Clinical Cases and Images

2010-12-01T20:49:00.003-05:00

Clinical Cases by Organ System. Click on the menu buttons above to explore the cases.

After a few weeks of clinical practice, medical students and residents realize that patients are often different from the classic disease descriptions in the textbooks. One experienced physician summarized this by saying: "his asthma did not read the book." How to bridge this gap between theory and practice? Our answer was to create this free case-based curriculum of clinical medicine. ClinicalCases.org was featured in the British Medical Journal and Medscape.com, and was referenced several times in the medical education literature. The project is hyperlinked in the websites of 31 medical schools in the U.S., Canada, South America, Europe and Asia, and has had more than 4 million page views since 2005.

This case-based curriculum was started by physicians at Cleveland Clinic and Case Western Reserve University for the purpose of medical education. The published reports do not follow real cases. Health professionals are invited to submit cases of educational value without HIPAA identifiers through an online form. Please read the website disclaimer.

Physical Examination Videos

2010-08-01T06:01:00.000-04:00

Vocal vs. tactile fremitus? Percussion of the spleen? You can refresh your physical exam skills by reviewing medical videos offered by several U.S. medical schools and other organizations.

Electrocardiograms, X-rays, CT scans

2010-08-01T05:03:00.005-04:00

Electrocardiograms (ECG/EKG)
ECG Wave-Maven by Harvard Medical School is a fully-fledged ECG-trainer. You can browse through typical or not so typical EKGs in the EKG World Encyclopedia by McGill University. Check out the arrhythmia simulator by SkillStat with a play, pause and quiz mode. ECG Palm Brain is a useful online and PDA reference. Our own A Systematic Approach to Electrocardiogram (ECG, EKG) Interpretation by Using 2 Mnemonics also be helpful along with EKGs with Dr. Koch: It's Not Only Educational It's Also Fun!

ECG Video part 1: For Med Students studying the basics of reading an electrocardiogram, from the University of Wisconsin. See part 2 of the video on YouTube.

X-rays and CT scans
The University of Virginia has a comprehensive web site dedicated to CXR and CT scans. Compare what you see on the screen to the CT scans of your patient. You are not sure if this is the tail of the pancreas? Just click with the mouse and the anatomical structure is colored in red. ICU CXR is another useful website from University of Virginia. It will answer such burning questions as "Is the central line where it is supposed to be?" or "Does he have a pneumothorax?!"

See more links by APDIM E-Learning Task Force: Cardiac Auscultation, Chest X-Rays, Electrocardiograms, Patient Images (Dermatology), Pulmonary Function Tests, 2009.

Procedure Guides Step-by-Step

2010-08-01T04:30:00.001-04:00

Central line placement. See also Central line placement with ultrasound guidance.
Thoracentesis (pleural tap)
Paracentesis (ascites tap)
Arthrocentesis (joint tap)
Arterial line placement is illustrated in The Internet Journal of Health.
Lumbar puncture in eMedicine
More procedure links

Clinical Images from NEJM

2010-08-01T03:04:00.003-04:00

Question & Answer

2010-08-01T02:00:00.001-04:00

Click for the answers of clinical questions from everyday practice.

Web Site Disclaimer

2010-08-01T01:50:00.004-04:00

Click here for full text.

All opinions expressed here are those of their authors and not of their employer.

Information provided here is for medical education only. It is not intended as and does not substitute for medical advice. If you are a patient, please see your doctor for evaluation of your individual case. Under no circumstances will the authors be liable to you for any direct or indirect damages arising in connection with use of this website.

The appearance of external hyperlinks to other websites does not constitute endorsement. We do not verify, endorse, or take responsibility for the accuracy, currency, completeness or quality of the content contained in these sites.

There is no real life patient data on this website. Please note: we do not write or “blog” about patients. All case descriptions are fictional, similar to the descriptions you can find in a multiple choice questions textbook for board exam preparation. Cases course and description do not follow real cases. Report a suspected HIPAA violation to: clinicalcases@gmail.com.

Updated: 10/01/2009

Clinical Cases in Test Format

2009-12-17T15:33:00.002-05:00

Editor: V. Dimov, M.D.

The answers are provided at the end of each case.

Anemia with hemoglobin 4.2 mg/dL. What is the cause?

Shortness of breath and diffuse ground glass pattern on CT of the chest. What is the cause?

Abdominal pain in a 93-year-old male. What is the cause?

Elderly female with CHF complains of abdominal pain, nausea and vomiting, dizziness, and confusion for 5 days. What is the cause?

Published: 05/17/2009
Updated: 07/28/2009

Radiology Resources

2009-11-05T09:42:00.002-05:00

The University of Virginia has a comprehensive web site dedicated to CXR and CT scans.

ICU CXR is another useful website from the University of Virginia.

