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Complications of Diabetes Mellitus: Right-Sided Endocarditis in a Diabetic PatientHigh-grade fever, chills, fatigue, malaise, and anorexia developed in a 35-year-old man following subclavian catheterization because of chronic renal failure of unknown cause. The patient, who had long-standing diabetes mellitus, was admitted to the ICU with the diagnosis of possible sepsis. The next day, he was found to have a grade 2/6 systolic murmur compatible with tricuspid regurgitation. This was confirmed when a 4-chamber echocardiogram (A) revealed a large single piece of vegetation (2 arrows) lying on the tricuspid valve, flapping in and out of the right ventricle. In a 2-dimensional echocardiogram of the right atrium and right ventricle (B), 3 arrows point to the vegetation. (RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; TV, tricuspid valve.)
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A Man With Transient Dyspnea After Taking TadalafilA 26-year-old man presented with sudden onset of palpitations and shortness of breath after incidentally taking tadalafil. He had no other symptoms and no history of illnesses during childhood. He drank socially but denied smoking and use of illicit drugs.
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Enoxaparin DermatosisThis is a very distinct, rare, and remarkable hemorrhagic rash, first recognized in 2006, with 7 known cases reported in the literature.
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Reviewing the effects of hyperglycemia and diabetes mellitus on COPDDiabetes mellitus is a group of disorders characterized by hyperglycemia and the resulting macrovascular and microvascular complications.
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STEMI With Underlying Paced RhythmAccording to the Sgarbossa criteria, the patient had an acute MI: ECG revealed a greater than 1-mm ST-segment depression in lead V2 and about 5-mm discordant ST-segment elevation in leads II, III, and aVF.
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Early Renal Disease:Until recently, practitioners focused on the timing of initiation of renal replacement therapy (dialysis) and transplantation once advanced kidney disease had developed. However, a new CKD classification system now provides an action plan for the earlier stages of the disease.
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Pneumatosis IntestinalisA 70-year-old woman with poorly controlled type 2 diabetes mellitus (hemoglobin A1c, 12.5%) and hypertension was brought to the emergency department for evaluation of abdominal pain and loose bowel movements.
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Young Man With a History of Vague Headaches Ascribed to SinusitisA 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.
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Traumatic HemothoraxTraumatic hemothorax usually results from penetrating or contused thoracic injuries that lead to rib fracture and damage of intercostal or pulmonary vessels. Hemorrhagic shock can occur with massive blood loss into the pleural space. The shock state may be exacerbated by decreased venous return.
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Traumatic HemothoraxTraumatic hemothorax usually results from penetrating or contused thoracic injuries that lead to rib fracture and damage of intercostal or pulmonary vessels. Hemorrhagic shock can occur with massive blood loss into the pleural space. The shock state may be exacerbated by decreased venous return.
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Chest Film Clinic: What caused a solitary pulmonary mass in this patient with fever?A 45-year-old man presented to the emergency department (ED) with fever and left-sided pleuritic chest pain. He had been in good health until 4 days earlier, when diffuse myalgias, weakness, and frontal headache developed. Two days later, these symptoms were accompanied by onset of fever (temperature, 39.4°C [103°F]) and left-sided pleuritic chest pain. He denied chills, rigors, shortness of breath, hemoptysis, and cough.
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Neurologic ComplicationsAlthough it has been evident since the early days of the HIV epidemic that a dementing illness often accompanies HIV infection and that the virus invades the nervous system soon after systemic infection, the clinical syndrome has evolved with the introduction of antiretroviral therapy.
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Acute EpiglottitisA 74-year-old nursing home resident was admitted to the hospital with shortness of breath and stridor. Radiographic examination of the neck revealed the “thumb sign” of a swollen epiglottis (Figure, white arrow); the black arrow indicates the normal posterior wall of the pharynx. Acute epiglottitis was diagnosed.
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How to handle the difficult airway, part 2Abstract: The laryngeal mask airway (LMA) and intubating LMA are valuable alternatives in patients in whom intubation has failed and who need oxygenation and ventilation immediately. The dual-lumen, dual-cuffed airway tube is effective in a variety of settings and can tolerate ventilation at pressures as high as 50 cm H2O; it is contraindicated in awake patients who have intact airway reflexes, caustic ingestions, and upper airway obstruction from a foreign body or pathology. Surgical airways are lifesaving techniques when intubation is unsuccessful or impossible through the mouth or nose. It may be particularly appropriate in patients with laryngeal or facial trauma, upper airway obstruction, or oropharyngeal injury. When patients aged 12 years and older cannot be ventilated by mask or intubated with traditional methods, surgical or needle cricothyrotomy is the procedure of choice. (J Respir Dis. 2005;26(7):298-302)
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Child With Appendicitis-like Symptoms9-year-old girl was seen in the emergency department (ED) with a 5-day history of non-bilious, non-projectile emesis, decreased appetite, and persistent right lower quadrant pain following an appendectomy 5 days earlier.
