Systems

More Smoke From the Tobacco Industry

February 8, 2007
More Smoke From the Tobacco Industry

Commentary By: Elizabeth Ross, PGY-3

Cigarette manufacturers have been steadily increasing the nicotine content in cigarettes over the last 7 years.  The news broke in August of this year when the Massachusetts Department of Public Health discovered that the level of nicotine that smokers typically consume per cigarette had risen about 10 percent.

The Harvard School of Public Health recently re-analyzed the data with the goal of ascertaining how the tobacco industry managed the increase in nicotine content.  The investigators found…

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How Should You Approach A Patient with an Incidental Finding of a Portal Vein Thrombosis?

February 7, 2007
How Should You Approach A Patient with an Incidental Finding of a Portal Vein Thrombosis?

A  70 year old man  with a history of prostate cancer, status post radiation treatment in August 2003, a history of abdominal surgery for unknown reasons, and a history of heavy alcohol use was seen at the VA.   The patient was referred for a complaint of bright red blood per rectum and was incidentally noted to have elevated liver enzymes. 

Colonoscopy revealed blood in the rectosigmoid, dilated vessels in the rectum and angioectasia, thought to be secondary to the radiation…

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Mystery Quiz #2-The Answer

February 6, 2007
Mystery Quiz #2-The Answer

Before you read the answer you will probably want to review the original post of the mystery quiz from last week.

The pathology has been correctly identified.  The photomicrograph shows lipoid pneumonia, which in fact was due to chronic mineral oil ingestion (aspiration). The patient suffered from constipation, due to long usage of oxycondone, and medicated himself with mineral oil. The pathology shows lipid material, some of it pooled into large coalescent droplets, some in macrophages.

Lipoid pneumonia…

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Ethics 101-How Do You Approach a Jehovah’s Witness Patient Who Needs a Transfusion?

February 5, 2007
Ethics 101-How Do You Approach a Jehovah’s Witness Patient Who Needs a Transfusion?

A 76 year old man with a history of coronary artery disease, diabetes and hypertension was brought in by his wife with two days of lethargy, slurred speech and right arm weakness. On presentation, the patient was awake and intermittently involved in conversation.  He was afebrile, with a pulse of 90 and blood pressure of 166/98  His exam was remarkable for dysarthria, orientation only to person, pinpoint pupils, left sided tongue deviation, 3/5 motor strength in the right upper extremity, 4/5 motor strength in…

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Bedside Rounds #1: Why is a pulsus paradoxus not a paradox?

February 1, 2007
Bedside Rounds #1: Why is a pulsus paradoxus not a paradox?

Welcome to our inaugural Bedside Rounds a new regular feature of Clinical Correlations.  Here you will learn not only practical physical diagnosis pearls, but also the historical context in which these findings were discovered.

Commentary By: Judith Brenner MD, Associate Program Director, NYU Internal Medicine Residency Program

When you take a deep breath in, what happens? Because of an increase in the negative intrathoracic pressure, blood is sucked into the right side of the heart. Temporarily, a filled right ventricle can bulge…

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Mystery Quiz #2 (with a hint…)

January 30, 2007
Mystery Quiz #2 (with a hint…)

Since we received little in the way of responses to our mystery quiz, we thought a hint might be in order, so here's the case again this time with a hint.  Please submit your answers by clicking on the "comments" link below this post.  As always, for those of you who are unwilling to attach your name,  you can post your comments anonymously. 

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration.  As part of a…

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How Should You Treat Agitation in Patients with Dementia?

January 29, 2007
How Should You Treat Agitation in Patients with Dementia?

Case: A 74 year old male with a history of hyperthyroidism, now treated and euthyroid, and with longstanding slowly progressive Alzheimer’s, has now become increasingly agitated at home, pacing the floors and not sleeping. In light of side effects and the recent warning against the use of atypical antipsychotics and the side effects of the older medications, what kind of stepwise approach to medications would you recommend to use to treat his agitation?

Commentary By Brian Bronson, MD Clinical Assistant Professor of Psychiatry,

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A New Take on Quitting Smoking…

January 26, 2007
A New Take on Quitting Smoking…

Landing on the front page of the New York Times today is a study from Science that may turn addiction medicine on its head…no pun intended.   Of 32 smokers who had suffered a brain injury, they found that 16 who had suffered damage to the insula were easily able to quit smoking almost fully disrupting their smoking behavior in comparison to the other 16 who had suffered damage elsewhere.  The insula is a region of the brain that has been previously implicated in…

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When Should You Order a T Wave Alternans Test?

January 25, 2007
When Should You Order a T Wave Alternans Test?

A 58 year old male is admitted for "presyncope".  He has not had chest  pain and his baseline ECG is unchanged.  The patient has an ischemic cardiomyopathy with an ejection fraction of 39% with mild reversible changes on a stress echo that was done 5 months prior to admission.  On telemetry, the patient has frequent  polymorphic premature ventricular contractions. The cardiology consult recommends a T wave alternans test.  What is the reason for this test?

Commentary By: Neil

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A drug for NASH that may work?

January 24, 2007
A drug for NASH that may work?

Commentary By: Sandra D'Angelo, PGY-3

Nonalcoholic steatohepatitis (NASH) is a disease in which patients have features of alcoholic hepatitis on liver biopsy without a prior history of significant alcohol consumption and negative hepatitis serologies. It is unclear how prevalent this disease is because most patients with liver function abnormalities do not undergo liver biopsy.  In those that have had a liver biopsy, the prevalence is estimated to be 7-9%.  It is most common in women between the ages of 40-60 and…

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Mystery Quiz #2

January 22, 2007
Mystery Quiz #2

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration.  As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below.  Click on the thumbnails below for full size images:

   

A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms…

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How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

January 17, 2007
How Aggressively Should You Treat a Patient with a Pulmonary Embolus?

An otherwise healthy 57 year old patient presents with shortness of breath and pleuritic chest pain.  The patient is hemodynamically stable without evidence of shock.  A chest CT reveals a pulmonary embolus.

Questions: 1. When should an echocardiogram to assess for right heart strain be performed in a patient with a pulmonary embolism?  Should stable patients without evidence of shock have a routine echo once a diagnosis of pulmonary embolism is made?

2. If the echo shows signs of right…

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