The clinical education of medical students: a perspective from internal medicine.
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Clinical Clerkship↗
Biomedical subjects
L M Tierney
Publications and source records attributed to L M Tierney.
Clinical spectrum of pulmonary mucormycosis.
Pulmonary mucormycosis is an uncommon, but important, opportunistic fungal pneumonia which is often diagnosed post-mortem. This review emphasizes clinical and pathologic characteristics of pulmonary mucormycosis that differentiate this infection from other fungal pneumonias. The most common clinical presentation of pulmonary mucormycosis is a rapidly progressive pneumonia with diffuse infiltrates on chest radiographic examination of a patient with an underlying hematologic malignancy treated with immunosuppressive drugs. Other immunocompromised hosts at risk for pulmonary mucormycosis include patients with diabetes mellitus who may develop a distinctive endobronchial form of this disease. Early consideration of this diagnosis, along with aggressive diagnostic evaluation, are critical to effective therapy and patient survival. While treatment with amphotericin B is the mainstay of therapy for pulmonary mucormycosis, diabetics with endobronchial disease may benefit from early, aggressive surgical resection of the involved lung tissue.
Adult↗
Dermatomyositis associated with chronic myelogenous leukemia.
Dermatomyositis and polymyositis have been well established in association with malignant neoplastic disease. Most commonly, this association has been noted in patients with solid tumors rather than in patients with neoplasms of hematopoietic origin. We describe here a patient with chronic myelogenous leukemia who developed typical dermatomyositis, which responded to therapy with corticosteroids. This concurrence has been reported in only one previous patient to our knowledge. The nature and implications of the association of dermatomyositis and neoplasia are discussed.
Adult↗
The predictive value of physical examinations for ascites.
To determine the predictive value of physical signs for ascites, we compared the results of physical examination with those of abdominal sonography in 90 men in hospital with liver disease. The positive predictive values of shifting dullness and prominent fluid waves were low (51% and 73%). We divided the patients into two groups: those with prolonged prothrombin times (72% prevalence of ascites by sonogram), and those with normal prothrombin times (15% prevalence). In patients with prolonged prothrombin times, a prominent fluid wave had a very high positive predictive value for ascites (96%). Many patients with prolonged prothrombin times had ascites despite negative physical signs. In contrast, in those with normal prothrombin times, both shifting dullness and prominent fluid waves were usually falsely positive. Patients with normal prothrombin times and no shifting dullness rarely (2%) had ascites. The predictive value of physical signs for ascites depends on the prevalence of ascites in groups of patients that are examined. The prothrombin time is a useful index for identifying inpatients with a high or low prevalence of ascites and the predictive value of physical signs is enhanced by interpreting them in combination with a patient's prothrombin time.
Ascites↗
Aortoesophageal fistula after perigraft abscess with characteristic CT findings.
Aortoesophageal fistula is a rare cause of massive gastrointestinal hemorrhage, and may occur as a sequela to prosthetic replacement of the thoracic aorta. Esophageal compression necrosis with leakage of microorganisms into the proximal suture line is probably central to pathogenesis. Like the more common aortoduodenal fistula, diagnosis by traditional radiographic and endoscopic methods is difficult. We report here such a fistula, in which computed tomographic soft tissue abnormalities were characteristic of perigraft abscess; fistulization occurred subsequently. CT holds potential for being a sensitive study to show localized perivascular infection, an important precursor to aortoenteric fistula, and as such should be positive early in the development of a fistula.
Abscess↗
Trace metals in human disease.
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Chromium↗
Erythema nodosum.
This self-limiting disease is characterized by painful, red, cutaneous and subcutaneous nodules, and is often a manifestation of a systemic illness. Sarcoidosis, tuberculosis, coccidioidomycosis, streptococcal infections, inflammatory bowel disease and several drugs can be associated. The lesions, usually on the lower extremities, evolve from raised and tender nodules to a bruised appearance to complete resolution. The prognosis of the skin lesions is excellent, but the clinician's attention must be directed toward the presence of an underlying disease process.
Anti-Inflammatory Agents↗
The comatose patient. A systematic diagnostic approach for you to follow.
Coma is a frightening state requiring immediate medical attention. Because the patient's history may be unavailable and the possible causes of coma are numerous, the physician must concurrently support and protect the patient and evaluate the cause of coma. A systematic, orderly approach to diagnosis, using modern diagnostic tools to complement thorough physical examination, can help illuminate and alleviate this often perplexing problem.
Coma↗
The bedside Sherlock Holmes.
There are a multitude of diagnostic clues contained in clothing, jewelry, possessions and other extracorporeal attachments that each patient brings with him or her to a physician. Because of the emphasis of classic physical diagnosis on the body of a patient solely, and because of modern practices that may have patients stripped of these articles before the first encounter with their physician, these interesting and enlightening findings are often ignored or unavailable. Incorporation of these observations into the panoply of data obtained from the history and physical examination will enhance both the accuracy and adventure of differential diagnosis. Such exercises in observation, moreover, may increase general physical diagnostic skills as well as enliven bedside rounds.
Clinical Competence↗
Generalized ulcerative sarcoidosis.
Cutaneous involvement is present in approximately 25% of patients with sarcoidosis. A large variety of morphologic patterns has been well described; ulcerative lesions are rare. A 30-year-old black man had generalized cutaneous granulomas, many of which demonstrated superficial ulceration. The exudative quality of these lesions was probably secondary to recurrent bacterial infection. Use of oral antibiotics, prednisone, and hydroxychloroquine sulfate controlled his disease activity.
Adult↗
Reversible interstitial pneumonitis associated with low dose bleomycin.
A patient with nodular histiocytic lymphoma was treated with bleomycin; she later developed interstitial pneumonitis documented by lung biopsy. The dose of bleomycin producing this complication was lower than previously reported, and the pulmonary toxicity was apparently completely reversible.
Abdominal Neoplasms↗
Heparin lock-induced alterations in the activated partial thromboplastin time.
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Blood Coagulation Tests↗
Nursing in Japan.
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Cross-Cultural Comparison↗