This 66-year-old black woman presented with a 2-year history of a painless skin eruption. She stated that her skin had “changed overnight” while she was caring for her mother who had been hospitalized.
The patient presents 6 weeks after a prolonged hospitalization for pancreatitis. More details and the office spirometry tracing here.
A PET/CT scan shows uptake of tracer consistent with malignancy in the left lower lobe and mediastinal nodes. What would be your next step?
At what point in a medical career do we allow identification with the sick and dying we treat to inform who we are?
When a patient presents to their primary care physician with a headache, it's not always diagnosed as the migraine it is. These 6 tips from a neurologist can help.
Nocardia asteroides is a rarecause of pulmonary or disseminatedinfection in immunocompetentpersons. Pleuralcompromise is common, butempyema necessitatis is veryrare. The authors describe anapparently immunocompetentpatient with N asteroides infectionwho had chest wallcompromise mimicking empyemanecessitatis.
Methicillin-resistant Staphylococcus aureus (MRSA) must be recognized now as one of the most common causes of infections acquired in the community. The majority of these infections involve the skin and soft tissue structures and confer significant morbidity on those affected.
A 63-year-old man with a history of hypertension and gastroesophageal reflux disease presented with progressive, sharp mid-abdominal pain of 3 weeks' duration.
Abstract: The management options for persons with obstructive sleep apnea-hypopnea syndrome (OSAHS) include lifestyle changes, continuous positive airway pressure (CPAP), oral appliances, and surgery. Lifestyle modifications work best in persons with mild OSAHS and may include weight loss and cultivation of good sleep habits, such as not sleeping supine. Before initiating CPAP therapy, polysomnography is recommended to determine the best airway pressure for the patient. Although the benefits of CPAP have been well documented, compliance remains an issue; some difficulties may be alleviated through patient/partner education and close follow-up. Oral appliances, which work by mechanically enlarging or stabilizing the upper airway, are preferred by some patients; however, they are less effective than CPAP at reducing the apnea-hypopnea index. Surgical interventions to alleviate upper airway obstruction can be used in select patients. (J Respir Dis. 2006;27(5):222-227)
The diagnosis of juvenile dermatomyositis can be challenging when proximal muscle weakness develops without characteristic skin manifestations. In this patient, rash appeared 2 months after the onset of muscle weakness. As a result, the initial diagnosis was viral myositis, which led to delayed therapy.
A 32-year-old man with no significant medical history presents with multiple scrotal lesions that he claims have been present for 2 years. They are non-tender and he reports no overt symptoms. The full case, here.
Child With Dysphagia, Fever, and Weight Loss
Primary care physicians treat the majority of patients in this country who have mental health disorders. But how well prepared are we for these patients when they present to our offices?
A 59-year-old woman presents with right-sided, nonradiating, “aching” chest pain that has been continuous and increasing in severity for the past 3 days. It began as a tightness that gradually became more painful; it is aggravated by palpation and movement and has not been relieved by acetaminophen.
ABSTRACT: The main therapeutic goals for patients who have an acute coronary syndrome are to reestablish normal epicardial flow and to increase distal myocardial perfusion. Fibrinolytic treatment with tissue plasminogen activator within 70 minutes of the onset of symptoms dramatically reduces the mortality rate from myocardial infarction. Other fibrinolytic agents include reteplase, which is given as a double bolus, and tenecteplase, which is given as a single bolus. In most hospitals, fibrinolytic therapy is more readily available than percutaneous transluminal coronary angioplasty (PTCA); however, PTCA may be the preferred approach if it is available within an hour and a half. Antiplatelet drugs, such as glycoprotein IIb/IIIa receptor antagonists, are used to improve distal myocardial perfusion. If follow-up coronary angiography is not available to assess whether epicardial blood flow and distal myocardial perfusion have been restored, a 12-lead ECG can provide valuable information. The resolution of ST-segment abnormalities is a marker for improved perfusion.
An 8-week-old boy is brought for evaluation of gradually worsening yellow skin discoloration of about 1 week's duration. His parents report that he has had constipation for the past several days; before that, he had green diarrhea and occasionally spit up after breast-feeding.
