Anemia

A 70-year-old woman with a history of ischemic heart disease was hospitalized because of generalized weakness, fatigue, and retrosternal chest pain on mild exertion. Her skin was pallid. Chest and heart evaluations were normal, and mild hepatosplenomegaly was discerned.

An 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.

Vague abdominal pain, malaise, anorexia, and the loss of 10 lb in 2 months prompted a 65-year-old man to seek medical evaluation. A year earlier he had undergone surgery for stage III carcinoma of the sigmoid colon. Because metastases to the lymph nodes were found in the resected colon, the patient was given postoperative chemotherapy. Histologic examination revealed poorly differentiated adenocarcinoma.

Persistent bloating, epigastric discomfort, and increased gastric acidity prompted a 47-year-old woman to seek medical care. Gastroesophageal reflux disease was diagnosed; antacids and H2-blockers were prescribed but provided no relief.

A week after the onset of headache, fever, chills, nausea, weakness, and malaise, a 23-year-old man presented to the emergency department of a hospital on Long Island in New York. He reported that analgesics had not eased his symptoms. The patient's only past hospitalization was a splenectomy secondary to an auto accident at age 16.

The extent of mucosal or transmural intestinal necrosis varies. Pneumatosis progresses from the submucosa through the muscular layer to the subserosa. The distal ileum and proximal colon are most frequently involved.

These are hyperpigmented, regularly bordered, sharply demarcated macules that are usually tan or light brown in whites and dark brown in dark-skinned persons. The lesions are characterized by an increased number of melanocytes and an increased amount of melanin in the epidermis.

A 10-year-old boy presented with right hip pain and a limp. The patient was taking no medications and had no personal or family history of disease. He denied a history of trauma.

In a 65-year-old man with a family history of colorectal carcinoma, an initial screening coloscopic examination revealed 2 arteriovenous malformations. These delicate red lesions with a vascular network and irregular edges were found in the cecum.

An 11-year-old boy presented to the hospital with a 3-day history of maculopapular rash over the face, trunk, and extremities. He had completed a 5-day course of trimethoprim-sulfamethoxazole for otitis media 1 week before presentation. His medical history was otherwise unremarkable. Over the past 3 days, the rash had become pruritic and the lesions progressively larger. Some lesions were vesicular and bullous. There was diffuse involvement of the oral mucosa, conjunctivae, and genitalia.

A 43-year-old woman was admitted to the hospital with left flank pain. The physical examination revealed a left abdominal mass. Laboratory test results identified normochromic-normocytic anemia (hematocrit, 33%; hemoglobin, 10.8 g/dL; and mean corpuscular volume, 88 fL) and microscopic hematuria (10 red blood cells per high-power field).

A 20-year-old woman, who had been confused and delirious for 2 days, was brought to the emergency department (ED). She had no significant past medical history and was taking no medication but had recently returned from a trip to Southeast Asia. In the ED, the patient had several convulsions and rapidly became comatose. She was unresponsive; her temperature was 37.9°C (100.3°F), and her blood pressure measured 80/50 mm Hg. The neurologic examination showed no signs of meningeal irritation. Cranial nerve examination was normal and showed mild, bilateral, symmetric increase in deep tendon reflexes. All other physical examination findings were normal.

A 74-year-old man was evaluated for iron deficiency anemia. The gastrointestinal (GI) work-up showed Schatzki's ring, gastritis, and two adenomatous polyps. Oral iron therapy was initiated, and the anemia improved.

A 62-year-old man was admitted to the hospital with iron deficiency anemia, as demonstrated by low serum iron and ferritin levels and high total iron–binding capacity. He had had this condition for at least the last 5 years and had been treated with ferrous sulfate sporadically. The history coupled with the laboratory findings and the telangiectatic lesions on his lower lip led to a diagnosis of hereditary hemorrhagic telangiectasia, or Rendu-Osler-Weber disease.

