HCA healthcare journal of medicine最新文献

Introduction: Spontaneous pneumomediastinum (SPM) is a rare condition defined by the presence of air in the mediastinum in patients without an observable traumatic cause. Pneumomediastinum is a somewhat rare condition that occurs 1 in every 25 000 individuals, aged 5 to 34 years old, with 76% occurring in men. Pneumomediastinum can further be divided into 2 categories: SPM and traumatic pneumomediastinum. Traumatic pneumomediastinum is most commonly seen with blunt force trauma or any iatrogenic procedures to the chest wall. Spontaneous pneumomediastinum frequently occurs due to air leaking through small alveolar sacs, which rupture within the surrounding bronchovascular sheath. Spontaneous pneumomediastinum can be further divided into primary and secondary causes; the main difference is that secondary SPM requires a preexisting condition (ie, lung disease). Primary SPM is considered when trauma or any iatrogenic causes are ruled out. Secondary SPM, which is more common, is usually seen with esophageal perforation. Few case reports have been published connecting the inhalation of marijuana, cocaine, and the use of opioids to SPM, and, until now, no published data links the ingestion of cleaning products to SPM.

Case presentation: This case report presents a 28-year-old White man who developed a SPM following the ingestion of bleach, dish soap, and laundry detergent and the inhalation of methamphetamines. This case report highlights the potential for chemical-induced pneumomediastinum and emphasizes the importance of considering unusual etiologies in patients presenting with acute chest pain and respiratory distress after chemical exposures with a suicide attempt.

Conclusion: Spontaneous pneumomediastinum is due to a pressure change within the thoracic cavity as a result of air leakage. This has been commonly seen with certain risk factors, such as cystic fibrosis, chronic obstructive pulmonary disease, and, most commonly, Boerhaave's syndrome. However, there are other less commonly known risk factors that can predispose a patient to or contribute to them developing SPM, including methamphetamine use and inhalation of laundry chemicals.

Background: Acute interstitial nephritis (AIN) is the most common cause of acute kidney injury (AKI) with subsequent renal impairment and is often underdiagnosed. Acute interstitial nephritis presents with a decline in kidney function and is characterized by an inflammatory infiltrate in the kidney interstitium. It is most often induced by drug therapy and is sometimes followed by infections with unknown causes. In a typical presentation of AIN, there is no evidence of hypocomplementemia; low complement is associated most commonly with autoimmune etiologies. Renal biopsy serves as the most definitive test for both the diagnosis and prognosis of AIN.

Case presentation: A woman in premenopause, with no significant past medical history, other than a remote history of seizures, presented to the emergency department (ED), in cardiac arrest, via emergency medical services (EMS). When EMS arrived, she was noted as hypotensive and tachycardic with agonal respirations, having received 3 rounds of defibrillation in the field. Per rapid assessment, the patient received CPR from a bystander for an unknown amount of time. Upon arrival at the ED, the patient again went into cardiac arrest, requiring 5 rounds of CPR, with 3 separate administrations of epinephrine, followed by intubation with mechanical ventilation. Initial labs presented significant results for acute respiratory acidosis without renal compensation, leukocytosis, elevated troponin consistent with myocardial infarction, mild normocytic anemia, and intrarenal AKI. Imaging was significant for a suprarenal mass, later confirmed to be pheochromocytoma. Over the next few days, the patient developed anuric kidney failure requiring dialysis, and a kidney biopsy was obtained for confirmation of AIN. However, she was also noted to have decreased complement, which is not typically found in interstitial nephritis.

Conclusion: We encountered a patient with interstitial nephritis and low complement level. The reason behind this rare phenomenon remains unclear in recent literature. As of 2024, only 11 other known cases of AIN have been found to have hypocomplementemia, making it a rare and curious pathophysiological process. More research and data are needed for further investigation into this exciting new pathology, its fundamental process, and potential treatment variations aside from those already used in AIN.

Background: Ovarian tumors are quite uncommon in the premenarchal age group, with the majority being functional cysts. Malignant tumors are unusual in this age group, making the diagnosis of ovarian malignancy in children quite challenging. Dysgerminoma is the most common malignant ovarian germ cell tumor in females. The clinical symptoms often include abdominal pain, distension, a palpable mass, reduced appetite, nausea, and vomiting.

Case presentation: We discuss the case of an 11-year-old premenarchal girl who was brought to the emergency department with abdominal pain persisting for 3-4 days, which had intensified over the 24 hours before she arrived at the emergency department. The pain was accompanied by vomiting. On examination, her lower abdomen showed tenderness, guarding, and rigidity, and a firm mass approximately 10 x 8 cm in size was palpable in the midline. Ultrasonography of the abdomen and pelvis revealed a large hypoechoic mass lesion, approximately 99 x 56 x 92 mm, in the right adnexa. A magnetic resonance imaging with contrast of the abdomen and pelvis was performed for confirmation, which substantiated the diagnosis of the right ovarian lesion with torsion. Following the patient's exploratory laparotomy, a right salpingo-oophorectomy and left oophoropexy were performed. The histopathological report confirmed the diagnosis of dysgerminoma.

Conclusion: Malignant ovarian tumors are quite rare in the premenarchal age group, and the primary goal should be to offer fertility-preserving surgeries. This allows the individual to retain reproductive functions. However, close monitoring is essential, and if needed, radical surgery should be considered to save the patient's life.

Introduction: Point-of-care ultrasound (POCUS) has become an indispensable tool for emergency physicians in assessing intra-abdominal pathology due to its real-time visualization, portability, and cost-effectiveness. While POCUS is not traditionally focused on adrenal gland assessment, incidental findings of adrenal masses during examinations have been reported. Our patient presented with a chronic obstructive pulmonary disease (COPD) exacerbation and was found to have a large adrenal mass, discovered incidentally, during thoracic ultrasound.

