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Choose a Set of Guidelines From a Major Medical Organization and Follow the RecommendationsBreast cancer remainsa significant healthconcern for women. Amongwomen at average risk,breast cancer will develop in1 of 8, and 1 in 30 will die ofthe disease.1 Although therehas been recent excitementabout the potential of geneticscreening to predict individualbreast cancer risk, itis important to keep in mindthat nearly 75% of women inwhom breast cancer hasbeen diagnosed have hadno risk factors other thansex and age.2
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Primary Care Condition CriticalIn January 2006, the American College of Physicians (ACP) warned that primary care, rightly referred to as the backbone of the nation's health care system, was on the verge of collapse. The ACP noted then that few young physicians were going into primary care and that many of those already in practice were leaving.
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Coccidioidomycosis risk in patients with diabetes or rhematological disease•Coccidioides species, the cause of coccidioidomycosis, are endemic to the desert soils of the southwestern United States as well as northern Mexico and limited areas of Central and South America. The organisms can become airborne with disruption of the soil, either through natural causes or activities of humans or animals. Nearly all Coccidioides infections are acquired through the inhalation of airborne arthroconidia (spores).
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Sézary SyndromeA 55-year-old woman with no significant medical history reported that diffuse erythematous, patchy, purpuric skin lesions over most of her body had been present for the past year. Applications of an over-the-counter corticosteroid cream helped control the pruritus but did not clear the skin lesions.
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Recurrent Epigastric Pain in an 82-Year-Old WomanAn 82-year-old woman who had recentlyarrived from Japan presented to theemergency department with a 3-dayhistory of abdominal pain that beganimmediately after she swallowed severalpills with a small amount of water.The severe, intermittent pain radiatedto the patient’s back and worsened withmeals. The patient denied chills, nausea,vomiting, coughing, diarrhea, andconstipation. She had well-controlledtype 2 diabetes mellitus and hypercholesterolemia,and had undergone anappendectomy 50 years earlier.
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Nonsustained Ventricular TachycardiaAn 8-year-old boy was brought to his pediatrician for well-child care. On physical examination, an irregularly irregular heart rate was detected.
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Disseminated HistoplasmosisA 38-year-old man had fever and fatigue for the past 6 days and tenderness in the left upper abdominal quadrant for the past 3 days. He also had a facial butterfly rash that had been present for 10 years and a 1-year history of lupus nephritis, treated with prednisone and mycophenolate. He denied respiratory complaints or recent weight loss.
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Apple Core LesionA 48-year-old woman was hospitalized for acute-onset abdominal pain. She had a history of adult-onset Still disease and severe osteoarthritis. She had been taking 650 mg of aspirin every 4 hours to relieve her arthritis pain and fevers.
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Acute Poisoning:We live in a world of toxins and potential toxins, and thus we are often just a misstep away from a toxic exposure and its consequences. Even that which is meant to cure can kill. All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy; exposure to the wrong dose of a medication (whether accidental or not) remains a common form of toxic exposure.
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Mycobacterium goodii Infection of a Total Knee ProsthesisMycobacterium goodii infection is uncommon and probablyoccurs via disruption of skin and bone integrity or theintroduction of a foreign body into viscera, namely implantationof a prosthetic device. We describe a case of nosocomial,total knee arthroplasty–associated M goodii infection thatrequired combined antibiotic and surgical therapy for clinicalmanagement. An infection control investigation revealed thatthe source of the organism might have been the water in theoperating room scrub faucets. [Infect Med. 2008;25:522-525]
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Foreign-Body Retrieval: Diamonds in the RugaeProgressive weakness, confusion, and decreased oral intake preceded hospital admission for this 73-year-old man with a history of Parkinson dementia and resection for esophageal adenocarcinoma. The real problem, seen here, was revealed on a chest x-ray film.
