Admission Physical Examination Research Articles

Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery Diagnosed in Adulthood

Introduction: An anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare heart malformation, with 90% of patients dying during the first year of life. If the right coronary artery compensation and multiple collateral circulation are sufficiently established, the patient's myocardial ischemia symptoms are mild and appear later, which is called the adult type ALCAPA. Case Description: A 42-year-old woman presented to our hospital with one-month history of the aggravation of active shortness of breath which gradually progressed to nocturnal paroxysmal shortness of breath and cough. Admission physical examination suggested mild edema of both lower limbs. Transthoracic echocardiography (TTE) showed that a small vessel shadow was abnormally connected to the pulmonary artery (PA), and moderate pulmonary artery hypertension. Coronary computed tomography angiography (CTA) showed an anomalous origin of the left main coronary artery (LMCA) dividing into the left anterior descending (LAD) and left circumflex (LCX) artery from the PA, with no clear connection to the left coronary sinus. The right coronary artery (RCA) was significantly dilated and originated from the normal Valsalva sinus. It was accompanied by multiple collateral circulations, most of which traveled anterior to the right ventricular free wall and anterior interventricular sulcus, and some emanated from the posterior descending branch of the posterior interventricular sulcus and walked toward the posterolateral wall of the left ventricle. Conclusion: Coronary computed tomography angiography (CTA) can be used to visualize the abnormal origin and distribution of the coronary artery's course and may be the first choice in the diagnosis of ALCAPA.

Contrast ultrasonography of nodular transformation of splenic sclerosing hemangioma: A case report

A 33-year-old male patient was admitted to our hospital due to splenomegaly and splenic space occupation on physical examination. Admission physical examination: general condition was normal, no fever, nausea, vomiting, abdominal distension, diarrhea and other symptoms, healthy in the past, no family history of disease.

A case report of thrombocytopenia induced by sodium valproate sustained release tablets in a schizophrenic patient

The patient, a 28-year-old female, was aggravated by suspicion for more than a year, and the total course of the disease was unknown. She was sent to the outpatient clinic of our hospital by the staff of the rescue station on December 20, 2020. Outpatient clinic with “schizophrenia?” Admitted to hospital. Psychiatric examination after admission found that patients had obvious victim delusion, absurd content, the object was generalized, and the patient firmly believed it. No obvious abnormalities were found in admission physical examination. The patient denied the history of severe somatic disease, drug allergy and infection. Deny taking any drugs recently. No obvious abnormalities were found in the blood routine examination, liver and kidney function, electrolyte, blood glucose, blood lipid, thyroxine, stool routine, infectious diseases (5 markers of hepatitis B, hepatitis C, syphilis, HIV antibody), electrocardiogram, electroencephalogram, chest CT, abdominal color ultrasound and so on. PANSS score 81. According to ICD-10 diagnostic criteria, schizophrenia was diagnosed after admission, and aripiprazole was given antipsychotic treatment. The initial dose was 10 mg/day, and increased to 20 mg/day after 3 days and maintained until discharge. On January 10, 2021, the patient developed impulsive behavior and was treated with sodium valproate sustained-release tablets (VAP) 500 mg/day to stabilize emotion. The effective concentration of drug treatment was 50-100 μg/mL [1]. During the follow-up of 7 February 2021, the platelet count of the patients was decreased, and the platelet count was 82 X 109 /L Considering the adverse drug reactions caused by VAP, VAP was stopped immediately on the same day. On February 16,2021, routine blood platelet count showed that it returned to normal. After March 10,2021, the platelet was in the normal range, and further increased compared with February 16 (See Table 1).

Seizures in a Term Newborn.

Seizures in a Term Newborn.