Head CT Interpretation. Vanderbilt University, audio-enabled slideshow.

APDIM E-Learning Task Force: Cardiac Auscultation, Chest X-Rays, Electrocardiograms, Patient Images (Dermatology), Pulmonary Function Tests, 2009.

Published: 11/05/2009
Updated: 11/05/2009

Spontaneous Primary Pneumothorax

2009-08-24T08:15:00.007-04:00

Authors: V. Mundra, M.D., J. Zapatier, M.D., H. Feiz, M.D., Cleveland Clinic Florida
Reviewer: V. Dimov, M.D.

A 16-year-old male patient came to the emergency department with complaints of shortness of breath and chest pain which started one day ago. The shortness of breath was mild in severity, made worse by exertion and relieved with rest, associated with pleuritic chest pain, left sided, 5-6/10, sharp in nature. He denied any similar symptoms in the past.

Past medical, social, surgical and family history

He also denied any use of illicit drug like cocaine or and any history of trauma. He did not have any past medical history or past surgical history. He had no family history of premature CAD or asthma. He did not smoke or drink alcohol. He was on no prescription medications and he participated in sports without any difficulty.

Physical examination

Blood pressure was 112/70 mm/Hg, HR 90 bpm, temp. 98.7 F and RR was 23/min, SpO2 90 % on room air. His height was 5’10’’ with BMI of 19.9. He was in mild respiratory distress. HENT exam was unremarkable. No crepitus was felt. Trachea was in the midline. On auscultation, there were no breath sounds on the left side with hyperresonance on percussion. S1 and S2 were normal with no murmurs/rubs or gallops. The abdomen was unremarkable. No pedal edema was appreciated. No clinical stigmata of Marfan’s syndrome like high arched palate or increased arm span were observed.

What is the next step in the management of this patient?

A chest X-ray was done which showed a large left pneumothorax with tracheal deviation to the right (figure 1). An emergency chest tube was placed and the lung re-expanded (figure 2).

Figure 1. A large left pneumothorax with tracheal deviation to the right (click to enlarge the image).

Figure 2. An emergency chest tube was placed and the lung re-expanded (click to enlarge the image).

CBC and BMP were normal. Urine toxic screen was negative. A CT scan of the chest was done which did not show any blebs/bulla or lung parenchymal abnormalities.

What happened next?

The chest was clamped after 48 hours but the pneumothorax expanded. Subsequently, he was given two more trials of clamping which were unsuccessful. Finally, after a week he was taken to surgery for a possible bronchopleural fistula leak. During surgery, he was found to have a bulla at the apex of the lung which was ligated. He tolerated the procedure well and the pneumothorax did not recur.

Diagnosis

Spontaneous Primary Pneumothorax.

Summary

Types of pneumothorax

Pneumothorax is the collection of air in pleural space.

1. Primary pneumothorax occurs in the absence of any lung disorder. It occurs mostly in tall thin young men. A subset of the patients may be predisposed by a genetic disorder, Marfan’s syndrome.

2. Secondary pneumothorax results from an underlying lung disorder. It may result from trauma, asthma, COPD, cystic fibrosis, or whooping cough. Smoking has been shown to increase the risk of pneumothorax.

3. Tension pneumothorax results from continuous/large air leak resulting in compression of great vessels of thorax and other structures.

Clinical symptoms of pneumothorax

Chest pain, dyspnea, chest tightness or hypotension.

Physical examination findings in pneumothorax

Decreased or absent breath sounds and hyperresonance on percussion on the affected side. Tracheal deviation may be evident.

Investigations in pneumothorax

A chest x-ray should be done to make the diagnosis. ABG may be needed.

Management of pneumothorax

The management of the patient depends on the extent and type of the pneumothorax.

A small-size primary spontaneous pneumothorax may be observed in ED with a follow-up chest x ray in 3-6 hours. The patient may be discharged home with a follow-up in 12-24 hours and a repeat chest x-ray to document the resolution of pneumothorax. Patients with a primary spontaneous pneumothorax with a large pneumothorax who are clinically stable should receive a chest tube with or without suction. They need a follow-up chest x-ray in 48 hours. Patients with primary spontaneous pneumothorax who are not stable should undergo urgent large bore 22-24F chest tube placement with suction.

In contrast, patients with a secondary pneumothorax with a small pneumothorax who are clinically stable, should be hospitalized and have a chest tube inserted because of the higher risk associated with it. Patients with a secondary penumothorax with a large pneumothorax who are clinically stable/unstable should undergo an urgent chest tube placement with suction.

The chest tube may be removed after 48 hours. The suction should be discontinued, if applied, at least 6 hours before the chest tube removal. A check x-ray should be done after the chest tube removal to check for an air leak.