An obese 61-year-old man with a history of heroin abuse was brought to the hospital after he had fallen onto his buttocks on a sidewalk. He was able to stand initially, but weakness and numb-ness in his legs rendered him suddenly unable to walk or prevent himself from voiding. He denied abdominal or back pain. His medical history included asthma, chronic obstructive pulmonary disease, and hypertension.
Dry powder inhalers are used by millions of patients with asthma or chronic obstructive pulmonary disease. Although these devices are easier to use than metered-dose inhalers, errors still occur and drug efficacy may be reduced or lost.
abstract: The mainstay of therapy for acute severe asthma includes ß2-agonists, anticholinergics, and corticosteroids. Other agents, such as leukotriene modifiers and magnesium sulfate, can be used in patients who have responded poorly to conventional therapy. Noninvasive positive pressure ventilation (NPPV) should be tried before intubation in alert, cooperative patients who have not improved with aggressive medical therapy. However, NPPV should not be attempted in patients who are rapidly deteriorating or in those who are somnolent or confused. Endotracheal intubation is recommended for airway protection or for patients who present with altered mental status or circulatory shock. Patients should be admitted to the ICU if they have difficulty in talking because of breathlessness, altered mental status, a forced expiratory volume in 1 second or peak expiratory flow rate of less than 25% of predicted, or a PaCO2 greater than 40 mm Hg after aggressive treatment in the emergency department. (J Respir Dis. 2007;28(3):113-117)
The most appropriate choice is B. The history andphysical findings suggest that the patient may have afracture or contusion of the foot from trauma. There areno systemic signs that suggest an underlying infectious,chronic inflammatory, or oncologic process. A plain x-rayfilm of the foot is necessary to seewhether a fracture is present andwhether immobilization will be necessary.In the absence of fever and localerythema, infection appears unlikely,and a CBC count is unwarranted.
Double aortic arch-a vascular ring anomaly in which both embryonic aortic arches persist and encircle the trachea and esophagus-is rare.
A 66-year-old woman presented with a 2-day history of acute onset of redness, pain, and swelling of the right breast.
Nicotine amounts aren't constant among cigar brands Even smokers of the same brand may be exposed to varying doses of nicotine and other smoke constituents.
A 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
ABSTRACT: Prostate-specific antigen (PSA) recurrence is the most common form of advanced prostate cancer. Salvage therapies may be effective even among some high-risk men, although long-term cancer control data are limited. The natural history of PSA recurrence is long but variable. The postrecurrence PSA doubling time can identify men at high risk for progression and death. Early hormonal therapy, possibly via combined androgen blockade, may reduce the risk of progression and improve cancer-specific survival among men with high-risk recurrence. Men with low-risk recurrences likely receive minimal benefit from aggressive early hormonal therapy and may actually be harmed.
WASHINGTON, D.C. -- The odds of getting an NIH grant are a lot better for Ph.D.s and M.D.s who also hold a Ph.D. than for physicians who have a medical degree alone, one study showed.
The objective of this study was to estimate the annual cost burden of Parkinson disease (PD) in the United States. Resource use and cost profiles were developed using all-payer statewide hospital discharge data from 6 states; emergency department visit, long-term–care, and national survey data; fee schedules; and published study findings. (Average direct and indirect costs per patient were calculated in 2007 US dollars.) The annual cost per patient was $21,626 (direct cost: $12,491). When applied to the US PD population (N = 500,000), the annual average cost was approximately $10.78 billion (direct costs, $6.22 billion; indirect costs, $4.56 billion). PD has substantial economic consequences for patients and their families, insurers, and society. (Drug Benefit Trends. 2009;21:179-190)
For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.
A 56-year-old woman with type 2 diabetes mellitus and hypertension presented with acute left-sided weakness and altered mental status, for which she was hospitalized. The patient, who was obese, was in her usual state of well-being until 2 months before this presentation, when she noted a gradual onset of generalized weakness. She received a diagnosis of severe hypokalemia that was refractory to oral potassium supplementation. The outpatient workup of the cause of her hypokalemia was in progress.