Anemia

ABSTRACT: Irritable bowel syndrome (IBS) is characterized by abdominal pain or discomfort, bloating, and constipation or diarrhea; the pain is typically relieved by defecation. The diagnosis is not one of exclusion; it can be made based on the answers to a few key questions and the absence of "alarm" symptoms. Fiber therapy, the elimination of particular foods, and regulation of bowel function can help relieve symptoms. Tegaserod or polyethylene glycol can be used to treat IBS with constipation. Loperamide and alosetron are of benefit in IBS with diarrhea (although the latter carries a small risk of ischemic colitis). Low-dose tricyclic antidepressants may be used to treat the abdominal pain associated with IBS. Probiotic therapy or rifaximin may help reduce bloating. Psychological therapies seem to improve well-being in patients with IBS.

A 40-year-old Hispanic homemaker is admitted with a 3-week history of high fever, chest pain, and a dry, irritating cough. Her illness began insidiously with increasing right upper chest pain that is sharp, pleuritic, and rates a 6 on a pain scale of 1 to 10. The pain is associated with temperatures of up to 38.8°C (102°F) and chills, rigors, and profuse sweating that increase in the evening. Worsening dyspnea has been accompanied by a drop in effort tolerance.

An 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

A 32-year-old man complains ofknee pain that resulted when he felland twisted his right knee skiing theday before. He suffered other minorcontusions from the fall, but none ofthese required medical attention. Heis otherwise in good health and hasno relevant medical history.

For 3 months, a 41-year-old womanhas had a pruritic acneiform eruptionon the lateral aspects of the neck andthe left side of the face. She is otherwisehealthy and takes no medication.

An 83-year-old woman is hospitalized for treatment of deep venous thrombosisin her left leg. She underwent left hip replacement surgery 2 months earlier.At that time, mild anemia (hemoglobin level, 10 g/dL) was noted, and iron therapywas initiated. An iron panel obtained shortly after the hip surgery revealeda serum iron level of 80 μg/dL, a transferrin level of 360 mg/dL, and a ferritinlevel of 50 ng/mL.

Apreviously healthy 22-year-oldHawaiian man presents to theemergency department (ED) of a hospitalin California with a 3-day historyof fever and chills. He has also had aprogressively worsening, persistent,dull aching pain in the right upperquadrant of the abdomen for the pastweek. The pain is localized-with noaggravating or relieving factors-andis not related to meals. The patienthas had no nausea, vomiting, loss ofappetite, jaundice, abdominal distension,cough, chest pain, dyspnea,weight loss, or lymphadenopathy.

A 27-year-old woman with a 2-dayhistory of nausea, vomiting, andpostprandial abdominal pain is admittedto the hospital. Acute cholecystitisis suspected

A preoperative evaluation performed shortly before a 66-year-old man is scheduledto undergo coronary artery bypass graft (CABG) surgery reveals a peripheralblood leukocyte count of 23,500/μL with 28% neutrophils, 70% lymphocytes,and 2% monocytes. The patient’s hemoglobin level is 14.5 g/dL; plateletcount is 265,000/μL.

A46-year-old white man is hospitalized with increasing dyspnea of 3weeks’ duration. He has a history of stable chronic obstructive pulmonarydisease secondary to heavy smoking (2 packs of cigarettes a day for 27years, discontinued 6 years previously) and uses inhaled bronchodilators.

A70-year-old African American man, who is a retiredelectrician, presents with increasing fatigue anddull back pain of 4 months’ duration. Although he usuallywalks about 2 miles a day, he now becomes exhaustedafter half a block. He reports exertional dyspnea but noparoxysmal nocturnal dyspnea or orthopnea. Recently, henoticed ankle edema.

Over the past 6 months, a 76-year-old African American woman has had increasingdifficulty in swallowing solid food and has lost 40 lb. She can now tolerateonly liquids and foods with a pudding-like consistency. Ingestion of moresolid food produces the sensation that it is “sticking in her chest,” and shesubsequently regurgitates it undigested. She denies heartburn, reflux, nausea,hematemesis, abdominal pain, and melena.