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Pulmonary Arteriovenous Malformation in a Woman With Severe Mitral Valve StenosisAn 86-year-old woman presented with a 1-week history of worsening dyspnea, wheezing, and orthopnea. She denied chest pain, cough, or fever. She did not smoke cigarettes. Her oxygen saturation was 86% on 2 L/min via nasal cannula.
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Pain Management for Osteoarthritis: Guideline ToplinesGet a topline review of OA pain management recommendations from the Osteoarthritis Research Society International and the American College of Rheumatology/Arthritis Foundation.
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Managing Diabetes to Prevent Cardiovascular Disease: A Guideline QuizDiabetes is a primary risk factor for atherosclerotic cardiovascular disease. Find out how well you know the guideline recommendations for reducing that risk with the first of 4 quizzes.
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Topics in Cardiometabolic Disease: Hypertension Guideline QuizCardiometabolic disease affects 1 out of every 2 Americans today. This first of 4 quizzes tests your knowledge of how to manage hypertension, heart failure, and renal disease.
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Metformin Ups Survival in T2DM and CirrhosisContinuing metformin after a diagnosis of cirrhosis can significantly decrease the risk of death in patients with diabetes, a new study suggests.
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Lymphoepithelial Cysts in a Patient With HIV: Is HAART the Answer?Lymphoepithelial cysts of the parotid gland may be diagnostic of HIV infection; they are typically bilateral, benign, and associated with lymphadenopathy.
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Concurrent Management of Achalasia and Morbid ObesityThe development of a standardized treatment that simultaneously addresses achalasia and obesity is becoming more imperative as obesity becomes epidemic in the US. Here’s a case in point.
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What caused this patient's cough and mild hemoptysis?The authors describe a previously healthy patient who required surgical resection of a large mucoid tumor lined with atypical columnar epithelium. The diagnosis was mucinous cystadenocarcinoma, a rare type of pulmonary cancer that is difficult to identify.
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MDIs, Spacers, and Dry Powder Inhalers: What Patients Are Likely to Do WrongInhaled medications are the cornerstoneof therapy for most of themore than 30 million Americanswho have asthma or chronic obstructivepulmonary disease(COPD). Unfortunately, many ofthese patients use aerosol deliverydevices incorrectly.
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HIV-Related Oral Lesions: Clues for Early DiagnosisA 30-year-old man with a 15 packyear smoking history presented for a follow-up evaluation of an asymptomatic whitish lesion on the tongue of 4 months’ duration. The lesion had not responded to oral therapy with either nystatin or fluconazole. The patient was distressed about the lesion’s appearance and his inability to remove it with a toothbrush.
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Behçet's DiseaseThis is a multisystem disorder characterized by oral and genital aphthae. Other symptoms include a myriad of cutaneous findings; variable systemic features include uveitis, synovitis, meningoencephalitis, and large- and smaller-vessel vascular disease.
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How Do Medical and Pharmacy Directors Perceive the Value of New Cancer Drugs?A total of 50 health care professionals, including 25 health plan medical directors, 20 health plan pharmacy directors, and 5 pharmacy directors for pharmacy benefit management companies were surveyed regarding their perceptions of the value of 3 novel cancer therapies. The physicians and pharmacists were asked to estimate the monthly average wholesale price of each therapy, overall survival benefit of bevacizumab for treatment of persons with advanced colorectal cancer and erlotinib for treatment of persons with non–small-cell lung cancer, and progression-free survival benefit of sunitinib malate for treating persons with advanced renal cell carcinoma. Most respondents overestimated drug costs and underestimated survival benefit associated with these treatments. Mean incremental cost-effectiveness ratio for all drugs studied was approximately $170,000/quality-adjusted life-year (QALY). Cost-effectiveness ratios were lower than the $300,000/QALY cited by oncologists in another study but significantly higher than those for many other costly interventions. Our study findings reflect the need for a better understanding of the value of the clinical benefits of novel cancer therapies in an environment of product innovation but with resource constraints. (Drug Benefit Trends. 2009;21:120-130)
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Transient ST Elevations and Conduction Delay After Traumatic Fracture of the SternumA 25-year-old man with no significant medical history was attempting to move a heavy container when he lost control and became pinned between the container and a concrete pole.
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Lemierre Syndrome: A Forgotten DiseaseSymptoms closely resemble "strep" throat but suspicion for Lemierre should run high when pharyngitis and fever persist.
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Neurotic ExcoriationA 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.
