Sleep Disorders

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)

Man With Worsening Cough and Dyspnea

Abstract: The management options for persons with obstructive sleep apnea-hypopnea syndrome (OSAHS) include lifestyle changes, continuous positive airway pressure (CPAP), oral appliances, and surgery. Lifestyle modifications work best in persons with mild OSAHS and may include weight loss and cultivation of good sleep habits, such as not sleeping supine. Before initiating CPAP therapy, polysomnography is recommended to determine the best airway pressure for the patient. Although the benefits of CPAP have been well documented, compliance remains an issue; some difficulties may be alleviated through patient/partner education and close follow-up. Oral appliances, which work by mechanically enlarging or stabilizing the upper airway, are preferred by some patients; however, they are less effective than CPAP at reducing the apnea-hypopnea index. Surgical interventions to alleviate upper airway obstruction can be used in select patients. (J Respir Dis. 2006;27(5):222-227)

An 84-year-old woman presented with a 10-month history of dysphagia to solids and a 4-month history of dysphagia and coughing to liquids. She was severely dehydrated and cachectic; over the past 10 months, she had lost 16.2 kg (36 lb). Rhonchi and gurgling sounds were audible on auscultation of the chest.

Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

The line on the gums of this 30-year-old man indicates lead poisoning. The patient had been employed for 8 months at a lead smelting plant in which no occupational safety precautions had been enforced. He was admitted to the hospital with the classic symptoms and signs of lead poisoning--pain in the nape of the neck that radiated down the spine, posterior thighs, and calves to the plantar aspect of the feet; colicky panabdominal pain; anorexia; weight loss; nausea; vomiting; constipation; bone and muscle tenderness; hyperesthesia of all extremities; insomnia; irritability; generalized weakness; malaise; and dizziness.

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.

A 41-year-old man is admitted for evaluation of acutechest pain, which started while he was watchingtelevision after dinner. The retrosternal pain was sudden,severe, pressing, and stabbing; it radiated to the neck andwas associated with dizziness and diaphoresis. The patientrated the pain as 9 on a scale of 1 to 10 (10 being the mostsevere). In the emergency department, he was given2 sublingual nitroglycerin tablets, which promptly relievedhis pain.

Delirium in older adults needs to berecognized early and managed as amedical emergency. Prompt detectionand treatment improve both shortandlong-term outcomes.1,2 Becausedelirium represents one of the nonspecificpresentations of illness in elderlypatients, the disorder can be easilyoverlooked or misdiagnosed. Misdiagnosismay occur in up to 80% of cases,but it is less likely with an interdisciplinaryapproach that includes inputfrom physicians, nurses, and familymembers.3

Abstract: As in adults and older children, pulmonary function testing in infants may help detect certain obstructive or restrictive diseases. However, different techniques and equipment must be used. The most commonly performed noninvasive tidal breathing test involves use of a face mask with a pneumotachograph; an alternative method is respiratory inductive plethysmography. Ratios derived from volume-time and flow-time tracings can help identify patients with obstructive lung disease, who have a shorter time to peak expiratory flow:expiratory time ratio than do healthy persons. Instead of spirometry, the rapid thoracic compression technique can be used to measure expiratory flow and construct a flow-volume curve. This method, which is performed with the patient under sedation, increases flow rates over tidal flow values and enhances the ability to detect abnormal airway function. (J Respir Dis. 2006;27(4):158-166)

Abstract: Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a common, yet often overlooked, form of symptomatic sleep-disordered breathing. OSAHS is a cause for concern for several reasons, one of which is its association with cardiovascular disease. Risk factors include obesity, hypertension, and upper airway malformations. Diagnostic clues include habitual snoring, witnessed apneas, choking arousals, excessive daytime sleepiness, and large neck circumference. Polysomnography is the definitive diagnostic test; it pro- vides objective documentation of apnea and hypopnea. Since OSAHS may contribute to adverse postsurgical events, consideration of this syndrome should be part of the preoperative assessment of patients. (J Respir Dis. 2006;27(4):144-152)

The patient presented with left-sided, throbbing headaches that had gradually increased in severity and frequency. These headaches, which occurred once or twice a month, were associated with photophobia, phonophobia, and nausea, and usually lasted 8 to 12 hours. The headaches affected the patient's job performance and attendance, and she complained of fatigue, lack of sleep, and difficulty in concentrating.

My patient complains of chronic fatigue. Her complete blood cell count and thyroid-stimulating hormone level are normal. Would it be worthwhile to measure her dehydroepiandrosterone sulfate (DHEA-S) level?

In this article, we review the factors that contribute to obesity. We then describe effective approaches to weight control, including exercise, dietary modification, drug treatment, and bariatric surgery.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

As many as 300,000 sportsrelatedconcussions arediagnosed each year inthe United States.1 Thisfigure underestimatesthe true incidence, however, becausemany concussive injuries are notrecognized by the injured persons,trainers, or physicians. A recentstudy found that 4 of 5 professionalfootball players with concussionwere unaware that they had sufferedthis injury.2

Weight gain is a well-known risk factor for the development of sleep-disordered breathing (SDB), and there is some evidence that weight loss can lead to improvement in SDB. Data from the Sleep Heart Health Study indicate that even modest changes in weight can be significant, especially in men.

Most pain in or around the oral cavity is attributable to tooth or mucosal pathology. However, tooth or mucosal pain may also be caused by a variety of other conditions, including brain pathology; vascular inflammatory and cardiac disease; jaw infection or neoplasm; neuropathic abnormality not associated with central pathology; pathology in the neck and thoracic region; myofascial and temporomandibular joint pathology; and disease of the ear, eye, or nose, or of the paranasal sinuses, lymph nodes, and salivary glands. Accurate diagnosis is facilitated when the features of pain presentation in this region are understood.

Obstructive sleep apnea (OSA) has been associated with cardiovascular disease, but the causal mechanisms are only partially understood. Researchers in São Paulo, Brazil, who investigated whether OSA contributes to atherosclerosis progression, observed that middle-aged patients with OSA who did not have overt cardiovascular disease demonstrated early signs of atherosclerosis.

Abstract: Shortness of breath is a common complaint associated with a number of conditions. Although the results of the history and physical examination, chest radiography, and spirometry frequently identify the diagnosis, dyspnea that remains unexplained after the initial evaluation can be problematic. A stepwise approach that focuses further testing on the most likely diagnoses is most effective in younger patients. Early bronchoprovocation challenge testing is warranted in younger patients because of the high prevalence of asthma in this population. Older patients require more complete evaluation because of their increased risk of multiple cardiopulmonary abnormalities. For patients who have multiple contributing factors or no clear diagnosis, cardiopulmonary exercise testing can help prioritize treatment and focus further evaluation. (J Respir Dis. 2006;27(1):10-24)

ABSTRACT: A number of nondental conditions may cause significant oral pain. Pain associated with temporal arteritis is localized to the maxillary posterior teeth, the maxilla, or the frontal-temple region. This pain is often associated with exquisite tenderness of the scalp and face. The pain of trigeminal neuralgia is typically felt in the anterior maxillary or mandibular anterior teeth; it radiates along the mandible toward or into the ear on the ipsilateral side of the trigger. Pain may remit for months or years but is often severe when it recurs. Burning mouth syndrome preferentially affects postmenopausal women older than 50 years; one half to two thirds of patients experience spontaneous remission within 6 to 7 years, with or without treatment. The pain of postherpetic neuralgia is unilateral and restricted to the affected dermatome; it may be aggravated by mechanical contact or chewing.

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.

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.