Persistent air leaks

Patients with prolonged air leaks should be observed for 4-7 days before advancing to a surgical procedure. However, more prolonged delays may decrease the effectiveness of thoracoscopy and increase the cost of care.

References

1. M H Baumann, C Strange, J E Heffner et al. Management of Spontaneous Pneumothorax-An American College of Chest Physicians Delphi Consensus Statement: CHEST February 2001 vol. 119 no. 2 590-602.
2. Waller, DA, McConnell, SA, Rajesh, PB Delayed referral reduces the success of video-assisted thoracoscopic surgery for spontaneous pneumothorax. Respir Med 1998; 92,246-249.
3. Schramel, FM, Sutedja, TG, Braber, JC, et al Cost-effectiveness of video-assisted thoracoscopic surgery versus conservative treatment for first time or recurrent spontaneous pneumothorax.

Cite this article as:

Mundra V, Zapatier J, Feiz H. Spontaneous Primary Pneumothorax. Clinical Cases and Images. Retrieved on August 24, 2009, from http://clinicalcases.org/2009/08/spontaneous-primary-pneumothorax.html.

Published: 08/24/2009
Updated: 08/24/2009

Neurology: Images in Clinical Medicine

2009-08-21T23:28:00.006-04:00

Editor: V. Dimov, M.D.

Occlusion and Reperfusion of the Middle Cerebral Artery. NEJM, 12/2007.
Dissecting Aneurysm of the Posterior Cerebral Artery. NEJM, 12/2007.
Retinal Arteriolar Cholesterol Emboli. NEJM, 02/2008.
Cerebral Embolism of Probable Aortic Origin. NEJM, 04/2008.
Changes in the Brain Stem and Fundus in Malignant Hypertension. NEJM, 05/2008.
Ocular Trauma Due to a Water-Bottle Cap. NEJM, 05/2008.
Severe Constipation. NEJM, 05/2008.
Central Hemiretinal Arterial Occlusion. NEJM, 06/2008.
Horizontal Pendular Nystagmus in a Patient with Ocular Albinism. NEJM, 07/2008.
Periungual Fibromas in Tuberous Sclerosis. NEJM, 09/2008.
Central Pontine Myelinolysis. NEJM Images in Clinical Medicine, 12/2008.
Monocular Paralysis of Vertical Ductions after Facial Trauma. NEJM, 01/2009.
Medication-Induced Gingival Hypertrophy. NEJM, 01/2009.
Traumatic Epidural Hematoma. NEJM, 02/2009.
Pendular Nystagmus and Palatomyoclonus from Hypertrophic Olivary Degeneration. NEJM, 02/2009.
Percussion Myotonia in type 1 myotonic dystrophy. NEJM, 03/2009.
Keyhole Pupils: Colobomas. NEJM, 04/2009.
Bilateral Subacute Subdural Hematomas. NEJM, 04/2009.
Combined-System Disease due to Vitamin B12 Deficiency. NEJM, 06/2009.
Traumatic Bleb. NEJM, 07/2009.
Myotonic Dystrophy. NEJM, 07/2009.
Retinal Detachment in Malignant Hypertension. NEJM, 08/2009.
Sigmoid Volvulus. NEJM. 09/2009.
Picture quiz: Eye sign in an 18 year old man with psychosis. BMJ, 09/2009.
A tumor of the iris. NEJM, 09/2009.
Unilateral Rhinorrhea in Allergic Rhinitis Due to... Cerebrospinal Fluid Leak. NEJM, 10/2009.
Keratoconus Complicated by Acute Corneal Hydrops. NEJM, 10/2009.

Published: 08/21/2009
Updated: 09/30/2009

Infectious Diseases: Images in Clinical Medicine

2009-08-21T23:26:00.002-04:00

Editor: V. Dimov, M.D.

Herpetic Glossitis. NEJM, 08/2007.
Purple Urine. NEJM, 09/2007.
Retiform Purpura. NEJM, 01/2008.
Crystalluria from Acyclovir Use. NEJM, 03/2008.
Ascariasis. NEJM, 04/2008.
Vestibular Papillomatosis. NEJM, 04/2008.
Clonorchis sinensis. NEJM, 04/2008.
Babesiosis. NEJM, 04/2008.
Keratoderma Blennorrhagica. NEJM, 05/2008.
Allergic Bronchopulmonary Aspergillosis. NEJM, 08/2008.
Corneal Dendritic Ulcer from Herpes Simplex Virus Infection. NEJM, 10/2008.
Ocular Myiasis. NEJM, 11/2008.
MRSA: The Hands Give It Away. NEJM, 01/2009.
Pediculosis of the Pubis. NEJM, 02/2009.
Lymphedema Tarda. NEJM, 03/2009.
Green Nails due to Pseudomonas aeruginosa. NEJM, 03/2009.
Cutaneous Anthrax. NEJM, 07/2009.
Air in the Urinary Tract due to emphysematous cystitis. NEJM, 07/2009.
Tortuous Varicosities in Chronic Schistosomiasis. NEJM, 08/2009.
An itchy ear that became painful: otitis externa with cellulitis. BMJ, 09/2009.
Pachyderma due to scabies. NEJM, 10/2009.

