1/8. Cardiopulmonary auscultation: duo for strings--Opus 99.In spite of increasing mechanization in medicine and reliance on "high-tech" diagnostic tools, bedside clinical skills of the attending physician can still identify findings that are missed by the more sophisticated devices. Using a stethoscope, we relied on our skills in inspection, palpation, percussion, auscultation, as well as echocardiography and phonocardiography to diagnose a patient whose murmur was very reminiscent of the D-sharp pizzicato in the Cello Sonata in F, Opus 99, by Johannes Brahms. Initial echocardiography was not helpful. We suspected an anomalous chorda and confirmed this with phonocardiography and a second echocardiography. Although advances in cardiac imaging are extremely helpful, the use of simple clinical skills, in addition to being fun, is not obsolete. Cardiopulmonary auscultation should receive more emphasis in the medical school curriculum and clinical training.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/8. Bell's palsy during interferon therapy for chronic hepatitis c infection in patients with haemorrhagic disorders.Two adult patients with life-long severe haemorrhagic disorders commenced on interferon-alpha2b therapy for chronic hepatitis c infection. Both developed Bell's palsy several weeks after commencing therapy, They were started on steroids and, in addition, the first patient discontinued interferon-alpha2b therapy while the second patient elected to continue with therapy. In both cases facial paralysis improved over the ensuing weeks. Bell's palsy is often idiopathic but has been reported. in association with herpesviruses. It is not a recognised complication of chronic hepatitis b or C infection, or interferon-alpha2b therapy. However, the interferons are associated with numerous adverse reactions including various neuropsychiatric manifestations and neurological syndromes. There are several reports of nerve palsies, including optic tract neuropathy, occurring during interferon therapy, and immune-based mechanisms are thought to play a role in the aetiopathogenesis. No reports of Bell's palsy in association with interferon therapy were identified in our literature search, although one possible case has been reported to the Committee of safety in medicine. Although Bell's palsy in our patients may have occurred by chance, a neuropathic effect of interferon-alpha2b on the facial nerve cannot be excluded and we urge physicians using interferons to be aware of this potential side-effect.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
3/8. Valve replacement in endocarditis: setting limits in noncompliant intravenous drug abusers.An intravenous (IV) drug abuser underwent repeated valve replacements because of recurrent infective endocarditis. Is it ethically permissible to withhold valve surgery in a recalcitrant, noncompliant IV drug abuser? We believe so, and in our analysis, discuss the principles of futility, rationing, personal responsibility, and justice. Because of her continued drug abuse, the patient is responsible and accountable for the medical consequences. The consequences are that physicians will not be able to provide her with beneficial treatments without disproportionate harm, and that society will no longer be able to provide resources for her treatment without unfairly jeopardizing the availability of resources for other members of society. Although valve surgery does not constitute futile treatment, maximizing and egalitarian principles of societal justice support the withholding of such an expensive intervention. The patient should be jointly evaluated by the physician, social worker, and psychiatrist. The medical team will emphasize patient compliance and willingness to undergo drug rehabilitation, and will offer the first valve replacement. The recidivist abuser with demonstrable non-compliance who sustains a second episode of endocarditis need not be offered another valve. To avoid bedside rationing, we recommend the formulation of such a policy by nations and professional bodies.- - - - - - - - - - ranking = 2keywords = physician (Clic here for more details about this article) |
4/8. Aortic dilation, dissection, and rupture in patients with turner syndrome.We report two patients with turner syndrome who had aortic dissection and rupture, one with prior repair of coarctation. We also note the high incidence (8.8%) of unrecognized aortic root dilation in a group of 57 patients with turner syndrome whom we prospectively evaluated by echocardiography. Our analysis and review of previously reported cases suggests that multiple risk factors may exist for aortic dissection, including coarctation, bicuspid aortic valve, and systemic hypertension, but that these need not be present. Aortic root dilation may be an additional finding that suggests the patient with turner syndrome is also at risk. When it is present, magnetic resonance imaging visualizes the entire aorta and allows quantification of the site and degree of dilation. In patients with dissection, the aorta often exhibits pathologic evidence of cystic medial necrosis similar to the finding in patients with marfan syndrome. Therapeutic methods to decrease risk, such as those directed toward prevention of bacterial endocarditis, blood pressure control, and perhaps prophylactic beta blockade or surgical reconstruction, may need to be considered. patients with turner syndrome, their families, and the physicians who care for them should be aware of the significance of unexplained chest pain, dyspnea, or hypotension as potential manifestations of aortic dissection or rupture.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
