The other antecedents and findings are very directly related to the increased risk of thrombotic phenomena. Osteoporosis is not a risk factor for thrombosis.

A 59-year-old woman with a personal history of breast cancer operated on 8 months ago and osteoporosis, suffers a fall and has a fracture of the neck of the right femur. She undergoes surgery and remains in the hospital resting in a cast for 10 days. A week after her discharge, she suddenly feels short of breath, which leads her to consult her family doctor who notices that her right calf has edema and pain on palpation. Which clinical elements would NOT be important in determining that she is at high clinical risk for pulmonary thromboembolism?

History of having been at rest for more than 3 days.

Presence of unilateral edema of the right calf.

Subacute pulmonary embolism in a hemodialysis patient, successfully treated with surgical thrombectomy.

A 53-year-old woman was admitted to our hospital with a 1-month history of gradually progressive resting dyspnea and lumbar backache. For the preceding 6 years, she had received regular hemodialysis for end-stage renal disease caused by autosomal dominant polycystic kidney disease and had taken tamoxifen for 3 years as post-operative chemotherapy for breast cancer. Before admission, the patient's symptoms had been attributed to volume overload, based on right thoracic fluid and leg edema. However, despite volume correction by dialysis therapy, her symptoms had not improved. The patient was transferred to our hospital, where she was diagnosed with subacute pulmonary embolism (PE). Emergent pulmonary thrombectomy was performed using cardio-pulmonary bypass. The patient was discharged from our hospital on post-operative day 23. Recent reports have shown that hemodialysis patients have a relatively higher risk of PE compared with the general population. Our case had additional risk factors for PE: female sex, decreased protein C level, tamoxifen use, and autosomal dominant polycystic kidney disease. These factors may have had a synergistic effect on the onset of PE.

Marie Keating Foundation

In 1994 Keating experienced breast pain and her doctor diagnosed her with mastitis, providing her with a prescription for antibiotics and telling her to come back if the pain persisted. As she was a sufferer of nosocomephobia, she didn't go back to the doctors even though she was in pain. She discovered a breast lump, and her doctor immediately sent her to Beaumont Hospital in the north of Dublin city for a biopsy where she was told that it was cancer even before tests were run. Over a year and a half later, on , Marie was diagnosed with Paget's disease of the breast which developed into breast cancer as it was not detected early enough. Although this was a shock to both her and her family, she underwent a full mastectomy the following month and began chemotherapy treatment. A year later, in September 1997, she was told that the cancer had gone but, because she rarely did her exercises, she developed lymphedema in her legs, and in the following month, she began to experience back pain

[Determination of treatment strategies for a 43-year-old single woman with Stage IV breast cancer].

The patient was a 43-year-old single woman. Her family history included schizophrenia in her mother and manic-depression in her father. Remicade® (infliximab) had been administered for 3 years to treat rheumatoid arthritis. The patient initially presented to our hospital with dyspnea. Computed tomography revealed left-sided breast cancer associated with multiple bone tumors and multiple pulmonary nodules. A poorly mobile mass with an ulcer was found in left breast. Core-needle biopsy and fluorescent in situ hybridization (FISH)revealed an invasive ductal carcinoma that was positive for estrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2, 2 +). The clinical diagnosis was Stage IV T4bN3M1 cancer (metastases to the lungs, liver, and bone). Because of the presence of bone metastasis, the patient was admitted and she received complete bed rest as supportive therapy. However, the patient decided to receive treatment on an outpatient basis after carefully discussing the following points: 1) treatment of pulmonary metastasis with dyspnea should receive priority; 2) anticancer agents not causing nausea were required; 3) the risk of bone fractures as a complication (spinal cord injury); 4) how she wanted to spend the limited time available with her family; and 5) how the patient wanted to.

[A case of phlebothrombosis of lower extremity and pulmonary embolism due to progesterone].

A case with lower extremity phlebothrombosis and pulmonary embolism caused by progesterone is reported in this paper. The patient is a 64-year-old woman who had been operated on for right breast cancer 22 years before. It was noticed that there was a relapsing cancer on her right shoulder 6 months before this episode. After effective treatment of 5-FU, she had received 1,200mg of Medroxyprogesterone acetate and 30mg of Tamoxifen daily for 4 months. With the complaint of dyspnea and left leg swelling 4 months after above treatment, she was admitted in our hospital. Laboratory data and angiograms showed venous thrombosis in her left leg and pulmonary embolism. Relapsing cancer had already disappeared by the time she was admitted. After discontinuance of these medicines, her condition had improved. Considering these observations, the patient's phlebothrombosis and embolism seem to have been caused by Medroxyprogesterone acetate.

Sandra Lee (chef)

Cancer and advocacy Lee announced on May 12, 2015, that she had been diagnosed with early-stage breast cancer. By then she had undergone a lumpectomy, and was scheduled to have a double mastectomy later in the week. Governor Cuomo was to take some personal time to be with her during and after the surgery. In August 2015, she contracted an infection in her right breast that resulted in her going on bed rest and intravenous drugs for three months. Lee announced that she is cancer free in late 2015.

InternalMed_Harrison

Long-term use (≥5 years for estrogen-progestogen and ≥7 years for estrogen alone) is more problematic because a heightened risk of breast cancer must be factored into the decision, especially for estrogen-progestogen. Reasonable candidates for such use include the small percentage of postmenopausal women who have persistent severe vasomotor symptoms along with an increased risk of osteoporosis (e.g., those with osteopenia, a personal or family history of nontraumatic fracture, or a weight below 125 lbs), who also have no personal or family history of breast cancer in a first-degree relative or other contraindications, and who have a strong personal preference for therapy. Poor candidates are women with elevated cardiovascular risk, those at increased risk of breast cancer (e.g., women who have a first-degree relative with breast cancer, susceptibility genes such as BRCA1 or BRCA2, or a personal history of cellular atypia detected by breast biopsy), and those at low risk of

Cases from the Osler medical service at Johns Hopkins University.

