>Editor’s note: To clearly illustrate the difference between arightward shift of axis and right axis deviation, Dr RichardHarrigan, associate professor of emergency medicine atTemple University School of Medicine in Philadelphia anda regular contributor to CONSULTANT’s “ECG Challenge”feature, provided the 3 ECGs shown here.
What is the risk of dementia in patients who have had an ischemic stroke?
A 20-year-old woman has had several episodes of syncope since she enteredcollege 2 months earlier. Although 1 or 2 episodes were associated with exercise,most were not. All occurred at times of surprise and/or emotional stress:she fainted twice when the bell rang at the end of a test, once after her alarmclock suddenly awakened her in the morning, and once when she received adisturbing phone call from home.
A 62-year-old woman presents with severe, sharp pain in her right mid chestthat worsens when she breathes. The pain began the previous night, shortlyafter she had been awakened by a shaking chill, followed by the sensationof fever. She also has a relatively nonproductive cough of recent onset.
A56-year-old woman with chest pain and emesis is brought to the hospitalby ambulance. En route, the pain resolves after nitrates, morphine,and aspirin are administered.
A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.
In his Hypertension Q&A, “When Snoring Has More OminousConsequences Than a Sleepless Spouse” (CONSULTANT,October 2003, page 1410), Dr Donald Vidt suggestsseveral questions that a physician can ask patients to screenfor obstructive sleep apnea (OSA).
A number of my patients have very high high-density lipoprotein cholesterol (HDL-C)levels as well as elevated total cholesterol and low-density lipoprotein cholesterol(LDL-C) levels. One such patient is a nonsmoking middle-aged woman whose weightand blood pressure are normal.
For 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).
A preoperative evaluation performed shortly before a 66-year-old man is scheduledto undergo coronary artery bypass graft (CABG) surgery reveals a peripheralblood leukocyte count of 23,500/μL with 28% neutrophils, 70% lymphocytes,and 2% monocytes. The patient’s hemoglobin level is 14.5 g/dL; plateletcount is 265,000/μL.
For over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3
This simple technique can quickly reduce leg edema.
A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.
What is the recommended treatment of a patient who has anasymptomatic splenic aneurysm that is 4 cm in diameter?
If elderly patients or those withchronic lung disease have troubleholding their breath in while you tryto listen for carotid bruits, have themtake a deep breath, exhale, and holdtheir breath out.
My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.
A 59-year-old woman complainsof progressively worsening bloatingand right upper quadrant pain thatbegan 1 day earlier. She denies feverand trauma. Her medical history includescholecystectomy for cholelithiasisand several emergency departmentvisits for treatment of woundssustained in falls. She has a history ofalcohol abuse, for which she now receivescounseling. However, she admitsthat she occasionally has boutsof heavy drinking.
A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.
A 59-year-old woman presents with generalized facialswelling and dyspnea that has progressed graduallyover the past month. The patient also reports a sensationof pressure in her neck and ears and swelling of the lowereyelids, neck, upper chest, and upper limbs. The bloodvessels on her upper chest are prominent. A dry, irritatingcough has worsened.
I recently diagnosed type 2 diabetes mellitus in a 33-year-old man who has no diabeticsymptoms, proteinuria, or evidence of nephropathy. His blood pressure is low(100/60 mm Hg).
A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.
A 55-year-old constructionworker who spends a gooddeal of time outdoors has had occasionalblurred vision and an irritatedeyelid for several days. He has wellcontrolleddiabetes and hypertension.Which of these conditions doyou suspect?
A 51-year-old man presents with aseverely infected leg and 1- to 2-cmlesions on all of his extremities andtrunk; the bases of the lesions aredepressed, atrophic, and scarred.According to the patient, the lesionstypically appear as tender nodulesor pustules, which spontaneouslyburst, drain purulent material, andeventually heal as pictured.
In Dr Sean Eric Koon's Case In Point, "Puzzling Rash in an Older Woman"(CONSULTANT, April 15, 2003, page 629), I agree with his conclusion that thispatient had cutaneous leukocytoclastic vasculitis (CLV) (Figure). I also agreethat she met the American College of Rheumatology's 1990 criteria for a diagnosisof hypersensitivity vasculitis.1 However, given the patient's history and laboratoryresults, I believe further evaluation was warranted to determine whether the medication was indeed to blame for her CLV or whether an underlying systemicdisease was responsible.Her white blood cell (WBC) count was 72,000/?L. CLV is known to producea mild leukocytosis--presumably caused by the inflammatory response of the vasculitis.Thus, one would expect to see only a slight elevation in the WBC count.Also, if the elevation had been produced by the inflammatory response of the CLV,the patient's erythrocyte sedimentation rate (ESR) would have been significantlyelevated. However, her ESR was 12 mm/h, which is essentially normal in awoman this age.The discovery of a value that is not consistent with the disease process makesme question Dr Koon's final diagnosis--or at least want to add to his differentiala disease that could be responsible for both the CLV and the level of leukocytosisseen here: hairy cell leukemia.Other facts in the case that tend not to support the conclusion that the patient'sCLV resulted from a drug reaction include the following:One would expect to see systemic symptoms, such as fever, malaise, anorexia,and/or myalgias if a drug reaction caused the CLV; this woman reportedly didnot experience any of these.Rashes associated with CLV produced by a drug reaction are generally describedby patients as pruritic, painful (sometimes significantly so), and/or associatedwith paresthesias, such as a burning or stinging sensation; this patient's rash isdescribed as "painless and nonpruritic."Thus, although an exogenous agent such as trimethoprim-sulfamethoxazole(TMP-SMX) can cause CLV, it would have been prudent in view of the findingsin this case to search for an endogenous cause, such as an underlying systemicdisease or malignancy.----Pamela Moyers Scott, MPAS, PA-CWilliamsburg, WVaThank you for your comments. You detected a typo; this patient's leukocytecount was actually 7200/?L. A value of 72,000/?L would indeedbe of concern and would prompt a new differential diagnosis. HerWBC count when last checked was 7300/?L.Ultimately, my determination was that the patient's rash was mostlikely triggered by a viral infection and not by the TMP-SMX. I felt that anotherhealth care provider had inappropriately treated her upper respiratory tractinfection with an antibiotic, so I stopped the medication. Because I could notcompletely rule out the antibiotic as a cause of this potentially serious condition,I recommended that she avoid it in the future. This is yet another exampleof how the treatment of colds with antibiotics can confuse the clinical pictureand possibly harm the patient.--Sean Eric Koon, MD  Fontana, Calif
A 68-year-old man with severe emphysema complains ofchest pain that began that morning. He has also had intermittentdiarrhea and occasional blood in his stool for thepast 2 weeks.