Published: 08/21/2009
Updated: 10/08/2009

Rheumatology: Images in Clinical Medicine

2009-08-21T23:25:00.003-04:00

Editor: V. Dimov, M.D.

Paget's Disease of the Mandible. NEJM, 02/2008.
Sarcoid Arthropathy. NEJM, 02/2008.
The Aorta in Osteoporosis. NEJM, 05/2008.
Severe Kyphosis. NEJM, 06/2008.
Systemic Sclerosis and Acral Osteolysis. NEJM, 06/2008.
Ankylosing Spondylitis. NEJM, 07/2008.
CREST Syndrome and Colonic Saccular Diverticula. NEJM, 09/2008.
Occult Hip Fracture. NEJM, 12/2008.
Subungual Exostosis. NEJM, 12/2008.
Chondrocalcinosis and Hypomagnesemia. NEJM, 01/2009.
Gingival and Periungual Vasculopathy of Juvenile Dermatomyositis. NEJM, 04/2009.
Familial Hypercholesterolemia. NEJM, 04/2009.
Lupus-Associated Intestinal Vasculitis. NEJM, 07/2009.
Baker's Cyst in a Patient with Rheumatoid Arthritis. NEJM, 09/2009.
Gouty Tophi. NEJM, 11/2009.

Published: 08/21/2009
Updated: 11/18/2009

Hematology and Oncology: Images in Clinical Medicine

2009-08-21T23:23:00.007-04:00

Editor: V. Dimov, M.D.

A Cobwebbing Trabecular Bone Pattern in β-Thalassemia Major. NEJM, 11/2007.
Reversal of Laryngeal Paresis in non–small-cell lung cancer. NEJM, 12/2007.
Leukemic Gingival Infiltration in AML. NEJM, 01/2008.
Chronic Venous Insufficiency and Dystrophic Subcutaneous Calcification. NEJM, 02/2008.
Erlotinib-Induced Hair Alterations. NEJM, 03/2008.
Babesiosis. NEJM, 04/2008.
Fluorescence Diagnosis of Subclinical Actinic Keratoses. NEJM, 05/2008.
Vitiligo and Cutaneous Melanoma. NEJM, 07/2008.
Dynamic Tumor Staging. NEJM, 07/2008.
Squamous-Cell Carcinoma Manifesting as a Cutaneous Horn. NEJM, 08/2008.
New-Onset Clubbing Associated with Lung Cancer. NEJM, 09/2008.
Gingival Hypertrophy and Leukemia. NEJM, 10/2008.
Keratoacanthoma. NEJM, 10/2008.
What Lies Beneath a Pacemaker? Bronchogenic Adenocarcinoma. NEJM, 10/2008.
Binocular Proptosis in Orbital Lymphoma. NEJM, 11/2008.
A Smooth, Shiny Tongue. NEJM, 02/2009.
Leukocytosis and Sublingual Microvascular Blood Flow. NEJM, 02/2009.
Venous Obstruction of the Thigh. NEJM, 03/2009.
White Tongue due to Palifermin. NEJM, 05/2009.
Tongue Necrosis in a Patient with Essential Thrombocytosis. NEJM, 05/2009.
Combined-System Disease due to Vitamin B12 Deficiency. NEJM, 06/2009.
Giant Congenital Nevus. NEJM, 09/2009.
Acquired Melanonychia after hydroxyurea treatment. NEJM, 09/2009.
A tumor of the iris. NEJM, 09/2009.
Pelvic Spleen. NEJM, 09/2009.
Pachyderma due to scabies. NEJM, 10/2009.
A 79 year old woman with a swollen right leg due to lymphoma. NEJM, 10/2009.
Swinging of the heart and electrical alternans due to a large pericardial effusion. NEJM, 10/2009.

Published: 08/21/2009
Updated: 10/28/2009

Endocrinology: Images in Clinical Medicine

2009-08-21T23:22:00.002-04:00

Editor: V. Dimov, M.D.

Hypogonadism Due to Pituicytoma in an Identical Twin. NEJM, 01/2009.
Chondrocalcinosis and Hypomagnesemia. NEJM, 01/2009.
The Aorta in Osteoporosis. NEJM, 05/2008.
Severe Kyphosis. NEJM, 06/2008.
Widened Mediastinum: Mediastinal Extension of a Goiter. NEJM, 03/2009.
Chvostek's Sign and Carpopedal Spasm. NEJM, 04/2009.
Familial Hypercholesterolemia. NEJM, 04/2009.
Graves' Hyperthyroidism. NEJM, 06/2009.
Investigating infertility. BMJ, 09/2009.
Injection-Site Lipoatrophy. NEJM, 11/2009.