A 56-year-old black woman with diabetes mellitus was admitted for hypoglycemia and confusion. Her past medical history included breast cancer, for which she had undergone a left lumpectomy and then mastectomy for in-breast recurrence. Her oral intake had decreased during the past month because of increasing discomfort from left-sided chest pain. During this period, she continued to take pioglitazone for diabetes at her originally prescribed dose. The patient's mental status improved quickly after taking orange juice and intravenous glucose, but the chest pain persisted. The pain, which was described as an ache along the left costal margin, increased with palpation, deep inspiration, or coughing. She had recently presented with similar complaints at another hospital where she had been prescribed a muscle relaxant that provided no relief from the pain. She also reported a 14-lb weight loss during the previous 3 months, as well as fatigue, weakness, and aches in her legs and arms. She denied fevers, chills, sweats, abdominal pain, nausea, or recent trauma. Laboratory values at the time of admission were: calcium, 11.8 mg/dL; total protein, 11.1 mg/dL; albumin, 3.2 g/dL; creatinine, 1.0 mg/dL; and hematocrit, 29.3%, with a mean corpuscular volume of 89.3. Chest radiography revealed a lytic lesion in the left lateral fourth rib and left humerus (). Serum and urine protein electrophoresis revealed a monoclonal spike in the gamma region consistent with monoclonal gammopathy. The serum spike was quantified at 3.78 g/dL. A skeletal survey showed many small well-defined lytic lesions in the skull (with one 1.5-cm lytic lesion in the upper posterior parietal bone), arms, and legs. A bone scan showed multiple foci of increased uptake in the right and left ribs as well as the proximal portion of the left femur. The peripheral blood smear revealed rouleaux formation () and plasma cells (). What is the diagnosis?

Insufficiency Fractures of the Distal Tibia and Fibula Following Total Hip Arthroplasty: A Case Report.

Although periprosthetic fractures of the femur have been well documented, insufficiency fractures following total hip arthroplasty (THA) have been rarely described. We report a case of an insufficiency fracture in the distal tibia and fibula that occurred after THA. A 54-year-old woman presented with severe pain in the bilateral hip joints and was diagnosed with end-stage osteoarthritis. She underwent THA on the right side. Although the postoperative course was uneventful, she suddenly experienced severe pain and swelling in the right leg without any history of trauma 22 weeks after the surgery. She was first diagnosed with cellulitis by her local doctor and was treated with oral antibiotics. Her symptoms persisted, and she returned to our hospital 1 month later. Her right distal leg and ankle were diffusely swollen and tender. Plain radiographs revealed a sclerotic linear zone in the distal tibia and fibula. She was diagnosed with insufficiency fractures in the distal tibia and fibula following THA. Local disuse osteoporosis and increased mechanical stress after THA as a result of pain relief could be the causes for her fracture. Her right leg and ankle were immobilized with a splint for another 4 weeks. Her symptoms subsided gradually, and fracture union was confirmed on the follow-up X-ray. Insufficiency fractures should be suspected in patients complaining of unexplainable pain, even in the distant area of the affected limb, for at least 6 months following THA.

Deep Venous Thrombosis of the Lower Extremity -- History and Physical

Specific historical features that assist in the diagnosis of a DVT are those related to DVT risk factors and include a history of cancer, exogenous estrogen therapy, recent surgery, smoking tobacco, previous history of DVT, immobility, age, history of a hypercoagulable state, and other comorbidities. Patients often will present with a chief complaint of unilateral leg swelling and discomfort. Be mindful to ask about symptoms related to a PE as well, such as chest pain, shortness of breath, and syncope. The physical exam most commonly demonstrates unilateral extremity swelling, warmth and discomfort over the vein, and, perhaps, a palpable "cord" where the DVT is located.

Post-partum sacral fracture associated with heparin treatment.

We report the case of a 19-year-old woman who consulted for low-back pain 3 weeks after her first delivery. This young woman had a personal history of protein C deficiency and was treated daily during her pregnancy with low-molecular-weight heparin. Her body mass index was 34 and she only gained 10 kg during her pregnancy. Since the delivery - which occurred without any complication - she had suffered from a gradually increasing right-buttock pain and limp. Magnetic resonance imaging (MRI) revealed a fracture of the right sacral ala. After analgesia and 1 month of home relative bed rest, the patient recovered her functional capacities. Regarding our patient, who had no potential clinical risk factors for osteoporosis, the causal effect of heparin is thus possible but not certain. This case report illustrates the fact that clinicians should have a high suspicion of pelvic fracture in post-partum women, even in very young ones, presenting sudden onset of low back and pelvic pain, especially when they have received heparin during pregnancy. MRI seems to be the key exam because it is able to detect and stage fractures or microfractures.

Chest Pain -- History and Physical -- History

Shortness of breath Nausea and vomiting Fever Diaphoresis Cough Dyspepsia Edema Calf pain or swelling Recent illness Evaluate for any of the following risk factors: ACS risks: prior myocardial infarction(MI), family history of cardiac disease, smoking, hypertension (HTN), hyperlipidemia (HLD), and diabetes Pulmonary embolism (PE) risks: prior deep venous thrombosis (DVT) or PE, hormone use (including oral birth control), recent surgery, cancer, or periods of non-ambulation Recent gastrointestinal (GI) procedures like scopes Drug abuse (cocaine and methamphetamines)

Leg ulcers and hydroxyurea: report of three cases with essential thrombocythemia.

