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Suspected UTI in Nursing Home Patients: When to TestIs it appropriate to routinely order urinalysis for patients in a nursing home (both with and without dementia) when they exhibit behavioral changes but show no signs or symptoms of urinary tract infection (UTI)?
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Intrathoracic GoiterA 69-year-old woman was admitted to the hospital with wheezing and dyspnea. She also complained of hoarseness and slight dysphagia that had caused a loss of 12 lb during the past 4 months. The patient had been treated for bronchial asthma as an outpatient, but the worsening episodes of wheezing were not being controlled by bronchodilator therapy.
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Man With Reflux Symptomsand Esophageal Papular LesionsA 51-year-old man with a 12.5-pack-year smoking history had symptomssuggestive of gastroesophageal reflux disease for 6 weeks.
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What Is This Penile Lesion?For 20 years, a lesion has been slowly growing on the penis of a 51-year-old man. He has noted bleeding and a foul-smelling discharge from the mass. Recently, the patient experienced a 30-lb weight loss. He has had 5 sex partners in his lifetime but has been monogamous for the past year.
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Atypical Celiac Disease: Could You Be Missing This Common Problem?For every recognized case of celiac disease, 8 more remain undiagnosed. The reason for this disparity is contingent on the varying presentations of the disease.
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Irrigation: Easy Technique for Difficult LocationsUse a saturated sterile cotton ball whenever you need to irrigate ears or other small, hard-to-reach places.
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Man With Headache, Diplopia, Nausea, and VomitingA 68-year-old man presents to the emergency department with diplopia and headache of acute onset accompanied by nausea and vomiting.
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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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Case ReportA 49-year-old white man, in whom HIV infection had been newly diagnosed (CD4+ cell count, 25/µL; HIV-1 RNA level, 274,000 copies/mL), was transferred to our hospital for further workup and treatment of multiple neurologic deficits. He had presented to another hospital with a 4-day history of left-sided weakness and numbness, left-sided facial droop, dysphonia, and dysphagia that led to the initial diagnosis of an acute stroke.
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Stroke: Update on New Therapies- and the Implications for Primary CareCurrently, 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.
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PanninculitisPainful, erythematous plaques had erupted 4 to 6 weeks earlier on the left upper arm and lower abdominal wall of a 54-year-old woman.
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Erectile Dysfunction:ABSTRACT: The number of medical therapies for patients with erectile dysfunction (ED) has increased in recent years because of our expanded understanding of the physiologic and neurologic causes of ED. Oral agents range from testosterone to antidepressants to phosphodiesterase inhibitors. Nitroglycerin and minoxidil have shown some effectiveness as topical agents. Alprostadil, which can be applied intraurethrally, is also effective as intracavernosal injection therapy. Prostaglandin E1 and papaverine are effective as intracavernosal injection agents. Some studies have shown that combined use of intracavernosal injection and oral therapy produces satisfactory erections.
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Anaphylaxis Presenting as MacroglossiaThree days after having eaten fish, a 66-year-old woman with a known allergy to fish and a history of schizophrenia was brought to the emergency department because of macroglossia-a presentation of anaphylaxis. The patient refused airway management (intubation or cricothyrotomy) and was therefore admitted to the medical intensive care unit for monitoring of her airway and hemodynamic status. She received corticosteroids, ranitidine, diphenhydramine, epinephrine, and oxygen (via nasal cannula).
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Indoor mold and your patient's health: From suspicion to confirmationAbstract: The manifestations of indoor mold-related disease (IMRD) include irritant effects, such as conjunctivitis and rhinitis; nonspecific respiratory complaints, such as cough and wheeze; hypersensitivity pneumonitis; allergic fungal sinusitis; and mycotoxicosis. The diagnosis of IMRD depends on eliciting an accurate history and excluding preexisting pathology that would account for the patient's symptoms. Laboratory tests, imaging studies, and spirometry can play an important role in ruling out other diagnoses, such as allergic or nonallergic rhinitis, asthma, and pneumonia. The diagnosis of IMRD also involves integrating the results of immunologic, physiologic, and imaging studies with the results of indoor air-quality studies. (J Respir Dis. 2005;26(12):520-525)
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Dorsal Dislocation of the Fourth and Fifth MetacarpalsSeveral hours after striking his closed fist against the side pillar of a passenger car, a 28-year-old man presented with acute pain and swelling of the left hand. The dorsum of the left hand appeared deformed and edematous; there were scattered abrasions but no lacerations, exposed bony fragments, ecchymosis, or active bleeding.
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Podcast: New Guidelines for Vaccinating Boys Against HPV InfectionWhat exactly are the new guidelines for vaccinating boys against HPV infection-and why is this development good news for both men and women?
