A 45-year-old man presented to the emergency department (ED) with fever and left-sided pleuritic chest pain. He had been in good health until 4 days earlier, when diffuse myalgias, weakness, and frontal headache developed. Two days later, these symptoms were accompanied by onset of fever (temperature, 39.4°C [103°F]) and left-sided pleuritic chest pain. He denied chills, rigors, shortness of breath, hemoptysis, and cough.
Abstract: In addition to causing pulmonary disease, infection with Mycobacterium tuberculosis can result in a wide range of extrapulmonary manifestations, including abdominal involvement. Patients with acute tuberculous peritonitis typically present with fever, weight loss, night sweats, and abdominal pain and swelling. Intestinal tuberculosis is characterized by weight loss, anorexia, and abdominal pain (usually in the right lower quadrant). A palpable abdominal mass may be present. Patients with primary hepatic tuberculosis may have a hard, nodular liver or recurrent jaundice. The workup may involve tuberculin skin testing, imaging studies, fine-needle aspiration, colonoscopy, and peritoneal biopsy. Percutaneous liver biopsy and laparoscopy are the main methods of diagnosing primary hepatic tuberculosis. Treatment includes antituberculosis drug therapy and, in some cases, surgery. (J Respir Dis. 2005;26(11):485-488)
Abstract: Important components of the workup for interstitial lung disease (ILD) include the history and physical examination, chest radiography, high-resolution CT (HRCT), pulmonary function testing and, in some cases, bronchoalveolar lavage (BAL) and/or biopsy. Pulmonary function tests usually show a restrictive ventilatory impairment. However, some patients have a mixed restrictive/obstructive pattern; in fact, almost 50% of patients with sarcoidosis have airflow obstruction at presentation. HRCT has an increasingly important role in the assessment of ILD. In some cases, the results may obviate the need for biopsy. BAL can help confirm the diagnosis of ILD; it also can identify conditions such as infection or hemorrhage or suggest an alternative diagnosis. Surgical lung biopsy has the advantage of yielding samples of lung tissue that are usually diagnostic, especially if HRCT is used to target lung regions. (J Respir Dis. 2005;26(11):466-478)
An HIV-positive 38-year-old man with a history of injection drug use presented to the emergency department with abdominal and back pain that worsened with motion. He denied fever and vomiting. During the past 2 months, the patient had been treated for a urinary tract infection (UTI) 4 times and evaluated for a renal calculus, which had been ruled out. He was currently receiving ciprofloxacin, ibuprofen, and HAART.
During a laparotomy for perforated sigmoid colon diverticulitis, a 75-year-old woman was found to have extensive peritonitis. She underwent sigmoid colon resection and colostomy. Postoperatively, she recovered slowly. The peritoneal fluid grew Escherichia coli, and she was given broad-spectrum intravenous antibiotic therapy.
New guidelines recommend a different regimen for patients with native valve endocarditis caused by MRSA.
Telltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.
As many as half of patients who are evaluated for abdominal pain do not receive a precise diagnosis. And for about half of those who are given a diagnosis, the diagnosis is wrong. In this article, I will use actual cases (not "textbook" examples) to illustrate an approach to abdominal pain that begins with a careful differential diagnosis. I also offer some general guidelines for evaluating patients.
An 81-year-old man is seen for follow-up of leukocytosis detected during a recent hospitalization for community-acquired pneumonia. The leukocytosis had not resolved by the time he was discharged.
A 35-year-old man with type 1 diabetes has had an asymptomatic rash on the lower extremities for the past several months. He denies trauma and recent illness. He has tried multiple "home remedies," but the rash has persisted. He smokes and drinks alcoholic beverages occasionally.
Progressive cough and dyspnea of 2 months' duration prompted a 23-year-old man to seek medical attention for the fourth time. On previous emergency department visits, he had received antibiotics, which failed to relieve his symptoms.
A 36-year-old woman with a history of HIV disease presented for evaluation of dyspnea of 1 week's duration. She had been taking trimethoprim-sulfa- methoxazole for Pneumocystis carinii pneumonia prophylaxis. Because of a presumed skin reaction to this medication, dapsone was recently substituted.
A previously healthy 40-year-old man presents with a 2-hour history of excruciating colicky pain of acute onset that emanates from the right flank and radiates to the groin. He rates the severity of the pain at 9 on a scale of 1 to 10. Before arriving at the emergency department, the patient experienced nausea and 2 episodes of nonbilious, nonbloody vomiting.
A 34-year-old woman presented with a blistering, intensely pruritic rash that had erupted 3 days earlier. Multiple papular lesions were densely clustered on areas of exposed skin. Excoriations were present, but there was no evidence of bacterial infection.