CASE 1: A 65-year-old woman with essential thrombocythemia (ET) had been taking oral hydroxyurea (HU), 1,000 mg daily, for 7 years. Six months ago, she developed an ulcer on the outer part of her left ankle, which healed spontaneously within 2 months. She presented with a new, tender, shallow ulcer, 2 cm x 2 cm in size, at the same site. Doppler examination revealed thrombosis of the left common femoral vein and a calcified atheroma plaque of the left common femoral artery. The dosage of HU was decreased to 500 mg daily when the platelet counts were found to be within normal levels. The ulcer completely healed within 2 months with occlusive wound dressings, and has not recurred within the follow-up period of 1 year. CASE 2: A 56-year-old women presented with multiple, painful, leg ulcers of 1 year duration. She had been diagnosed as having ET and had been on HU therapy, 1,500 mg/day, for the past 5 years. Interferon-alpha-2b was started 3 months ago, in addition to HU, which was tapered to 1,000 mg daily. She had suffered from hypertension for 20 years treated with nifedipine and enalapril, and had recently been diagnosed with diabetes mellitus which was controlled by diet. Examination revealed three ulcers located on the lateral aspects of both ankles and right distal toe. Arterial and venous Doppler examinations were within normal limits. Histopathology of the ulcer revealed nonspecific changes with a mixed inflammatory cell infiltrate around dermal vessels. The ulcers completely healed within 10 weeks with topical hydrocolloid dressings. After healing, she was lost to follow-up. A year later, it was learned that she had developed a new ulcer at her right heel, 3 months after her last visit (by phone call). This ulcer persisted for 8 months until HU was withdrawn. CASE 3: A 64-year-old woman with ET presented with a painful leg ulcer of 6 months' duration. She had been taking oral HU for 5 years. She had a 20-year history of hypertension treated with lisinopril. Examination revealed a punched-out ulcer of 2 cm x 2 cm over the right lateral malleolus. Doppler examination of the veins revealed insufficiency of the right greater saphenous and femoral veins. Angiography showed multiple stenoses of the right popliteal and femoral arteries. As her platelet count remained high, HU was continued. During the follow-up period of 13 months, the ulcer showed only partial improvement with local wound care.

Leo Stern (historian)

Later years

A case of quadruple primary malignancies including breast, tongue, and thyroid cancers and osteosarcoma in a young female without karyotype abnormality.

The patient was a 41-year-old, premenopausal woman with a chief complaint of well-circumscribed palpable, right breast mass without nipple discharge. Although she noticed the lump 3 months previously, the size of the tumor (1.1 × 0.9 cm(2)) had been stable. The patient's mother suffered from gastric cancer. Her previous history of the triple different malignancies was as follows: (1) left osteosarcoma [amputation of left lower leg at 15 years old (y/o)]. After the operation, she was treated with various kinds of anticancer drugs including a total of 45 g ifosphamide and 342 g methotrexate; (2) tongue cancer (right radical neck resection; 23 y/o); and (3) thyroid cancer (right lobectomy; 40 y/o). There was no evidence of recurrence of these malignancies at the present consultation. At the time of tongue cancer operation, chromosome abnormality was investigated, but the results were normal. Physical examination showed a well-delimited, elastic-firm, mobile tumor in the central outer right breast. Regional lymph nodes were not palpable. Mammography showed a focal asymmetry in the right upper breast on the mediolateral oblique view. Ultrasonography revealed a hypoechoic mass with irregular margins. Distant metastases could not be detected by whole-body computed tomography scan. The histology of the Mammotome(®) (vacuum-assisted core needle biopsy) specimen revealed that this tumor was low-grade ductal carcinoma in situ (DCIS). She underwent breast-conserving surgery with sentinel lymph node biopsy. On permanent histopathological examination, the diagnosis of the tumor was intracystic papilloma with low-grade DCIS. Surgical margin was negative, and sentinel lymph node metastases could not be observed. Estrogen and progesterone receptor (ER/PR) were strongly positive, but human epidermal growth factor receptor-2 (HER-2) overexpression was not tested because the lesion was DCIS. She has received no adjuvant therapy and is currently disease free 3 months after surgery.

Value of the history in the office diagnosis of breast cancer.

A review of the histories of 1059 patients with breast problems seen consecutively in office consultation revealed an incidence of breast cancer of 13%. Patients over 50 years of age or whose mother or sister had had breast cancer had a substantially greater likelihood of having breast cancer. The finding of the problem on routine examination, a family history of breast cancer in a relative other than the mother or a sister, or prominent breast pain or nipple discharge made the diagnosis of cancer less likely. Menstrual status, a history of previous benign disease, nulliparity, current hormone therapy and duration of symptoms did not help identify the patient likely to have breast cancer. Much time could be saved for both doctor and patient in taking the history from patients with breast disorders. Only the patient's age and the history of the mother and sisters with regard to breast cancer will help identify the "high-risk" patient. Other historical findings are either valueless or should be used to reassure these usually anxious women.

Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) in an osteoporotic patient chronically treated with bisphosphonates.