Published: 08/21/2009
Updated: 11/12/2009

Nephrology: Images in Clinical Medicine

2009-08-21T23:20:00.002-04:00

Editor: V. Dimov, M.D.

Renal Failure from Vitamin C after Transplantation. NEJM, 01/2008.
Green Urine. NEJM, 03/2008.
Crystalluria from Acyclovir Use. NEJM, 03/2008.
Bladder Foreign Body. NEJM, 06/2008.
Bilateral Kidney Calcifications. NEJM, 07/2008.
Peculiar Morphology of Stones in Primary Hyperoxaluria. NEJM, 07/2008.
Uremic Frost. NEJM, 2005.
Chvostek's Sign and Carpopedal Spasm. NEJM, 04/2009.
Visualising rhabdomyolysis. Lancet, 01/2009.
Air in the Urinary Tract due to emphysematous cystitis. NEJM, 07/2009.
Thoracic Kidney. NEJM, 10/2009.

Published: 08/21/2009
Updated: 10/21/2009

Pulmonology: Images in Clinical Medicine

2009-08-21T23:19:00.005-04:00

Editor: V. Dimov, M.D.

Reversal of Laryngeal Paresis in non–small-cell lung cancer. NEJM, 12/2007.
Severe Kyphosis. NEJM, 06/2008.
Dynamic Tumor Staging. NEJM, 07/2008.
Allergic Bronchopulmonary Aspergillosis. NEJM, 08/2008.
New-Onset Clubbing Associated with Lung Cancer. NEJM, 09/2008.
What Lies Beneath a Pacemaker? Bronchogenic Adenocarcinoma. NEJM, 10/2008.
Recurrent Aspiration Pneumonia. NEJM, 11/2008.
"Popcorn" Calcifications in a Pulmonary Chondroid Hamartoma. NEJM, 03/2009.
Widened Mediastinum: Mediastinal Extension of a Goiter. NEJM, 03/2009.
Pulmonary Arteriovenous Fistula. NEJM, 04/2009.
Infection 57 Years after Plombage. NEJM, 06/2009.
Plombage Cavities. NEJM, 06/2009.
Chest radiography of life-supporting medical interventions labeled from A to K. Lancet, 08/2009.
Unilateral Epistaxis. NEJM, 08/2009.
Unilateral Rhinorrhea in Allergic Rhinitis Due to... Cerebrospinal Fluid Leak. NEJM, 10/2009.
A breathless woman with asthma. BMJ Picture Quiz, 10/2009.

Published: 08/21/2009
Updated: 10/10/2009

Cardiology: Images in Clinical Medicine

2009-08-21T23:16:00.003-04:00

Editor: V. Dimov, M.D.

Mapping the Atrioventricular Node. NEJM, 12/2007.
Retinal Arteriolar Cholesterol Emboli. NEJM, 02/2008.
Cerebral Embolism of Probable Aortic Origin. NEJM, 04/2008.
Changes in the Brain Stem and Fundus in Malignant Hypertension. NEJM, 05/2008.
Giant Left Atrium. NEJM, 05/2008.
Starr–Edwards Heart Valves 38 Years Later. NEJM, 05/2008.
The Aorta in Osteoporosis. NEJM, 05/2008.
Spontaneous Thrombolysis of an Obstructed Mechanical Aortic Valve. NEJM, 06/2008.
Bifid Uvula and Aortic Aneurysm. NEJM, 07/2008.
Imaging of Thebesian Venous System. NEJM, 08/2008.
Austin Flint Murmur. NEJM, 09/2008.
Pneumopericardium. NEJM, 10/2008.
What Lies Beneath a Pacemaker? Bronchogenic Adenocarcinoma. NEJM, 10/2008.
Venous Obstruction of the Thigh. NEJM, 03/2009.
Widened Mediastinum: Mediastinal Extension of a Goiter. NEJM, 03/2009.
Prosthetic Mitral Valve with Partial Thrombosis. NEJM, 04/2009.
Familial Hypercholesterolemia. NEJM, 04/2009.
Asymmetric Edema of the Upper Lung Due to Mitral Valvular Dysfunction. NEJM, 07/2009.
Chest radiography of life-supporting medical interventions labeled from A to K. Lancet, 08/2009.
Retinal Detachment in Malignant Hypertension. NEJM, 08/2009.
Swinging of the heart and electrical alternans due to a large pericardial effusion. NEJM, 10/2009.

Published: 08/21/2009
Updated: 10/26/2009

Gastroenterology: Images in Clinical Medicine

2009-08-21T23:14:00.008-04:00

Editor: V. Dimov, M.D.