Clinical findings predictive of maternal adverse outcomes with pyelonephritis

BACKGROUNDPyelonephritis, a leading cause of infection during pregnancy, is associated with increased maternal adverse outcomes. Therefore, early recognition and intervention of pyelonephritis are important. Early recognition of pyelonephritis has historically been dependent on fever and costovertebral angle tenderness. However, the reliability of these findings to distinguish women who will develop maternal adverse outcomes is limited. OBJECTIVEThis study aimed to identify clinical variables on presentation that are predictive of maternal adverse outcomes associated with pyelonephritis during pregnancy. STUDY DESIGNA retrospective cohort study of pregnant women admitted with pyelonephritis at a single hospital from October 1, 2015, to July 31, 2021, was conducted. The primary outcome was a composite maternal adverse outcome consisting of any of the following: maternal intensive care unit admission, surgical intervention, hypotension requiring vasopressors, acute respiratory distress syndrome, pulmonary edema, mechanical ventilation, high-flow nasal cannula, disseminated intravascular coagulation, altered mental status, dialysis, organ failure, venous thromboembolism, or maternal death. Differences in maternal characteristics and clinical signs and symptoms on admission were stratified by the presence or absence of a maternal adverse outcome. Categorical variables were analyzed using the Fisher exact test. Continuous data were analyzed with Wilcoxon rank-sum test. Sensitivity and specificity and likelihood ratios with 95% confidence intervals were calculated for the detection of maternal adverse outcomes by specified admission physical examination and laboratory findings. RESULTSOf 97 women that met the inclusion criteria, 28 (28.9%) had maternal adverse outcomes. Moreover, 50 of 97 women (51.5%) had fever on presentation, with no difference between cohorts recognized. Admission vital signs were not significantly different between cohorts. Costovertebral angle tenderness was present in 78 of 97 women (80.4%) on presentation, with no difference between cohorts. Compared with women without a maternal adverse outcome, women with maternal adverse outcomes were more likely to have leukocytosis (18/28 [64.3%] vs 20/69 [29.0%]), thrombocytosis (3/28 [10.7%] vs 5/69 [7.2%]), bandemia (8/28 [28.6%] vs 7/69 [10.1%]), and an abnormal serum potassium (20/28 [71.4%] vs 32/63 [50.8%]). CONCLUSIONAdmission vital signs may not reliably identify women with pyelonephritis at risk of maternal adverse outcomes. Laboratory studies, particularly a complete blood count and electrolytes, may provide a means of distinguishing those at risk of maternal adverse outcomes.

An audit of ECG monitoring in patients admitted to the general adult wards at clock view hospital

AimsTo identify whether patients admitted to the general adult inpatient wards at Clock View Hospital, an inpatient unit in Mersey Care NHS Foundation Trust, have an ECG performed following admission and whether, if this done, the ECG report is properly documented in the patient's electronic record, and whether those patients with an abnormal ECG have any further investigations requested.BackgroundAn important risk factor for development of cardiac disease is use of psychotropic medications. Antipsychotics can increase the QTc interval.NICE guidelines recommend that, before starting antipsychotic medication, an ECG should be offered if physical examination identifies cardiovascular risk factors, there is personal history of cardiac disease or if the individual is being admitted to hospital. The Royal College of Physicians states all patients should be assessed for cardiovascular disease, including having a routine ECG. Mersey Care's physical health policy recommends all new admissions to inpatient wards have an ECG performed within 24 hours of admission as part of their admission physical examination and investigation.MethodA sample of 60 patients discharged from the general adult wards at Clock View Hospital between 16th of July 2019 and 30th of September 2019 was obtained. An audit tool was designed and each patient's electronic record scrutinised to determine whether an ECG was performed within 24 hours of admission; in those patients who didn't, whether the reason why was recorded; and whether those patients who had an abnormal ECG were referred for further investigation. The quality of documentation of ECG reports was also analysed.ResultAge range of patients was 19–66 years. Only 31 patients had an ECG performed within 24 hours of admission. Of the remaining 29, there was documentation of why an ECG was not performed in only 16 cases. Thirteen patients had an abnormal ECG, but only three were referred for further investigation. Of the ECG reports that were analysed, only a minority met the required standard for “good”, with there being no documentation of the ECG report in one third of cases.ConclusionThere is significant room for improvement in performance of ECG monitoring and documentation of the ECG report. The importance of the ECG as part of the admission process needs to be highlighted in the induction of junior doctors. Training nursing staff on the wards to perform ECGs would reduce the likelihood of unnecessary delay to a patient having an ECG done following admission.