The aim of the study is to report the rare association of two complications of long-term treatment of osteoporosis with bisphosphonates in the same Caucasian elderly patient. A female patient of Italian descent, age 87 years, consulted in February 2013. She had a history of osteoporosis and had taken alendronate weekly for 7 years (1999-2006). Due to low back pain, an orthopedist had indicated i.v. zoledronic acid, 5 mg/year for 3 years (2006-2008). She received occasional supplements of ergocalciferol. In 2009, she suffered a fall and sustained a subtrochanteric fracture of the left femur. She was operated on and recovered uneventfully. In 2012, she consulted a dentist due to loose teeth. She underwent the removal of a molar and was given a denture. She had discomfort when using the prosthesis, and developed an ulceration in the gum of the mandible, which exposed the bone and did not heal for 2 months. After radiologic studies, the diagnosis was osteonecrosis of the jaw. She improved after surgical debridement and local and systemic antibiotics. In early 2013, laboratory tests were normal except for a slight elevation of serum PTH and CTX-I. Calcitriol 0.25 mcg/day was prescribed; after 3 months serum calcium, phosphate, PTH, and CTX-I showed no variation. Two years later, she experienced acute low back pain after a fall; MRI showed recent crushing of D12, and chronic deformities of D11 and L1. Bone densitometry of her right hip (DXA) showed a T-score of -2.3 at the femoral neck. An X-ray film of the right femur showed diffuse thickening of both cortices. She was treated with nasal calcitonin and analgesics. After the back pain subsided, she was treated with s.c. denosumab. Although the association of ONJ and AFF was known in cancer patients treated with high doses of bisphosphonates, it is very rare in patients with osteoporosis receiving these drugs at usual doses. Only three cases have been reported, all in oriental women. This appears to be the first reported case in a Caucasian woman.

Julia Carson

Illness and death On September 29, 2007, the Indianapolis Star reported that Carson had been an in-patient at Indianapolis's Methodist Hospital for the preceding eight days. She was being treated for an infection in her leg near the area where a vein was removed in 1996 during double bypass heart surgery. Year-to-date, Carson had participated in 87 percent of the House votes, but had missed 42 of 77 votes during the month. Carson had battled lung cancer before, but it had gone into remission before being re-diagnosed during the leg vein treatment, as the Star announced on November 25. She died on December 15, at the age of 69; her death was announced by her friend, former U.S. Representative Andrew Jacobs Jr.

Palliative Chemotherapy: Does It Only Provide False Hope? The Role of Palliative Care in a Young Patient With Newly Diagnosed Metastatic Adenocarcinoma.

<bCase Study</b A 48-year-old female with recent diagnosis of adenocarcinoma of unknown origin and metastatic disease to the peritoneum initially presented to a nearby academic hospital with abdominal pain. She underwent exploratory laparotomy with tumor debulking surgery at that time. Shortly thereafter, she was readmitted to the same hospital with evidence of partial small bowel obstruction and treated conservatively with bowel rest, nasogastric (NG) tube placement, and intravenous (IV) fluid administration. Eventually the NG tube was removed, and she was discharged home. The following day, she received cycle one of palliative chemotherapy with cisplatin and gemcitabine at her local outpatient oncology clinic. She experienced persistent nausea and intermittent vomiting throughout the night and presented to our local community hospital for evaluation. At the time of admission, she was passing minimal flatus and had passed only a small bowel movement that morning. She had experienced nausea, vomiting, and poor oral intake for over a week. Other presenting symptoms included mild to moderate abdominal pain involving the upper abdomen. Upon evaluation, abdominal x-ray revealed dilated loops of small bowel, consistent with partial small bowel obstruction. An NG tube was placed, and the patient's symptoms were initially improved with bowel rest. Her medical history was significant for pulmonary embolism detected at the time of her adenocarcinoma diagnosis, and she was on oral anticoagulation and home oxygen. She also had a history of depression and total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) due to fibroids. Her social history revealed she was an office worker and married with two sons, ages 18 and 24. The 18-year-old son lived at home with the patient and her husband. The patient was eagerly awaiting the birth of a granddaughter, due in a few weeks' time. Her mother and father were also present daily during her hospitalization and were a major source of support for her and her family. At the time of hospital admission, a surgical team consultation concluded she was not a candidate for palliative surgery due to extensive disease burden. She was seen in consultation by medical oncology, who recommended resuming chemotherapy once the acute partial small- bowel obstruction resolved. <bPalliative Care Consult</b A palliative care consultation was requested to assist with symptom management, including pain and nausea relief. At the time of consultation, the patient appeared in mild distress due to abdominal pain and distention. Vital signs were stable. Physical exam was significant for absent bowel sounds and a mildly distended but nontender abdomen. The NG tube was in place, draining bilious gastric fluid. She had mild nonpitting edema involving the bilateral lower extremities. Discussion with the patient revealed values consistent with improving symptoms and extending life expectancy as long as possible. The patient expressed wishes for "aggressive treatment," which she defined as continuation of chemotherapy and full resuscitation. The palliative care team discussed symptom management options with the patient. Nonsurgical management of partial bowel obstruction was continued, including bowel rest, NG tube decompression, and IV fluids. Pain was controlled initially with IV morphine as needed. After symptom improvement and evidence of bowel function recovery, the NG tube was removed. However, after a short time, she required NG tube replacement due to recurrent nausea and vomiting. Discussion was initiated with the patient, who opted for placement of a venting gastrostomy tube (G-tube) and total parenteral nutrition (TPN), with the goal of symptom relief and administration of nutrition, which would allow for continuation of chemotherapy. During placement of the venting G-tube, the gastroenterology (GI) team noted extensive tumor involving the stomach, which made placement of the tube difficult. Additionally, anticoagulation was held during G-tube placement, and postoperatively, the patient experienced acute, right-sided chest pain and shortness of breath. Computed tomography (CT) scan with pulmonary embolus (PE) protocol revealed a new PE, and anticoagulation was changed to enoxaparin. Shortly thereafter, she became febrile and developed leukocytosis. Blood cultures revealed coagulase-negative staphylococcus from a Port-a-Cath source. She was treated with appropriate antibiotic therapy; however, follow-up blood cultures revealed persistent coagulase-negative staphylococcus bacteremia. Her indwelling Port-a-Cath was removed. After appropriate antibiotic therapy, a peripherally inserted central catheter line was inserted and TPN restarted. <bReinstituting Palliative Chemotherapy</b Palliative care discussion with the patient confirmed her desire to reinstitute palliative chemotherapy, with the goal of restoring bowel function and returning home. Chemotherapy was resumed on day 15, despite concerns and even objections from several nursing staff members. The patient experienced treatment side effects, including prolonged thrombocytopenia. A platelet function antibody returned positive, consistent with heparin-induced thrombocytopenia. Enoxaparin was discontinued, and fondaparinux (Arixtra) was initiated. Platelet count recovered shortly thereafter. The patient required intense symptom management due to intractable abdominal pain and nausea and vomiting despite adequate venting G-tube decompression. Medical management was maximized with antiemetics, antisecretory agents, steroids, and antipsychotic agents, and symptoms eventually improved after cycle 2 of chemotherapy. Thereafter, the patient was discharged home. At the time of discharge, her symptoms were well controlled on minimal pain medications. She was still experiencing intermittent nausea but was passing flatus. By reducing the tumor burden, chemotherapy significantly improved her quality of life. She spent a total of 7 weeks in the hospital. During that time, she received two cycles of chemotherapy plus best supportive care and symptom management. Despite intermittent nausea and vomiting, administration of palliative chemotherapy allowed this patient to achieve her primary goals, which included returning home to her family and regaining some bowel function. Over the next several months, she received several more cycles of outpatient palliative chemotherapy. She experienced mild to moderate nausea and intermittent vomiting despite G-tube venting. Eventually, her disease progressed, and the patient chose to forgo any further intervention or chemotherapy. She was enrolled in hospice care and died comfortably at home surrounded by her family.

