The American journal of medicine
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Heart disease has not been well characterized in patients with systemic lupus erythematosus (SLE) and the antiphospholipid syndrome. During a prospective study of cerebrovascular disease in autoimmune disease and SLE, 11 lupus patients were identified with an antiphospholipid syndrome characterized by significant cardiac valvular disease in addition to cerebral infarction, deep vein thromboses, and thrombocytopenia. Patients were reviewed for criteria for systemic lupus and underwent echocardiographic studies and measurements of anticardiolipin antibodies, VDRL, and the lupus anticoagulant. ⋯ This report expands previous descriptions of antiphospholipid syndromes by describing a subset of lupus patients with significant aortic and mitral valvulitis in addition to circulating antiphospholipid antibodies, thrombocytopenia, and recurrent thromboses.
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To identify diagnostic errors caused by faulty clinical cognition, we analyzed 40 consecutive transcripts of problem-solving exercises published in a pedagogic series of clinical reasoning. The analysis disclosed multiple errors in cognition and produced a provisional classification of these errors based on a framework derived from cognitive science. ⋯ We instantiated each type of error by providing detailed specific examples, and identified the consequences of each error. We conclude that cognitive errors can be identified and classified, that they can produce serious morbidity, and that a classification of cognitive errors is a step toward a deeper understanding of the epidemiology, causes, and prevention of diagnostic errors.
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In this report, we have presented our experience with a patient with a rare cutaneous granulocytic sarcoma. In addition to hematoxylin and eosin, myeloperoxidase stain and specific stains for lysozyme and esterase were helpful in confirming the histologic diagnosis of granulocytic sarcoma. ⋯ Treatment with corticosteroids at the time of surgery may have prevented a local recurrence of granulocytic sarcoma despite positive tissue margins. Our experience underscores the importance of directing treatment toward the granulocytic sarcoma whereas the myelodysplasia concurrently present may not require therapy for several years.
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Many symptoms in outpatient practice are poorly understood. To determine the incidence, diagnostic findings, and outcome of 14 common symptoms, we reviewed the records of 1,000 patients followed by house staff in an internal medicine clinic over a three-year period. The following data were abstracted for each symptom: patient characteristics, symptom duration, evaluation, suspected etiology of the symptom, treatment prescribed, and outcome of the symptom. Cost estimates for diagnostic evaluation were calculated by means of the schedule of prevailing rates for Texas employed by the Civilian Health and Medical Program of the Uniformed Services for physician reimbursement. ⋯ The classification, evaluation, and management of common symptoms need to be refined. Diagnostic strategies emphasizing organic causes may be inadequate.