Evaluation of Diagnostic Accuracy of Cervical Palpation, Contrast Enhanced Multi-detector Computed Tomography, and Intraoperative Macroscopic Nodal Assessment of Cervical Lymph Node Metastasis of Head and Neck Squamous Cell Carcinoma in Filipinos: A Preli

Objectives. 1) To determine if there is an association between physical examination by cervical palpation, preoperative contrast-enhanced multi-detector computed tomography (MDCT), and intraoperative lymph node assessment, with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck. 2) To determine the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy, and likelihood ratios of cervical palpation, contrast enhanced MDCT, and intra-operative lymph node assessment compared with final histopathology in the evaluation of cervical lymph node metastasis in Filipino patients with squamous cell carcinoma of the head and neck.
 Methods. Study Design. Retrospective; Cross-sectional. Setting. Tertiary Government Hospital Charity Section, Department of Otorhinolaryngology, Department of Radiology, Department of Pathology. Participants, Patients or Population. Retrospective chart review of all biopsy proven head and neck squamous cell carcinoma patients admitted at the charity ward of a Otorhinolaryngology Department from 2008-2010 who had documented admission physical examination, a preoperative contrast enhanced multi-detector computed tomography (MDCT) scan of the neck done in the same institution within 20 days or less from date of surgery, and underwent neck dissection with appropriate cervical lymph node level specimen labeling with subsequent post-operative histopathologic evaluation of submitted specimens for neck node metastasis by the Pathology Department of the same institution. After set of exclusion criteria was applied, the analyzed sample included 82 lymph node level samples from 9 patients with head and neck Squamous Cell Carcinoma (SCCA).
 Results. Pre-operative contrast enhanced MDCT, and intraoperative nodal assessment, were both significantly correlated with the final histopathologic evaluation of neck node metastasis as evaluated with Fisher’s Exact test (p = 0.00). Cervical palpation however was not able to show a significant association (p=0.099).Cervical palpation had a sensitivity of 25.00% (8.3352.59%), specificity of 90.91% (80.61-96.25%), NPV of 83.33 (72.30-90.73%), PPV of 40.00 (13.69-72.63%), accuracy of 78.05%, and a likelihood ratio of 3.33. Preoperative contrast enhanced MDCT had a sensitivity of 43.75% (20.75-69.45%), specificity of 93.94% (84.4498.04%), NPV of 87.32 (76.80-93.69%), , PPV of 63.64 (31.61-87.63%), accuracy of 84.15%, and a likelihood ratio of 12.06. Intraoperative surgical evaluation had a sensitivity of 68.75% (41.48-87.87%), specificity of 93.94% (84.44-98.04%), NPV of 92.54 (82.74-97.22%), PPV of 73.33 (44.83-91.09%), accuracy of 89.02%, and a likelihood ratio of 34.10. Further analysis with McNemar’s Test comparing MDCT and Intraoperative assessment showed no significant difference (p = 0.387).
 Discussion and Conclusions. In the evaluation of cervical lymph node metastasis for head and neck squamous cell carcinoma in the local setting, the extent of neck dissection, clinical staging and prognosis, as well as adjuvant therapy can be guided by pre-operative contrast enhanced MDCT and intraoperative nodal assessment. Contrast-enhanced MDCT can aid treatment planning in preoperative or non-operative cases; but intraoperative evaluation can be used to guide final extent of surgery. Evaluation solely by physical examination by cervical palpation unfortunately in this study was not able to show a significant association with final histopathology.

Case 2: A Large Prenatally Undiagnosed Mass in a Preterm Infant, What Could It Be?

A 2.2-kg female infant is born at 28 4/7 weeks’ gestation to a 21-year-old gravida 1, para 0 woman with adequate prenatal care. During pregnancy, the mother is treated for Chlamydia with repeat negative cultures. She has negative serologies and a normal fetal ultrasonographic scan at 20 weeks’ gestation. Delivery is via cesarean section due to premature labor and frank breech presentation. At delivery, the infant is noted to have no respiratory effort and a large sacrococcygeal mass (Fig 1) . Positive pressure ventilation is started and the infant undergoes intubation 3 minutes after birth. Figure 1. Infant at delivery noted to have large sacrococcygeal teratoma. The admission physical examination findings are significant for a sacrococcygeal nodular, firm and nonpulsatile 20×30–cm mass, with minimal ulceration that is displacing the lower limbs anteriorly. Magnetic resonance imaging (MRI) of the pelvis shows a presacral mass with a large external component and relatively small internal component; the cephalad portion of the mass occurs at the level of L5, splaying the aortic bifurcation (Fig 2) . The infant’s vital signs are stable with minimal ventilatory support. Laboratory studies are positive for anemia (hemoglobin 11.4 g/dL [114 g/L]), a normal α-fetoprotein (AFP) level for gestational age (60,500 ng/mL [60,500 μg/L]), and a slightly elevated aspartate aminotransferase level (141 IU/L [2.35 μkat/L]). Figure 2. Magnetic resonance imaging scan of the pelvis showed a presacral mass (red arrow) with a large external component and relatively small internal component. On day 2 after birth, the infant develops hypotension and worsening respiratory failure; she is started on inotropes and high-frequency oscillation. The lesion becomes more tense and darker in color, concerning for intralesional hemorrhage. The infant also develops thrombocytopenia (platelets 66,000/μL [60×109/L]) and receives multiple platelet and red blood cell transfusions in preparation for surgery. Resection of the mass …