Ruth Lyons (broadcaster)

Later years, retirement and death The mid-1960s were a time of illness and sorrow for Lyons and her family. She had maintained close ties with her younger sister, Rose; her sister died in 1964 after a ten-year battle with cancer. Lyons suffered a minor stroke in December 1964 and had to take a leave of absence from her television program. In January 1965, there was another family medical crisis; 20-year-old Candy had discovered a lump in her breast which turned out to be malignant. She underwent surgery and radiation; by September, she was well enough to join the cast of The 50-50 Club on a permanent basis. In early 1966, it became apparent that Candy's illness was now terminal; she wanted to return to Europe one last time. The Newman family left New York in early June. When they arrived in Italy, Candy was quite ill and was hospitalized; they began preparations for their return to the US on June 14. On June 19, 1966, Candy died aboard the ship before it reached New York.

Mesenteric cysts and mesenteric venous thrombosis leading to intestinal necrosis in pregnancy managed with laparotomy: a case report and review of the literature.

Mesenteric cyst is a rare clinical entity especially in pregnancy; therefore, few cases have been reported in the literature. The standard method of their treatment is surgical excision either with laparotomy or laparoscopy. In addition, mesenteric vein thrombosis is a rare and life-threatening condition in pregnancy and needs immediate treatment because it can lead to intestinal necrotic ischemia. This is the first report of the coexistence of mesenteric cysts and mesenteric vein thrombosis during gestation. A 27-year-old Greek woman, gravida 2 para 1, presented at 10 weeks' gestation to the Emergency Unit of our hospital complaining of diffuse abdominal pain which deteriorated the last 3 days, which was localized in her right iliac fossa, along with vomiting. She had undergone open laparotomy and right salpingo-oophorectomy at the age of 23 due to an ovarian cyst. Besides this, her personal and family medical history was unremarkable. She had never received oral contraceptives or any hormone therapy. On arrival, a clinical examination revealed tenderness on palpation of her right iliac fossa, without rebound tenderness or muscle guarding. Within 10 hours of hospitalization, her symptoms deteriorated further with rebound tenderness during the examination, tachycardia, and a drop of 12 units in her hematocrit value. An emergency laparotomy was performed. Two mesenteric cysts and a 60 cm necrotic part of her intestine were revealed intraoperatively. In the postoperative period, she complained of acute abdominal pain, tachycardia, and dyspnea. Computed tomography imaging revealed mesenteric vein thrombosis and pulmonary thromboembolism. She was treated with low molecular weight heparin and she was discharged on the 11th postoperative day. To the best of our knowledge, this is the first report in the literature of a simultaneous mesenteric cyst and mesenteric vein thrombosis in pregnancy. It is known that pregnancy is a state of hypercoagulation and clinicians should bear in mind this rare clinical condition in their diagnostic algorithm for acute abdominal pain.

[Usefulness of detection of breast cancer: the part played by the internist].

The prognosis of breast cancer is the result of many factors, among which the mass of the tumor at the time of diagnosis remains the most significant: small tumors have a better prognosis than larger ones and are less often accompanied by positive lymph nodes. It is therefore justifiable to search for them systematically by breast examination of all patients over 30. Large-scale mass screening campains in the USA, with clinical and mammographic examination of tens of thousands of women, have proven that it is possible to detect more "early" cancers and reduce general mortality in the groups studied. The number of cancers thus detected is nevertheless so small that it does not justify the investment of so much labour and money in this kind of campaign. Systematic breast examination at regular intervals (6 months to 1 year) with regular mammographies should be confined to patients in the high risk groups: women who have already undergone surgery for cancer of one breast, and patients with a marked family history of breast cancer. For the rest of the female population, the solution seems obvious: every physician should get into the habit of performing regular clinical examination of the breasts. Most gynecologists are already doing so, but they only examine a small part of the population. The most important role in the detection of breast cancer falls to the internists and the general practitioners: they should assume responsibility for all their patients' breasts, in the same manner as they do for heart and lung examinations. They will then request additional examinations (mammography, thermography) as soon as clinical examination reveals a pathological finding. The results of GILBERTSEN [5] confirm that clinical examination remains the most valuable and least expensive method for breast cancer detection.

