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Elderly Man With Weakness, Poor Appetite, and Abdominal Cramping on DefecationAn 83-year-old man complains of weakness, easy fatigability, and poor appetitethat began 4 to 6 weeks ago. He becomes short of breath on his daily walksand has lost about 20 pounds over the last 3 months. He denies nocturia,paroxysmal nocturnal dyspnea, exertional chest pain, fever, cough, melena,and hematochezia. His only GI symptom is occasional crampy abdominal painwith bowel movements.
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A Young Woman With Sudden Loss of Vision in One EyeA 17-year-old sexually active young woman presented with sudden loss of vision in the left eye 2 weeks before presentation.
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Chilaiditi SyndromeDull, intermittent, midepigastric abdominal pain of 1 day's duration prompted a 73-year-old man to seek medical attention. He had no other symptoms.
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Swallowed Toothbrush in a Bulimic AdolescentA 16-year-old girl of normal weight for height (body mass index, 21) was evaluated for a 6-month history of binge-purge cycles and amenorrhea. She met the diagnostic criteria for bulimia nervosa and began treatment that involved a multidisciplinary team. During the second month of therapy, the patient presented to the emergency department after she accidentally swallowed a toothbrush while trying to induce vomiting with the brush’s handle.
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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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An Unusual Presentation of Septic HipEmphysematous cholecystitis is a rare condition that is the result of infection with Clostridium perfringens and other gas-producing organisms including Escherichia coli, Bacteroides fragilis, and Klebsiella species.
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Fracture After Fall in a Middle-Aged African American WomanA 58-year-old African American woman comes for a follow-up visit after sustaining a fracture of the right radius, which occurred when she tripped on loose carpeting and broke her fall with an outstretched hand.
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Hematemesis Secondary to a Bronchogenic CystA 24-year-old man with an unremarkable medical history presented to the emergency department with abdominal pain and hematemesis of 3 days' duration. His symptoms were postprandial, and each episode yielded up to half a cup of blood without clots. He denied using NSAIDs or alcohol. He had had an episode of hematemesis 2 years earlier that resolved spontaneously, for which he had not sought treatment. His vital signs were normal, and his physical examination was notable only for moderate epigastric tenderness without rebound or guarding.
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Infection of the Cutaneous Apocrine GlandsHidradenitis suppurativa is a chronic acneiform infection of the cutaneous apocrine glands.
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COX-2 Inhibitor–Induced RashA 63-year-old man was given oral celecoxib, 100 mg bid, for shoulder pain. Three days later, a pruritic rash appeared on his back, then spread to the chest, lower legs, and face. He stopped the celecoxib on his own and self-administered diphenhydramine for the pruritus. The rash and itch persisted, which prompted the patient to seek medical care. He had no respiratory symptoms.
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A Rash of Rough Spinous Patches on a Young GirlThe rash has been present for 2 years. Originally on the trunk and extremities it has now spread to her face and hands. She has been diagnosed as having and been unsuccessfully treated for nummular eczema and tinea corporis. What's your Dx?
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Fifth DiseaseThe parents of a 2-year-old sought treatment for a rash on their son's face. The child had had a low-grade fever for 3 days before the rash erupted. An intermittent lace-like rash was beginning to develop on the extremities. The patient was otherwise asymptomatic.
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Takotsubo Syndrome in an African American Woman With Typical PresentationAlso known as “broken-heart syndrome,” Takotsubo syndrome is a stress-induced cardiomyopathy.
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Might Obstructive Sleep Apnea Explain Your Patient’s Nightmares?Consider OSA in your the differential diagnosis in patients who present with nightmarers. Continuous positive airway pressure (CPAP) can provide effective treatment.
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Nonspecific symptoms are among the obstacles to diagnosis Pulmonary alveolar proteinosis: An easy-to-miss diagnosis key words: Alveolar proteinosis, Surfactant, Whole lung lavageabstract: Pulmonary alveolar proteinosis (PAP) is characterized by the accumulation of lipoproteinaceous material in the alveoli. The most common symptoms are dyspnea on exertion and nonproductive cough. Weight loss, fatigue, chest pain, and hemoptysis have also been reported. Chest radiographs typically show bilateral, symmetrical airspace disease with an ill-defined nodular or confluent pattern, which gives a "bat wing" appearance, as is seen in heart failure. Pulmonary function tests usually demonstrate mild restrictive disease. Findings on examination of sputum specimens or bronchoalveolar lavage fluid can suggest the diagnosis; however, open lung biopsy is the diagnostic gold standard. Whole lung lavage remains the standard of care for PAP and is warranted in patients with severe dyspnea and hypoxemia. Subcutaneous human recombinant granulocyte-macrophage colony-stimulating factor appears to be a promising alternative to whole lung lavage for symptomatic patients. (J Respir Dis. 2007;28(5):177-184)
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Shiny Pink Nodule on Malar CheekA 68-year-old woman presents with a new 6-mm nodule with central ulceration and a rolled border on the right cheek. What's your diagnosis? How would you treat?
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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)