Hématome spontané du rein

We here report the case of a 54-year old patient with a history of appendectomy performed 6 years before and suffering from left lower back pain evolving for 3 months aggravated 3 days before admission to the Emergency Department. Moreover, there was no sign of hematuria or stones emission nor of lumbar or abdominal trauma. On admission physical examination showed fairly good general condition, slight discoloration of the conjunctivas, hemodynamic stability. Laboratory tests showed hemoglobin at 7.7g/dl, the remainder of the laboratory tests was normal. Uroscan revealed a predominantly posterior heterogeneous,voluminous left peri-renal collection with spontaneous hyperdense areas (A). The patient underwent two packed red blood cell transfusion. Simple monitoring associated with analgesic and antibiotic treatment to avoid superinfection of the hematoma was performed based on hemodynamic stability. Control uroscan was performed one month later showing marked regression of the hematoma (B).

Admission Peripheral Edema, Central Venous Pressure, and Survival in Critically Ill Patients.

The clinical significance of peripheral edema has not been well described in critical illness. To assess the clinical significance of peripheral edema detected on physical examination at the time of hospital admission for patients who were treated in an intensive care unit (ICU). Using a large inception cohort of critically ill patients, we examined the association of peripheral edema, as documented on hospital admission physical examination, with hospital and 1-year survival. Of 12,778 patients admitted to an ICU at a teaching hospital in Boston, Massachusetts, 2,338 (18%) had peripheral edema. Adjusting for severity of illness and comorbidities, including pulmonary edema, admission peripheral edema was associated with a 26% (95% confidence interval [CI] = 1.11-1.44, P < 0.001) higher risk of hospital mortality. In those patients whose peripheral edema could be graded, trace, 1+, 2+, and 3+ admission peripheral edema was associated with a 2% (95% CI = 0.80-1.31, P = 0.89), 17% (95% CI = 1.00-1.56, P = 0.05), 60% (95% CI = 1.26-2.04, P < 0.001), and 54% (95% CI = 1.04-2.29, P = 0.03) higher adjusted risk of hospital mortality, respectively, compared with patients without edema. The association was consistent across strata of patients with diabetes, congestive heart failure, sepsis, and premorbid diuretic or calcium channel blocker use. In a subset of patients with central venous pressures measurements obtained within 6 hours of ICU admission, the highest central venous pressure quartile (>13 cm H2O) was similarly associated with a 35% (95% CI = 1.05-1.75, P = 0.02) higher adjusted risk of hospital mortality compared with the lowest quartile (≤7 cm H2O). Peripheral edema, as detected on physical examination at the time of hospital admission, is a poor prognostic indicator in critical illness. Whether peripheral edema simply reflects underlying pathophysiology, or has an independent pathogenic role, will require further interventional studies.

Term Newborn with Unilateral Craniofacial Defects

A newborn presents with congenital right-sided craniofacial asymmetry, absence of right eye and ear, and small facial structures on the right (Fig 1). Figure 1A and B: Front and profile views of craniofacial defects, including absence of right orbit, right microtia, depressed right fronto-parietal area and facial asymmetry. ### Prenatal and Birth Histories ### Presentation The infant was transferred to the neonatal intensive care unit from an outside hospital with multiple craniofacial anomalies. His admission physical examination was notable for a depression on the right side of the skull and face with a depressed right frontoparietal bone, absence of right eye, right microtia, and a nevus flammeus noted over the glabella and nose. ### Vital Signs ### Physical Examination