Sickle cell disease with osteogenesis imperfecta.

A 16 yr old female presented with generalized weakness and easy fatigability since 2 months. Her medical history included that she had sickle cell disease (ss pattern) on regular treatment. She denied smoking and consumption of alcohol. She had adequate calcium intake and her menstrual history was non-contributory. History of right tibial diaphysial fracture 1 year back followed by refracture at the same site 6 months later. On examination patient was 146 cm tall & weighed 48 kg. She had pallor, blue-grey sclera,scar mark of previous operation on right leg. Her mother and two maternal aunts also had blue-gray sclera. She had normal dentition and other systems were normal. Radiological screening showed diffuse osteopenia of all visualized skeleton, biconcave vertebral bodies in lumbar spine, Old healed fracture of right tibial diaphysis with intra-medullary nail in situ, wormian bones seen along the lambdoid suture, old healed fracture with sclerosis noted involving diaphysis of first metatarsal. Secondary causes of osteoporosis were ruled out. Skeletal involvement is sickle cell disease is usually in the form of avascular necrosis, dactylitis, joint effusions or osteomyelitis however osteoporosis and long bone fractures are not known in sickle cell disease. Owing to high index of suspicion a diagnosis of osteogenesis imperfecta was pursued, since the patient presented at 16 years age with relatively minor symptoms type 1A osteogenesis imperfecta (mildest form) was established. Systemic screening for disease complications included osteopontogram, audiogram and consultation with ophthalmologist and geneticist. Therapy with calcium and vit D was initiated and an in depth discussion regarding biphosphonates was pursued. Anaemia was corrected with blood transfusion and treatment of sickle cell disease was continued. Family screening was offered. Fractures particularly adults older than 45 are associated with osteoporosis. This case illustrates the importance of family history, fracture history and clinical correlation when assessing patients with osteoporosis. Mild OI most often presents after infancy and should be considered whenever children or adults have recurrent fractures. Early diagnosis of this disease by family physicians will enable initiation of therapy as well as patients education regarding management of modifiable risk factors linked with osteoporosis (e.g. diet, smoking, alcohol). Genetic counseling and family screening could also be offered.

Innocent Murmur -- History and Physical -- Benign Continuous Murmurs

Venous Hum [3] Most common continuous benign murmur, most often seen between 2 to 8 years of life Soft, whirling, low-pitched murmur, grade 1 to 3/6, heard best in high right sternal border and the right infraclavicular area in the upright position. Murmur does not radiate, disappears completely when supine or when patient extends the neck and turns to the right. Mammary Souffle [3] Least common, usually heard primarily in young adult women, especially when pregnant or lactating. Soft, blowing, high-pitched systolic murmur, grade 1 to 2/6, heard best over anterior chest, specifically over the breasts, softer when upright or with high stethoscope pressure.

Treatment of Pregnancy-Associated Breast Cancer.

KS is a 33-year-old Caucasian married woman who works full time as an accountant and has one daughter who is 2 years old. She enjoys reading and exercising in her spare time. She initially presented in July 2015 at the age of 31 years with a 1-cm breast mass in the left inner breast, which prompted a mammogram to be obtained. The mammogram revealed diffuse and occasionally grouped left breast calcifications. Additionally, there was focal edema at the site of the mass. A follow-up mammogram was recommended to document stability in 6 months, which demonstrated an interval increase in number and size of segmental pleomorphic calcifications in the lower inner breast spanning 6 cm in size. A stereotactic core needle biopsy was completed and revealed high-grade ductal carcinoma in situ (DCIS) that was estrogen receptor (ER) and progesterone receptor (PR) positive. KS underwent genetic testing due to her young age at diagnosis of noninvasive breast cancer. She was tested with the breast/ovarian cancer panel, which was negative for mutation.She preceded to bilateral nipple-sparing mastectomy with left sentinel node biopsy and immediate implant reconstruction in February 2016. The operative pathology revealed 3.3 cm of high-grade DCIS. The surgical margins were negative (less than 1 mm posteriorly and less than 2 mm anteriorly). There was 1 sentinel node and 2 nonsentinel nodes negative for malignancy. The right breast was negative for cancer and both retro areolar margins were negative.KS did well during the ensuing routine follow-up every 6 to 12 months in surgical oncology at an academic medical center. She was not recommended to take adjuvant endocrine therapy given the benefit of bilateral mastectomy.In 2017, at a routine oncology follow-up visit, she expressed a desire to have more children. After a negative clinical exam, she and her husband were advised that future contraception may be pursued. KS was in her usual state of good health when she noticed a left breast mass in the inferior reconstructed breast in June 2017. She presented to the nurse practitioner (NP) in the surgical oncology clinic for evaluation. At that time, she was 17 weeks pregnant and being seen in the same facility for high-risk obstetrics and gynecology care. KS had no other concerning symptoms for recurrent cancer, and her pregnancy had been progressing smoothly.The surgical oncology NP noted a 1-cm firm superficial mass in the breast at 6 o'clock. She had no other bilateral breast findings or adenopathy. Upon review of systems, she denied new persistent headache, shortness of breath, abdominal pain, weight loss, night sweats, or fatigue.Due to her pregnancy and the superficial presentation of the breast mass, a left breast ultrasound was ordered. It revealed an 8-mm irregular hypoechoic mass 7 cm from the nipple at the 6 o'clock position in the reconstructed breast.A diagnostic workup ensued with a left breast ultrasound-guided core needle biopsy. KS was given a diagnosis of clinical stage T1b, N0, grade 2 invasive micropapillary carcinoma: ER positive (Allred 6), PR positive (Allred 8), HER2/<ineu</i, immunohistochemistry 3+, and fluorescence in situ hybridization amplified.After discussion of this recurrent cancer diagnosis, her team opted for a bilateral diagnostic mammogram (with abdominal shielding) and bilateral axillary and breast ultrasound to evaluate the contralateral breast and lymph nodes. There was no adenopathy, a small amount of accessory breast tissue in the right axillary tail region, and a biopsy clip was noted in the left inferior breast at 6 o'clock. The new cancer was not seen on mammogram, likely due to the proximity to the implant.

