History and physical examination: the cornerstones of the third millennium in medicine

Woman, 76aa, log on to first aid point of for fever, sore throat and polyarthralgia 2 weeks EO: right knee arthritis, palpable cervical-axil-lary lymphnodes, soft ankle edema,functional impairment with pain in shoulder blades, small flat scar interscapular hepatosplenomegaly con-firmed by US. Lab tests: marked phlogosis (VES: 57 mm/h; PCR: 35mg/dl) with rise ferritin and procalcitonin (0,89 pg/ml), anemia, neutrophilic leucocytosis (20000/ml), 3 out of 3 blood cultures pos for MSSA, pos RF, no consumption of complement, immune serology neg-ative CT chest-abdomen: structural upheaval right subscapularis mus-cle to cystic degeneration, with uptake of contrast medium (measures: 13 x 12 cm). Smaller similar injury to the left of the subscapularis (7x6 cm), with colliquativa of deltoid and infraspinatus TTE: thickened an-terior mitral cusp TEE: small non-mobile vegetations on mitral valve, in resolution.After review of anamnesis,previous month excision of small lipoma interscapular,without sequelae and surgical wound in order to follow-up. We therefore posed diagnosis of sepsis with infection of soft tissues of shoulder girdle, associated with bacterial endocarditis by MSSA. After 1 month of continuous IV infusion prolonged antibiotic therapy, patient\u2019s overall conditions were satisfactory. Emblematic case of soft tissue infection secondary to the front door by contiguit

Take back the \u2018\u2018ultrasonographic stethoscope\u2019\u2019

Background: Cardiovascular pathology represents one of the most prevalent disease in Internal Medicine departments; echocardiography represents an essential method for its diagnosis and follow-up. Moreover, it is necessary for an internist to master ultrasonography in most of its various applications, being Internal Medicine departments in the center of the diagnostic process of most of the medical pathologies. Methods: For this reason our department programmed in the formative package of ASUR7, an echocardiography course; internists of different hospitals received yearly 92 h of theoretical-practical training. A certificate of attendance was released after overcoming a final examination. The course was done mainly bedside, focusing on the pathologies of the patients admitted to the Internal Medicine Department of the Osimo Hospital. Every session was guided by 3 expert tutors (one for patient) and 4 trainees for each tutor. Results: In two years 30 internists of our region (specialists coming from different hospitals or post graduate from the internal medicine school of the Marche Polytechnic University) got the \u2018\u2018stethoscope of the third millennium\u2019\u2019 back in their hands. Conclusions: this experience can well represent not only the skill acquisition, but facilitates the Internist to holistic vision of patient and strengthens his diagnostic capacity

Usefulness of echocardiography and tissue Doppler imaging (tDI) in the management of the acute patient: a clinical case report

ase Presentation Male, 64 years old,overweight,hypertensive,current smoker. Arrived to our emergency department(ED)for epigastric pain, swe-ating, nausea, bradicardia (45 bpm) and hypotension. At physical exami-nation, pain at palpation in epigastric region. At admission ECG,sinus bradicardia, negative T-waves in inferior leads without ST-segment altera-tions. Blood chemistry showed troponin I 2.18 ng/ml, d-Dimers 1290 ng/ml. Echocardiography showed hypokinesis of left ventricle inferior wall associated to diffuse hypokinesis and systodiastolic dysfunction of right ventricle RV), as diagnosed with TDI (TAPSE not evaluated for suboptimal window). Right chambers didn\u2019t result dilated,with normal PAPs.Inferior vena cava was dilated (25 mm) and non-collapsing.Our first diagnosis was RV NSTEMI-ACS, and the patients was treated and then admitted in our Internal Medicine Department (critical care area). At arrival, a new ECG showed 1 mm ST-elevation in DII,DIII and aVF leads,associated with epi-gastric pain. Patient was then taken to our Hub hospital for urgent corona-rographic examination, which showed an occlusion of 100% in proximal right coronary artery with a large endoluminal thrombotic occlusion. After PTCA and stenting,the patient was admitted again in our department in good clinical conditions.conclusion Echocardiography and ultrasound examination,integrated with TDI examination can be useful to the Internist working in ED and in critical care area for a correct and fast diagnosis. In this case,it is important to enlighten how echocardiography allowed a correct bedside differential diagnosis