Causes of pleural effusions in horses resident in the UK

SummaryPleural effusions (PE) reportedly occur most commonly secondary to bacterial pneumonia with neoplastic effusions contributing a minority of cases. The majority of reports originate from the USA and Australia, where long distance transport of horses, a recognised risk factor, may occur more frequently than in the UK. Anecdotally, a greater proportion of horses with PE are diagnosed with neoplasia in the UK than has been reported. The aim of this retrospective study was to describe the causes of PE in horses in the UK, and to identify markers that can help differentiate between septic and neoplastic causes of PE. Medical records from 4 equine hospitals in the UK were searched for horses diagnosed with PE. Information recorded included case background, admission physical examination and biochemical findings, and characteristics of the effusion (volume, cell count, total protein [TP] concentration). A total of 69 horses were identified, with 26 (38%) diagnosed with a neoplastic effusion. The remainder were categorised as septic, including 14/43 (32.5%) that had a history of international transport. Horses with septic effusions were significantly younger (8 vs. 13 years; P = 0.001) and had significantly smaller volumes of pleural fluid drained at admission (9.8 l vs. 32.2 l; P&lt;0.001). Horses with septic PE had a significantly higher rectal temperature (38.6°C vs. 38.2°C; P = 0.03), fibrinogen concentration (7.8 g/l vs. 5.3 g/l; P = 0.01) and serum amyloid A concentration (230 mg/l vs. 59 mg/l; P = 0.02) than those with neoplastic effusions. Significantly higher pleural fluid cell count and TP concentration were identified in horses with septic PE (63.9 × 109/l vs. 8.6 × 109/l; P&lt;0.001; 57.5 g/l vs. 35.9 g/l; P = 0.04). These results suggest that in the UK, neoplastic effusions account for a greater proportion of PE than previously reported. A large volume of PE in an older horse with a low cell count and relatively low TP concentration should increase the index of suspicion of neoplasia.

Peripheral Edema, Central Venous Pressure, and Risk of AKI in Critical Illness

Although venous congestion has been linked to renal dysfunction in heart failure, its significance in a broader context has not been investigated. Using an inception cohort of 12,778 critically ill adult patients admitted to an urban tertiary medical center between 2001 and 2008, we examined whether the presence of peripheral edema on admission physical examination was associated with an increased risk of AKI within the first 7 days of critical illness. In addition, in those with admission central venous pressure (CVP) measurements, we examined the association of CVPs with subsequent AKI. AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Of the 18% (n=2338) of patients with peripheral edema on admission, 27% (n=631) developed AKI, compared with 16% (n=1713) of those without peripheral edema. In a model that included adjustment for comorbidities, severity of illness, and the presence of pulmonary edema, peripheral edema was associated with a 30% higher risk of AKI (95% confidence interval [95% CI], 1.15 to 1.46; P<0.001), whereas pulmonary edema was not significantly related to risk. Peripheral edema was also associated with a 13% higher adjusted risk of a higher AKI stage (95% CI, 1.07 to 1.20; P<0.001). Furthermore, levels of trace, 1+, 2+, and 3+ edema were associated with 34% (95% CI, 1.10 to 1.65), 17% (95% CI, 0.96 to 1.14), 47% (95% CI, 1.18 to 1.83), and 57% (95% CI, 1.07 to 2.31) higher adjusted risk of AKI, respectively, compared with edema-free patients. In the 4761 patients with admission CVP measurements, each 1 cm H2O higher CVP was associated with a 2% higher adjusted risk of AKI (95% CI, 1.00 to 1.03; P=0.02). Venous congestion, as manifested as either peripheral edema or increased CVP, is directly associated with AKI in critically ill patients. Whether treatment of venous congestion with diuretics can modify this risk will require further study.

Failure of ventricular capture and pacemaker exit block secondary to moderate hyperkalemia

An 81-year-old woman was admitted to our institution with bradycardia, weakness and presyncope. At admission physical examination revealed a pulse rate of 42 per minute, blood pressure of 95 / 50 mmHg, and an oxygen saturation of 93 % on room air. The interrogation of the device showed a correct ventricular sensing and a threshold for ventricular pacing of 6.5 V at 1 ms pulse width. Analytic test showed a creatinine 3.78 mg / dl, Urea 187 mg / dl, sodium 133 mEq / L, potassium 6.2 mEq / L, and pH 7.37. Our patient showed a moderate acute hyperkalemia, which caused pacemaker exit block and capture failure.