A 20-Year-Old Woman With Thoracic Pain and Progressive Dyspnea on Exertion.

A 20-year-old woman presented with dry cough, right-sided thoracic pain, and gradually progressive dyspnea on exertion. She had no hemoptysis or fever. There was no relevant medical history. She was a never smoker and used no medication besides oral contraceptives. There were no other risk factors for a pulmonary embolism. There was a family history of ovarian and breast cancer. Physical examination showed a mildly ill-looking woman, with shallow breathing and normal blood oxygen saturation. Auscultation revealed normal breath sounds without crackles or wheezing. Laboratory testing showed a significantly increased D-dimer (4,560 μg/L [normal, < 500 μg/L]), elevated C-reactive protein (131 mg/L [normal, < 5 mg/L]), normal leucocytes, and elevated lactate dehydrogenase (825 units/L [normal, 50 to 250 units/L).

Case 242: Radiation-induced Angiosarcoma.

History In 2004, this woman received a diagnosis of invasive mammillary carcinoma, tubular variant, strongly positive for estrogen and progesterone receptors. Her lesion was found at screening mammography performed at an outside institution when she was 59 years old. She underwent partial mastectomy, with partial axillary node dissection and sentinel node mapping. A 0.6 × 0.5 cm Nottingham grade 1 infiltrating ductal carcinoma was removed from the right upper outer quadrant, margins were free of tumor, and there was no angiolymphatic invasion. The six dissected lymph nodes were negative for malignancy. Her surgical history was otherwise unremarkable. Her medical history was positive for hypercholesterolemia and depression. Pertinent family history included breast cancer in both her mother and her sister. Given the patient's age, tumor size, lack of nodal involvement, and clear surgical margins, she met recommended MammoSite criteria, and she underwent accelerated partial breast radiation. She subsequently received 340 cGy of radiation twice a day for a total dose of 3400 cGy in 10 administrations in February 2005. Accelerated partial breast radiation treatment was completed in February 2005, and she received subsequent routine care. Prior to 2014, the only postoperative complication was a chronic radiation bed seroma, which required periodic percutaneous drainage. She did not develop postsurgical lymphedema. In December 2013, 9 years after accelerated partial breast radiation treatment, she experienced progressive painful pruritic breast fullness, skin dimpling, and skin discoloration of the mastectomy scar and radiation bed. She sought medical care in January 2014 after she noticed a periareolar ulcerating skin plaque, more noticeable nipple retraction, and new onset of retroareolar aching. At physical examination ( Fig 1 ), there was generalized periareolar erythema, dimpling, firmness, and fixation involving the central breast and right upper outer quadrant. There was more conspicuous retraction of the nipple when compared with that seen at prior examinations. Nipple discharge was not present. There was a 1-cm periareolar ulcerating skin plaque. The only discrete palpable finding was lumpectomy bed seroma. There was no palpable axillary adenopathy. [Figure: see text] A diagnostic mammogram was obtained and compared with the most recent studies available. Ultrasonography (US) and magnetic resonance (MR) imaging were performed. Her most recent mammogram, obtained 3 months earlier in September 2013, reported Breast Imaging Reporting and Data System (BI-RADS) category 2 findings (ie, stable postoperative benign findings).

Novel Mutation in <i>CACNA1A</i> Associated with Activity-Induced Dystonia, Cervical Dystonia, and Mild Ataxia.

<iCACNA1A</i encodes the pore-forming <iα</i1 subunit of the neuronal voltage-gated Cav2.1 (P/Q-type) channels, which are predominantly localized at the presynaptic terminals of the brain and cerebellar neurons and play an important role in controlling neurotransmitter release. Mutations in <iCACNA1A</i have been associated with several autosomal dominant neurologic disorders, including familial hemiplegic migraine type 1, episodic ataxia type 2 (EA2), and spinocerebellar ataxia type 6. A 37-year-old woman presented with a history of slowly progressive, activity-induced stiffness, and pain in her right leg since age 15 and cervical dystonia since age 20. She denied any right leg stiffness or pain at rest, but when she began to walk, her right foot turned in and her right leg stiffened up. She also had neck pain, stiffness, and spams. There was no family history of similar symptoms. On physical exam, her strength, tone, and reflexes were normal in all extremities at rest. There was mild head titubation and very mild past pointing on finger-to-nose testing. MRI of the brain and spinal cord was unremarkable. This patient's clinical picture was felt to be most consistent with paroxysmal kinesigenic dyskinesia, as she has attacks of dystonia that are triggered by voluntary movement, last from a few seconds to a minute, and are relieved with rest. She was trialed on carbidopa/levodopa without improvement. A dystonia panel showed two potentially pathologic mutations, one in <iCACNA1A</i and the other in <iPNKP</i, along with a variant of unknown significance in <iATP7B</i. The mutation in <iCACNA1A</i is C2324 G < A. It is heterozygous, autosomal dominant, and computer modeling suggests pathogenicity. This mutation has not been reported previously and is likely the cause of her paroxysmal dystonia; dystonia is sometimes seen during episodes of ataxia in EA2, and <iCACNA1A</i knockout mice exhibit dystonia and cerebellar atrophy. After receiving her genetic diagnosis, the patient was trialed on acetazolamide without improvement in her dystonia symptoms. This is the second case report of a patient with cervical dystonia and cerebellar ataxia associated with a mutation in <iCACNA1A</i.

