeks. He had mild tachycardia and hypertension. The patient had a history of ulcerative colitis, which had been diagnosed 4 years earlier. He also reported that both his children had contracted streptococcal pharyngitis 1 month earlier.
The clinical evaluation should initially determine whether there is a potentially life-threatening cause of chest pain, including pulmonary embolus, acute coronary syndrome, aortic dissection, or tension pneumothorax. The patient's chest pain worsens with deep inspiration and recumbency, which suggests either a pleuritic cause or a musculoskeletal cause.
An interactive medical case associated with this article is available at NEJM.org [Original Article]

静脈血栓症、膜性腎症、原発性硬化性胆管炎、過敏性大腸症候群の織りなす事例。疫学の世界では、むしろ単一の原因が求められることは稀だが、いざ臨床の場にあると、単一原因を見つけてしまうと安堵して他の原因を見逃してしまうことは往々としてある。特に、医療に限らずカタストロフィは複合要因によって招かれることは肝に銘じておきたい。

A Missed Connection

A CLINICAL PROBLEM-SOLVING article by Prashant Bhave from Northwestern University, Chicago.
A 63-year-old woman presented to the emergency department with edema and red discoloration of the skin of her legs. The edema had first appeared almost 2 years earlier but had worsened markedly within the past week and now extended to her midabdomen. She was able to walk about half a block before stopping to catch her breath. She also reported orthopnea, paroxysmal nocturnal dyspnea, and occasional sharp chest pains while walking. She noted that she had gained weight and had mild leg pain but did not have fevers, chills, or night sweats.
The patient was born in El Salvador and immigrated to the United States when she was 45 years of age. She had a remote history of tuberculosis but did not recall any details of the treatment for it.
A history of tuberculosis could put this patient at risk for constrictive pericarditis. In addition, histoplasmosis, which is also seen in Central America, can cause constrictive pericarditis, as well as fibrosing mediastinitis; either condition could raise cardiac filling pressures.  Because the patient lived in Central America for most of her life, she is also at risk for Chagas' disease. (206 words / 82 sec = 150 wpm) [Original Article]

高拍出性心不全の鑑別診断がポイントです。貧血、甲状腺機能亢進症、脚気、SIRSの他に隠されたつながり、シャント（A-V fistula, Bony shunt, Cardiac shunt）の想起が必要です。

Simple and Complex

A CLINICAL PROBLEM-SOLVING article by Siyang Leng from University of Pittsburgh Medical Center, Pennsylvania.
A 43-year-old man presented to the emergency department with chest pain that had started 1 hour earlier and had awakened him from sleep. The pain was severe, substernal, burning, radiating to the left arm, and accompanied by nausea and vomiting.
On physical examination, he appeared to be in considerable distress, clutching his chest. Cardiac examination revealed a regular rhythm without extra heart sounds, no jugular venous distention, and no lower-extremity edema. The fasting serum glucose level was 192 mg per deciliter. An electrocardiogram showed an acute injury pattern in the anterolateral wall of the heart that was consistent with ST-segment elevation myocardial infarction (STEMI) in the territory of the left anterior descending coronary artery.
The patient underwent left-sided cardiac catheterization. Percutaneous coronary intervention of the left anterior descending artery was performed, and two drug-eluting stents were placed.
On recheck the day after the cardiac catheterization, the white-cell count was 13,800 per cubic millimeter, the hemoglobin level was 15.6 g per deciliter, and the platelet count was 610,000 per cubic millimeter. A peripheral-blood smear showed an increased number of platelets and occasional giant platelets.
This case illustrates that even a seemingly straightforward presentation of a common illness may involve a more complex underlying disorder, which, when recognized, changes the approach to the patient. [Original Article]

Further Reading

• Kardasz I, De Caterina R. Myocardial infarction with normal coronary arteries: a conundrum with multiple aetiologies and variable prognosis: an update. J Intern Med 2007;261:330-348

AudacityでClinical Problem-Solvingを抽出

Audacityが、どういうソフトかということは、Wikipediaを参照してください。ここでは、audiosummaryからClinical Problem-Solvingを切り出す方法についてメモしておく。

1. 「ファイル→取り込み...→オーディオの取り込み...」(Ctrl + Shift +I)でaudiosummaryの音声ファイルを読み込む。
2. 「編集→選択→すべて」(Ctrl + A)でポッドキャスト全体を選択。
3. 「解析→Silence Finder...」で無音部にラベルする。(設定は、無音閾値26-dB、無音持続時間1.5秒、ラベル位置0.7秒とした。)
* 「編集→設定...」(Ctrl + P)でSilence Finderのキーボードショートカットを"Ctrl + Shift + E"とでも設定しておくと便利。
4. ラベルを参考にClinical Problem-Solvingの前後を「編集→オーディオの削除→削除」(Ctrl + K)で削除する。（後を削除してから前を削除すると分かりやすい。）
5. 「ファイル→書き出し」でファイル名をつけて保存する。
* 「編集→設定...」(Ctrl + P)でSilence Finderのキーボードショートカットを"Ctrl + Shift + W"とでも設定しておくと便利。

肝心な部分は耳で確認し、手動での操作となるので間違うこともあり得る。Clinical Problem-Solvingはだいたい１，２分の長さなので、１、２MB程度の容量となる。保存する時にフェールセーフのために容量の確認をすることをお薦めする。