Isolated abdominal aortic dissection in a young female patient

A 43-year-old woman presented with acute lower abdominal pain radiating to both sides of the groin. She had no history of smoking, drug abuse, surgeries, trauma, or any chronic diseases. There was no family history of vascular disease. On the admission physical examination, she was normotensive, had normal pulses on four limbs, and presented tenderness and pain on abdominal aortic palpation and in her lower abdomen. Contrastenhanced abdominal and thoracic computed tomography showed a distal infrarenal abdominal aortic dissection compromising both common iliac arteries (A) and a saccular dilation of the left common iliac dissected artery (B and C). The patient had partial remission of pain with opioids and elected to undergo an endovascular treatment. A coil embolization of the left internal iliac artery (the level at which the dissection ended) was performed, and then a unibody bifurcated endoluminal graft was deployed, covering most of the infrarenal aorta and both common iliac arteries. The patient recovered uneventfully, with total pain remission. The patient did not meet diagnostic criteria for Takayasu disease and had neither Marfan nor Ehlers-Danlos syndrome; her serologic inflammatory and infectious markers were negative, and she had no other radiologic signs of arterial disease of the aorta or its major branches. At 1-month follow-up, computed tomography angiography showed total thrombosis of the dissection’s false lumen as well as of the saccular dilation and patency of the infrarenal aorta and iliac arteries (D). Isolated abdominal aortic dissection, an extremely rare entity, is estimated to occur in 0.4% to 2% of all aortic dissections. It may be classified on the basis of etiology as iatrogenic, traumatic, or spontaneous. Most patients with spontaneous abdominal aortic dissections present with dissection of the infrarenal aortic segment, extending or not to the iliac arteries. Although there is no consensus in the literature on the treatment indications, most authors advocate treatment of all symptomatic patients and of those asymptomatic with radiologic evidence of aneurysmal dilation. There is no standardized technique, and although the endovascular approach used in this case was successfully undertaken, long-term follow-up is warranted to see how the device behaves in a young patient with small-caliber arteries.

Clinical Research Abstracts of the British Equine Veterinary Association Congress 2015.

Pleural effusion (PE) is reported to occur most commonly secondary to bacterial pneumonia or lung abscesses, with neoplastic effusions contributing the minority of cases. The majority of these reports originate from America and Australia, where long distance transport of horses, a recognised risk factor, appears to occur more frequently. Anecdotally, neoplastic PE is more commonly diagnosed in the UK. To describe the causes of PE in horses resident in the UK, and to identify potential markers that can help differentiate between infectious and neoplastic causes of PE. Retrospective clinical study. Medical records from 4 referral hospitals in southern England were searched for horses diagnosed with PE. Information gathered from medical records included signalment, diagnosis (infectious vs. neoplastic), admission physical examination and biochemical findings, and characteristics of the effusion (volume, cell count, total protein [TP] concentration). Statistical comparisons were made between the neoplastic and infectious group using appropriate testing. Seventy horses were identified, of which 28 (40%) were neoplastic and 42 were infectious. Horses with infectious effusions were significantly younger (median 7 vs. 13 years; P = 0.002) and had significantly smaller volumes of pleural fluid drained at admission (9.8 vs. 32.3 l; P<0.001). Horses with infectious PE had a significantly higher rectal temperature (38.6 vs. 38.2°C; P = 0.03), fibrinogen concentration (7.8 vs. 5.7 g/l; P = 0.02) and serum amyloid A concentration (223 vs. 104 mg/l; P = 0.02). Pleural fluid characteristics identified a significantly greater cell count and TP concentration in horses with infectious PE (47 x 10(9)/l vs. 3.4 x 10(9)/l; P<0.001; 54 vs. 31 g/l; P = 0.001). These results suggest that in the UK neoplastic effusions account for a greater proportion of PE than previously reported. A large volume of PE in an older horse with a low cell count and TP concentration should increase the index of suspicion of neoplasia. Ethical animal research: This was a retrospective study of clinical cases. Explicit owner informed consent for inclusion of animals in this study was not stated. None. Competing interests: None declared.

Factors affecting dural penetration and prognosis in patients admitted to emergency department with cranial gunshot wound.

To explore the effect of admission physical examination findings, anamnesis, and computed tomography on dural penetration and prognosis in patients with cranial gunshot wound (CGW). In this study, the medical data of 56 subjects who were admitted to the Emergency Department of Dicle University Hospital with CGWs between January 2011 and December 2013 were retrospectively reviewed. The effects of type of incident (suicidal vs non-suicidal), pupil diameter and light reflex, hemodynamic status, type (bullet or pellet), velocity, trajectory of foreign material, trauma scores, and imaging findings on dural penetration and mortality were explored. The mean age of the study population was 24.8±13.50years. Thirty (53.6%) patients had penetrating injuries and 26 (46.4%) had non-penetrating injuries; 9 (16.1%) patients died and 47 (83.9%) survived. Suicidal injury, pupil diameter and light reflex, bullet as foreign material, and high velocity and lateral trajectory of foreign material significantly affected dural penetration and mortality (p<0.05). In addition, dural penetration, bilobar, multilobar, or bihemispheric involvement of brain parenchyma, presence of intracranial hemorrhage, subarachnoid hemorrhage, ventricular hemorrhage, fracture, shift, edema, and trauma scores significantly affected mortality (p<0.05). In CGWs, dural penetration and prognosis can be predicted by physical examination findings and patient characteristics on initial admission.

