The symptoms associated with acute myocardial infarction in a series of 777 elderly hospitalized patients are reviewed. Their ages ranged from 65 to 100, with a mean of 76.0 years. The spectrum of presentation changed significantly with increasing age. Chest pain or discomfort were less frequently reported, although present in the majority of patients up to 85 years. Syncope, stroke, and acute confusion became more common and were often the sole presenting symptom. Shortness of breath, although the most frequently reported symptom in the absence of chest pain, was equally common at all ages. Thus, in patients aged 85 years or over, "atypical" presentation of myocardial infarction became the rule, and in the very old the clinician must be prepared to screen for the diagnosis in most acutely ill patients.
Fifteen cases of acute renal failure follwoing scorpion sting were studied. The onset of disease was characterized by the occurrence of hemoglobinuria within 24 h of the sting. Most of the patients developed oliguria, edema, hemolytic anemia, and hemolytic jaundice. Renal failure developed within a few days after the sting, and in five patients was severe enough to need dialysis. The onset of diuresis in oliguric patients occurred between 6 and 21 days following the sting. Renal biopsies were possible in four cases and showed mesangial proliferation, variable degrees of tubular changes, and mild interstitial infiltration. The pathogenesis of acute renal failure in these patients is discussed
The diagnostic features and outcome of acute myocardial infarction in 100 very elderly (aged 85 years or more) hospitalized patients are reviewed and compared with those in a group of younger elderly (aged 65-84 years). The diagnostic triad of chest pain, sequential ECG changes and raised cardiac enzymes was present in only 24 very elderly patients and in 27 the diagnosis was not initially suspected. Presenting symptoms were often atypical and characteristic ECG changes could not be demonstrated in 25 patients. Very elderly patients had a higher mortality during the first few days in hospital, despite no greater incidence of cardiac failure and similar infarct size to the younger patients. Subsequent in-hospital mortality was similar in both groups. A higher index of suspicion of myocardial infarction in acutely ill very elderly patients should lead to earlier diagnosis, more appropriate management and may improve immediate prognosis.
Medical Memoranda MEDICAL JOURNAL the platelet counts weekly and the knowledge that a cyclical variation may occur are important in assessing the severity of the thrombocytopenia, the response to treatment, and the timing of surgical procedures.The documented case in which a patient with clinical thyrotoxicosis and cyclic thrombocytopenia was found to have platelet, thyroid, and mitochondrial antibodies-the latter thought to be suggestive of primary biiary cirrhosis (Doniach et al., 1966) Constipation and abdominal distension are well-recognized features of hypothyroidism, but serious atony of the gastrointestinal tract and urinary bladder may result in retention or incontinence of faeces or urine and even in death from intestinal obstruction without external features of hypothyroidism being obvious. CASE REPORTIn 1958 a man aged 59 complained of sore tongue, tiredness, dyspnoea on exertion, paraesthesiae, and intermittent constipation and diarrhoea. He had a normoblastic macrocytic anaemia (haemoglobin 13 g./100 ml.) with histamine4ast achlorhydria. X-ray 'examination showed normal stomach, small intestine, and colon.The vitamin-B12 therapy that he was already receiving was continued. In 1960'the macrocytic anaemia was still present. In 1964 he again complained of intermittent constipation and diarrhoea. A barium enema showed a voluminous colon requiring three times the normal quantity of barium.In January 1967 he was readmitted with persistent bouts of constipation and diarrhoea with distension. For the first time there were external features of hypothyroidism. His skin was coarse and dry, his speech was slow and hoarse, and his movements were lethargic. Psychomotor retardation and delayed tendon jerks were present. The thyroid was not enlarged. Pubic and axillary hair were present. The abdomen was distended and tympanitic. Ascites could not be detected. The pulse was 80 and the heart slightly enlarged. The electrocardiogram showed no features of hypothyroidism. There was anaemia (Hb 9 g./100 ml., P.C.V. 27%, M.C.H.C. 33.3%). X-ray examination of the abdomen showed distension of stomach, small intestine, and colon with fluid levels. Barium enema showed gross megacolon; five times the normal quantity of barium was required. The right side of the colon could not be filled, being distended by faeces, but the left half emptied well. The serum cholesterol was 280 mg./100 ml. and serum carotene 60 g&g./100 ml. Thyroid function tests showed P.B.I. 2-6 ,ug./100 ml. (normal 3-8 ,ug./100 ml.); 24-hour iodine uptake was only 2% of a 5-uCi tracer dose.Although the possibility of mechanical obstruction was entertained it had become evident that the megacolon was part of the gastrointestinal atony of " internal myxoedema." He was treated by gastric aspiration, intravenous fluids, and triiodothyronine 10 ,pg. b.d., but he died on 23 February 1967. Bladder retention was presnt for 24 hours before death.At necropsy there was slight left ventricular enlargement. The peritoneal cavity contained 750 ml. of fluid (protein 3-7 g./...
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