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Three Suspicious Lesions on an Elderly Woman's FaceAn 82-year-old woman presents for evaluation of an ear lesion--and receives a complete skin exam. Can you identify the 3 other lesions found?
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Top 10 Primary Care AppsDrugs, diseases, guidelines, databases-all at the touch of an app. Here: a selection of smartphone/tablet applications that may make your clinical practice a little easier this coming year.
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Recurrent Fever of Unknown Origin Responsive to PrednisoneThere are no guidelines for the workup for classic FUO. Diagnostic modalities are guided by the spectrum of differentials as well as local prevalence of disease.
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Case In Point: A man with renal failure, dyspnea, and an apparent lung massA 54-year-old man with chronic renal insufficiency presented with shortness of breath, nonproductive cough, and chest pain. The patient had hypertension, type 2 diabetes mellitus, and a 30-pack-year history of cigarette smoking. He denied alcohol or illicit drug use and prolonged exposure to asbestos, chemicals, or fumes.
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Pneumococcal Pneumonia: Update on Therapy in the Era of Antibiotic ResistanceSir William Osler once called pneumococcalpneumonia “the captain of themen of death.”1 Pneumonia is the sixthleading cause of death in the UnitedStates and the fourth leading causeamong Americans 80 years of age andolder.2
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Adult Intussusception: A Rare Cause of Bowel ObstructionAdult intussusception is a rare entity, accounting only for 1% to 5% of cases of bowel obstruction.
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Bilobar pulmonary sequestration: A rare case involving 2 adjacent lobesWe present a case of a 20-year oldman with massive hemoptysisresulting from pulmonarysequestration that involved 2lobes (the right lower and middlelobes). Preoperative embolizationand subsequent surgicalbilobectomy were performed.Although the patienthad a difficult and prolongedpostoperative course, he eventuallyhad a full recovery.
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Scarring After Tattoo RemovalThree carbon dioxide laser treatments were used to remove a 35-year-old woman's tattoo.
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Extraintestinal Manifestations of Inflammatory Bowel Disease: Common and ManageableExtraintestinal manifestations of inflammatory bowel disease affect the musculoskeletal, dermatologic, ocular, renal and pulmonary systems.
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Ebola Hemorrhagic Fever and Marburg Hemorrhagic FeverEbola virus and Marburg virus are responsible for Ebola hemorrhagic fever (EHF) and Marburg hemorrhagic fever (MHF), respectively.
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When to suspect allergic bronchopulmonary aspergillosisAbstract: Inhalation of Aspergillus is responsible for a variety of lung infections and diseases; Aspergillus fumigatus is the most common causative agent. Allergic bronchopulmonary aspergillosis (ABPA), caused by sensitivity to A fumigatus, is diagnosed primarily in persons with asthma or cystic fibrosis. Differentiating ABPA from other Aspergillus-related lung infections and diseases is often challenging. A patient's symptoms, underlying risk factors, and any prior pulmonary disease contribute to the diagnosis. Findings include pulmonary infiltrates, total serum IgE levels greater than 1000 IU/mL, IgE and IgA anti-A fumigatus antibodies, peripheral blood and pulmonary eosinophilia, and central bronchiectasis. Untreated ABPA often results in chronic bronchiectasis, pulmonary fibrosis, and dependence on corticosteroids; an accurate diagnosis of ABPA is critical to avoiding irreparable disease. (J Respir Dis. 2006;27(3):123-134)
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Lower Quadrant Pain and Emesis in a Young BoyThe 9-year-old was admitted after 1 day of symptoms; he had no fever, diarrhea, constipation, dysuria, or rash. More details here. What's your diagnosis?
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Chest Pain: Is It Life-Threatening, or Benign?Ruling out coronary artery disease is the first step in assessing chest pain.
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Case In Point: Coexisting Hodgkin disease and lung cancer in a patient with AIDSThe patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.
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Is Prior Authorization for Prescribed Drugs Cost-Effective?With the increasing managed care restrictions on health care coverage, a look into the efficacy of some of these procedures is needed. This study examines the cost burden of implementing prior authorization (PA) for prescription drugs. Seventy-five prescriptions dispensed by 2 Philadelphia pharmacies requiring PA were tracked and the savings analyzed. Requiring PA proved to be financially beneficial to MCOs but resulted in an increase in uncompensated time for physicians and pharmacies. Two classes of drugs, antihistamines and proton pump inhibitors, accounted for 48% of the medications requiring PA. By educating plan members in advance concerning coverage limits for these medications, MCOs could decrease the use of PA and reduce the amount of time spent by physicians, pharmacists, and patients in dealing with this procedure. (Drug Benefit Trends. 2008;20:136-139)
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Disseminated Fusariosis Following Cutaneous Injury From Contact With a Palm TreeOpportunistic fungal infections are increasingly common inpatients who undergo hematopoietic stem cell transplant(HSCT). Voriconazole is frequently used in allogeneicSCT recipients who receive immunosuppressant therapy forgraft versus host disease to prevent invasive aspergillosis.Indications for voriconazole use include invasive aspergillosis,candidemia, Scedosporium apiospermum infection, and fusariosis.We describe a case in which disseminated Fusarium infectiondeveloped in an HSCT recipient who was receiving voriconazoletherapy. [Infect Med. 2008;25:528-530]
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Pneumococcal Pneumonia: Update on Therapy in the Era of Antibiotic ResistanceSir William Osler once called pneumococcalpneumonia “the captain of themen of death.”1 Pneumonia is the sixthleading cause of death in the UnitedStates and the fourth leading causeamong Americans 80 years of age andolder.2
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Why Is the Trial Dose Not Available?An important study demonstrated the efficacy of chlorthalidone for the treatmentof systolic hypertension in elderly persons,1 and the results have been validatedby other studies.
