Atrial Fibrillation

A 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.

A 22-year-old man complained of progressive shortness of breath and abdominal distention. Three years before, he had completed chemotherapy for Hodgkin's disease and had since been in remission. Recently, he had been treated for tonsillitis with oral antibiotics.

A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.

A 63-year-old African American man presented with orthopnea and pedal edema that had worsened during the past 4 months. Macroglossia was noted.

Tai Chi (also known as T'ai Chi Chuan, Taijiquan) is a form of mind-body exercise that has its roots in ancient Chinese martial arts. Throughout Asia, it is often practiced for preventive health, especially among the elderly. In recent years, Tai Chi has become popular in the West among all age groups and has been studied as a therapy for various medical conditions.

A 67-year-old woman was referred for evaluation of exertional dyspnea, with multiple episodes of fever, cough, and pneumonia. She had a long history of cough with sputum and had been admitted several times for exacerbations of chronic obstructive pulmonary disease and pneumonia. She received maintenance therapy with an ipratropium and albuterol combination, fluticasone, and salmeterol, but she continued to experience exertional dyspnea, with an average of 5 or 6 exacerbations and 2 hospital admissions a year.

56-year-old woman presents for evaluation of several syncopal episodes that occurred during the past 2 weeks. These episodes were associated with various activities--eating while seated, walking slowly, and standing upright--and rendered her briefly unconscious.

A 55-year-old man complains of fatigue. Although he sleeps 8 hours every night, he has to push himself to perform his usual daily activities. He has also experienced loss of libido and episodic impotence, which he ascribes to the fatigue.

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.

Abstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)

A 62-year-old woman with a 25-year history of dyspnea was hospitalized because of hypoxemia. The dyspnea had become more severe during the past few years; it was worse in the standing position, was not exacerbated by walking, and was immediately relieved on lying down. She had no seasonal variation or environmental trigger of the dyspnea.

32-year-old man presents with a 4-day history of fever (temperature as high as 38.8 C to 39.4 C with severe rigors, chills, and profuse night sweats; generalized myalgias, including dull, aching headache; and dry cough.

Abstract: Although smoking cessation is still the most impor- tant intervention in chronic obstructive pulmonary disease (COPD), a variety of pharmacologic therapies are available to help manage symptoms. Short-acting ß2-agonists and/or ipratropium should be taken as needed, and the use of additional therapies is based on the severity of disease. Patients with moderate or severe COPD should regularly take 1 or more long-acting bronchodilators. The long-acting ß2-agonists salmeterol and formoterol have been demonstrated to improve health-related quality of life. Newer therapies include the long-acting anticholinergic tiotropium and a salmeterol-fluticasone combination. These agents improve forced expiratory volume in 1 second and may reduce the rate of acute exacerbations. For patients with moderate to very severe COPD, participation in a pulmonary rehabilitation program can improve health status, quality of life, and exercise tolerance. (J Respir Dis. 2005;26(7):284-289)

Abstract: Although excessive daytime sleepiness is most often simply the result of inadequate sleep, other causes must be considered as well. Common causes of daytime sleepiness include obstructive sleep apnea/hypopnea syndrome (OSAHS) and medication side effects. The differential diagnosis also includes narcolepsy and restless legs syndrome (RLS). In many cases, the answers to a few simple questions can provide the necessary clues to the diagnosis. Loud snoring is associated with OSAHS, while sudden muscle weakness triggered by intense emotion is consistent with narcolepsy. Referral for sleep evaluation is indicated to evaluate for OSAHS, narcolepsy, RLS, and idiopathic hypersomnia. Methods of measuring daytime sleepiness include the Multiple Sleep Latency Test and the Epworth Sleepiness Scale. (J Respir Dis. 2005;26(6):253-259)

Congestive heart failure (CHF) was recently diagnosed in a 71-year-old woman whose ejection fraction was 30%. The following CHF regimen was prescribed: metoprolol, 25 mg/d; digoxin, 0.25 mg/d; hydrochlorothiazide, 50 mg/d; enalapril, 5 mg/d; and spironolactone, 25 mg/d. A low-salt diet was also recommended.

ABSTRACT: Syncope is often benign and self-limited; however, it may sometimes indicate a life-threatening condition. Advanced age, heart disease, and abnormal ECG findings are associated with potentially adverse outcomes. The initial evaluation, which consists of a careful history taking, physical examination, and ECG, often suffices to make the diagnosis. Neurally mediated disorders, the most common cause of syncope, are usually benign. Cardiac syncope, which usually requires admission and further assessment, may result from rhythm disturbances or from outflow obstruction attributable to structural or pathophysiologic mechanisms. Patients with cardiac syncope may be evaluated with echocardiography, Holter monitoring, stress testing, loop event recorders, or electrophysiologic studies. Other causes of syncope include orthostatic hypotension, use of certain medications, a primary neurologic disorder, and psychiatric disturbance. A significant number of patients have unexplained syncope.

