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A case of miliary TB complicated by ARDS and pancytopeniaWe present a case of a 35-year-old man with fever and pancytopenia, who had rapid progression to acute respiratory distress syndrome (ARDS), multiorgan failure, and disseminated intravascular coagulopathy secondary to disseminated tuberculosis (TB). Although both sputum and bronchoalveolar lavage (BAL) fluid smears were negative for acid-fast bacilli, the polymerase chain reaction (PCR) assay on the BAL fluid was positive for Mycobacterium tuberculosis. This case emphasizes the need to include TB in the differential for ARDS and the value of PCR testing of BAL fluid, especially in high-risk patients.
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What Caused Cough and Hemoptysis in a Patient Recently Treated for Exudative Tonsillitis?A 22-year-old man presentedwith a 3-week history ofcough and hemoptysis withright-sided chest pain and decreasedoral intake associated with a 4.5-kg(10-lb) weight loss. Ten days beforehospital admission, he was involvedin a fistfight, which resulted in his arrest.He was taken to jail and placedin a holding cell for 3 hours. Shortlybefore his pulmonary symptoms developed,he was seen by his primarycare physician because he had a sorethroat and exudative tonsillitis, forwhich amoxicillin/clavulanate wasprescribed. He stopped taking theantibiotic after 3 days.
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Stroke Rounds: Muddled Thinking May Signal CV Event RiskResults of a new study suggest that changes in cognitive function may reflect more global vascular damage and serve as a surrogate marker.
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A Rare Finding of Lymphangiomatosis: Case ReportPatient was hemoccult positive with anemia but colonoscopy and EGD were negative. What test would you order next?
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High-resolution CT can play an essential role Idiopathic pulmonary fibrosis, part 1: Presentation and diagnosis key words: Interstitial lung disease, Idiopathic pulmonary fibrosis, Usual interstitial pneumoniaabstract: Idiopathic pulmonary fibrosis (IPF) is a chronic interstitial lung disease of unknown etiology that leads to progressive fibrosis and respiratory failure. Patients with IPF typically present in their sixth to seventh decade of life with the insidious onset of progressive dyspnea and cough. Lung histopathology reveals the distinct lesion of usual interstitial pneumonia (UIP), and other causes of UIP, such as collagen-vascular disease, drug exposure, or occupational exposures, must be excluded. A confident clinical diagnosis of IPF can often be made without resorting to surgical lung biopsy if certain clinical features are present and a typical pattern is identified on high-resolution CT (HRCT) scanning of the thorax. Changes on HRCT scans that are typical for UIP include a predilection for peripheral and basilar lung zones with patchy involvement and sparing of more central areas, especially in upper lung zones. (J Respir Dis. 2007;28(7):283-292)
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Apical Ballooning SyndromeAfter a family argument, an 83-year-old woman experienced chest pain, a "racing heart," and a choking sensation and was brought to the emergency department. The chest pain lasted 10 to 15 minutes; was sharp, substernal, and nonradiating; and was associated with dyspnea and a bout of emesis. A sublingual nitroglycerin tablet partially alleviated the pain, but the patient felt syncopal. Her symptoms persisted despite the administration of supplemental oxygen and a second sublingual nitroglycerin tablet. The patient had a history of gastroesophageal reflux disease, allergic rhinitis, and osteoarthritis. Her oral medications included esomeprazole (40 mg/d), aspirin (81 mg/d), and fluticasone nasal spray. She had discontinued valdecoxib 3 weeks earlier.
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Herniation of a Lung Bulla Through a Thoracostomy SiteFor 3 months, a 63-year-old man had experienced progressively worsening dyspnea. He denied fever, weight loss, and hemoptysis. Eight months earlier, he had had a right thoracotomy to drain a right empyema. Comorbidities included morbid obesity, type 2 diabetes mellitus, hypertension, and obstructive sleep apnea. However, he did not have any intrinsic lung disease.
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Vibrio vulnificus InfectionA 59-year-old man, who was unable to walk, was brought to the emergency department with severe leg pain, worsening weakness, increasing fatigue, chills, and fever of 3 days' duration. The symptoms began after a round of golf. In addition to the leg pain, which particularly affected the calf muscles, the lower extremities were red and swollen.
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Perifolliculitis Abscedens Et SuffodiensFor about 10 years, a 26-year-old man had recurring cystic lesions on his scalp that would periodically enlarge, shrink, and occasionally drain. One lesion had been excised by another physician, but it later recurred. The patient had been taking minocycline (100 mg) daily for this condition.
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Pulmonary nocardiosis mimicking empyema necessitatisNocardia 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.
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Atrial Fibrillation:When - and How - to Convert to Sinus RhythmYour patient with atrial fibrillation (AF)is hemodynamically stable and youhave successfully established rate control.Your next step is to weigh therisks and benefits of attempting to restoresinus rhythm. In up to one half ofpatients, AF of recent onset convertsspontaneously to normal sinus rhythmwithin 24 hours. Thus, in some cases,the most appropriate approach maybe to control the ventricular response,identify and treat comorbid conditions,initiate anticoagulation, and closelymonitor the patient.