Episode 5276

Sonia Fowler (Natalie Cassidy) prepares to visit a doctor after finding a lump in her breast. She is accompanied by her girlfriend Tina Carter (Luisa Bradshaw-White), and the doctor refers Sonia for further tests. Back at home, Sonia tells her step-grandmother Dot Branning (June Brown) that she could have cancer and cries in Dot's arms. She admits she is also worried that Tina will no longer love her if she loses her breasts. Dot tells her to be strong and fight it. Sonia then tells Tina that she will have a double mastectomy, regardless of the results.

Isolated pulmonary veno-occlusive disease and pulmonary arterial thrombosis in systemic sclerosis - a lethal combination.

Isolated pulmonary hypertension secondary to systemic sclerosis is not uncommon. Our patient with systemic sclerosis presented with a very aggressive form of pulmonary hypertension due to a lethal combination of pulmonary veno-occlusive disease (PVOD) and pulmonary arterial thrombosis. This combined presentation has never before been reported in medical literature. A 75-year-old woman with a 4-month history of atypical chest pains was admitted with a 3-week history of worsening symptoms of shortness of breath, reduced exercise tolerance, and bilateral pitting edema. On examination she had thickened skin in her hands, telangiectasia on her face, maculopapular rash in her legs, raised jugular venous pressure, and bilateral pitting edema. Her autoimmune profile revealed positive anticentromere antibodies, and her echocardiogram showed right ventricular systolic pressure of 91 mmHg. She also had renal impairment secondary to hypoperfusion. A diagnosis of isolated pulmonary hypertension secondary to limited systemic sclerosis was made. As she was clinically improving on slow diuretic infusion and awaiting transfer to a specialist center for management of pulmonary hypertension, our patient died due to cardiopulmonary arrest. Her postmortem revealed that she died of a combination of PVOD and pulmonary arteriopathy due to thrombosis. This is clearly a unique case both in presentation and difficulty of management. Pulmonary vasodilators used in therapy of pulmonary arteriopathy can be detrimental in patients with PVOD. There is no definitive investigation, curative treatment, or management, that exists for a combination of PVOD and pulmonary arteriopathy due to thrombosis secondary to systemic sclerosis.

Alicia Parlette

Alicia Rose Parlette (January 11, 1982 – April 22, 2010) was a journalist and copy editor who was diagnosed with alveolar soft part sarcoma in 2005 while employed by the San Francisco Chronicle newspaper. At the age of 16, Parlette began experiencing pain in the area of her right hip that forced her to drop out of cross country running. An MRI scan revealed a spot that was interpreted as a hemangioma. Six years later, after she developed a severe cough, further scans showed spots in her lungs. Half a year later, she developed a lump in her right breast, which was excised and biopsied, leading to the correct diagnosis of the cancer she had probably been carrying for at least seven years.

High altitude pulmonary edema (HAPE) in a Himalayan trekker: a case report.

High altitude pulmonary edema is a non-cardiogenic form of pulmonary edema that develops in unacclimatized individuals at altitudes over 2500 m. Early recognition of symptoms and immediate descent are important for successful treatment. Despite early signs and symptoms of high altitude illness, many trekkers tend to push themselves to the maximum limit. Some of them, such as the case reported here, choose to ascend on horse-back which is extremely dangerous and can be fatal. A 55 years of age Indian ethnic South African lady was emergency air-lifted from 4410 m altitude in the Nepal Himalayas to Kathamandu (1300 m) with a suspected case of high altitude pulmonary edema. She had continued ascending despite experiencing mild altitude symptoms at Namche (3440 m), and these symptoms worsened considerably at Tengboche (3860 m). At the very start of her trek, just after Lukla (2800 m), she suffered from sore throat, and had consequently begun a course of antibiotics (azithromycin) for a suspected throat infection. She had planned to continue ascending on horse back to complete the trek, however her condition deteriorated further and she had to be medically evacuated.On admission to the clinic her axillary temperature was 99.4 F, blood pressure 120/60 mmHg, pulse rate 72/min, respiratory rate of 25 breaths/min, and pulse oximeter showed saturation of 90% on room air at rest. Right sided crackles on the axillary and posterior region were heard on chest auscultation. Heel to toe test showed no signs of ataxia. The chest radiograph showed patchy infiltrates on the right side. An echocardiogram was done which revealed a high pulmonary artery pressure of 50 mm of Hg. She was diagnosed as resolving high altitude pulmornay edema. She was treated with bed rest, supplemental oxygen and sustained release nifedipine 20 mg (orally) twice a day. On the third day her crackles had cleared significantly and repeat chest radiograph as shown showed remarkable improvement. She felt much better. A repeat echocardiogram revealed a normal pulmonary artery pressure. The case report highlights numerous points:1) Many high altitude trekkers have invested significant time, money and physical efforts in in their ventures and are determined to ascend despite early warning and illnesses. 2) Despite no history of altitude illnesses in previous altitude exposure,inter-current illness (in this case a nonspecific respiratory tract infection) may contribute to the development of high altitude pulmonary edema. 3) Continuing ascent using other transport means, whilst suffering from symptoms of high altitude illness, worsens the condition and could be life threatening. 4) Acetazolamide does not prevent high altitude pulmonary edema-perhaps more so in the cases that have inter-current illness. 5) Descent is the golden rule in all altitude illnesses. Actually 'descent' is advised in any undiagnosed illness at high altitude among sojourners. 6) Finally, an experienced guide who has mountain medicine training is essential. They can be crucial in noticing early signs and symptoms of altitude illnesses to inform the client's safety as in this case.

Leo Stern (historian)

Halle