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Hyperbilirubinemia and Diffuse Skin Lesions in a Woman with Diabetes, CVDCan you identify the cause of the hyperpigmented umbilicated lesions seen bilaterally on the patient's extremities and on her back?
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Chiari I Malformation in a Young Man With Persistent Neck PainA 4-year history of headache and severe neck pain led to a diagnosis of Chiari I malformation in this patient. Here: symptoms, diagnostic tests, and treatment approaches.
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OsteopoikilosisA 21-year-old man presented for evaluation after he sprained his right ankle while hiking. Radiographs of the ankle showed no fractures but revealed diffuse sclerotic lesions in most of the visualized bones.
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Retropharyngeal AbscessSharp, shooting posterior neck pain prompted a 29-year-old man to seek medical attention. The pain began 4 days earlier and progressed to the point that it occurred with swallowing. He wore a wool scarf to restrict his cervical range of motion. During the history taking, he remained rigid and avoided rotation and flexion or extension of the spine.
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How to quickly zero in on the diagnosis Hemoptysis: A review of causes, evaluation, and treatment key words: Hemoptysis, Bronchoscopy, Embolizationabstract: Hemoptysis has many causes, including bronchiectasis, lung cancer, and bronchitis. The initial goals of the history and physical examination are to differentiate hemoptysis from epistaxis and hematemesis and then to establish its severity. A variety of signs and symptoms may suggest the underlying cause. For example, hematuria suggests vasculitis or an immunologically mediated disease, such as Wegener granulomatosis or systemic lupus erythematosus. The workup includes chest radiography and measurement of hemoglobin and hematocrit levels, platelet count, international normalized ratio, activated partial thromboplastin time, and creatinine level. Chest CT scanning often identifies sources of bleeding that are not apparent on radiographs and sometimes can be used in conjunction with bronchoscopy. Patients with massive hemoptysis should be hospitalized for rapid evaluation and intervention; treatment may include interventional bronchoscopy, angiography, or embolization. (J Respir Dis. 2007;28(4):139-148)
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Are These Hyperpigmented Lesions Cause for Concern?A 26-year-old white male aviator presents to his primary care physician for his annual military physical examination. The patient is healthy, takes no medications, and has no history of serious medical disorders. Genital examination reveals multifocal, confluent, slightly variegated, hyperpigmented macules with irregular borders located in a circumferential distribution on the penile shaft and glans.
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Making the most of pulmonary function testing in the diagnosis of asthmaAlthough the results of a thorough history and physicalexamination often suggest the diagnosis of asthma, confirmatorytesting is required and may be helpful in more subtlecases. Spirometry before and after bronchodilator administrationis the first step for the initial diagnosis; it also is an importantcomponent of the long-term assessment of asthma control.When the results of spirometry are normal in a patient in whomasthma is suspected, bronchoprovocation challenge testingwith methacholine is generally considered the next diagnosticstep. Numerous alternative methods of bronchoprovocationtesting have been developed, such as the challenge with adenosine5'-monophosphate. Novel methods such as the forced oscillationtechnique and the measurement of exhaled nitric oxidehold promise for more effective diagnosis and monitoringof asthma in the future. (J Respir Dis. 2008;29(4):157-169)
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Cutaneous Mycobacterium InfectionThis rash, which covered a 68-year-old woman's body, was noted to have worsened during the past 2 months. A cephalosporin antibiotic had failed to clear the condition. The patient, a nursing home resident, suffered from emphysema, asthma, and heart disease. She had been receiving oxygen therapy and prednisone for 1 year.
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Acquired AngioedemaA 68-year-old man presented to the emergency department (ED) complaining of an itchy rash over his body. His past medical history included hypertension, contact dermatitis, and penicillin allergy.