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The technique of adult flexible bronchoscopy: Part 1ABSTRACT: Flexible bronchoscopy was clinically introduced byShigeto Ikeda in 1968 and is now used widely for diagnosticand therapeutic interventions. A combination of advancingtechnology and ingenuity has fostered the development of anexpanded array of devices and applications. The newer videobronchoscopes offer higher-resolution images than fiberopticbronchoscopes. The advantages of fiberoptic technology arelower cost and greater technical ease of adapting to smallerdiameterbronchoscopes. Hybrid bronchoscopes have an imaginglens and fiberoptic bundles that transmit the viewingimage to a charge couple device (CCD) chip in the body of theoperator end of the bronchoscope. The digital image is transmittedfrom the CCD chip to the external processor for viewingon a monitor, for digital storage, or for printing. (J Respir Dis.2008;29(11):423-428)
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Dislocated Septal CartilageDislocation of the triangular cartilage of the nasal septum is caused by pressure on the nose before and during delivery. It should not be confused with the transient flattening of the nose during birth.
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Focus on the Needs of Individual Patients- Not of Society as a WholeAny discussion of theutility and reliabilityof mammography mustfocus on what is good forindividual patients-not onwhat the results of a Europeanpublic health researchproject have determined isgood for society as a whole.What is good for most patientsis annual screeningmammography beginningat age 40 years (and for patientsat very high risk forbreast cancer, mammogramsbeginning much earlier,and possibly performedmore frequentlythan once a year).1
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8 Questions on Management of Chronic Coronary Disease: A Guideline Topline QuizBased on the updated 2023 AHA/ACC recommendations, the 9-question quiz tests what you know about the most current approaches to CCD treatment.
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Human and Animal Bites:Each year almost 5 million Americans sustain an animal or human bite. Dog bites alone represent 0.4% to 1% of all emergency department (ED) visits and can range from trivial to life-threatening.
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COPD Management & Pharmacotherapy: A GOLD Guideline ToplineGet GOLD Report updates at-a-glance on initiating pharmacotherapy, avoiding exacerbations, treating dyspnea, how to approach using ICS, plus other topics.
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Pearly Pink Chest LesionsCan you identify the 2 slowly expanding growths on the chest of this 68-year-old man?
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LeukoplakiaA 39-year-old man was concerned that his history of long-termnicotine exposure placed him at increased risk forthroat cancer. He had used about 2 cans of “dip” each weekfor many years. The patient habitually placed the tobaccoin the right lower lip area; to avoid spitting, he always swallowedthe spent wad. The patient did not smoke; he usedalcohol occasionally.
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Takotsubo Syndrome in an African American Woman With Typical PresentationAlso known as “broken-heart syndrome,” Takotsubo syndrome is a stress-induced cardiomyopathy.
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What’s New in the Treatment of Osteoporosis?That’s the question we put to Dr. Kenneth Saag. In the next few minutes, Dr. Saag, will summarize the latest developments in osteoporosis therapy.
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Complications of Body ArtPrimary care providers are seeingan increasing number ofpatients who have snakes orbarbwire coiling around theirarms or gold rings danglingfrom their eyebrows and navels. Tattooingand body piercing are particularlypopular among adolescents andyoung adults-many of whom may notbe aware of the possible medical complicationsof these ancient practices.
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Takotsubo Cardiomyopathy in a Man With a Gunshot WoundA 48-year-old African American man with no significant medical history sustained a gunshot wound to the face and shoulder.
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Incomplete LV Rupture Secondary to MI: A Case of Intramyocardial DissectionMyocardial rupture is the most feared and often lethal complication of acute MI. It was a potential diagnosis for this patient who presented with sinus tachycardia, ST-segment elevation from V1 to V4, II, III, and aVF with associated Q waves. Follow the workup and outcome here.
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Follow-up of Childhood Cancer Survivors: The Role of the Primary Care PhysicianA 16-year-old boy with a history of leukemia at age 12 years complains of right hip pain of several months' duration. A 34-year-old woman who had Hodgkin lymphoma at age 14 years comes in for a routine physical.
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Post-Test on Rheumatoid Arthritis in Primary CareUse this short test to gauge how much you’ve learned about a condition that needs more primary care involvement.
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The 10 Most Common Prescribing Errors: Tips on Avoiding the PitfallsNumerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.
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Thyrotoxicosis presenting as pulmonary hypertensionThe authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.
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The Dangers of ATVsAn all-terrain vehicle-ATV-is described by the American National Standards Institute as one that "travels on low pressure tires, with a seat that is straddled by the operator, and with handlebars to be used for steering."1 By this definition, an ATV is designed for interactive riding by a single operator. Drivers are able to shift their weight freely in all directions depending on the situation and terrain. According to ATV safety standards and recommendations, children younger than 6 years are never to be on an ATV of any size-alone or with someone else.
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Pulmonary hypertension in the elderly, part 2: TreatmentABSTRACT: The treatment of pulmonary arterial hypertension(PAH) is directed at the underlying cause, such as diastolicheart failure or chronic thromboembolic disease. Patients withidiopathic PAH or PAH associated with connective-tissue diseasewho have World Health Organization (WHO) functionalclass II or III PAH should receive a trial of oral bosentan, ambrisentan,and/or sildenafil; inhaled iloprost is an alternative oran additive agent. If patients fail to respond to these interventionsor if they have WHO functional class IV PAH, considersubcutaneous or intravenous treprostinil or epoprostenol. Theuse of these latter agents is much more complicated and maybe difficult to initiate in elderly patients. (J Respir Dis. 2008;29(12):468-474)
