Obesity Medicine

PITTSBURGH -- Poor sleep is a frequent companion of depression in children, according to researchers here.

abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

The authors report a case of idiopathic eosinophilic pneumonia in a man with sclerosing cholangitis and ulcerative colitis associated with features of sarcoidosis.

Asked to evaluate bilateral unexplained upper-thigh bruises on a profoundly impaired woman newly admitted to our rehabilitation unit 2 weeks after an intracerebral hemorrhage. Patient received high-dose dexamethasone to reduce perihemorrhage edema.

ABSTRACT: Irritable bowel syndrome (IBS) is characterized by abdominal pain or discomfort, bloating, and constipation or diarrhea; the pain is typically relieved by defecation. The diagnosis is not one of exclusion; it can be made based on the answers to a few key questions and the absence of "alarm" symptoms. Fiber therapy, the elimination of particular foods, and regulation of bowel function can help relieve symptoms. Tegaserod or polyethylene glycol can be used to treat IBS with constipation. Loperamide and alosetron are of benefit in IBS with diarrhea (although the latter carries a small risk of ischemic colitis). Low-dose tricyclic antidepressants may be used to treat the abdominal pain associated with IBS. Probiotic therapy or rifaximin may help reduce bloating. Psychological therapies seem to improve well-being in patients with IBS.

A 40-year-old Hispanic homemaker is admitted with a 3-week history of high fever, chest pain, and a dry, irritating cough. Her illness began insidiously with increasing right upper chest pain that is sharp, pleuritic, and rates a 6 on a pain scale of 1 to 10. The pain is associated with temperatures of up to 38.8°C (102°F) and chills, rigors, and profuse sweating that increase in the evening. Worsening dyspnea has been accompanied by a drop in effort tolerance.

Television ads promote a quick pharmaceutical "fix" for erectile dysfunction (ED). The afferent limb is greater recognition of the problem by health care providers and the lay public. The efferent limb is a prescription for a phosphodiesterase inhibitor. The downside of this reflex action may be a lack of insight into the clinical significance of ED.

An 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.

A 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.

For 3 months, a 66-year-old retired man has had increasingweakness of the lower legs with stiffness,tingling, and numbness; worsening ataxia; anergia; andexertional dyspnea of insidious onset. He has lost 8 lb,and his appetite is poor. He denies fever, cough, chest orabdominal pain, paroxysmal nocturnal dyspnea, orthopnea,ankle swelling, bleeding disorders, hematemesis,melena, headache, vision problems, sciatica, joint pain,bladder or bowel dysfunction, and GI symptoms. He hasnocturia attributable to benign prostatic hypertrophy.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

Q:How can I accurately determine when a patient’s hypertension isresistant to treatment-and what is the best approach to theevaluation?

A 32-year-old man complains ofknee pain that resulted when he felland twisted his right knee skiing theday before. He suffered other minorcontusions from the fall, but none ofthese required medical attention. Heis otherwise in good health and hasno relevant medical history.

A 16-year-old boy presents for evaluation of various lesionsthat have appeared on his extremities since he joined thewrestling team 2 months earlier. He is otherwise healthyand takes no medications.

Your middle-aged patientwith type 2 diabetes wishesto start a weight-trainingprogram. What recommendationswill you offerhim? Another diabetic patient hasperipheral neuropathy; which exercisesare safest for her?

A thin 26-year-old man has hadintermittent diarrhea with abdominalpain, nausea, vomiting, and occasionalepisodes of hematochezia for8 months. He also complains of weaknessand fatigue and has lost 4.5 kg(10 lb) in the past year. The patientis homosexual and admits to havinghad unprotected sexual intercourse.He denies any significant travelhistory.

Cataracts areone of themost importantcauses ofreversibleblindness in elderly persons.1 A recent report thatpredicts a surge in cataractincidence has heightenedawareness of the importanceof proper timing andtechniques for cataract extraction.The study, authoredby the Eye DiseasesPrevalence ResearchGroup, estimated that thenumber of Americans withcataracts will increase byapproximately 50% in thenext 20 years as the populationages.2 Cataracts werethe leading cause of low vision(less than 20/40 bestcorrected visual acuity inthe better-seeing eye)among whites, blacks, andHispanics.

Apreviously healthy 22-year-oldHawaiian man presents to theemergency department (ED) of a hospitalin California with a 3-day historyof fever and chills. He has also had aprogressively worsening, persistent,dull aching pain in the right upperquadrant of the abdomen for the pastweek. The pain is localized-with noaggravating or relieving factors-andis not related to meals. The patienthas had no nausea, vomiting, loss ofappetite, jaundice, abdominal distension,cough, chest pain, dyspnea,weight loss, or lymphadenopathy.

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 "Consultations & Comments" response to a reader’scomments about statins and cancer risk in elderly patients(CONSULTANT, October 2003, page 1389), Dr David Nashnotes that the increased number of deaths from cancer thatoccurred in the second year of the Pravastatin in Elderly Individualsat Risk of Vascular Disease (PROSPER) study canprobably be attributed to disease that was already present beforethe start of the trial.

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 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.

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 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.

Patients on a low-fat diet who dislikethe color, taste, or consistency of fatfreemilk can try adding nonfat milkpowder.