Peutz–Jeghers Syndrome. NEJM, 08/2007.
Small-Bowel Intussusception. NEJM, 12/2007.
Trichobezoar. NEJM, 11/2007.
Chronic Budd–Chiari Syndrome and Abdominal Varices. NEJM 12/2007.
Small-Bowel Obstruction. NEJM, 03/2008.
Ascariasis. NEJM, 04/2008.
Clonorchis sinensis. NEJM, 04/2008.
Giant Ovarian Cyst. NEJM, 05/2008.
Severe Constipation. NEJM, 05/2008.
Severe Kyphosis. NEJM, 06/2008.
Colonic Saccular Diverticula. NEJM, 09/2008.
Pneumopericardium. NEJM, 10/2008.
Spider Angiomas. NEJM, 01/2009.
A Tuba Player with Air in the Parotid Gland. NEJM, 02/2009.
Fecaliths in Crohn's Disease. NEJM, 05/2009.
Spontaneous Evisceration, Perforated Umbilical Hernia. NEJM, 06/2009.
Epiploic appendagitis. Lancet, 06/2009.
Ingested Magnets. NEJM, 06/2009.
Lipomatosis of the Tongue. NEJM, 06/2009.
Telltale Triangle of Pneumoperitoneum. NEJM, 07/2009.
Lupus-Associated Intestinal Vasculitis. NEJM, 07/2009.
Tortuous Varicosities in Chronic Schistosomiasis. NEJM, 08/2009.
Testicular Torsion in a Hydrocele. NEJM, 08/2009.
Esophageal Foreign Body: A Spoon. NEJM, 08/2009.
Pneumatosis Cystoides Coli. NEJM, 08/2009.
Sigmoid Volvulus. NEJM. 09/2009.
De Garengeot's Hernia. NEJM, 09/2009.
Picture quiz: Eye sign in psychosis. BMJ, 09/2009.
Uvular Necrosis after Endoscopy. NEJM, 09/2009.
An elderly woman with obstruction: obturator hernia. BMJ, 09/2009.
Pelvic Spleen. NEJM, 09/2009.
Geographic Tongue. NEJM, 11/2009.
Extensive Bowel Infarction. NEJM, 11/2009.

Published: 08/21/2009
Updated: 10/27/2009

Elderly female with CHF complains of abdominal pain, nausea and vomiting, dizziness, and confusion for 5 days due to digoxin toxicity

2009-08-02T05:51:00.001-04:00

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

Click here for the case description and questions.

What is the most likely diagnosis?

Digoxin toxicity.

Laboratory results

Figure 1. Digoxin toxicity. Treatment with digoxin was started in the hospital and the patient was discharged to SNF, she was re-admitted 4 days later with digoxin toxicity.

What would you do?

Stop digoxin.
Monitor digoxin levels.
Control symptoms.
Sitter in the room.

What happened?

The initial digoxin level was elevated at nearly twice the upper therapeutic level. All symptoms resolved as digoxin level decreased to therapeutic range. Heart rate was controlled by increasing metoprolol dose.

She was discharged back to the nursing home in good condition.

Final diagnosis

Digoxin toxicity.

Summary

Digoxin toxicity was first described in 1785.

Approximately 0.4% of all hospital admissions, 1.1% of outpatients on digoxin, and 10-18% of nursing home patients develop toxicity. Advanced age ( older than 80 years) is an independent risk factor associated with increased morbidity and mortality.

Serum concentrations associated with toxicity overlap between therapeutic and toxic ranges because of the many factors which can potentiate digoxin toxicity.

References

Digitalis Toxicity. eMedicine, 2006.
Toxicity, Digitalis. eMedicine, 2006.

Digoxin from Oxford handbook of clinical medicine By Murray Longmore, Ian Boden Wilkinson, Supraj R. Rajagopalan:

Published: 08/02/2009
Updated: 08/02/2009

Elderly female with CHF complains of abdominal pain, nausea and vomiting, dizziness, and confusion for 5 days. What is the cause?

2009-08-02T05:48:00.003-04:00

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 96-year-old African American female (AAF) was admitted from a nursing home with complaints of abdominal pain, nausea and vomiting (N/V), dizziness, confusion and double vision for 5 days. She was discharged from the hospital just 4 days ago. Digoxin was started during that previous hospitalization for control of tachycardia in atrial fibrillation. One day prior to discharge, digoxin level was 1.8 mg/mL and digoxin dose was decreased to 125 mcg PO Q 48 hr.

Past medical history (PMH)

Hypertension, atrial fibrillation, coronary artery disease, stroke, congestive heart failure.

Medications

Metoprolol, digoxin, ASA (aspirin), lisinopril, furosemide (Lasix), Coumadin (warfarin), esomeprazole (Nexium).

