Atrial Fibrillation

What is the role of the primary care practitioner in the care of patients with HIV infection?Although the treatment of human immunodeficiency virus type 1 (HIV-1) infection is usually directed by subspecialists, many patients who are taking highly active antiretroviral therapy (HAART) continue to see their primary care physician. What is the most effective regimen-and what complications should we be on the lookout for?

Primary care physicians are called upon to assess risk in patients undergoing a variety of surgical procedures. In some ways, perioperative medicine is quickly evolving into a “subspecialty” of its own. Recently, Jaffer and associates1 updated the area with new data accumulated over the past 2 years.

The role of coenzyme Q10 in the development of heart failure and as a potential treatment is still being studied. The latest American College of Cardiology Foundation/American Heart Association heart failure guidelines state:

THE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.

A 59-year-old man presented with painful paraparesis of acute onset, severe low back pain, and shortness of breath. On initial examination, he had 0/5 strength and numbness in his lower extremities. The skin from below his umbilicus to his lower legs was pale.

In 2000, the World Allergy Organization (WAO) published a consensus definition of anaphylaxis as a severe, life-threatening generalized or systemic hypersensitivity reaction. The reaction is caused by the release of bioactive mediators from mast cells and basophils.

Patients with heart failure are often hospitalized for dehydration and acute renal failure. Thus, they need to be educated about dehydration as well as about the signs of fluid retention.

A 62-year-old woman admitted to behavioral hospital unit because of agitation complicating end-stage Parkinson disease. The disease has progressed over 20 years.

Sometimes we try to distill long experience into words, whether aphorisms or full paragraphs. Rilke’s wonderful prose poem expresses this very well in the part that begins, “For the sake of a single verse, one must see many cities, men and things. . . . ” While medicine has only some features in common with poetry, what reverberates is the wish to impart an affecting draught of beauty or wisdom or insight, in the case of poetry, after many years and decades of immersion in life; and I here offer some fruits of long observation and participation “hip deep” in clinical care and in the teaching of residents.

A 37-year-old man was brought to the emergency department (ED) after he had 2 near-syncopal events. The first occurred in the morning and rapidly resolved; the second occurred later in the day at work. The night before he had a headache and neck pain. In the ED, he reported left arm and leg weakness and was noted to have left facial droop.

Here we provide a list of questions with links that can help you respond to patients who may be asking you about H1N1 virus infection (swine flu). Topics include travel restrictions and recommendations for persons with chronic disorders.

An 82-year-old woman reports vision changes in her right eye that have developed gradually over the past several months. She needs significantly brighter light when sewing, reading, and doing other close work. She has also experienced “gaps” in visual images- blank spaces and blind spots in the center of things she looks at; at times she has difficulty in recognizing faces. Her left eye seems unaffected. She fears that she has had a stroke, although she has no speech difficulty, extremity weakness, abnormal sensory sensations (such as numbness or tingling), or any other neurological symptoms.

In the United States, an estimated 5 million people have heart failure and about 550,000 new cases occur each year.1 The incidence is rising as more patients survive what were once fatal myocardial infarctions (MIs). Coronary artery disease (CAD) and hypertension are the most common causes of heart failure. The less frequent causes include diabetes; viral infections; valvular heart disease; drugs (eg, doxorubicin); and postpartum, alcoholic, and familial cardiomyopathies.2,3

Here is a common clinical scenario. Your patient was admitted to the hospital with an acute myocardial infarction (MI). Intervention has been successful, and the patient's condition is now stable. The cardiologist is concerned about the patient's hemoglobin value of 9 g/dL. Active bleeding, hemolysis, and other potential causes of anemia (iron or vitamin B12 deficiency, for example) have been excluded. The decision is made to transfuse to raise the hemoglobin level above 10 g/dL.

My patient is a 52-year-old woman who is premenopausal but who experiences dyspareunia as a result of vaginal dryness. She has tried over-the-counter lubricants, but they have not relieved her symptoms. She takes warfarin, 5 mg qod/7 mg qod, to prevent recurrent deep venous thrombosis (DVT). Her first DVT was in 1978 and was associated with the use of an oral contraceptive. Is low-dose vaginal estrogen cream a safe option for this patient?

