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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)
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Teenager With Small Red Papules on Her Arms and Thighs17-Year-old girl with a 7-month history of small, red papules on her arms and thighs. Rash is not painful or itchy. Otherwise in good health.
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NeurocysticercosisAn 18-year-old woman from Mexico was hospitalized because of severe headache with nausea and vomiting. Her headaches had started 4 years earlier and had progressively worsened. They occurred mainly in the occipital region and were pulsating, worse on bending down, and unrelieved by any medication. They were often accompanied by dizziness and presyncope.
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Making the most of pulmonary function testing in the diagnosis of asthmaAlthough the results of a thorough history and physicalexamination often suggest the diagnosis of asthma, confirmatorytesting is required and may be helpful in more subtlecases. Spirometry before and after bronchodilator administrationis the first step for the initial diagnosis; it also is an importantcomponent of the long-term assessment of asthma control.When the results of spirometry are normal in a patient in whomasthma is suspected, bronchoprovocation challenge testingwith methacholine is generally considered the next diagnosticstep. Numerous alternative methods of bronchoprovocationtesting have been developed, such as the challenge with adenosine5'-monophosphate. Novel methods such as the forced oscillationtechnique and the measurement of exhaled nitric oxidehold promise for more effective diagnosis and monitoringof asthma in the future. (J Respir Dis. 2008;29(4):157-169)
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Wellness Program Improves Self-Efficacy in Multiple SclerosisHere: more evidence that with the proper tools and motivation, health and wellness are attainable goals-even within the constraints of MS.
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Metastatic CarcinomaA 60-year-old Caucasian man with a history of invasive squamous cell carcinoma of the lung presents with the lesions shown. Metastases to the skin can be a clinical finding in many malignancies.
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Poor Sleep May Hike Mortality in Metabolic SyndromeIn the context of metabolic syndrome, sleep is thought to be an added and modifiable risk factor.
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Coffee: No Harm, No Foul If Only 4 Cups DailyNewest news on coffee, from BMJ: "...more likely to benefit health than to harm it..." High vs low intake reduces risk of diabetes and Alzheimer disease. Plus, more.
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Septic Pulmonary EmboliA51-year-old man who was an active injection drug user was admitted to the ICU with septic shock and severe respiratory distress. Notable findings were fever, multiple opacities on a chest radiograph, and an elevated white blood cell count.
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Community-acquired pneumonia: An update on therapyAbstract: In the assessment of community-acquired pneumonia, an effort should be made to identify the causal pathogen, since this may permit more focused treatment. However, diagnostic testing should not delay appropriate empiric therapy. The selection of empiric therapy can be guided by a patient stratification system that is based on the severity of illness and underlying risk factors for specific pathogens. For example, outpatients who do not have underlying cardiopulmonary disease or other risk factors can be given azithromycin, clarithromycin, or doxycycline. Higher-risk outpatients should be given a ß-lactam antibiotic plus azithromycin, clarithromycin, or doxycycline, or monotherapy with a fluoroquinolone. If the patient fails to respond to therapy, it may be necessary to do bronchoscopy; CT of the chest; or serologic testing for Legionella species, Mycoplasma pneumoniae, viruses, or other pathogens. (J Respir Dis. 2006;27(2):54-67)
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Infectious MononucleosisAn 18-year-old man presented with a 3-day history of fever, sore throat, and neck swelling. He had previously been healthy, and his immunizations were up-to-date. There was no history of travel outside the country or of an animal bite or scratch.
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Acute Pancreatitis Secondary to Neuroendocrine TumorRight upper quadrant pain of 24 hours’ duration prompted a 20-year-old man with a history of gastritis to seek medical attention. The pain was sharp and nonradiating, with no alleviating or aggravating factors. The patient occasionally consumed alcohol and regularly smoked cigarettes (tobacco and marijuana). He denied nausea, vomiting, diarrhea, and diaphoresis. Right upper quadrant pain of 24 hours’ duration prompted a 20-year-old man with a history of gastritis to seek medical attention. The pain was sharp and nonradiating, with no alleviating or aggravating factors.