Physical examination

In pain, combative and confused.
VSS.
Chest: Occasional bibasilar crackles.
Cardiovascular System: Clear S1 and S2, irregularly irregular rhythm, HR 101 bpm.
Abdomen: Soft, epigastric tenderness, no rebound, + BS.
Extremities: No edema.

What is the most likely diagnosis?

What would you do?

Click here for the answer and final diagnosis in this case.

Published: 08/02/2009
Updated: 08/02/2009

A Systematic Approach to Electrocardiogram (ECG, EKG) Interpretation by Using 2 Mnemonics

2009-07-23T11:42:00.001-04:00

Author: V. Dimov, M.D. Published in the Proceedings of the 3rd Annual Cleveland Clinic Perioperative Medicine Summit, CCJM.

This is a 2-step approach remembered by 2 mnemonics:

Step 1: Evaluate all elements of the EKG systematically: A RARE PQRST.

Step 2: Differential diagnosis. Look for diseases that may have caused the abnormalities noted in step 1: DR III EEE !

This systematic approach to reading electrocardiograms (ECGs or EKGs) works every time, just like a machine. By using it, you will not miss any major abnormalities in electrocardiograms (EKGs).

What is the meaning of the mnemonics?

A RARE PQRST:

Age, e.g. a 60-yo patient is likely have a different pathology from a 30-yo patient
Rate, e.g. fast or slow?
Axis, e.g. left or right?
Rhythm, e.g. regular or irregular?
Evaluate each EKG element as follows:
P wave, e.g. peaked or absent? PR interval - short or prolonged?
Q wave, e.g. deep Q wave? QT inerval - - short or prolonged?
R wave, e.g. tall? look at QRS complex width for RBBB or LBBB
ST segment, e.g. elevation or depression?
T wave, e.g. peaked or inverted? U wave?

DR III EEE:

Drugs , e.g. Digoxin, tricyclic antidepressants
Rhythm and rate abnormalities, e.g. AV block of 1,2,3 degree, AFib, SVT? Interval prolongation?

Ischemia?
Infarct? Deep Q wave?
Infection, e.g. pericarditis

Enlargement, e.g. LVH, RVH, left or right atrium enlargement?
Electrolyte disturbances, e.g. hyperkalemia, hypokalemia, hypercalcemia,
Endocrine causes, e.g. hypothyroidism

How to use this approach in practice?

Look at the EKG and write down on a piece of paper:

A R A R E P Q R S T
D R I I I E E E

Circle the abnormalities you discover in step 1 -- A RARE PQRST. Then, connect and try to explain these abnormalities by looking at the list of possible etiologies presented in step 2 -- DR III EEE. That's it!

An example:

A systematic approach to the EKG of a patient with AFib (click to enlarge).

References

Proceedings of the 3rd Annual Perioperative Medicine Summit, Cleveland Clinic, September 10-12, 2007, CCJM.
Imaging: Electrocardiograms, X-rays, CT scans
ECG Wave-Maven by the Harvard Medical School and Beth Israel Deaconess Medical Center.
The lost art of electrocardiography - DoctorRW.blogspot.
Reading an EKG - UAB.edu.
ECG scribbles. An Approach. Anaesthetist.com.
APDIM E-Learning Task Force: Cardiac Auscultation, Chest X-Rays, Electrocardiograms, Patient Images (Dermatology), Pulmonary Function Tests, 2009.
Can't-Miss ECG Findings, Life-Threatening Conditions: Slideshow. Medscape, 2009.

Audio

Audio lecture: Basics of EKG. Dr. Dwight Dishmon. Podcasting Project for the UT Internal Medicine Residency Program, 2006.

Video

ECG Video part 1: For Med Students studying the basics of reading an electrocardiogram, from the University of Wisconsin.

ECG Video part 2.

Published: 05/15/2003
Updated: 07/23/2009

Abdominal Pain Due to a Large Abdominal Aortic Aneurysm (AAA) and Diverticulosis

2009-07-10T22:51:00.002-04:00

Author: V. Dimov, M.D.
Reviewer: A. Aneja, M.D.

Click here for the case description and questions.

The CT of the abdomen was significant for:

1. Large abdominal aortic aneurysm (AAA).
2. Diverticulosis.

Abdominal aortic aneurysm (AAA) on the CT of the abdomen (click to enlarge the images).

Abdominal aortic aneurysm (AAA) on the CT of the abdomen (click to enlarge the images).

Diverticulosis on the CT of the abdomen (click to enlarge the images).