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Diagnostic Images, Treatment IssuesA39-year-old man is brought to theemergency department (ED)after his car struck a tree. He experienceda transient loss of consciousnesswith a 3-minute episode of retrogradeamnesia at the scene of the accident,despite wearing a seat belt andshoulder harness. He was disorientedto date and place.
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Close observation is the key to successful extubation Tips on extubation in mechanically ventilated children key words: Endotracheal intubation, Mechanical ventilation, Pediatric pulmonologyabstract: Proper assessment of the child's readiness for extubation and preparation for extubation are essential to minimize the need for reintubation and to maximize the child's safety in the periextubation period. Readiness for extubation requires that the child have adequate respiratory drive, the ability to maintain a patent airway, adequate oxygenation, and ability to ventilate spontaneously. Respiratory drive can be assessed by decreasing the ventilator settings to a minimal level and observing the child's respiratory effort and respiration rate. Evidence of increased work of breathing, such as tachypnea, retractions, and nasal flaring, suggests that the child may not be ready for extubation. If stridor and respiratory distress develop after the endotracheal tube is removed, nebulized racemic epinephrine is often quite effective; in addition, intravenous corticosteroids should be administered for 24 hours to help decrease the edema more quickly. (J Respir Dis. 2007;28(5):203-207)
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Diabetic Man With Pruritic Pretibial RashA 69-year-old man seen because of a pruritic pretibial rash of 3 months' duration. Started as reddish brown papules that slowly enlarged and changed.
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Girl With Mildly Pruritic Maculopapular RashA 10-year-old girl has had a worsening rash for 1 week. The mildly pruritic, nontender eruption initially appeared on the child's thighs and then spread to the arms and face. The child's right hand, feet, and ankles have been swollen for the past 4 days, which has made ambulation intermittently painful.
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A Comparison of the Clinical Effectiveness and Cost-Effectiveness of Treatments for Moderate to Severe PsoriasisThis study investigated the clinical effectiveness and cost-effectiveness of treatments for moderate to severe psoriasis from a managed health care systems perspective. An analysis was conducted of randomized clinical trials evaluating biologic and oral systemic medications and phototherapy for patients with moderate to severe psoriasis.
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Counseling for Smoking Cessation Gets Its Own CPT CodesCHICAGO -- Physicians will be able to report smoking-cessation counseling efforts soon using two new Current Procedural Terminology (CPT) codes that address tobacco use specifically.
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Clostridium subterminale - Infection Secondary to an Open FractureClostridia are anaerobic, spore-forming, gram-positive bacilli that are ubiquitious in nature. They can be isolated from soil and the GI tract of animals and humans.1
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Boerhaave SyndromeAn 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.
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Pheochromocytoma: Do You Know the Classic Triad of Symptoms?A 49-year-old man presents for a routine examination. He has a 15-year history of essential hypertension and a 7-year history of hypercholesterolemia and type 2 diabetes mellitus.
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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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Disseminated Histoplasmosis in a Woman With History of Polymyositis and Possible DermatomyositisFor 3 days, a 28-year-old woman with a history of polymyositis and possible dermatomyositis had fever, chills, and nonproductive cough. She complained of rash, joint pain, and progressive immobility because of severe muscle weakness. For the past 6 years, she had been taking prednisone (60 mg/d), hydroxychloroquine (200 mg bid), and tramadol (100 mg q6h prn for pain).
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Preventive measures are still the best strategy Aspiration syndromes: Pneumonia and pneumonitis key words: Aspiration, Pneumonitis, Pneumoniaabstract: While the risk factors for aspiration pneumonia are similar to those for aspiration pneumonitis, the 2 syndromes have different presentations. Aspiration pneumonia tends to occur in older patients or in those with neurological diseases, and the aspiration is not usually witnessed. Aspiration pneumonitis is more likely to occur in patients undergoing anesthesia or in those with acute drug and alcohol overdoses, and the aspiration is often witnessed. The workup may include bedside assessment of the cough and gag reflexes, chest radiography, videofluoroscopic imaging, or fiberoptic endoscopy. Empiric antibiotic therapy should be avoided in most patients with pneumonitis; however, antibiotics may be indicated for those at high risk for bacterial colonization of oropharyngeal and gastric contents who have fever, increasing sputum production, or new infiltrates or for those who fail to improve within 48 hours. (J Respir Dis. 2007;28(9):370-385)
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Physician Groups Press Congress to Override SCHIP VetoWASHINGTON -- The AMA said it was "deeply disappointed" with President Bush's veto of the SCHIP reauthorization, and the American Academy of Pediatrics called the action "hurtful to children."