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Unilateral Scleral Jaundice in an Elderly Man: An Odd FindingLeft scleral icterus is the only prominent physical finding in the 86-year-old who presented with transient aphasia, ataxia, and general asthenia. Can you dx?
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Pulmonary involvement in a patient with lymphocytic colitisMicroscopic colitis is a noninfectiouscolitis that is characterizedby chronic nonbloodydiarrhea and macroscopicallynormal colonic mucosa. Extraintestinalmanifestationsare rarely seen. In this report,we describe a nonspecific interstitialpneumonitis in a patientwith lymphocytic colitis.
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Benzocaine-induced methemoglobinemia in bronchoscopyBenzocaine-induced methemoglobinemia has been a well-documented illness that is usually simple to cure but can be life-threatening if not recognized. As the use of "scope" procedures becomes more commonplace, the early recognition of hypoxemia resulting from methemoglobinemia is essential. The authors report a case of benzocaine-related methemoglobinemia following bronchoscopy.
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Catastrophic Antiphospholipid Syndrome in Secondary SyphilisCatastrophic antiphospholipid syndrome (CAPS), first described by Asherson and colleagues1 in 1992, refers to a clinical scenario in which multiple vascular occlusive events involving small vessels that supply blood to organs occur over a short period.
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Chest Film Clinic: What caused progressive dyspneain this patient with chronic asthma?A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.
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Abnormal Uterine Bleeding: A Primary Care PrimerAbnormal uterine bleeding can be defined as bleeding that deviates from the patient's normal pattern; it may be heavier, more frequent, or abnormal in timing. Bleeding of any kind in a postmenopausal patient should be considered abnormal unless she is receiving hormonal therapy that is associated with regular cyclic withdrawal bleeding.
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Cutaneous Leukocytoclastic VasculitisThis hypersensitivity reaction may be secondary to medications, infection, collagen-vascular disorders, or an occult malignancy. When it is localized to the skin, prognosis is excellent.
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Beer Brews Up Good Medicine for the BrainThis adult beverage may actually provide health benefits, specifically for Alzheimer, Parkinson, and other neurological conditions.
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The 10 Most Common Prescribing Errors: Tips on Avoiding the PitfallsNumerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.
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A Rare Reversal of Clostridium perfringens Necrotizing FasciitisWhile currently receiving chemotherapy with mitoxantrone for Gleason grade 7 prostate cancer, a 64-year-old man presented with rectal bleeding.
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We Have Too Many Specialists and Too Few General Practitioners"Primary care docs should be paid more, specialists less. More reimbursement for talking...less for testing and procedures." And, there's more.
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A practical guide to managing asthma in childrenAbstract: All children with asthma should have periodic office visits, usually every 3 to 6 months, in which asthma action plans are updated. Periodic assessment of lung function by peak expiratory flow or office spirometry can help determine the appropriate treatment strategy. Low daily doses of inhaled corticosteroids remain the first and most effective choice of therapy for persistent asthma. If this approach is inadequate, adding a second medication, such as a leukotriene modifier or a long-acting ß2-agonist, is suggested. Short-acting ß2-agonists remain the most important therapy for intermittent asthma. For most children, the best route is via a metered-dose inhaler with either a spacer or valved holding chamber. If these agents are inadequate, a short course of oral corticosteroids may be required. (J Respir Dis. 2005;26(8):348-358)
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Liver Enzyme Abnormalities:What to Do for the PatientYou routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.
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Anorectal Complaints: Office Diagnosis and Treatment, Part 2Anorectal abscesses and fistulae, pilonidal disease, rectal prolapse, pruritus ani, and anal masses are discussed, with an emphasis on diagnosis and treatment of these conditions in the primary care office setting.
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Heart Disease and SyncopeSyncope is defined as a sudden, brief loss of consciousness and postural tone followed by spontaneous complete recovery. It accounts for 3% of emergency department visits and 1% of hospital admissions.
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Congenital ClubfootThis 3-month-old boy has an untreated right clubfoot deformity. The foot is stiff and uncorrectable. The vertical midfoot crease indicates significant deformity. An anteroposterior (AP) simulated weight-bearing radiograph shows parallelism of the long axis of the talus and calcaneus; this indicates varus alignment of the hindfoot. There is also forefoot adduction.