Report of the CT of abdomen and pelvis with IV contrast:

There is a large infrarenal distal abdominal aortic aneurysm (AAA), estimated to measure approximately 8.0 cm A.P. x 7.4 cm transversely. There is a large amount of mural thrombus, projecting posteriorly and to the right, in the proximal aneurysm, while being more circumferential in the distal aneurysm, which extends virtually to the level of the aortic bifurcation. The enhancing lumens directly abuts the anterior wall of the aneurysm proximally, but no definite aortic leak or evidence of retroperitoneal bleed is seen. Old aortic dissection is suspected. There is calcification at both renal artery ostia.

GI tract was not well evaluated in the absence of oral contrast. There are fluid density lesions in both kidneys, likely representing bilateral renal cysts; these should be confirmed by ultrasound. No free air or free fluid is seen. There is severe degenerative change with associated spinal stenosis in the lumbar region.

Pelvis: There is extensive sigmoid diverticulosis, without obvious CT changes of sigmoid diverticulitis. There is considerable redundancy of the sigmoid colon.

Impression from the CT of abdomen

1. Large distal AAA, with associated mural thrombus; no definite aortic leak or retroperitoneal bleed. Old aortic dissection suspected.
2. Probable bilateral renal cysts, which should be confirmed by ultrasound.
3. Sigmoid diverticulosis.
5. Severe degenerative change in the lumbar spine with associated spinal stenosis.

What happened?

The abdominal pain subsided. Treatment options were discussed with the patient and his family and they decided on monitoring and conservative treatment.

Final diagnosis

A Large Abdominal Aortic Aneurysm (AAA) and Diverticulosis.

References

Abdominal Aortic Aneurysm. Am Fam Phys, Vol. 73 No. 5, April 1, 2006.
Abdominal Aortic Aneurysm. eMedicine Specialties > Vascular Surgery > Medical Topics, 2008.
Abdominal aortic aneurysm. Medical Encyclopedia, U.S. National Library of Medicine.

Published: 04/11/2006
Updated: 07/05/2009

Abdominal pain in a 93-year-old male. What is the cause?

2009-07-10T22:46:00.004-04:00

Author: V. Dimov, M.D.
Reviewer: A. Aneja, M.D.

A 93-year-old African American male (AAM) had an outpatient work-up and a CT scan of the abdomen was done. The report is pending.

Past medical history (PMH)

Deep vein thrombosis (DVT) 10 years ago.

Medications

Coumadin (warfarin).

Social history (SH)

He drinks 60 oz of vodka daily, quit smoking 50 years ago.

Physical examination

Elderly gentleman in no apparent distress (NAD).
Vital signs stable (VSS), the rest of the examination was unremarkable.

What do you see in the images of the CT of the abdomen below:

(click to enlarge the images).

(click to enlarge the images).

(click to enlarge the images).

Click here for the answer and final diagnosis in this case.

Published: 04/11/2006
Updated: 07/05/2009

Amiodarone-Induced Pulmonary Toxicity

2009-05-28T13:44:00.004-04:00

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

Click here for the case description and questions.

What happened next?

Amiodarone-induced pulmonary toxicity was suspected.

The patient was diagnosed with AFib with RVR (difficult to control) one year ago. He was started on Amiodarone 400 mg qd, then the dose was decreased to 200 mg qd.

What are the tests of choice for Amiodarone-induced pulmonary toxicity?

High-resolution CT scan of the chest and PFT with DLCO.

High-resolution CT of the chest (click to enlarge the images).

High-resolution CT of the chest (click to enlarge the images).

High-resolution CT of the chest (click to enlarge the images).

Report of the CT of the chest: Nonspecific diffuse ground glass mosaic pattern of the lung parenchyma. There are bilateral linear scars or atelectases particularly into the lower lobes and right middle lobe. Impression: Nonspecific ground glass mosaic pattern indicating interstitial lung disease.

Final diagnosis

Amiodarone-induced pulmonary toxicity.

What did we learn from this case?

Amiodarone-induced lung toxicity occurs in 6-15% of the patients treated with the medication. A decrease of 15% in DLCO helps make the diagnosis.

Toxicity occurs even with the lower amiodarone doses such as 200 mg qd.

The treatment is with a corticosteroid trial, similar to the therapy of other idiopathic interstitial lung diseases. However, there is no conclusive evidence that that steroids are beneficial in the treatment of amiodarone-induced lung toxicity.

References

Pneumonitis and pulmonary fibrosis associated with amiodarone treatment: a possible complication of a new antiarrhythmic drug. This is the first report of Amiodarone-induced pulmonary toxicity, Circulation, 1982.
Amiodarone - Reevaluation of an Old Drug. Annals of Int Med.
Amiodarone-Induced Pulmonary Toxicity. NEJM Images.
Pulmonary Fibrosis, Idiopathic. eMedicine.
Amiodarone pulmonary toxicity. VH.org.
Amiodarone: Guidelines for Use and Monitoring. AFP 12/03.

Published: 05/20/2009
Updated: 05/20/2009