When I started my practice many years ago I had to do internal medicine call. It was good in some respects, keeping my well-earned internal medicine skills sharp, but after a while I had to question the appropriateness of a rheumatologist handling drug overdoses and pre-eclampsia. I then restricted my call to rheumatology and allergy since we were in the same department, and finally to rheum call alone. After a decade with little general internal med I can see that I've now become a bit rusty. Heart sounds are now limited to present or not present. I pray infections I stumble upon are treatable with the three antibiotics I know, and hope that they are still being manufactured. Where's chloramphenicol when you need it? I actually read the computer generated ecg report, and I completely ignore, so far without any perceptible negative consequence, all D-dimer results.
But chest x-rays are still just chest x-rays and even I can see that the film in a recent article of Nature Reviews Rheumatology was a bit off. The article discusses leflunomide induced lung disease but it would appear that it also causes dextrocardia:
The incidence of ILD in the cohort decreased over time, as fewer patients with pre-existing ILD were prescribed the drug following the issue of a safety notice in January 2004. Although not mentioned in the safety notice, the use of a loading dose also declined.
In a separate study, a UK-based group reviewed the clinical characteristics of 32 published cases (including 6 from Japan) of leflunomide-induced pneumonitis in patients with RA. The investigators were prompted to undertake the retrospective review after finding a dearth of information in the literature and clinical guidelines.