The American journal of medicine
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Idiopathic thrombocytopenic purpura was diagnosed in a 26 year old man who had rectal bleeding and marked thrombocytopenia (10,000 platelets/mm3). Complete recovery followed treatment with steroids and splenectomy. There was no clinical, laboratory or histopathologic evidence of thrombotic thrombocytopenic purpura. ⋯ The presence of Howell-Jolly bodies and a negative scan indicated that an accessory spleen was not present. Since thrombotic thrombocytopenic purpura developed in the absence of a spleen in this case, it may be that in some, if not all, instances of thrombotic thrombocytopenic purpura the spleen is not importantly related to the pathogenesis of thrombotic thrombocytopenic purpura; this is in contrast to the situation in idiopathic thrombocytopenic purpura. Benefits attributed to splenectomy in thrombotic thrombocytopenic purpura, therefore, may in fact be due to the platelet inhibitory properties of common anesthetic agents, or to some other factor in the surgical procedure rather than to removal of the spleen per se.
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Remarkably little is known about the cognitive processes which are employed in the solution of clinical problems. This paucity of information is probably accounted for in large part by the lack of suitable analytic tools for the study of the physician's thought processes. Here we report on the use of the computer as a laboratory for the study of clinical cognition. ⋯ The information used by the program is organized in a highly connected set of associations which is used to guide such activities as checking the validity of facts, generating and testing hypotheses, and constructing a coherent picture of the patient. As the program pursues its interrelated goals of information gathering and diagnosis, it uses knowledge of diseases and pathophysiology, as well as "common sense", to dynamically assemble many small problem-solving strategies into an integrated history-taking process. We suggest that the present experimental approach will facilitate accomplishment of the long-term goal of disseminating clinical expertise via the computer.