A 34-year-old woman presented to the hospital with low-grade fever, fatigue, dyspnea with minimal exertion, and dry cough. She had emigrated from China 3 years earlier. She had been healthy and had no allergies or food intolerances.
Journal Of Respiratory Diseases
The American College of Chest Physicians (ACCP) has established guidelines for the prevention of venous thromboembolism (VTE); however, a recent study by Amin and associates documents a very low rate of adherence to these guidelines in acute-care hospitals in the United States. In fact, they found that about two thirds of at risk medical patients are not receiving appropriate VTE prophylaxis at the time of discharge.
Many physicians consider oral antihistamines
to be the first-line therapy
for allergic rhinitis. While these
agents effectively reduce the symptoms
of itching, sneezing, and rhinorrhea,
they do not have much of
an effect on nasal congestion. Intranasal
antihistamines appear to
have an edge over the oral agents in
that they do reduce nasal congestion
and they have a rapid onset of
action. A recent review of the literature
provides additional evidence of
the efficacy of intranasal antihistamines
in the treatment of both allergic
rhinitis and vasomotor rhinitis,
which is the most common form
of nonallergic rhinitis.
If you have ever been confounded by a case or have correctly interpreted a subtle finding, then you probably have encountered a diagnostic puzzler that you might want to share with other readers of The Journal of Respiratory Diseases.
A 43-year-old homeless woman presented with a 2-week history of fever, chills, sweats, generalized pain, and cough that was productive of purulent green-yellow sputum mixed with blood. She reported a 15-lb weight loss over the past 6 weeks.
Although the results of a thorough history and physical
examination often suggest the diagnosis of asthma, confirmatory
testing is required and may be helpful in more subtle
cases. Spirometry before and after bronchodilator administration
is the first step for the initial diagnosis; it also is an important
component of the long-term assessment of asthma control.
When the results of spirometry are normal in a patient in whom
asthma is suspected, bronchoprovocation challenge testing
with methacholine is generally considered the next diagnostic
step. Numerous alternative methods of bronchoprovocation
testing have been developed, such as the challenge with adenosine
5'-monophosphate. Novel methods such as the forced oscillation
technique and the measurement of exhaled nitric oxide
hold promise for more effective diagnosis and monitoring
of asthma in the future. (J Respir Dis. 2008;29(4):157-169)
A 5-month-old boy presented with fever, cough, and tachypnea that he had had for 1 month. There also was a history of poor weight gain for 2 months. The child was born full-term at a private hospital, and the mother's antenatal course was uneventful. There was no postnatal history of bleeding, jaundice, diarrhea, poor feeding, vomiting, or seizures. There was no family history of tuberculosis.
When encountering a patient who may have occupational asthma, what is your approach to the initial evaluation? What are the most useful questions to ask?
The foundation of arterial blood gas (ABG) analysis
consists of determining whether the patient has acidosis or alkalosis;
whether it is a respiratory or metabolic process; and,
if respiratory, whether it is a pure respiratory process. If the patient's
pH and PCO2 are increased or decreased in the same direction,
the process is metabolic; if one is increased while the
other is decreased, the process is respiratory. In a number of
clinical situations, pulse oximetry is preferred to ABG analysis.
However, pulse oximetry may not be accurate in patients who
are profoundly anemic, hypotensive, or hypothermic. While
venous blood gas (VBG) analysis does not provide any information
about the patient's oxygenation, it can help assess
the level of acidosis or alkalosis. VBG analysis may be particularly
useful in patients with diabetic or alcoholic ketoacidosis.
(J Respir Dis. 2008;29(2):74-82)
Two studies provide further evidence that relatively low levels of air pollution have adverse respiratory effects. However, one of the studies suggests that improvement in air quality can slow the decline in pulmonary function.