Newborn With Unilateral Lower Extremity Vascular Malformation and Limb Asymmetry

A newborn presents with a unilateral lower-extremity vascular malformation and limb asymmetry. (Figure 1) Figure 1. ### Prenatal and Birth Histories ### Presentation The infant was transferred to the neonatal intensive care unit for issues related to prematurity. His admission physical examination was notable for a large, non-blanching, erythematous patch over the right lower extremity associated with lower limb asymmetry, with right greater than left. ### Vital Signs ### Physical Examination

Autoimmune Hepatitis Associated with Sjögrenʼs Syndrome: A Case Report

Purpose: Introduction: Autoimmune hepatitis (AIH) is a chronic necroinflammatory liver disorder characterized by periportal hepatitis and the presence of serum autoantibodies. It can be associated with a number of other autoimmune diseases. Here,we report a case of AIH associated with Sjögren's syndrome, which is rare and seldom reported in literature. Case: A 45-year-old Northeast Chinese female was admitted to our hospital. The patient suffered from fatigue and anorexia, and had persistently high level of serum aminotransferase for twelve months. Over the last six months, she had dry eyes and dry mouth. She denied any family history or illicit drugs. On admission physical examination, mild percussion pain over the liver was identified, and no enlargement of the parotid and submandibular glands. Laboratory data revealed increased levels of alanine aminotransferase (391 U/L), aspartate aminotransferase (202 U/L), and γ-globulin. Serological testing for autoimmune displayed high titer of anti-nuclear antibodies (1/3200), and positive values of anti-SSA and anti-SSB. Histological examination showed a large number of IgG-positive lymphocytes in labial salivary gland biopsy specimen, as well as a lymphoplasmacytic interface hepatitis in liver biopsy specimen. Discussion: In this study, we demonstrated that AIH was concomitant with Sjögren's syndrome, which is rarely reported in literature. Therefore,we should pay attention to possible existence of Sjögren's syndrome when evaluating clinically symptomatic extrahepatic manifestations of AIH.

Visual Diagnosis

1. Jamie M. Pinto, MD* 2. Viola Cheung, DO* 3. Min Zheng, MD, PhD† 4. Saad A. Saad, MD* 1. *K. Hovnanian Children’s Hospital, Neptune, NJ. 2. †Jersey Shore University Medical Center, Neptune, NJ. A 7-week-old girl presents to the emergency department with a 1-day history of fever. Her mother reports that the infant is fussier than usual, particularly when feeding. Her urine and stool output remain normal. The infant has had no cough, rhinorrhea, vomiting, or diarrhea. There are no known sick contacts. Neither of her two older siblings has had a recent febrile illness. The patient did receive her second hepatitis B vaccination on the day before presentation. The patient was born term via repeat cesarean delivery. Her medical history is significant only for a questionable ovarian cyst on prenatal ultrasonography. The perinatal course was uncomplicated, with no prolonged rupture of membranes or maternal fever. Abdominal ultrasonography was planned but was not performed due to unexplained circumstances. The patient was discharged from the hospital with her mother on day 4 after birth. Admission physical examination reveals an alert, well-appearing girl in no acute distress. Her temperature is 38.6°C, heart rate is 181 beats per minute, respiratory rate is 52 breaths per minute, and blood pressure is 105/61 mmHg. The remainder of her physical examination is within normal limits and does not reveal a fever source. The infant is started on intravenous ceftriaxone after urine, blood, and cerebrospinal fluid are obtained for culture. Despite intravenous antibiotic administration, the infant’s fever is unremitting. She has several temperature elevations per day ranging from 38.1°C to 39.1°C. Her chest radiograph is unremarkable. Results of finalized urine culture are negative on hospital day 2. Blood culture and cerebrospinal fluid culture results show no growth at 5 days. Interval physical examination reveals mild right-sided …