Case presentation: This case report presents the discovery of an adrenal mass in a patient with respiratory distress due to a COPD exacerbation, emphasizing the importance of sonographers' ability to identify abnormal imaging within their POCUS framework. The clinicians promptly communicated the incidental finding to the patient, leading to further imaging and labs while in the emergency department and subsequent hospital admission. Traumatic arteriovenous fistulas and visceral vascular injuries are rare.

Conclusion: Although adrenal glands are not the primary focus for emergent pathology, the identified mass prompted a comprehensive evaluation, ultimately revealing a nonhormone-secreting adrenal cortical carcinoma. The rarity of this malignancy and the discrepancy between imaging and laboratory results underscore the need for a thorough investigation, with the focus suggesting that POCUS, despite its limitations, can play a crucial role in prompting additional imaging for accurate diagnosis and informed patient management. This case also highlights the significance of transparent communication while empowering patients and guiding further investigations for a comprehensive understanding of the pathology.

Description Constipation is a common condition among geriatric patients with different presenting symptoms and potential serious complications. Additionally, the condition causes a significant burden on our healthcare system. Here, we summarized recommendations from several societies, including the American College of Gastroenterology, American Geriatrics Society, and American Academy of Family Physicians to provide guidance on managing constipation with geriatric patients. Our aim was to emphasize the importance of prevention of constipation in this population and methods to do so. We also give recommendations on how to manage constipation when it does develop and how to manage it across different healthcare settings. These recommendations should aid providers in managing this prevalent and burdensome condition.

Description The HCA Healthcare Journal of Medicine would like to thank those behind the scenes who make this publication possible. Our journal would not be possible without the assistance of our peer reviewers, authors, and board members.

Background: In January 2022, the United States Medical Licensing Examination (USMLE) Step 1 exam became pass/fail and the transition to using USMLE Step 2 scores for residency interview screening appeared imminent. While this change was intended to result in holistic reviews of residency applicants, the impact remains unclear. In this study, we aimed to determine how USMLE scoring changes might affect female candidates and applicants from underrepresented groups (URM).

Methods: We performed a retrospective cross-sectional study of all applicants to a single institution. Data for applicants were extracted from their 2021-2022 residency applications and included age, race, sex, medical school, region, USMLE Step 1 score, and USMLE Step 2 scores. All applicants who graduated from a US medical school with both USMLE Step 1 and Step 2 scores were eligible for inclusion. Our primary outcome was the difference between USMLE Step 1 versus Step 2 scores. Two comparisons were made; female candidates were compared to male candidates and URM compared to non-URM.

Results: On regression analysis, we noted that female candidates (coefficient = 4.007; 95% CI, 2.64-5.37, P < .001) had greater improvements between USMLE Step I and Step II scores compared to male applicants, while URM (coefficient = -5.056; 95% CI, -7.6 to -2.5, P < .005) demonstrated smaller differences between USMLE scores compared to the reference group (non-URM).

Conclusion: Making USMLE Step 1 pass/fail may benefit female candidates during the interview process, while adversely impacting URM. As the application process evolves, the impacts on female and URM need to be carefully evaluated to achieve equitable representation in residency programs.

Background: Endometriosis is a common condition in which endometrial glands and stroma are implanted outside the uterine cavity. Rarely, the skin can be involved.

Case presentation: We describe a case of a 41-year-old woman who presented to the dermatology clinic complaining of a brown umbilical nodule with slight erythema. It was occasionally painful and hemorrhagic. She denied a history of endometriosis and abdominal surgeries. A shave biopsy of the nodule was consistent with a diagnosis of cutaneous endometriosis. The patient was referred to her gynecologist for further evaluation and treatment.

Conclusion: This unique case demonstrates primary cutaneous endometriosis in the umbilicus of a female patient. Cutaneous endometriosis can be classified as primary or secondary. Primary cutaneous endometriosis is rarer and has an unclear etiology, developing seemingly spontaneously without history of surgical interventions. Secondary cutaneous endometriosis typically arises within surgical scars following abdominal operations, which is believed to be a result of iatrogenic implantation of endometrial cells. Definitive treatment involves surgery. This case highlights the importance of considering cutaneous endometriosis in the differential diagnosis of a female patient with painful and intermittently hemorrhagic skin nodules.

Description This article draws attention to Winnicott's concept of the "good enough mother" and how it can be applied to those in medicine. It emphasizes that no one is perfect, and our children learn best from our imperfections. I was reminded of that while kayaking on the Lost Spring Lake in Ocala, FL, and took this picture. If we can find beauty in nature's imperfections, we can also find it within our own imperfections.

Introduction: Life threatening hypoglycemia can occur during critical illness in infants with underlying hyperinsulinemia or metabolic conditions, such as glycogen storage diseases. Using a continuous glucose monitor (CGM) can provide insight into glycemic trends with this high-risk patient population in the intensive care setting. Barriers to usage of CGMs in the intensive care unit include familiarity with CGMs devices among staff, safety, and cost.

Case presentation: We describe the first reported case of safely utilizing the newest Dexcom G7 continuous glucose monitor in an infant with hyperinsulinemia undergoing high frequency oscillatory ventilator (HFOV) support for acute respiratory distress syndrome (ARDS) to detect early hypoglycemic episodes during critical illness while on continuous glucose infusion.

Conclusion: There is limited information on using the Dexcom G7 CGM device in infants with underlying hypoglycemic conditions on HFOV support. The use of HFOV poses a unique physiological challenge for using a CGM device. We demonstrate that the Dexcom G7 is safe to use while on HFOV. The device provided important glycemic trends, which helped to reduce the number of point-of-care tests and allowed for early detection of hypoglycemia.