An 80-year-old man, who could not walk because of a large mass on his right leg, was brought to the emergency department. The mass had been increasing in size on the anterior region of his right thigh for approximately 6 months. The patient also complained of “lumps” that had developed on his extremities during the past 2 months.

Pain and swelling of the left lower leg and a low-grade fever of 1 week's duration sent a 24-year-old African American man for medical evaluation. The patient had a history of vitiligo since childhood.

For 2 years, a 60-year-old woman with long-standing hypertension had experienced worsening dizzy spells, fatigue, and chest discomfort. She also had cold extremities, significant dyspnea on exertion, and orthopnea. The patient was taking amlodipine and furosemide.

Dyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.

A 6-year-old boy presented with bloody diarrhea; fatigue; decreased appetite; weight loss; and occasional, mild abdominal pain for the past 2 months. The child had 6 to 8 bowel movements daily, 1 or 2 of which occurred at night.

A 6-year-old boy is brought for evaluation of bloody diarrhea, fatigue, decreased appetite, weight loss, and occasional, mild abdominal pain of 2 months' duration. The child had 6 to 8 bowel movements daily, 1 or 2 of which occurred at night.

Alimentary tract duplications are uncommon. Gastric duplication accounts for only 3.8% of these duplications. The cause is not known, but faulty separation of the endoderm and notochord early in embryonal development is thought to be responsible. The anomaly occurs in twice as many female as male infants.

During investigation of a long-standing iron-deficiency anemia, a 67-year-old woman was found to have cecal colon cancer, Duke's stage B. A right hemicolectomy was performed at that time, and she had periodic follow-up examinations. Four years later, during a routine outpatient visit, her carcinoembryonic antigen (CEA) serum level was found to be 27.7 ng/mL (upper normal limit, 5 ng/mL). Four months earlier, her CEA level had been normal.

A 65-year-old woman, who was confined to a wheelchair because of severe rheumatoid arthritis, was concerned about nodules that had erupted on her fingers and hands during the previous 3 weeks. Her medical history included colon cancer, chronic renal insufficiency, anemia, and hypertension. The nonpruritic nodules were painful when they began to form under the skin; however, once they erupted, the pain disappeared.

A variety of rheumatic diseases-systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and the vasculitides among them-manifest as “lumps, bumps, and holes” involving the extremities. Each of these diseases works through specific mechanisms on different structures of the skin to produce a distinctive pathology. In doing so, each provides clues to the cause, which the history and physical examination can help confirm.

A 30-year-old woman was brought to the hospital with syncope, bradycardia, and hypotension. For the past 6 years, she had vomited after eating meals and after occasional episodes of binge eating.

Systemic lupus erythematosus (SLE) was diagnosed in an 18-year-old man who presented with polyarthritis, fever, hypoxia, fatigue, anemia, neutropenia, and abnormal urinary sediment. A renal biopsy showed diffuse mesangial proliferative glomerulonephritis (World Health Organization class II). Serologic tests were positive for fluorescent antinuclear antibody (FANA), SS-A, SS-B, anti-Sm and anti-dsDNA antibodies, and rheumatoid factor; a direct Coombs' test result was positive as well.

A 53-year-old man presented with a 3-day history of bilateral pain in the lower extremities. He also had a 3-month history of thickening and desquamation of skin, with associated itching, and a 5-lb (2.27-kg) weight loss. The skin changes initially appeared on the hands and subsequently became generalized.

A 60-year-old woman with a history of iron deficiency anemia was hospitalized because of an episode of melena. A colonoscopy performed a year earlier had shown left-sided diverticulosis but was otherwise unremarkable.

57-year-old woman is hospitalized because of a 3-week history of persistent left-sided dull flank pain that worsens with movement and is associated with intermittent high fever.

Although proton pump inhibitors (PPIs) are highly effective, clinical failure in patients with gastroesophageal reflux disease (GERD) is seen regularly--not only in GI clinics but also in primary care offices. In fact, the prevalence of failure with PPIs has increased in proportion to the expanding indications for their use.