Clinical Problem-Solving

Jerome P Kassirer先生達がHospital Practice誌で始めたClinical Problem-Solvingは、CPCが法学のケースメソッドを医学教育に応用したものであるのに対し、より臨床の現場に即し、認知科学の成果を診断過程に応用したものである。認知科学の裾の広さは、ダニエル・カーネマンらがノーベル経済学賞を受賞したことからも窺い知ることができる。HP誌での連載の成果は、"Learning Clinical Reasoning"にまとめられ、Kassirer先生が1991年NEJM誌の編集長に就任した翌年の今日、NEJMでのClinical Problem-Solvingの連載が始まった。最近出版された"Learning Clinical Reasoning"第二版では、NEJM誌での連載の症例が付け加えられた。翻訳は、岩田健太郎教授が手掛けている。第二版の症例集の部分の目次とNEJM誌のオリジナル記事へのリンクを下に掲げておく。

Diagnostic Hypothesis Generation

• Case 1 Generation of Diagnostic Hypotheses 

• Case 2 Hypothesis Triggering by an Expert 

• Case 3 A Diagnostic Coup 

• Case 4 A Quick and Accurate Solution 

• Case 5 Better Late Than Never

• Case 6 A Hit After a Miss 

• Case 7 The Critical Role of Context in the Diagnostic Process 

• Case 8 A Masked Marauder

• Case 9 A Serious Lack of Focus 

Refinement of Diagnostic Hypotheses

• Case10 What is a Differential Diagnosis? 

• Case11 An Orderly, Sequential Approach 

• Case12 Weak Reasoning: Diagnosis by Drug Reaction

• Case13 Narrowing Down the Diagnostic Options 

• Case14 A Picture is Worth a Thousand Words 

• Case15 Strategies of Information Gathering 

• Case16 A Fatal Flaw in Sutton's Law 

• Case17 How to Disregard Red Herrings 

• Case18 Discrimination: The Problem of Look-Alikes 

• Case19 Location, Location, Location 

Use and Interpretation of Diagnostic Tests

• Case20 Interpreting a Negative Test Result 

• Case21 Diagnosis and the Risks of the Primrose 

• Case22 Path Searching for a Pony 

• Case23 Interpreting Hoofbeats: Can Bayes Help Clear the Haze?

• Case24 Short-Circuiting the Diagnostic Process 

• Case25 The Bypass on the Way to the Bypass 

• Case26 It is What You Believe That Counts 

• Case27 Renal Rescue by Reverend Bayes 

• Case28 A Diagnostic Fluke 

• Case29 Surprise! 

• Case30 Tripping Over Technology 

• Case31 The Probability of a Probability 

Causal Reasoning

• Case32 Judging Causality 

• Case33 Post Hoc, Ergo Propter Hoc 

• Case34 The Case for Causal Reasoning 

• Case35 The Tricky Task of Attributing Causation 

• Case36 The Right Answer for the Wrong Reason 

Diagnostic Verification

• Case37 A Point-By-Point Dissection of Clinical Reasoning 

• Case38 Leaving No Stone Unturned 

• Case39 Verification 

• Case40 A Meticulous Approach 

• Case41 A Diagnostic Quandary 

• Case42 Diagnosis by Fiat 

• Case43 Iron Pyrite and Diagnostic Confirmation 

Therapeutic Decision Making

• Case44 The Surgeon Opts to Operate: Why? 

• Case45 Treat or Keep Testing? 

• Case46 Watch and Wait, or Operate? 

• Case47 An Apple or an Orange? 

Examining Evidence

• Case48 A Difficult Tradeoff  

• Case49 Making Judgments When the Evidence is Not 

• Case50 Definitive Using and Citing Published Evidence 

• Case51 A Little Math Makes the Medicine Go Down

• Case52 A Rewarding Pursuit of Certainty

• Case53 Treating Before Knowing

Cognitive Errors

• Case54 A Defective Detective 

• Case55 Remedies for Faulty Hypothesis Generation

• Case56 A Disaster Averted 

• Case57 Derailed by the Availability Heuristic 

• Case58 Wrong Diagnosis, Wrong Tests, Wrong 

• Case59 Treatment Reconsidering Failures of Therapy 

• Case60 The Cheetah and the Snail 

• Case61 A Collection of Cognitive Diagnostic 

Errors Some Cognitive Concepts

• Case62 A Message about Methods 

• Case63 Memory: How We Overcome its Limitations 

• Case64 Diagnosis and the Structure of Memory;  Disease Polymorphism and Mental Models

• Case65 Intuitive and Inspirational, or Inductive and Incremental? 

• Case66 Knowledge and Clinical Expertise

Learning Clinical Problem Solving

• Case67 Learning Clinical Reasoning from Examples 

• Case68 Making a Silk Purse out of a Sow's Ear 

• Case69 Optimizing Case Discussions

今年の抱負

1. NEJMのポッドキャストのClinical Problem-SolvingのDictation、Shadowing、Reproductionを日々行う。
2. 上記を通じて４月までにコーパスを作成する。
3. 同様のことをCabot Casesで継続する。
4. Cabot Cases Corpusを12月までに作成する。
5. 機械学習の手法を使って症例提示英語のリスニングの速習に関し何らかの成果を抽出する。(具体的には、上記素材の英語のリスニングを３ヶ月で可能にする合理的方法論)

５の機械学習に関しては、右のシロエリハゲワシが表紙のオライリー本がRを使って実践的に学べる模様。ちょうど12章立てなので１ヶ月に１章ずつ、英文・和文両方でじっくり読み進めていくつもり。著者自身によるコードや補足資料がGithubで公開されています。それにしても、英文の電子版が1,485円だから、出版のタイムラグやコスパを考えると、英語のSpeed Readingもぜひ身につけたいスキルの１つ、Kindleでの英語は老眼になりかけた目にも優しいですし…
　もう一冊、本職関連で、「サパイラ(Sapira's Art and Science of Bedside Diagnosis )」を英語、日本語双方でじっくり読んでおきたい。

今年の心構え

• Purpose, Prior Planning, Passion, Patience and Persistence Prevent Piss Poor Performance. 
• Concentration in Core Competance.