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Fever:A methodical approach to diagnosis usually reveals the cause of fever. In patients with simple fever, a careful history taking and physical examination combined with basic laboratory and imaging studies (complete blood cell count with differential, urinalysis, and possibly a chest film and blood cultures) usually yield the diagnosis. In patients with prolonged fever whose cause remains undiagnosed after extensive examination (fever of unknown origin), repeat the history taking and physical examination; also order routine laboratory studies, an HIV test, a tuberculin skin test, 3 sets of blood cultures, and chest films. In addition, abdominal CT scanning is often useful. Further testing at this point may include fluorodeoxyglucose positron emission tomography, technetium-tagged white blood cell scanning, transesophageal echocardiography, liver biopsy, bone marrow examination, and/or temporal artery biopsy. Exploratory laparotomy is rarely indicated.
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Allergic RhinitisPhysical clues to allergic rhinitis include the allergic crease on the dorsum of the nose and allergic "shiners" or periorbital ecchymosis.
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Diagnostic Images, Treatment IssuesA39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.
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HIV-Associated LymphomaFor 2 months, a 30-year-old man with a history of cocaine abuse had had a painful gingival mass and difficulty in eating. Examination revealed a large, fungating mass in the anterior oropharynx that extended posteriorly up to the retromolar region. Posterior cervical lymph nodes were enlarged bilaterally, with no other peripheral lymphadenopathy.
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Acne ConglobataFor 3 months, a 24-year-old man-a military aviator-had a worsening rash on his chest. He had no lesions elsewhere. Culture of the ulcers grew Pseudomonas. A 2-week course of antibiotic therapy was ineffective.
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“Tear Out” Sheets for Quick ReferenceAlthough topical corticosteroid therapy can be highly effective, such treatment can be costly-especially whenbrand-name products are prescribed for extensive or chronic conditions. Here we describe an economical approachthat does not sacrifice either efficacy or safety.
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Using low molecular weight heparins as "bridging anticoagulant therapy"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)
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Pertussis: A cause of cough in adults as well as childrenSince pertussis has been considered to be primarily apediatric disease, it is often overlooked as a cause of cough inadults. However, the incidence has been increasing in adolescentsand adults, and these persons are the major reservoir forthe disease. The first stage of illness is characterized by flu-likesymptoms; then patients typically have paroxysms of severecoughing-several short dry coughs, followed by a deep inspiratoryeffort and the characteristic "whoop." The most commoncomplication of pertussis is pneumonia, but other complicationsinclude bronchitis, laryngitis, atelectasis, pneumothorax,subconjunctival hemorrhage, subdural hematoma,and seizures. The diagnosis can be confirmed by isolation ofBordetella pertussis in culture; rapid diagnostic tests, such as thedirect fluorescent antibody method and polymerase chain reaction;and serological tests to detect antibodies to B pertussis.First-line therapy for pertussis includes a macrolide antibiotic.(J Respir Dis. 2008;29(4):172-178)
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Man With Severe Joint Pain and Normal HemogramA 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.
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Fever in a Woman With an Abnormal White Blood Cell CountThe patient has a small-fiber sensory neuropathy that is managed with lamotrigine. She is a physical therapy student who has frequent patient contact. She drinks alcohol occasionally but denies smoking and illicit drug use; she says she is not sexually active.
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Snake Bite: A Small Puncture Can Create a Large ProblemAn 8-year-old boy from southern Ohio was outside playing when he saw a snake lying in the driveway. The boy picked up the snake to show his father and then dropped it. He picked it up again and was bitten. He sustained a tiny puncture wound to the palmar aspect of his distal left ring finger and a scratch to the distal long finger.
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Focusing on Depression in Expectant and New FathersPrenatal and Postpartum Depression Not Limited to Mothers
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Cytomegalovirus InfectionCough, fever, diarrhea, and weight loss had disturbed a 52-year-old woman for 1 month. AIDS had been diagnosed 5 years earlier, but she had declined medical treatment. The patient's vital signs were stable when she was admitted to the hospital. Physical examination results were unremarkable except for thrush and mild, diffuse abdominal tenderness.
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Sports Concussion: Implications of the Exam After Head InjuryAs many as 300,000 sportsrelatedconcussions arediagnosed each year inthe United States.1 Thisfigure underestimatesthe true incidence, however, becausemany concussive injuries are notrecognized by the injured persons,trainers, or physicians. A recentstudy found that 4 of 5 professionalfootball players with concussionwere unaware that they had sufferedthis injury.2
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Ovarian Hyperstimulation SyndromeFor 4 days, a 34-year-old pregnant woman had dyspnea and right-sided chest pain. She denied fever, chills, sweats, cough, lower extremity pain, and edema. Surgical and social histories were unremarkable. She was taking progesterone and clomiphene citrate for the past 6 months for assisted reproduction.
