A 53-year-old man presents to the emergency department(ED) with chest pain that started the previous night. Thepain began about 30 minutes after he had smoked marijuanaand inhaled cocaine. He describes the pain as tightnessin the left side of the chest that radiates into theneck; he also has a tingling sensation in both the left sideof the neck and the left arm.
My patient has lung cancer with liver metastasis.
A 64-year-old woman with a history of uncorrected ventricular septal defect was hospitalized with progressive dyspnea and right heart failure. The patient had recently emigrated to the United States, where she received the diagnosis of ventricular septal defect with significant pulmonary arterial hypertension (Eisenmenger syndrome).
Abstract: Exercise intolerance is common in persons with chronic obstructive pulmonary disease and can result from multiple physiologic factors, including dynamic hyperinflation, gas exchange abnormalities, and pulmonary hypertension. In the initial assessment, keep in mind that many patients underestimate the degree of their impairment. The 6-minute walk test is very useful in assessing the degree of exercise intolerance; when more extensive assessment is indicated, cardiopulmonary exercise testing (CPET) is the gold standard. CPET is particularly useful for defining the underlying physiology of exercise limitation and may reveal other causes of dyspnea, such as myocardial ischemia or pulmonary hypertension. Strategies for improving exercise tolerance range from the use of bronchodilators and supplemental oxygen to participation in a pulmonary rehabilitation program. (J Respir Dis. 2006;27(5):208-218)
An examination of the evidence on the cardioprotective benefits associated with various intensity levels, types, and amounts of physical activity, as well as tips on a beneficial yet realistic exercise program.
Cerebrovascular accidents occur in a small but significant number of young persons, many of whom do not have traditional risk factors for vascular disease.
Which test--antistreptolysin O titers, coronary angiography, enzyme-linked immunosorbent assay (ELISA), Western blot testing for Borrelia burgdorferi, or genetic testing for long QT syndrome--would help you diagnose a young man with worsening chest pain, frontal headache, and diffuse muscle and joint pain?
A woman has white, numb, cold hands after vigorous exercise, emotional stress, and exposure to cold. Is this caused by Buerger disease (thromboangiitis obliterans), acute arterial occlusion, Raynaud disease, or acrocyanosis?
Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.
Are there any generally accepted guidelines for performing arthrocentesis in patients who are receiving anticoagulants?
A 3-day history of intermittent fainting spells brings a 49-year-old man to youroffice. His only significant medical history includes seasonal allergic rhinitis,for which he takes terfenadine, and mild depression, which is being treatedwith amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,for acute pharyngitis.
Your 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.
Atrial fibrillation (AF) is the most commonsustained cardiac arrhythmia; itaffects about 2.2 million Americans.The prevalence of AF, which increaseswith age,1 is approximately 5.9% in personsolder than 65 years2 and greaterthan 10% in those older than 75 years.3
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.
Delirium in older adults needs to berecognized early and managed as amedical emergency. Prompt detectionand treatment improve both shortandlong-term outcomes.1,2 Becausedelirium represents one of the nonspecificpresentations of illness in elderlypatients, the disorder can be easilyoverlooked or misdiagnosed. Misdiagnosismay occur in up to 80% of cases,but it is less likely with an interdisciplinaryapproach that includes inputfrom physicians, nurses, and familymembers.3
Abstract: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common, yet often overlooked, form of symptomatic sleep-disordered breathing. OSAHS is a cause for concern for several reasons, one of which is its association with cardiovascular disease. Risk factors include obesity, hypertension, and upper airway malformations. Diagnostic clues include habitual snoring, witnessed apneas, choking arousals, excessive daytime sleepiness, and large neck circumference. Polysomnography is the definitive diagnostic test; it pro- vides objective documentation of apnea and hypopnea. Since OSAHS may contribute to adverse postsurgical events, consideration of this syndrome should be part of the preoperative assessment of patients. (J Respir Dis. 2006;27(4):144-152)
An 86-year-old woman complains that she has felt "not at all well" for the past day. Her symptoms include diffuse generalized weakness and nausea; she denies chest pain, shortness of breath, abdominal pain, leg swelling, palpitations, and light-headedness. Five years earlier, a pacemaker was implanted as therapy for sick sinus syndrome and atrial fibrillation.
An 82-year-old woman presents with a history of sporadic episodes of light-headedness that began several months earlier and are becoming progressively more frequent. The episodes are unrelated to time of day, degree of activity, or posture. They cause her to feel as if she will lose consciousness, although she has never experienced total syncope.
Are beta-blockers still considered first-line therapy for uncomplicated hypertension?
A 59-year-old woman comes to your office for evaluation of her heart murmur.During the last several months, she has tired more easily and has had less energy.Recreational activities, such as lap swimming, have become difficult becauseshe is easily winded. She denies chest pain, foot swelling, and nocturnal dyspnea.
A 3-year Australian study found that when patients who underwent bypass surgerywere given coenzyme Q10 for a week or more before the operation, their heartmuscle tolerated stress better, recovered more quickly, and had better pumpingability after surgery than did the heart muscle in patients given placebo.1
Numerous factors, includingother drugs, diseases,and diet, affectthe response to warfarin.Some of these factorsdecrease the response and maylead to therapeutic failure; othersenhance the response and may resultin life-threatening bleeding.
Q:What is the best and most efficient method ofevaluating pulmonary function in primary careoffice practice?
Abstract: In the assessment of central airway obstruction and disease, no imaging technique is an adequate substitute for bronchoscopy. The indications for rigid bronchoscopy include multiple malignant and benign disorders, with most interventions performed for treatment of complications of lung cancer. The rigid bronchoscope is a useful tool for managing most types of airway stenoses, and it facilitates other endobronchial therapies, including stent placement, argon plasma coagulation, balloon dilatation, electrocautery probes, and laser therapy. Certain patients with benign lesions or postintubation or post-tracheostomy stenosis may benefit from rigid bronchoscopic techniques instead of surgery. Although use of the rigid bronchoscope requires general anesthesia, it provides a stable airway and often results in fast removal of foreign bodies. (J Respir Dis. 2006;27(3):100-113)
n the first 7 days after a transient ischemic attack (TIA), the risk of a stroke is 10%.1 If half the patients who presented with TIAs were admitted and received an immediate workup within that 7-day window, only 5% of them would have a stroke.1 Thus, many patients would undergo unnecessary tests. Some would have complications, and the costs would be prohibitive. What is needed is a way to identify patients who are at high risk for a stroke in the immediate future--and who require emergent assessment.