These pinpoint pustules, some with excoriations, and surrounding erythema appeared on the posterior trunk and outer arms of a 15-year-old boy after he had wrapped his upper body in a wool blanket. These lesions were occasionally pruritic, especially on the arms, where most of the excoriations were noted.
A 70-year-old man was hospitalized after he fell and was unable to rise because of weakness. He denied dyspnea, chest pain, palpitations, vertigo, light-headedness, preceding aura, hematemesis, hematochezia, and melena. For the past year, the patient had had intermittent low-volume, watery diarrhea that had recently begun to occur daily; he had also lost 13.5 kg (30 lb) during the past 6 months. Shortly after he was admitted, scrotal edema, discoloration, bullae, and erythema of the upper left thigh developed.
The use of analgesics, specifically acetaminophen, has been proposed as one of the mechanisms for the rise in asthma prevalence in the last 30 to 40 years.1 Acetaminophen, approved by the FDA in 1951, is one of the most commonly used analgesics in adults and children. The association between asthma and acetaminophen has been reported in case reports, in the setting of oral challenge tests, and in larger clinical studies.2
These sinuses are lined by a membrane. When this membrane becomes inflamed--usually as a result of an infection or obstruction--you can get sinusitis. Sinusitis can be acute, recurrent, or chronic. Acute sinusitis responds well to treatment within a few weeks. Recurrent sinusitis is characterized by episodes that repeat at least 4 times a year. Sinusitis is considered to be chronic when symptoms persist for at least 12 weeks after treatment of acute sinusitis has ended.
A 24-year-old Korean woman, who was 20 weeks' pregnant, was referred to an allergist for an elimination diet and evaluation of the risk of allergies to her unborn child. She had a several-year history of perennial allergic rhinitis with seasonal exacerbations.
Abstract: Many patients with sarcoidosis are asymptomatic at presentation and have bilateral hilar adenopathy on a chest radiograph obtained for other reasons. Symptomatic patients usually present with chronic cough, dyspnea, or noncardiac chest pain. Extrapulmonary organ involvement is not uncommon. Lung biopsy shows well-formed noncaseating granulomas in a bronchovascular distribution. Interstitial lung disease also may result from collagen vascular disease, such as systemic lupus erythematosus and Sjögren syndrome. In patients with acute hypersensitivity pneumonitis, cough, dyspnea, and flu-like symptoms occur within 12 hours of exposure to the inciting antigen, such as pigeon stool or moldy hay. Some patients have a subacute or chronic course, probably as a result of continued exposure to the offending antigen. In acute hypersensitivity pneumonitis, the chest radiograph may show diffuse small nodules, whereas in chronic disease, reticular lines or fibrosis may be seen. (J Respir Dis. 2005;26(10):443-448)
Abstract: Chronic rhinosinusitis can be caused or aggravated by a number of factors, including bacterial, viral, and fungal infections; asthma; allergies; and obstruction caused by nasal polyps or a deviated nasal septum. The diagnosis can usually be established clinically. Imaging studies are not routinely necessary, but a CT scan of the sinuses should be obtained if the patient has significant ocular or orbital symptoms or if sinus surgery is planned. Treatment consists of antibiotics, with consideration of a change in the regimen if the patient has already received a full course of a first-line agent. The course of treatment may need to extend to 4 weeks. Also consider adjunctive therapy, such as intranasal corticosteroids and decongestants. Patients who have allergic rhinitis may also benefit from an antihistamine and/or a leukotriene modifier. Sinus surgery is reserved for patients who do not respond to medical therapy. (J Respir Dis. 2005;26(10):415-422)
Influenza vaccinationcontinues to be the primarymethod of preventinginfluenza and its lifethreateningcomplications.In preparation forthis year’s influenza season,the Advisory Committeeon ImmunizationPractices (ACIP) has publishedits recommendationsfor the preventionand control of influenza.1
A 4-year-old boy is admitted with a 2-week history of high fever with rigors; profuse night sweats; progressive dull, aching, nonradiating right upper quadrant pain; and watery, foul-smelling diarrhea that contains no blood or mucus.
A 24-year-old woman complains of a severe, throbbing headache that is present when she is upright and is relieved when she lies down. When she is upright, she also experiences dizziness, blurred vision, light sensitivity, nausea, and occasional diplopia.
In patients with underlying disease, a preoperative evaluation and targeted perioperative management strategies can minimize surgical complications and maximize healing. This article focuses on how to identify surgery patients at risk for complications caused by diabetes, chronic obstructive pulmonary disease (COPD), and other medical conditions; I also describe strategies to minimize such risk.