Q:My patient is a 66-year-old man with long-standing hypertension and atherosclerotic heart disease. During a recent coronary arteriogram, the cardiologist performed renal artery screening, which revealed a left renal artery stenosis. Renal artery angioplasty and stenting were recommended. Is this appropriate?

Benign prostatic hyperplasia (BPH)-histologically defined as stromal and epithelial hyperplasia beginning in the periurethral transitional zone of the prostate-affects up to 80% of 80-year-old men.[1,2] With progressive prostatic enlargement, bladder outlet obstruction can result. Although the exact mechanism is unknown, lower urinary tract symptoms (LUTS) can signal progressive BPH.

Silent myocardial ischemia (SMI)- objective documented ischemia in the absence of chest discomfort or other anginal equivalents-is a major component of the total ischemic burden for patients with ischemic heart disease.1 In the United States, an estimated 2 to 3 million persons with stable coronary artery disease (CAD) have evidence of silent ischemia. 2

An 89-year-old woman is seen because of a white area on the tongue. She has been hospitalized on a behavioral health unit for 2 weeks; 1 day ago, enoxaparin was begun for a new left leg deep venous thrombosis. Recent antibiotic therapy for a urinary tract infection; candidal vulvitis followed and was treated with topical clotrimazole. Has penicillin allergy.

A 93-year-old man with known Alzheimer dementia has his admission physical examination on transfer to a geropsychiatric hospital unit due to behavioral difficulties. A language barrier and his stoicism minimize communication, but his devoted wife translates and recounts that he is not in any physical discomfort. Has sometimes needed oxygen treatment in the past.

Now that baby boomers have reached the age of Medicare eligibility, joint replacements are on the rise. Because patients who undergo hip or knee arthroplasty require anticoagulation, primary care physicians have a key role in the care of these persons- before as well as after surgery.

It can be difficult to determine whether unusual, paroxysmal behavior represents a seizure or a nonepileptic event. Patients with sudden flailing movements or unresponsive staring may, in fact, be experiencing psychogenic events. Other types of pathological spells, such as syncope and migraine, can also be mistaken for epileptic seizures.

An 84-year-old Ethiopian woman presented with tender, violaceous, nonblanching nodules that had coalesced into plaques on the soles of both of her feet over the past 3 months. Similar discrete nodules were found on the dorsal aspect of her right wrist.

A 46-year-old man with AIDS (CD4+ cell count, 150/μL) presented with a painful nodular lesion on the plantar surface of his right foot. The lesion had appeared 1 month earlier as a painless, 1-cm, raised, reddish purple nodule and had progressively enlarged to 5 cm. Six months earlier, the patient had cryosurgery to remove a similar, larger lesion on the posterior aspect of his right midcalf.

A 49-year-old man presented to the emergency department (ED) with substernal chest pain that had started an hour earlier. The pain radiated to the left arm, was constant, and was associated with diaphoresis, nausea, and dyspnea. A similar episode 4 days earlier had spontaneously resolved. He denied fever or chills, pleuritic chest pain, vomiting, and diarrhea.

What should be added to the regimen of a patient with type 2 diabetes mellitus when initial oral therapy no longer adequately controls glucose levels?

Selecting the most effective stroke prevention strategy for patients with cerebrovascular disease is an acknowledged challenge. In addition to decisions about the appropriateness of carotid surgery or angioplasty and stenting, there is the often tricky matter of designing the most effective medical regimen.

Selecting the most effective stroke prevention strategy for patients with cerebrovascular disease can be challenging.

A 25-year-old woman presents for a prenatal visit. She has an unremarkable medical history except for hypermobility of the joints and a tendency to bruise easily. Her mother and sister also have very lax joints.

A 92-year-old woman presents with sharp abdominal pain of 1 day's duration, accompanied by 1 episode of emesis. The pain is neither relieved nor exacerbated by food ingestion.