Jun Haeng Lee, MD


Refractory Ulcer:What to Do Next?

ABSTRACT: Undiagnosed or persistent Helicobacter pylori infection and surreptitious or unrecognized NSAID use are the most common causes of refractory peptic ulcers. The use of antibiotics, bismuth, or proton pump inhibitors (PPIs) suppresses the H pylori bacterial load and may obscure the diagnosis. H pylori infections have also become more difficult to cure because of increased antibiotic resistance. For refractory infection, select an antibiotic based on in vitro susceptibility testing. When this is not available, combination therapy with a PPI, tetracycline, metronidazole, and bismuth is often effective. To detect surreptitious or inadvertent NSAID use, review the drug history in detail. When there is any doubt about such use, check platelet cyclooxygenase function.

Jun-ho Choe, MD


Acute Suppurative Thyroiditis in a Patient With Aplastic Anemia

Acute suppurative thyroiditis (AST) is a rare inflammatorycomplication in patients with hematological malignancy.Infection spreads to the thyroid from a distant site throughthe bloodstream or the lymphatics. Defects such as persistentthyroglossal duct and pyriform sinus fistula are associatedwith the development of AST. Ultrasonography, bariumswallow testing, CT, and fine-needle aspiration are usedfor diagnosis. Treatment includes the administration ofparenteral antibiotics, drainage, and excision. We describea patient with aplastic anemia and bacteremic AST.[Infect Med. 2008;25:339-342]

Jurgen Bardutzky, MD


Stroke: Update on New Therapies- and the Implications for Primary Care

Currently, the only approved therapy for acute ischemic stroke is tissue plasminogen activator (tPA), initiated within 3 hours of stroke onset. New patient selection criteria are emerging that may improve the effectiveness and safety of thrombolysis. For example, evidence of extensive early ischemia on CT may predict a poor outcome regardless of whether tPA is administered. New imaging techniques, such as diffusion MRI, perfusion MRI, and MR angiography, may be able to identify salvageable tissue and distinguish it from irreversibly damaged tissue. Such findings may allow the 3-hour window for tPA therapy to be extended in certain patients. Other approaches to ischemic stroke therapy that are being studied include intra-arterial thrombolysis, new thrombolytic agents, platelet aggregation inhibitors, endovascular interventional techniques (alone and in combination with pharmacologic thrombolysis), and neuroprotective therapy with various agents to ameliorate the consequences of ischemia in brain tissue.

Justin B. Usery, PharmD BOB LOBO, PharmD


Lithium-Drug Interactions

Bipolar disorder (also known as manic-depressive illness) affects nearly 6 million adults in the United States.1 This psychiatric disorder was first described at the time of Hippocrates and is currently one of the most prevalent and severe mental illnesses in our society.

Justine H. S. Fong, MD


Pseudostrabismus (Pseudoesotropia)

The parents of this 5-month-old boy were concerned that his eyes wereturned in toward the nose. The infant was otherwise healthy. Physical findingswere normal. In particular, when a light source was projected onto theeyes, the light reflex was centered in both eyes.

Jyothsna Talluri, MD


Splenic Infarction

A 53-year-old woman presented with sudden onset of left upper quadrant abdominal pain. She had a history of atrial fibrillation, hypertension, and congestive heart failure.

K. Basioukas, MD


Heterozygous Familial Hypercholesterolemia

A 56-year-old woman was referred for management of severe hyperlipidemia. Her family history included hypercholesterolemia and premature coronary artery disease.

K. Economos, MD


Eosinophilic Granuloma of the Vulva

A 46-year-old woman sought treatment of vaginal pruritus of 6 months' duration. She also was bothered by generalized skeletal aching that was most prominent in her legs. The patient had a history of hypertension.

K. Katte, MD


Cerebellar Hemorrhage in Woman With History of Hypertension

A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

K. Narasimhan, MD



Acute abdominal pain, fever, and chills prompted a 51-year-old man to visit his local hospital twice in one week. On both visits, a clinical and laboratory workup was negative. He then presented to a tertiary care center with worsening symptoms. His history included hypertension and tobacco and alcohol use.

K. Rauhilla, MD


Calcification of the Mediastinum in an Asymptomatic Woman

A 72-year-old woman presented for her annual physical examination. She had been treated for tuberculosis 20 years earlier. The patient did not smoke cigarettes; she denied fever, chills, and rigors.

K. Scott Whitlow, DO


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.

K. Shanmugam, MD


Nonarteritic Anterior Ischemic Optic Neuropathy

A 43-year-old white man presented to the emergency department with dyspnea, abdominal bloating, fever with chills, night sweats, decreased oral intake, and myalgia of 1 week's duration. He was found to have heart failure caused by systolic dysfunction. Viral myocarditis was the presumptive diagnosis after investigation for other causes.