5/8. Group C beta-hemolytic streptococcal endocarditis: report of a pediatric case.A 9-year-old boy with a ventricular septal defect and a bicuspid aortic valve developed bacterial endocarditis due to group C streptococci. He responded to an initial antibiotic regimen of nafcillin plus gentamicin and was cured by the use of penicillin g following the isolation of the organism. The unusual nature of this case is discussed and physicians are cautioned to recognize this organism as a potential cause of infectious endocarditis in the pediatric population.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
6/8. Cardiovascular evaluation of the young athlete.heart murmurs and cardiovascular defects, elevated blood pressure, and arrhythmias cause considerable concern to many physicians evaluating or certifying students for competitive athletic participation. The purpose of this article is to present a practical approach to the evaluation and management of these problems.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
7/8. Native valve endocarditis due to corynebacterium striatum: case report and review.We report the first known case of native valve endocarditis due to corynebacterium striatum and review 51 previously reported cases of native valve endocarditis due to non-diphtheriae corynebacteria. Of the 52 patients with corynebacterial endocarditis, 11 (21%) had no predisposing conditions and 27 (52%) had structural heart disease; endocarditis in the remaining 14 patients (27%) was associated with noncardiac predisposing factors including injection drug use, chronic hemodialysis, vasculitis, alcoholism, liver transplantation and hemodialysis, a peritoneovenous shunt, and prior aspiration of a noninfected bursa. The mortality rate associated with corynebacterial endocarditis was 31%. The majority of corynebacteria in this series were sensitive to penicillin, erythromycin, gentamicin, and vancomycin. Non-diphtheriae corynebacteria are capable of producing acute valvular damage, even in patients without conditions that are predisposing for endocarditis. The occurrence of bacteremia due to non-diphtheriae corynebacteria in the appropriate clinical setting should alert physicians to the possible diagnosis of endocarditis. Empirical antibiotic therapy with vancomycin, with or without an aminoglycoside, should be initiated pending antibiotic susceptibility testing.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
8/8. Bioimpedance cardiac output measurements in patients with presumed congestive heart failure.OBJECTIVE: To describe preliminary ED experience with thoracic electrical bioimpedance (TEB) for evaluation of patients with complaints suggestive of congestive heart failure (CHF). methods: A 6-month, prospective, observational study was performed using a convenience sample of patients with signs and symptoms consistent with CHF. patients were excluded if they had received medication prior to arrival in the ED, if they were obese, and if they had unstable vital signs. They also were excluded if they were combative, refused to sign consent, or had invasive lines that did not allow for TEB lead placement. patients also were excluded if the study could not be completed because the patient was taken from the department for a diagnostic test, or if there were no good follow-up records available 6-12 months after the patient's visit. The patient's physician was blinded to the output of the TEB monitor. cardiac output (CO), stroke volume (SV), end-diastolic volume (EDV), thoracic fluid index (TFI), and acceleration index (ACI) were recorded at 5-minute intervals. Results were evaluated for the time intervals 0-5 minutes, 30-35 minutes, and 60-65 minutes. RESULTS: Seven patients were included in the study. The echocardiographic diagnoses were hypertrophic cardiomyopathy (2 cases), dilated cardiomyopathy (2 cases), ischemic cardiomyopathy (1 case), right ventricular hypertrophy (1 case), and pericardial effusion (1 case). Significant changes were seen in all cardiac parameters, with variance from individual to individual. CONCLUSIONS: Significant differences in TEB variables exist between patients who appear similar on initial examination in the ED. Changes noted on TEB may help to further elucidate physiologic differences. The clinical use of TEB-based hemodynamic measurements to guide presumed CHF patient management remains speculative.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |