MNEMONICS "I'M VINDICATED"

リーディング13分54秒。

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おそらくは、臨床医学でもっとも実用的なVINDICATEの語呂合わせは、英語版Wikipediaに記載があるほどに有名なのだが、なぜか過去のNEJMのClinical Caseの連載では登場したことがない。ちなみに私は、I'M VINDICATED (Iatrogenic, Metabolic, Vascular, Infection, Neoplastic, Drugs, Inflammatory, Congenital, Autoimmune, Trauma, Endocrine, iDiopathic)で覚えています。VINDICATE以外でも、語呂合わせが引き合いに出される例は少なく、CPCの"Case 9-1984"では、低血糖の鑑別の語呂合わせ"EXPLAIN"が紹介されております。

As a first approximation, the mnemonic that I use for the differential diagnosis of fasting hypoglycemia in an adult is based on the word "EXPLAIN." "EX" refers to exogenous drugs, such as insulin, sulfonylureas, and alcohol. "P" indicates pituitary insufficiency. "L" denotes liver failure and a variety of enzyme deficiencies that affect hepatic glycogenolysis and gluconeogenesis. "A" is for adrenal insufficiency. "I" initially represented islet-cell tumors or hyperplasia but with the description of two new syndromes it also stands for immune-mediated hypoglycemia associated with anti-insulin receptor antibodies and spontaneously occurring anti-insulin antibodies. We more commonly associate such antibodies with insulin resistance, but antibodies of both types have been accompanied by severe hypoglycemia. In vitro antireceptor antibodies are acutely insulinomimetic, which may explain their ability to produce hypoglycemia. "N" refers to neoplasms, nonpancreatic.

Wasting Away

リーディング１１分４５秒。今日もディクテーション第３弾。今更ながらなんだけど、kindleにmacから文書を送れるようになっていることに気がついた。"send to kindle"というサービス。これで、"Wappwolf Away"ですねー。

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A CLINICAL PROBLEM-SOLVING article by Ole-Petter Hamnvik from Brigham and Women's Hospital, Boston.
A 40-year-old woman presented to the emergency department with pain, weakness, and poor oral intake. In the 3 months preceding presentation, she noticed the gradual onset of bilateral diffuse flank pain that progressed to affect her lower back, abdomen, and both arms and legs. She eventually became homebound. The patient reported poor appetite and reduced food intake and had lost approximately 4 kg. Nausea developed 2 days before presentation, and the patient became unable to take anything by mouth, which prompted her to seek evaluation.
The physical examination revealed a cachectic, ill-appearing woman in distress from pain. The medical history included an immature teratoma, which had been treated 10 years before presentation and a history of chronic infection with hepatitis B virus. Because the infection did not respond adequately to the prior regimens, treatment had been changed to tenofovir 10 months earlier.
Laboratory results revealed severe hypokalemia. A bone scan showed multiple abnormal areas with increased tracer uptake, particularly in the left humerus, the right femoral neck, and the bony thorax.
This patient had a dramatic presentation, which raised the suspicion for metastatic cancer. Although the findings on the bone scan strengthened this suspicion, several metabolic abnormalities — including profound hypokalemia and metabolic acidosis — were not consistent with this diagnosis.

Missing Elements of the History

リーディング１１分５６秒。引き続きディクテーション第２弾。

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A CLINICAL PROBLEM-SOLVING article by Larry Allen from University of Colorado School of Medicine, Aurora.
A 59-year-old woman with a history of bilateral total hip replacements and a total knee replacement sees her physician for cough, exertional dyspnea, and foot swelling that had developed 2 weeks earlier while she was on vacation in Denmark. She received a diagnosis of pneumonia and “travel-related edema” and was treated with a course of antibiotics. Over the next week, the patient had progressive dyspnea, edema, and fatigue.
CT of the chest showed cardiomegaly and changes consistent with pulmonary edema; these findings prompted admission to her local hospital. Her jugular venous pressure was 13 cm of water, with normal respiratory variation. Cardiac examination revealed a regular rhythm, normal S1 and S2 sounds, an S3 gallop, and a grade 2/6 holosystolic murmur across the precordium. Cardiac catheterization ruled out coronary disease as the cause of new-onset heart failure. Treatment with furosemide, carvedilol, and lisinopril was initiated.
Despite some initial improvement in symptoms, six months after the onset of symptoms, she was having difficulty climbing one flight of stairs because of progressive dyspnea. Repeat echocardiography showed increased pericardial effusion.
As this case progressed, unusual causes of heart failure were considered. Additionally, the patient learned that her metal-on-metal hip implant was recalled.

An Unusual Case of Abdominal Pain

リーディング１３分５４秒。溜まっていたディクテーションを片付ける。

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A CLINICAL PROBLEM-SOLVING article by Russell Goodman from Brigham and Women's Hospital, Boston.
A 41-year-old man presented to the emergency department with abdominal pain. The pain was excruciating and sudden in onset, originating in his right lower quadrant and radiating to his right groin and flank. It was slightly reduced when he was lying down but was otherwise unaffected by position. He reported nausea and one episode of nonbloody, nonbilious emesis shortly after the onset of the pain. Two weeks before presentation, the patient had had a less severe episode of similar pain but in his left lower quadrant, with radiation to his left flank, which subsequently resolved. He reported that he had had fatigue for several months preceding these episodes.
On physical examination, the patient appeared uncomfortable. Intravenous narcotics were administered.
The initial evaluation of a patient with acute abdominal pain should focus on identifying life-threatening causes and surgical emergencies. This patient's vital signs are reassuring, suggesting the absence of an immediately life-threatening condition, although he has marked hypertension. The history of fatigue may indicate an underlying systemic illness that preceded the episodes of acute pain, but it is nonspecific. The fact that there were two discrete episodes in which the patient had similar symptoms in different distributions suggests an underlying process that is being manifested in different anatomical locations over time.