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Cerebral Phaeohyphomycosis Caused by Fonsecaea monophora in a Renal Transplant PatientFonsecaea species have been reported as causative agents ofchromoblastomycosis, eumycetoma, and fungal pneumonitis.However, Fonsecaea rarely involves the CNS, with few cases ofcerebral infection reported in the literature. Fonsecaea monophoramay have greater neurotropic potential than other species ofthis genus. We describe a rare presentation of brain abscesscaused by F monophora in an immunocompromised renaltransplant patient. [Infect Med. 2008;25:469-473]
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Cryptococcal Meningitis: Review of Current Disease ManagementThe incidence of cryptococcal infections in the HIV-infectedpopulation has diminished because of the effectiveness of anti retroviraltherapy, whereas the incidence in non–HIV-infectedhosts has grown. Despite improvements in antifungal therapy,successful outcomes in the management of cryptococcalmeningitis are dependent on a high index of clinical suspicion,appropriate use of diagnostic assays, early and aggressiveantifungal therapy, and recognition of complications such asincreased intracranial pressure and immune reconstitutionsyndromes. Published guidelines for the care of patients withcryptococcal meningitis are available and may be adapted toindividual patient requirements. Basic and clinical studies areneeded to further define the components of immune protection,optimal therapy in special patient populations, and the recognitionand treatment of complications of cryptococcal meningitis.[Infect Med. 2008;25:11-23]
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Young Girl With Hair Loss and Enlarging Scalp LesionA 7-year-old black girl comes toyour office with a 10-week historyof scaling and scalp redness,and hair loss. About 3 weeks beforethe visit, the child’s motherfirst noticed a boggy, drainingyellow plaque on her daughter’sparietal scalp. A different physicianprescribed ketoconazoleshampoo. At 1-week follow-up,the symptoms had not abated;the clinician then prescribed oralcephalexin as well as a topical mixture of the antifungal agent, clotrimazole, and the high-potency topicalcorticosteroid, betamethasone. After 2 weeks of therapy, the symptoms were no better.
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Update on Coverage Mandates for Patients With AutismThe treatment of patients with autism spectrum disorders (ASDs) and their various complications has become one of the most discussed and demanded insurance coverage mandates in multiple states. Insurance mandates are being heavily pushed by advocacy groups, especially Autism Speaks, with good success.
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Life-Threatening Asthma, Part 1:Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.
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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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Tuberculosis:Cutaneous lesions can develop in anumber of pulmonary diseases, suchas tuberculosis and sarcoidosis, as wellas in other diseases that may have pulmonaryinvolvement, such as Wegenergranulomatosis, collagen vasculardiseases, varicella, and pneumococcalinfections. In many cases, knowledgeof the clinical and histologic characteristicsof the skin lesions associatedwith these diseases can greatly facilitatediagnosis.
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Ups and Downs of Trampoline UseA 14-year-old girl came to the officewith severe hip pain, which occurredafter she attempted a cheerleadingmaneuver on a trampoline. She reportedthat she was bouncing as highas she could and landed on the trampolinewith her left knee flexed andher right hip extended. On impact,she felt a “pop” that was immediatelyfollowed by right hip pain.
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Anorexia Nervosa-Associated Raynaud PhenomenonEvaluation of intermittently discolored, cold fingers was sought by a 39-year-old woman with long-standing anorexia nervosa. The patient had never smoked and was not taking any vasoconstrictive drugs.
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What are the pulmonary effects of smoking marijuana?Marijuana is the most commonly used illicit drug in the United States. The prevalence of marijuana use has remained stable over the past several years, with 14.6 million persons older than 12 years reporting past-month use in 2005. Given the prevalence of illicit use and interest in the medicinal use of marijuana, an understanding of the potential negative health consequences of marijuana smoking is needed. While tobacco smoking is clearly associated with numerous adverse respiratory complications, including increased cough and wheeze, the development of chronic obstructive pulmonary disease (COPD), lung cancer, and an increased incidence of infections,1-3 the relationship between marijuana and pulmonary disease is controversial, despite similarities in many compounds found in marijuana and tobacco smoke.
