Obesity Medicine

During the past few months, a 50-year-old woman had experienced cough, dyspnea, mild hemoptysis, and a 30-lb weight loss. She had no fever, chills, or rigors. The patient had smoked cigarettes for 30 years.

An obese 61-year-old man who had chronic obstructive pulmonary disease and sleep apnea heard a “pop” in his stomach while lifting a heavy weight; severe abdominal pain followed. He was short of breath the next morning, and his physician empirically prescribed cephalexin.

A 67-year-old man with a 5-month history of cough, shortness of breath, and pain in the left anterior chest wall sought medical evaluation. The patient denied fever, chills, and hemoptysis. He reported a recent weight loss of 25 lb. The patient had smoked cigarettes for 37 years.

A 70-year-old man-nursing home resident-had had a cough, fever, and copious foul-smelling sputum for 1 week. Hemoptysis was noted off and on during the previous 3 days. The patient had no recent weight loss. A chest x-ray film and a CT scan showed an air-fluid level in the left oblique fissure of the lung as well as pleural thickening and infiltrates in the left lower zone.

A 37-year-old man presented with fever, chills, myalgia, headache, and left-sided pleurisy of 2 weeks' duration. He also complained of weight loss and loss of appetite. The patient had recently returned from a family visit to Missouri.

Systemic lupus erythematosus (SLE) was diagnosed in an 18-year-old man who presented with polyarthritis, fever, hypoxia, fatigue, anemia, neutropenia, and abnormal urinary sediment. A renal biopsy showed diffuse mesangial proliferative glomerulonephritis (World Health Organization class II). Serologic tests were positive for fluorescent antinuclear antibody (FANA), SS-A, SS-B, anti-Sm and anti-dsDNA antibodies, and rheumatoid factor; a direct Coombs' test result was positive as well.

Here are two cases that demonstrate the discovery of aortic aneurysms through careful and complete physical examination and via radiographic studies obtained to evaluate other conditions.

A 67-year-old woman presented to the emergency department (ED) with severe, sharp, central chest pain of sudden onset and mild shortness of breath. The pain had been present for 15 minutes. The patient was obese; her medical history included hypertension, myocardial infarction, and osteoarthritis.

Abstract: The idiopathic interstitial pneumonias (IIPs) are the most commonly diagnosed forms of interstitial lung disease. These diseases represent specific clinicopathologic entities characterized by varying degrees of lung parenchymal inflammation and fibrosis. While most patients present with chronic dyspnea and have evidence of restriction on pulmonary function testing, certain findings can help differentiate among the IIPs. For example, patients with idiopathic pulmonary fibrosis (IPF)--the most common IIP--commonly present in the sixth or seventh decade of life, while those with desquamative interstitial pneumonia or respiratory bronchiolitis with interstitial lung disease typically present in the third or fourth decade of life and have a history of smoking. IPF is characterized by usual interstitial pneumonia (UIP) on lung biopsy; a UIP pattern can also be identified by high-resolution CT. (J Respir Dis. 2005;26(9):372-378)

A 53-year-old man presented with a 3-day history of bilateral pain in the lower extremities. He also had a 3-month history of thickening and desquamation of skin, with associated itching, and a 5-lb (2.27-kg) weight loss. The skin changes initially appeared on the hands and subsequently became generalized.

A 63-year-old woman presents to the emergency department with a 3-day history of abdominal pain, nausea, and obstipation. The pain is located in the left lower quadrant and is sharp, constant, and nonradiating.

For 2 days, a 79-year-old moderately obese woman had experienced abdominal pain, nausea, and vomiting. The pain was at the level of the incision for the colon cancer surgery she had undergone several years earlier. The patient was in mild distress. The central abdomen was tender; bowel sounds were high-pitched.

A 51-year-old man presents with a painful inguinal rash that has persisted for 3 months despite application of a combination corticosteroid and antifungal cream. The rash is associated with a strong odor.

Urinary incontinence is common--especially among older adults--but underdiagnosed. Many persons with this disorder are reluctant to discuss it with their physicians; often, only direct questioning can uncover the problem.

57-year-old woman is hospitalized because of a 3-week history of persistent left-sided dull flank pain that worsens with movement and is associated with intermittent high fever.

Although proton pump inhibitors (PPIs) are highly effective, clinical failure in patients with gastroesophageal reflux disease (GERD) is seen regularly--not only in GI clinics but also in primary care offices. In fact, the prevalence of failure with PPIs has increased in proportion to the expanding indications for their use.

These yellow asymptomatic lesions on the inner upper eyelids of a 36-year-old woman had persisted for 2 years. She had a history of type 2 diabetes mellitus, migraine, nicotine dependence, bipolar disorder, and obesity. Her medications included quinapril, insulin aspart injection, sumatriptan, ziprasidone, and temazepam.

Scaling patches that resist antifungals; an outbreak of red papules; a velvety,hyperpigmented rash--can you identify the disorders pictured here?

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

Abstract: Pleural tuberculosis and lymph node involvement are the most common extrapulmonary manifestations of tuberculosis. Most patients with pleural involvement complain of pleuritic chest pain, nonproductive cough, and dyspnea. The pleural effusion is usually unilateral and small to moderate in size. The diagnosis depends on the demonstration of acid-fast bacilli in pleural fluid or biopsy specimens, or the presence of caseous granulomas in the pleura. The gold standard for the diagnosis of lymph node tuberculosis is the identification of mycobacteria in smears on fine-needle aspiration cytopathology, histopathology, or mycobacterial culture. On ultrasonography and CT, the lymph nodes show enlargement with hypoechoic/hypodense areas that demonstrate central necrosis and peripheral rim enhancement or calcification. Treatment involves the combination of 4 antituberculosis drugs for 2 months, followed by 2-drug therapy for 4 months. (J Respir Dis. 2005;26(8):326-332)

What is the evidence that diet can reduce or increase the risk of common cancers? Is this evidence strong enough to warrant counseling patients to follow particular dietary guidelines?

A 62-year-old woman with a 25-year history of dyspnea was hospitalized because of hypoxemia. The dyspnea had become more severe during the past few years; it was worse in the standing position, was not exacerbated by walking, and was immediately relieved on lying down. She had no seasonal variation or environmental trigger of the dyspnea.

ABSTRACT: Early treatment with disease-modifying anti-rheumatic drugs (DMARDs)--alone or in combination-- can prevent joint damage and minimize disability. Until recently, the DMARDs used predominantly in patients with rheumatoid arthritis had been methotrexate, sulfasalazine, and hydoxychloroquine. Older DMARDs such as gold, d-penicillamine, and azathioprine have fallen out of favor because of their long- term toxicities or modest benefit. Six newer DMARDs--leflunomide, etanercept, infliximab, adalimumab, rituximab, and anakinra--have greatly expanded the current treatment options.

32-year-old man presents with a 4-day history of fever (temperature as high as 38.8 C to 39.4 C with severe rigors, chills, and profuse night sweats; generalized myalgias, including dull, aching headache; and dry cough.

The authors describe a rare cause of diffuse thoracic lymphadenopathy--Cogan syndrome. This case was remarkable for the temporal development of extensive lymphadenopathy independent of other hallmark symptoms and signs of this syndrome. In the appropriate clinical setting, Cogan syndrome should be considered in the differential diagnosis of thoracic lymphadenopathy.