A 51-year-old man with a history of AIDS (CD4 count of 59 cells/µL), anemia, neutropenia, and AIDS-related dementia presented with persistent fever, abdominal pain, and diarrhea of 2 months' duration. He did not adhere to his regimen of HAART and prophylactic therapy with atovaquone and azithromycin.
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)
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.
Read the cases of 4 patients whose chief complaint is a 2-week history of neck pain, try your hand at making a quick diagnosis, then go to the next page to read the outcome.
A cardiovascular risk reference guide, Framingham global risk assessment scoring guide, cardiovascular checklist, and cardiovascular risk-reduction treatment plan.
The growing epidemic of type 2 diabetes makes it imperative to identify persons at risk, screen for impaired glucose tolerance (IGT), and treat to prevent progression. Calculation of body mass index (BMI) is an appropriate starting point for identification of patients with possible IGT.
Cardiovascular (CV) risk-reduction regimens require comprehensive assessment, patient education, and follow-up, which can be difficult and time-consuming in a busy primary care practice. Moreover, compliance among patients at high risk can be poor. The use of evidence- based risk assessment checklists and patient education materials can enhance care and improve compliance; in addition, thorough documentation can ensure full reimbursement for services.
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.
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.
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)
For patients with osteoarthritis, nonpharmacologic treatment can be an effective adjunct to drug therapy. Patient education is essential; both community-based and independent self-care programs are available. Weight loss can improve function and alleviate symptoms; however, it is more effective when dietary modification is accompanied by increased physical activity.
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.
Skin signs of systemic disease: sarcoidosis, rheumatoid nodules, Muir-Torre syndrome, diabetic vasculopathy, hyperlipidemic nodules, zinc deficiency, and Sister Mary Joseph nodule.
Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)
The metabolic syndrome represents a clustering of conditions and/or risk factors that lead to an increased incidence of type 2 diabetes mellitus and cardiovascular disease. These conditions include abdominal obesity, dyslipidemia, hypertension, insulin resistance, and a proinflammatory state.
A verrucous birthmark, a rash at the commissure of the lips, proximalnail changes--can you identify the disorders pictured here?
A 72-year-old man presented after several months of dyspepsia and 1 day of hematemesis. He was not taking NSAIDs.
A 72-year-old morbidly obese man who had diabetes mellitus was admitted to the hospital from a nursing home with a fever of 4 days' duration. A tracheostomy had been performed 3 months earlier for respiratory failure. The patient was being treated with corticosteroids for chronic obstructive pulmonary disease.
A 45-year-old man presented with a 2-month history of progressive fatigue, weight loss of 10 lb, abdominal pain, and pruritus. The patient had been taking a maintenance dose of oral mesalamine since he received a diagnosis of ulcerative colitis 14 years before.
A 71-year-old man, who had recently returned from a month in Europe, complained of left lower leg swelling and pain of 1-week's duration. For many years, this obese patient had chronic venous insufficiency of both legs and chronic osteoarthritis of the knees that severely limited his ability to walk. The patient was admitted to the hospital with extensive cellulitis of the left lower leg.
After 6 weeks of persistent low back pain, an overweight 72-year-old woman sought medical evaluation. There was no history of trauma.
A 49-year-old woman, severely obese but otherwise healthy, appeared for a preemployment medical examination. She neither smoked cigarettes nor drank alcohol. She had no respiratory problems and recalled no family history of such. A baseline mammogram taken 4 years earlier showed no abnormalities, and the patient was not under care for any medical condition. Results of physical examination were normal, except for the obesity-which made it difficult to determine breast masses with confidence.
An 80-year-old woman presented with recurrent abdominal pain for 1 month, constipation, and vomiting. She had no diarrhea, rectal bleeding, or weight loss.