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Case In Point: Young Woman With Abdominal Pain and FullnessA 23-year-old woman presents withweight loss, epigastric pain, abdominalfullness, and mild nausea. Shereports that she has had a slow-growingmass on her upper middle abdomen.She denies vomiting and doesnot have evidence of jaundice. Theonly significant finding in her medicalhistory is a myringotomy performedmany years earlier. She currentlytakes an oral contraceptive.
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Superior Mesenteric Vein ThrombosisA 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.
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Anemia: Discerning the Cause in Different Clinical SettingsA 77-year-old woman who had hadanorexia and weakness for 3 monthswas seen after a syncopal episode. Sheappeared pale but alert. Heart rate was110 beats per minute; respiration rate,22 breaths per minute; and blood pressure,170/70 mm Hg. Her hematologicindices were: hemoglobin level, 4.3 g/dL;mean corpuscular volume (MCV), 60fL; mean corpuscular hemoglobin concentration(MCHC), 29 g/dL; red bloodcell count, 1.6 million/μL; white bloodcell count, 7500/μL; and platelet count,452,000/μL.
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Case In Point: Erythema Ab IgneA 14-year-old African American boy presented during the winter months with a painless, nonpruritic, periumbilical rash that had been present for approximately 1 month. Initially bluish, the rash had become dark brown.
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MRI Diagnosis of Bone BruiseA 41-year-old man fell 3 ft into a bilge; he landed on his left leg and experienced immediate generalized pain in that knee. Three days later, he consulted his physician, who found minimal effusion in the knee and tenderness of the medial collateral ligament (MCL). No abnormalities were seen on plain x-ray films.
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Celebrating DeathCan the death of a terrorist be something to celebrate? Should it be? What can this tell us about ourselves? What is the "proper" reaction?
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Monitoring adolescents with cystic fibrosisabstract: There is increasing evidence that close monitoring and early intervention lead to better outcomes in patients with cystic fibrosis. At each office visit, spirometry should be performed and sputum culture specimens should be obtained; if the patient cannot produce sputum, a throat culture can be done instead. New respiratory symptoms or other evidence of worsening lung disease should prompt antibiotic therapy, increased airway clearance, and adjunctive anti-inflammatory medication as appropriate. Close attention should be paid to the patient's diet, appetite, stooling pattern, and growth measurements. Adolescents should be given additional information about their medications and adjunctive therapies to encourage them to take on a larger role in their own care. (J Respir Dis.2006;27(7):298-305)
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Commentary on the USPF's Recommendations on PSA TestingA video series from James Mohler of Rosweel Park Cancer Institute on PSA testing in the wake of changing guidelines from the US Preventive Task Force.
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Dorsal Dislocation of the Fourth and Fifth MetacarpalsSeveral hours after striking his closed fist against the side pillar of a passenger car, a 28-year-old man presented with acute pain and swelling of the left hand. The dorsum of the left hand appeared deformed and edematous; there were scattered abrasions but no lacerations, exposed bony fragments, ecchymosis, or active bleeding.
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Headache as a Rare Presenting Symptom of Löfgren SyndromeLöfgren syndrome is a form of acute sarcoidosis characterized by a triad of symptoms: hilar adenopathy, erythema nodosum, and arthralgias.
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Woman With Purpura FulminansThe patient is severely ill. Temperature is 39°C (102.2°F). Shortly after admission, she requires intubation with ventilatory support. Hypotension, acrocyanosis, and an ecchymotic rash consistent with purpura fulminans (A) rapidly develop.
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Escherichia coli in Traveler's DiarrheaTraveler's diarrhea (TD) occurs in persons traveling fromindustrialized countries to less developed regions of the world.Because of the growing ease of travel and an increasinglyglobalized economy, TD is becoming more common. Increasingantibiotic resistance among causative bacterial organisms andalso emergence of new pathogens are additional challenges inthe management of TD. Enterotoxigenic and enteroaggregativepathotypes of Escherichia coli are the principal causes of TD.This review discusses the epidemiology of these pathogens, aswell as elements of prevention, diagnosis, and management.[Infect Med. 2008;25:264-276]
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Monitoring the response to therapy for pulmonary arterial hypertension, part 2Despite the recent development of several new therapies, pulmonary arterial hypertension (PAH) remains an incurable disease. Careful monitoring of disease progression is vital to ensuring that patients receive maximal medical therapy before the onset of overt right-sided heart failure. In part 1 of this article, I reviewed the role of the history and physical examination, chest radiography, electrocardiography, echocardiography, and pulmonary artery catheterization. In part 2, I focus on MRI, cardiopulmonary exercise testing (CPET), the 6-minute walk test, and biomarkers.
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Rhabdomyolysis Secondary to Urinary Tract Infection With E coliRhabdomyolysis is linked to infection in up to 31% of cases. However, only 19 cases of rhabdomyolysis related to E coli infection have been reported.
