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Interdigital Pilonidal SinusIn the web space of his left hand, a 50-year-old barber had a painful cystlike lesion. The lesion had recurred intermittently, despite oral antibiotic treatment and warm compresses. The patient's father, also a barber, had a similar, more severe condition, which eventually required surgical intervention.
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Questioning Medicine: The Vitamin D CrazeThe verdict is in: there’s not enough evidence to support screening of asymptomatic individuals for low vitamin D. Here: a look behind the curtain.
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Two Cases of Rhythm DisturbanceFor 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).
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Concurrent Management of Achalasia and Morbid ObesityThe development of a standardized treatment that simultaneously addresses achalasia and obesity is becoming more imperative as obesity becomes epidemic in the US. Here’s a case in point.
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Nasal Septal AbscessA 63-year-old man with myelodysplasia presented with oral thrush, intranasal dryness, and congestion that developed 2 months earlier. Intranasal saline rinse and sleeping with the head elevated temporarily relieved the nasal symptoms.
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Bilateral Nodular FasciitisAsymptomatic, enlarging growths had been present on the bottom of a 56-year-old woman’s feet for 3 years. The nodules initially arose-first on the left foot, then on the right-at the sites of blisters on the insteps after the patient had taken a long hike in uncomfortable boots.
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Scrotal Lesions:The differential diagnosis of intrascrotal pathology includes a myriad of benign and malignant entities. Timely detection is imperative to reduce the morbidity associated with many of these disease processes.
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Asthma:ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.
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Kaposi's Sarcoma in the Sigmoid ColonA 2-week history of diarrhea mixed with bright red blood was the presenting complaint of a 40-year-old man who was seropositive for HIV. Stool studies and culture results were negative for microorganisms. Colonoscopy demonstrated only the raised vascular lesion seen here in the sigmoid colon, which may have been responsible for the bleeding.
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Antihypertensive Treatment: How to Maximize Results for Your PatientsQ:Many of my patients appear to have white-coathypertension: their pressure is elevated whenmeasured in my office-but normal when measured athome. Am I ignoring significant hypertension if I do nottreat these patients? Or am I overtreating if I do treat?
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Melanoma of the Foot: Often OverlookedSeen here is an ulcerated tumor with irregular borders on the left foot of a 37-year-old man. He said the tumor had developed several years ago.
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Mild Traumatic Brain Injury:Traumatic brain injury may occur without visible head injury; it manifests as confusion, focal neurologic abnormalities, an altered level of consciousness, or subtle changes on neuropsychological testing. The initial evaluation includes assessment of the patient's airway and respiratory, circulatory, and neurologic status.
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New Advances in Antiretroviral TherapyIt is estimated that approximately 33.2 million persons worldwide were living with HIV infection in 2007.1 With the development of effective antiretroviral treatment strategies, HIV infection has now become a manageable chronic disease.2 Despite advances in treatment, drug resistance, long-term adverse effects, and high adherence requirements represent ongoing challenges to durable viral suppression.
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Unexplained Chest Pain:ABSTRACT: Once you have excluded a cardiac origin of chest pain, focus the evaluation on esophageal, psychiatric, musculoskeletal, and pulmonary causes. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are the most common causes of unexplained chest pain (UCP). If you suspect an esophageal disorder, empiric antisecretory therapy is the most cost-effective initial approach. If the patient remains symptomatic, order a 24-hour esophageal pH study with symptom analysis while the patient receives maximal acid suppression. Once GERD is excluded, the patient may be treated for visceral hyperalgesia with low-dose tricyclic antidepressants or standard doses of selective serotonin reuptake inhibitors. Panic disorder-the most common psychiatric disorder in patients with UCP-is often associated with atypical symptoms, such as palpitations and paresthesias, and other psychiatric disorders. If you suspect panic disorder, one approach is to give the patient a short-term, nonrefillable prescription for a benzodiazepine and refer him or her for psychiatric evaluation.
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Gastric Outlet Obstruction Following Treatment for CholangiocarcinomaFor 2 weeks, a 60-year-old man had severe nausea and vomiting. Two years earlier, he had had a cholangiocarcinoma, which was treated with palliative cholecystectomy followed by a course of rebeccamycin, an investigational chemotherapeutic agent.
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Pulmonary Arteriovenous MalformationsHaving suffered progressive shortness of breath for 2 years, a 35-year-old man was eventually hospitalized. The patient's dyspnea had worsened over the past year, but he had neither chest pain nor palpitations. His primary care physician first noticed finger clubbing 8 months ago.