A 34-year-old man presents to the emergency department with progressive, generalized weakness and shortness of breath that began 2 weeks earlier. He has no history of cardiac disorders, and he denies chest pain, palpitations, and abdominal pain. He admits to recent methamphetamine use.

The parents of this 2-year-old boy brought their son for evaluation of swelling of the right leg and excoriation and serosanguineous discharge from the ankle region of 3 days' duration.The child had had a hemangioma of the right ankle since birth. Subsequently, there was gradual spread of the lesion along the leg to the buttocks.

Abstract: In most patients, a life-threatening exacerbation of asthma is preceded by a gradual worsening of symptoms. However, some patients have a sudden onset of worsening symptoms, and these patients are at increased risk for respiratory failure and death. Risk factors for near-fatal asthma include a history of a life-threatening exacerbation, hospitalization for asthma within the past year, delay in time to evaluation after the onset of symptoms, and a history of psychosocial problems. Regularly monitoring peak expiratory flow rate (PEFR) is particularly important because it can identify a subset of high-risk patients--specifically, those with large fluctuations in PEFR and those who have severe obstruction but minimal symptoms. Signs of life-threatening asthma include inability to lie supine, difficulty in speaking in full sentences, diaphoresis, sternocleidomastoid muscle retraction, tachycardia, and tachypnea. (J Respir Dis. 2005;26(5):201-207)

A 68-year-old man presents to the emergency department with diplopia and headache of acute onset accompanied by nausea and vomiting.

An 80-year-old man complains of lancinating pain in his right axilla and chest that began 2 days earlier and has kept him awake at night. He has had no fever, cough, sputum production, dyspnea, or symptoms suggestive of congestive heart failure.

Abstract: Bridging anticoagulant therapy is used to minimize the risk of thromboembolic complications when warfarin therapy must be temporarily interrupted because of surgery or another procedure. The decision to use this strategy depends on the patient's risk of thromboembolic complications and the risk of bleeding associated with the specific procedure. One approach is to withhold 4 or 5 daily doses of warfarin before surgery and initiate low molecular weight heparin (LMWH) 3 or 4 days before surgery. The last dose of LMWH is administered at least 24 hours before the procedure. After the procedure, prophylactic-dose LMWH can be administered subcutaneously once daily. The use of therapeutic-dose LMWH should be deferred until at least 24 or 48 hours after procedures that have a low or moderate risk of bleeding and until 48 or 72 hours after high-risk procedures. (J Respir Dis. 2005;26(4):170-172)

What steps can older patients take now to improve their health and quality of life and maintain their independence?

Cardiovascular disease is the chief cause of death among women. Nevertheless, in a recent survey of women, only 13% responded that their own greatest health threat was heart disease.

A 69-year-old woman was hospitalized with fever, chills, and nausea. Three weeks earlier, she had received a 2-week course of oral levofloxacin for pneumonia, which resolved. Her history included rheumatic heart disease; diabetes mellitus; depression; a hysterectomy; 2 mitral commissurotomies; nonrepairable mitral valve regurgitation, for which she received a St Jude Medical bileaflet valve; a left-sided cerebrovascular accident; and paroxysmal atrial fibrillation. Her medications included verapamil, furosemide, metoprolol, potassium chloride, metformin, nortriptyline, and warfarin. She denied tobacco and alcohol use.

ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.

A 23-year-old man presents to theemergency department (ED) withacute chest discomfort, which startedin the morning. He describes the discomfortas more akin to palpitationsthan to actual pain. The discomfortis midsternal, nonradiating, nonpleuritic,and associated with dyspnea; itis neither exertional nor positional.There is no viral prodrome.

A 47-year-old man presented to theemergency department with adrooping right eye. He also complainedof a constant right-sidedheadache of 1 week’s duration; thepain involved the temporal region.Another physician had diagnosednew-onset migraine and prescribedsumatriptan, which failed to alleviatethe pain. The patient had no weakness,vomiting, or double vision.Both his father and his son hadMarfan syndrome.

A 72-year-old woman first noticed progressive enlargement of the maxillary area of her face 18 years earlier. She denied facial trauma and significant dental caries. Her medical history consisted of breast cancer managed by a mastectomy and type 2 diabetes mellitus of 3 years’ duration.

ABSTRACT: High-sensitivity C-reactive protein (hs-CRP), a marker of low-grade vascular inflammation, reflects baseline inflammatory predilection-a key factor in the genesis and rupture of atheromatous plaque. Measurement of hs-CRP is recommended in persons who have an intermediate (10% to 20%) 10-year risk of coronary artery disease; a level above 3 mg/dL indicates higher cardiovascular risk. Although dietary therapy and statins may lower hs-CRP levels, such reductions have not been shown to prevent cardiovascular events or death. Elevated homocysteine levels have been associated with an increased risk of cardiovascular disease. Consider screening in patients with a personal or family history of cardiovascular disease who do not have well- established risk factors. Supplementation with folic acid and vitamin B12 reduces homocysteine levels by about 30%. Elevated fibrinogen levels have been associated with ischemic heart disease and stroke; however, fibrinogen-lowering therapy has not led to better outcomes than standard treatment regimens.