Pulmonary arterial hypertension (PAH) can be difficult to diagnose because the symptoms are nonspecific and the physical findings are usually subtle (Table). In 2004, the American College of Chest Physicians (ACCP) published clinical practice guidelines for the diagnosis and management of PAH.1 Highlights of the ACCP's recommendations for patient assessment include the following:
The authors describe a woman who presented with severe pulmonary hypertension. A cardiopulmonary cause was initially sought, but thyrotoxicosis was the underlying cause.
abstract: Pulmonary arterial hypertension (PAH) is 1 of 5 types of pulmonary hypertension (PH). Symptoms may include dyspnea on exertion, fatigue, near-syncope, and palpitations. Physical findings include lower extremity edema, jugular venous distention, and a loud P2. Findings on chest radiography, transthoracic echocardiography, and electrocardiography can suggest the presence of PAH; however, right heart catheterization is the gold standard for confirming the diagnosis and for differentiating PAH from other forms of PH. It is essential to exclude chronic thromboembolic PH, since this can be surgically corrected. The treatment of PAH depends on the severity. In addition to the standard treatments, such as diuretics and anticoagulation, more advanced treatment options include prostaglandin therapy (epoprostenol, treprostinil, and iloprost), endothelin receptor antagonists (bosentan), and phosphodiesterase inhibitors (sildenafil).
Diabetic nephropathy, the leading cause of end-stage renal disease (ESRD) in the United States, affects 20% to 30% of patients with diabetes. Early diagnosis and aggressive treatment may delay the progression of kidney disease.
A 15-year-old boy complains of moderate to severe headaches that occur daily and usually last all day; the pain typically worsens toward the end of the day. How will you help this patient?
Two weeks after undergoing a laparoscopic partial nephrectomy for renal adenocarcinoma, a 78-year-old man with myelodysplastic syndrome was hospitalized with nonhealing abdominal wounds. The patient had started a course of oral cephalexin 4 days before admission to treat erythematous areas at 2 of the trocar port sites.
Abstract: A number of factors can complicate the diagnosis of asthma in elderly patients. For example, the elderly are more likely to have diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) that--like asthma--can cause cough, dyspnea, and wheezing. Spirometry can help distinguish asthma from COPD, and chest radiography and measurement of brain natriuretic peptide levels can help identify CHF. Important considerations in the management of asthma include drug side effects, drug interactions, and difficulty in using metered-dose inhalers. When discussing the goals of therapy with the patient, remember that quality-of-life issues, such as the ability to live independently and to participate in leisure activities, can be stronger motivators than objective measures of pulmonary function. (J Respir Dis. 2006;27(6):238-247)
A staff nurse calls the physician to see "something really bizarre-we have no idea what this is": the plastic of a urine collection bag of an 81-year-old woman has turned purple, although the urine within is more orange-brown and distinctly less odd looking.
Man With Worsening Cough and Dyspnea
The mumps outbreak in midwestern states appears to be slowing, but as college students return home and engage in summer travel, it's possible that mumps will spread. Are you prepared?
This patient has a febrile illness that began shortly after he returned from foreign travel. The differential diagnosis is intriguing--malaria, yellow fever, typhoid fever, and dengue.
ANN ARBOR, Mich. - Even if there were a foolproof vaccine against avian flu, but with a small risk or mortality from the vaccine itself, many people would take their chances with the virus.
ROCKVILLE, Md. - The FDA approved a shingles vaccine, and Merck said it is ready to accept physician orders, with rapid shipment promised.
Since gout can precipitate olecranon bursitis, should I routinely order a crystalanalysis for patients who present with this bursitis?
A young child is brought to your office with a several-dayhistory of earache, sore throat, and low-grade fever. The nurse is concernedabout lesions she noticed on the child’s tongue while attempting to take histemperature.
A 52-year-old man complains of right knee pain that hasbeen increasing steadily for several weeks. Two years earlierhe underwent a total arthroplasty of the same knee to treatsevere osteoarthritis secondary to a meniscal injury. He hasno history of recent trauma or increased activity.
Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.
For the past few weeks, pruriticpatches have been erupting on a38-year-old man’s extremities. He recallsthat similar lesions occurredduring the last 2 winters. The patienthas a history of seasonal allergies;he owns a cat and 2 dogs.
A 6-year-old girl presents witha several-month history ofgenital discomfort that includesitching, irritation, andoccasional bleeding. Themother reports that there isblood on the toilet paper afterthe child wipes herself. Therehas also been some spottingin the child’s underwear. Thepatient seems to be grabbingat her crotch frequently.
A 1-year-old woman comes to theemergency department (ED) 3hours after a male friend punched herin the left lower back. The blowknocked her to the floor and madeher feel faint. She also noticed bloodin her urine when she voided athome after the injury.
To reduce the incidence of candidalinfections in patients with dermatologicproblems, instruct them to drythe affected area with a blow-dryeron a cool or warm setting before theyapply topical medications.
The patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.
Four cases to test your diagnostic skills: bizarre circular ecchymoses, abdominal ecchymosis, myriad nodules, and cavernous dilated blood vessel in a patient’s arm.
Young Man With Painless Penile Ulcer
Is prophylactic oophorectomy recommended for healthy postmenopausal women with a strong family history of cancer?
