A Coin in the Airway Victor Bor-Chang Hsue, Vijay Patel N Engl J Med 2024; 390: e33 DOI: 10.1056/NEJMicm2312266 A healthy 14-year-old boy presented to the emergency department with a 6-hour history of hoarseness and difficulty swallowing after having accidentally swallowed a coin. On physical examination, the patient was breathing comfortably without stridor or drooling. Radiographs of the chest (Panel A, posteroanterior view) and ...

IMAGES IN CLINICAL MEDICINE Spontaneous Oral Purpura in Immune Thrombocytopenia Jakob L. Drivenes, Anette Bygum N Engl J Med 2024; 390:1029DOI: 10.1056/NEJMicm2312260 A 76-year-old man presented to the dermatology clinic with a 2-day history of blood-filled blisters on the tongue. The lesions had appeared suddenly without antecedent trauma. He reported no other bleeding symptoms. The physical examination was notable for multiple hemorrhagic bullae on the t...

IMAGES IN CLINICAL MEDICINE Green Dialysis Effluent and Plasma Bao-ping Xu, Xiao-tao Wang N Engl J Med 2024; 390:e27DOI: 10.1056/NEJMicm2311085 A 72-year-old man with end-stage kidney disease who began receiving continuous renal-replacement therapy in the intensive care unit (ICU) was noted to have green-colored dialysis effluent and plasma. Seven hours earlier, the patient had presented to the emergency department with a gastrointestinal perforation. An e...

IMAGES IN CLINICAL MEDICINE Constrictive Pericarditis Meghan Nahass, John Kassotis N Engl J Med 2023; 389:2087DOI: 10.1056/NEJMicm2301671 A 69-year-old woman presented to the emergency department with a 3-year history of dyspnea on exertion. She had a history of focal pleural plaques that had been attributed to asbestos exposure that occurred during her work at an insulation-manufacturing company. Physical examination was notable for signs of volume overlo...

IMAGES IN CLINICAL MEDICINE Transverse Leukonychia (Mees’ Lines) Annabel M. Follows, George A. Follows N Engl J Med 2023; 389:e48DOI: 10.1056/NEJMicm2304533 A 30-year-old man presented to the hematology clinic with a 4-month history of white lines across his fingernails. Five months before presentation, he had received a diagnosis of primary mediastinal large B-cell lymphoma and began to receive systemic chemotherapy. The nail changes had first appeared mi...

IMAGES IN CLINICAL MEDICINE Venous Thoracic Outlet Syndrome Sang Jun Park, Hyun Jin Cho N Engl J Med 2023; 389:e32DOI: 10.1056/NEJMicm2301198 A 36-year-old woman was referred to the thoracic surgery clinic after she had presented with a 3-week history of swelling and bluish discoloration of the left arm and hand that occurred when she raised her arms (Panel A). The symptoms started after she had spent 10 days typing at a desk. Computed tomography of the ch...

Abdominal Pain and Hypotension in a 70-Year-Old Woman Educational ObjectiveBased on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis. Case A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain. She reported no hematemesis, hematochezia, or melena and had no history of abdominal s...

Abdominal Pain and Hypotension in a 70-Year-Old Woman Educational ObjectiveBased on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis. Case A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain. She reported no hematemesis, hematochezia, or melena and had no history of abdominal s...

IMAGES IN CLINICAL MEDICINE Superior Mesenteric Artery Syndrome Thibault Kerdiles, Julien Gras N Engl J Med 2023; 389:359DOI: 10.1056/NEJMicm2213146 A 26-year-old man from Somalia presented to the emergency department with a 5-month history of dry cough, night sweats, and unintentional weight loss of 18 kg. During this period, epigastric pain and episodes of postprandial vomiting had also developed. His body-mass index (the weight in kilograms divided by t...

Challenges in Clinical Electrocardiography  March 13, 2023 Computer-Estimated Heart Rate vs True Heart Rate—Be Aware of the Software Laszlo Littmann JAMA Intern Med. Published online March 13, 2023. doi:10.1001/jamainternmed.2022.6613 Case Presentation Apatient in their 60s was admitted to the intensive care unit for gastrointestinal bleeding and shock associated with liver cirrhosis, portal hypertension, and ruptured esophageal varices. E...