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.

A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

A 12-year-old black girl is hospitalized because of increasinglysevere dyspnea and sore throat. The sorethroat started about a week earlier and was accompaniedby fever and chills. The patient was evaluated at an urgentcare center when her symptoms worsened, where she wasgiven ampicillin for a presumptive “strep throat.” A generalizedmaculopapular erythematous rash developed within24 hours of the start of therapy, and the ampicillin waspromptly withdrawn. The rash cleared gradually thereafter.Now the patient’s sore throat has worsened to the pointthat she has difficulty with drinking and eating. She hasbecome increasingly dyspneic during the past 24 hours.

A 56-year-old African American woman complains of malaise, nausea, and vomitingof several weeks’ duration. In addition, urinary output is reduced, and shehas mild dyspnea. She denies abdominal pain, diarrhea, constipation, and bonepain; however, she has had a mild but persistent backache for several months.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

A 32-year-old man presents to the emergency department(ED) with generalized joint pain of several days'duration, which he believes is a sickle cell crisis similarto others he has had. He says that 4 to 6 mg of oralhydromorphone usually relieves the pain of these crises,but he recently ran out of his medication and is unableto contact his primary care physician because she ison vacation. He frequently interrupts to ask for a 6-mghydromorphone injection.

For 3 months, a 57-year-old woman has had a persistent green nail that is occasionallyslightly sore; the nail plate has lifted. Another physician prescribed a7-day course of levofloxacin for a suspected Pseudomonas infection; the treatmenthad no effect on the nail. A subsequent 7-day course of norfloxacin wasalso unsuccessful. The patient is otherwise healthy.

SAN ANTONIO -- Breast cancer patients may get similar benefit with less toxicity from adjuvant chemotherapy containing Taxotere and Herceptin but not the cardiotoxic anthracycline Adriamycin, researchers said.

SAN ANTONIO -- Breast cancer patients may get similar benefit with less toxicity from adjuvant chemotherapy containing Taxotere and Herceptin but not the cardiotoxic anthracycline Adriamycin, researchers said.

PORTLAND, Ore. -- Gleevec (imatinib) has led to an overall 60-month survival rate of 95% for chronic myeloid leukemia (CML) patients with who took the tyrosine kinase inhibitor daily, found an international study. Yet the drug doesn't cure the disease.

ROCHESTER, N.Y. -- Low doses of Mifeprex (mifepristone) -- the compound at the heart of the abortion pill -- shrink uterine fibroids and improve quality of life for women with the condition, according to researchers here.

ABSTRACT: Age-related changes that affect drug distribution, such as increased total body fat, decreased muscle mass, and decreased total body water, necessitate reduction in the dosage of water- and lipid-soluble agents. Because creatinine clearance declines with age, the dosage of agents that are excreted primarily by the kidney must also be lowered to prevent toxicity. Examples include aminoglycosides, fluoroquinolones, penicillins, procainamide, lithium, angiotensin-converting enzyme inhibitors, and digoxin. A good rule of thumb to follow until creatinine clearance can be calculated is to reduce the total dose by half in frail elderly persons or in those with established renal disease. Anticholinergic agents should be used with caution because they are associated with urinary retention, heart block, constipation, dry mouth, blurred vision, sedation, and acute or chronic confusion in elderly patients.

PHILADELPHIA -- Infants who are put on food-elimination diets to avoid allergens could be inadvertently robbed of the proteins and nutrients they need to grow, researchers warned here.

NEW YORK -- Veteran television journalist Ed Bradley has died of complications of chronic lymphocytic leukemia (CLL) at the age of 65.

ANN ARBOR, Mich. -- Chronic iron deficiency in infancy may lead to long-term cognitive deficits, particularly in poor families, according to a study of Costa Rican children.

ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.