K.h. Katsanos, MD


Multiple Myeloma Presenting With CHF

Dyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.

K.l. Bourantas, MD


Multiple Myeloma Presenting With CHF

Dyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.

Kamal Boulous, MD


Inflammatory Breast Cancer

A 40-year-old woman was concerned about an area of redness and tenderness on her left breast. Despite antibiotic therapy prescribed by another physician, the rash had progressed during the past month to erythema and nodules that involved the anterior chest and right breast.

Kamalkumar Kolappa, MD


Pellagra I a 45-Year-Old Man

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Kamran Zakaria, MD


Pulmonary Embolism and Deep Venous Thrombosis

For 2 months, a 31-year-old woman had had dyspnea and dull, continuous retrosternal pain. She was admitted to the hospital, and a helical CT scan of the thorax identified a saddle pulmonary embolism. An ultrasonogram revealed deep venous thrombosis (DVT) in the left leg. Intravenous heparin was given; the patient was discharged, and warfarin was prescribed.

Kanchan Gupta, MD


Extrapulmonary tuberculosis, part 4: Skeletal involvement

Abstract: Spinal tuberculosis is the most common form of osteoarticular involvement in patients with tuberculosis. Localized pain is a common presenting symptom. In patients who do not present until vertebral wedging and collapse have occurred, a localized knuckle kyphosis is obvious, especially in the dorsal spine. In some patients, a retropharyngeal abscess develops, causing dysphagia, dyspnea, and/or hoarseness. Peripheral joint tuberculosis is characterized by an insidious onset of slowly progressive, painful, and swollen monoarthropathy, most commonly affecting the hip or knee. The radiologic features include juxta-articular osteoporosis, peripheral osseous erosion, and gradual narrowing of the interosseous space. Treatment involves antituberculosis drugs; the indications for surgery are relatively limited. (J Respir Dis. 2005; 26(12):543-546)

Kanwar Rauhila, MD


Wheezing in a 52-Year-Old Woman With a History of Colon Cancer

A 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.

Karen Appold


Sleep Disturbances Up Alzheimer Disease Risk in Men

The older the age at which self-reported sleep disturbance was indicated, a Swedish study found, the higher the risk of Alzheimer dementia.

Karen Bonuck, PhD


Sleep Disorders in Young Children May Lead to Special Education Needs

Sleep-disordered breathing and behavioral sleep disturbance in young children may lead to learning disabilities.

Karen Clark, MD


Green Nail Syndrome

Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.

Karen Mark, MD


Tympanic Membrane Perforation:An Unusual Complication of Varicella-Zoster Virus Infection

Otological complications associated with varicella-zostervirus infection are common; however, tympanic membraneinvolvement is rarely reported. We describe a patient withherpes zoster in whom hemorrhagic otitis media with tympanicmembrane perforation developed. To our knowledge,this is the first report of an HIV-infected patient with thisunusual presentation. [Infect Med. 2008;25:561-562]

Karen Wohlheiter, MS


Diabetes and Mental Illness: Factors to Keep in Mind

Persons with severe mental illnesses (SMI), such as schizophrenia, are at increased risk for comorbid conditions- including type 2 diabetes-independent of therapy. SMI sufferers especially at risk for type 2 diabetes are women, African Americans, and persons older than 45 years. Among the possible causes of increased susceptibility to type 2 diabetes are such schizophrenia-associated conditions as impaired glucose tolerance, overweight, obesity, inadequate nutrition, lack of exercise, and inadequate self-care. Other obstacles to good health care among patients with schizophrenia include impaired communication ability, denial of illness, social withdrawal, and undertreatment because of comorbid conditions. Different antipsychotic medications may also contribute to preexisting insulin resistance or glucose intolerance. Clinicians can optimize care by understanding the most significant barriers for each patient and incorporating this knowledge into an active treatment plan.

Karen Wood, MD


Obesity Hypoventilation Syndrome: Simple to Diagnose, Potentially Deadly if Overlooked

Obesity hypoventilation syndrome (OHS) shares clinical symptoms with obstructive sleep apnea (OSA) such as daytime sleepiness, headaches, and memory problems. Both the symptoms and their sequelae, however, can be much more severe in OHS. Here, guidance on what to look for and how to manage OHS.

Kari Blaho, MD


Crack Thumb

A 41-year-old man complaining of left-sided chest pain for 2 hours was examined in the emergency department (ED). On arrival, his blood pressure was 160/100 mm Hg; heart rate, 90 beats per minute; respiratory rate, 18 breaths per minute; oxygen saturation, 99%; and temperature, 37.2°C (99°F).

Karin Soby Gilkison, MD, MPH


Varicella-Zoster Virus Infection

Are these tender, vesicular erythematous lesions symptomatic of HIV/AIDS? Of Ramsay Hunt syndrome? Of herpes simplex or varicella-zoster virus? What's your diagnosis?

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