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Cardiofaciocutaneous SyndromeThe mother of a 7-year-old boy with cardiofaciocutaneous syndrome sought treatment for the cutaneous aspects of her son's disease. Dry skin and keratosis pilaris of the upper outer arms were noted.
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Sudden One-Sided Weakness in a Young WomanCerebrovascular accidents occur in a small but significant number of young persons, many of whom do not have traditional risk factors for vascular disease.
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Ventricular AneurysmA 72-year-old woman who had fallen and injured the left side of her chest came to the emergency department complaining of pain in that area. She was physically stable and not short of breath. A soft systolic murmur was heard over the left precordium; the lungs were clear. A posteroanterior chest film showed no rib fracture but it did show an enlarged heart and a large, calcified ventricular aneurysm.
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An unusual case of malignant invasive thymomaMalignant thymoma is an indolent tumor arising from the thymic epithelial cells located in the anterior mediastinum. These tumor cells spread via regional metastasis or invade surrounding structures, including the pleural space.
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Congestive Heart Failure Therapy:ABSTRACT: Recent studies, although suggestive, do not yet support the routine use of angiotensin II receptor blockers in combination with angiotensin-converting enzyme (ACE) inhibitors in patients with congestive heart failure (CHF). For CHF patients in normal sinus rhythm, consider digoxin when a regimen of diuretics, ACE inhibitors, and β-blockers at optimal dosages does not relieve symptoms completely. Anticoagulation may be warranted in CHF patients with atrial fibrillation, previous embolic events, severely reduced systolic performance, or potential chamber clots. β-Blockers are indicated for patients with mild to severe CHF, unless there is a specific contraindication, and therapy should be initiated once euvolemia has been achieved. Avoid NSAIDs and cyclooxygenase-2 inhibitors in patients with CHF because the prostaglandin-blocking properties of these agents may promote fluid retention.
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Handle With Care: The Dangers of Cervical Spine Fracture in Patients With Ankylosing SpondylitisPatients with ankylosing spondylitis areat increased risk for fractures (particularlyextension fractures of the cervicaland thoracolumbar spine) and spinalcord injury. Fractures in these patientsare extremely unstable; in fact, they areamong the most complication-prone ofall cervical spine injuries likely to beseen in the primary care setting.
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The keys to quickly identifying anaphylaxisAbstract: The classic presentation of anaphylaxis includes urticaria, angioedema, dyspnea, and systemic hypoperfusion. However, anaphylaxis may be more difficult to recognize if syncope, bronchospasm, or cardiovascular collapse is the predominant feature. Essential components of the history include previous allergic reactions, medication use, recently ingested foods, and exposure to latex. Although angioedema is often obvious, it also can be subtle and may require asking patients about changes they have observed. Other findings include tachypnea; wheezing; inspiratory stridor; conjunctival injection; rhinorrhea; and hoarseness, which may suggest laryngeal edema. Oxygen with ventilatory support, epinephrine, and crystalloid volume resuscitation are the mainstays of therapy for anaphylactic shock. Additional therapy often includes H1 antagonists, H2 antagonists, and corticosteroids. (J Respir Dis. 2005;26(7):308-316)
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Tinea Corporis: An OverviewDermatophyte infections have a predilection for certain anatomic sites, such as the feet, groin, and scalp. Tinea corporis refers to involvement of the trunk and extremities. The condition arises either from direct exposure to an infected source or by extension from an adjacent affected site. Itch is a common symptom, but the intensity of the pruritus can vary from patient to patient.
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PSA Recurrence of Prostate Cancer: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.
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Lowering the Bar: Love Potion Number 9 Million?Better living through science: reprinted from partner MedPage Today, this review looks at the "diseasification" of "low T" and "hypoactive sexual desire."
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Trump's Meeting with Wakefield Rattles Vaccine SupportersSome infectious disease specialists are anxious about the future of US vaccine policy; others are willing to suspend judgment, for now.
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Man With GI Symptoms and Weight Loss Attributable to Primary Duodenal AdenocarcinomaA 71-year-old man presents with a2-week history of early satiety, decreasedappetite, postprandial nauseaand vomiting, jaundice, dark urine,acholic stools, and generalized pruritus.In addition, he reports a 4.5-kg(10-lb) weight loss within the past2 months.
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Elderly Man With HypothermiaOn a warm August day, a 79-year-old man is hospitalized because of progressive lethargy over the past week. Previously, he was alert and able to converse. He has no chest pain, dyspnea, or cough. His history includes hypertension of unknown duration, chronic obstructive pulmonary disease, and a recent hospitalization for pneumonia.
