54 yo F with no PMHx, but admittedly has not been seen by an MD in many years, presents after her daughter visited from our-of-town and found her slightly confused. The patient is disoriented, but able to provide some history. She describes progressive fatigue over several weeks. Vitals signs are remarkable for hypothermia 94F, HR 52, BP 150/90, RR 12, SpO2 100%RA. Exam is notable for AAO2, no focal neuro deficits, prominent facial swelling, and non-pitting lower extremity edema. FS glucose 160. Laboratory analysis is concerning for mild hyponatremia and severe hypothyroidism.
about 6 years ago
We read with great interest the pilot study on fracture risk in 46 critically ill patients by Rawal and colleagues . Bone mineral density (BMD) was assessed with portable calcaneal dual X-ray absorptiometry (DXA) on days 1 and 10. The authors found no overall change in BMD, but increased fracture risk in the subgroup with 'ARDS' (acute respiratory distress syndrome) (n = 34). There are several serious methodological problems: it is unclear if the group assignment is valid as only one of the four Berlin definition criteria  for the diagnosis of ARDS is given: oxygenation (no information on timing, chest imaging and origin of the edema). Although peripheral DXA devices are certainly an interesting option for BMD in critically ill and other patients , precision errors supplied by the manufacturer should not be used. In fact, each center must determine its (own) precision error and least significant change, which is also operator dependent . The manufacturer stated a 0.9 % coefficient of variation, which is not necessarily applicable to the study setting where it remains unclear how the measurements were performed. This could be an important limitation. Hence, it is unlikely that a 2 % BMD change within such a short time frame as described would reflect anything else other than random variability. Lastly, it is also unclear what the described statistical difference refers to - it should be noted that the smaller subgroup (n = 12) numerically increased their BMD. Undoubtedly, fracture risk following critical illness is a very important topic that requires further high-quality studies .
almost 6 years ago
A 40 year old premenopausal white woman presented to a general gynaecologist with diffuse redness, swelling, and rapidly progressive pain in her left breast. She did not have a fever. Her medical history included one full term pregnancy with spontaneous delivery 19 years earlier. Her maternal grandmother had died of breast cancer at age 65 years. On physical examination, a warm and painful diffuse oedematous erythema was found in the inner quadrants of the breast (fig 1⇓), but she was otherwise in good general health.
over 5 years ago
This is a good practical case and very useful for new clinicians. For any clinician:No foley catheter unless oliguric, anuric, obstructed since any catheter is a foreign body and increases infection risk.Rehydrate if U/A has high spec gavity, mucous membranes dry, or if BUN is >30 times the creatinine as in this case. Even CHF pts get dry if not in heart failure. If in doubt, do CXR, BNPT, listen for crackles.Start with 250cc IVF if BNPT not less than 150 or give carefully while checking lung bases posteriorly after each bolus along with pulse ox, etc as above. Half of pts in acute renal failure are septic. Look for and eliminate source such as pneumonia, foreign body, pyelonephritis, joint infections. May be afebrile/ low temp or low WBCs with sepsis. Do cultures, check lactate ASAP to detect sepsis BEFORE the BP drops. Lactic acid "the troponin of sepsis." If septic, give a lot of fluids (up to 10 liters often) since capillary leak syndrome will lead to severe hypotension. If septic expect edema to develop with IV boluses yet be aware pt is intravascularly depleted. No pressors without fluids "pressors are not your friend" as per lecturers on Surviving Sepsis campaign.
over 5 years ago
Varicose veins, sometimes called varicosity, occur when a valve in the blood vessel walls weakens and the blood stagnates. This in turn leads to problems with the circulation in the veins and to oedema or swelling. The vein then becomes distended, its walls stretch and sag, allowing the vein to swell into a tiny balloon near the surface of the skin. The veins in the legs are most commonly affected as they are working against gravity, but the vulva (vaginal opening) or rectum, resulting in haemorrhoids (piles), can be affected too. Pregnancy seems to increase the risk of varicose veins and they cause considerable pain, night cramps, numbness, tingling, the legs may feel heavy, achy, and they are rather ugly. Treatments for varicose veins are usually divided into three main groups: pharmacological treatments, non-pharmacological and surgery. The review identified seven trials involving 326 women. Although there was a moderate quality evidence to suggest that the drug rutoside seemed to be effective in reducing symptoms, the study was too small to be able to say this with real confidence. Similarly, with reflexology and water immersion, there were insufficient data to be able to assess benefits and harms, but they looked promising. Compression stockings do not appear to have any advantages. More research is needed.
over 5 years ago