診断基準

リーディング15分36秒。さすがに繰り返して読んでいると、リスニングは自然と分かるようになる。

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CPSに頻出する診断基準をまとめてみた。

Light's criteria
The high levels of lactate dehydrogenase and protein in the pleural fluid meet Light's criteria for exudative pleural effusion, but they do not point to a specific diagnosis.

Duke criteria
The MRI findings, together with the positive blood cultures, the predisposing cardiac condition of mitral prolapse, and the positive test for rheumatoid factor, satisfy the Duke criteria for the diagnosis of definite infective endocarditis.

Jones criteria
The major Jones criteria are migratory arthritis, carditis, chorea, erythema marginatum, and subcutaneous nodules, and the minor criteria are arthralgia, fever, elevated levels of acute-phase reactants, and a prolonged PR interval.

Wells criteria
Wells' criteria are helpful in predicting the risk of pulmonary embolus. According to these criteria, in the absence of an active malignant condition, a history of deep venous thrombosis, recent immobilization or surgery, or hemoptysis, the patient's tachycardia and clinical symptoms suggest an intermediate probability of acute pulmonary embolus.

その他
The 1997 update of the 1982 American College of Rheumatology revised criteria for classification of SLE is fulfilled by the following findings: a positive test for antinuclear antibodies, immunologic findings (dsDNA), hematologic involvement (lymphopenia), arthritis, and evidence of glomerular injury (proteinuria [>0.5 g of protein per day] and red-cell casts). Serologic studies and clinical features relevant to other glomerulonephritides (anti–streptolysin O, ANCA, and HIV) are negative.

The Great Imitators

リーディング14分22秒。

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William Oslerが多彩な臨床像を呈する梅毒を称して"The Great Imitator"と言ったことに始まる。現在では、臨床像が多彩で他疾患と鑑別が困難な疾患を一般に指すようになった。同義の表現に、red herrings, mimic, masquerade as, protean manifestationsなどがある。NEJMのClinical Caseの記事に出てくるものだけでも下記のような疾患がある。

1. Since syphilis is known as “the great imitator,” and syphilitic hepatitis is rare, it is not surprising that the diagnosis of cholestatic jaundice due to Treponema pallidum infection was delayed. "A Hand-Carried Diagnosis"
2. Melioidosis has protean manifestations and has been called the "great imitator," apparently usurping that title from syphilis. "Case 22-2001"
3. Xanthogranulomatous pyelonephritis is the great imitator of renal neoplasms and remains difficult to diagnose. "Case 17-2000"
4. Like syphilis, the acquired immunodeficiency syndrome, and systemic lupus erythematosus, carbon monoxide poisoning is a great imitator. "Pain in the Marriage"
5. Osler's classic characterization of syphilis as the great imitator also applies to certain autoimmune diseases, such as systemic lupus erythematosus and the primary antiphospholipid syndrome. "Case 4-1995"
6. Syphilis, known as the "great imitator," could have caused the penile lesion and lymphadenopathy. "Case 45-1994"
7. Secondary syphilis, "the great imitator," can have a variety of manifestations similar to those of the acute illness in this patient. "Case 1-1992"
8. Bronchioloalveolar-cell carcinoma has been described as "another great imitator." "Case 17-1991"
9. Nevertheless, we must always remain respectful of aortic dissection, the modern-day "great imitator," as Dr. Roman W. DeSanctis has frequently emphasized. "Case 27-1990"
10. Even HIV infection, the great imitator of this generation, is difficult to force into this mold. "Case 40-1990"
11. Another infectious disease that is a great imitator is syphilis, and this patient, having had gonorrhea, should be considered at risk for this other venereal disease. "Case 36-1985"
12. The renal-cell carcinoma has been referred to as "the great imitator" and "the internist's tumor." "Case 5-1981"
13. Endocarditis has replaced syphilis as "the great imitator" in elderly patients and certainly has to be considered in any elderly person who presents with cardiac failure. "Case 10-1974"

"suspect"と"doubt"

リーディングは、14分32秒。リスニングに関しては右本が示唆に富む。

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"The medical history raises the suspicion for metastatic cancer as the cause of her symptoms."という文に出会ったが、suspicionの動詞"suspect"は、"doubt"と紛らわしい。下記のように覚えれば、いいらしい。

I suspect  I think so（そう思う）
I doubt  I don't think（でないと思う）

語源辞典を参照すると、"doubt"のほうは、ラテン語の"dubitare"由来だそうです。「２つから選ばなくてはならない状況にある」ことが原義だそうで、何故、黙字の"b"があるのか、whetherを伴うことが多いのか納得がいきます。そう言えば、ドイツ語の「疑い」"Zweifel"にも「２」(zwei)が入ってますね。