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Hairy Hyperpigmented Lesion on a Teenager’s BackA 16-year-old boy with asymptomatic, hyperpigmented, hairy lesion on his left upper back. The pigmentation, first noted 5 years earlier, had progressively spread across his torso. The coarse and dark hair confined to the hyperpigmented area had appeared at age 13 years. Medical history uneventful. Review of systems showed no abnormalities. No family history of similar skin lesions.
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Worsening Neurological Symptoms in an Older Man With History of Rectal CancerA 65-year-old man, who was lost to follow-up after abdominal-perineal resection for rectal adenocarcinoma 9 months earlier, presents with progressively worsening neurological symptoms, including bilateral hearing loss, dizziness, gait disturbance, ataxia, and blindness in the right eye.
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Massively Dilated EsophagusFor the past year, a 52-year-old man had dysphagia, which he described as a “knot stuck in the throat” and an associated 25-lb weight loss. He denied fever, chills, headache, abdominal pain, and diarrhea. The patient had been living in the Dominican Republic until about 1 year earlier, when he moved to the United States. He had a 30 pack-year smoking history; he also had hypertension, asthma, and coronary artery disease (none of which were pharmacologically treated). He denied alcohol and illicit drug use.
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Actinic Keratosis and Squamous Cell Carcinoma: Photodamage in ProgressActinic keratosis and squamous cell carcinoma often are clinically indistinguishable. Get tips on what to look for and how to treat.
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Temporary Henna Tattoo Could Leave an Indelible MarkWhen in the Caribbean, why not get a tattoo? This man could now tell you exactly why to resist the vacation temptation.
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Middle-Aged Woman With Numerous Skin LesionsA 54-year-old woman presents for an initial consultation. She has multiple chronic disorders, including type 2 diabetes mellitus and hypertension, for which she takes various medications-none of which are new.
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Paraesophageal Hiatal HerniaA 97-year-old woman with a history of hypertension and a paraesophageal hiatal hernia presented with abdominal distention and shortness of breath. Three days earlier, she had fallen and sustained a hairline pelvic fracture; she was evaluated in the emergency department and given narcotics for the pain. Subsequently, the patient's abdomen became increasingly distended, and she had no bowel movement for 3 days.
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Woman With Lousy EyelashesFor several months, a 45-year-old woman had ocular irritation, tearing, blurred vision, and swelling of the eyelids in both eyes. During that time, she had been treated for allergic conjunctivitis and blepharitis by several physicians, including an ophthalmologist. Her medical history included lupus and seasonal allergies, for which she was taking hydroxychloroquine and loratadine.
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Economic Burden Associated With Parkinson DiseaseThe objective of this study was to estimate the annual cost burden of Parkinson disease (PD) in the United States. Resource use and cost profiles were developed using all-payer statewide hospital discharge data from 6 states; emergency department visit, long-term–care, and national survey data; fee schedules; and published study findings. (Average direct and indirect costs per patient were calculated in 2007 US dollars.) The annual cost per patient was $21,626 (direct cost: $12,491). When applied to the US PD population (N = 500,000), the annual average cost was approximately $10.78 billion (direct costs, $6.22 billion; indirect costs, $4.56 billion). PD has substantial economic consequences for patients and their families, insurers, and society. (Drug Benefit Trends. 2009;21:179-190)
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Rate-Related Septal Infarct PatternA 64-year-old asymptomatic woman with a 10-year-history of hypertension was referred for blood pressure control. She had no other significant medical history. The patient denied exertional chest discomfort or dyspnea. Her medications included atenolol, lisinopril, and hormone replacement therapy.
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Boy With Frequent, Severe Unilateral HeadachesA 14-year-old boy presents with frequent severe headaches characterized by sharp, throbbing pain behind his left eye and left temple.
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Evaluating hypoxemia in the critically illAbstract: Prompt correction of hypoxemia is a basic goal in the treatment of critically ill patients. Improvements in global oxygen delivery may be achieved by several means, such as providing an adequate fraction of inspired oxygen and using packed red blood cell transfusions for volume resuscitation. Low levels of positive end-expiratory pressure often help improve arterial oxygen tension. Measurement of mixed venous oxygen saturation (Sv?248-175?O2) can be useful in patient assessment. Sv?248-175?O2 may be decreased in patients with hypoxemia, hypovolemia, or anemia and may be elevated in patients with sepsis. Serum lactate levels may not quantitate the degree of tissue hypoxia, but serial measurements can help monitor the patient's response to therapy. For patients with septic or hypovolemic shock, early fluid resuscitation with isotonic crystalloid solution is essential. Catecholamine vasopressors can be useful when fluid administration fails to restore adequate blood pressure. (J Respir Dis. 2005;26(5):209-219)
