Sleep Disorders

A 68-year-old man presents to the emergency department with diplopia and headache of acute onset accompanied by nausea and vomiting.

How important is control of obesity in the treatment of hypertension?

What steps can older patients take now to improve their health and quality of life and maintain their independence?

A 67-year-old man presented for evaluation of atrophy of the left thenar eminence that had developed within the past 2 weeks. He denied hand weakness. The patient had had symptoms of bilateral carpal tunnel syndrome for more than 12 years. His main symptom was numbness of the fingertips, which made buttoning his shirt and pants pocket difficult. He also had difficulty with fine manipulation, such as picking up paper clips.

A 23-year-old man presents to theemergency department (ED) withacute chest discomfort, which startedin the morning. He describes the discomfortas more akin to palpitationsthan to actual pain. The discomfortis midsternal, nonradiating, nonpleuritic,and associated with dyspnea; itis neither exertional nor positional.There is no viral prodrome.

A 67-year-old man presented for evaluation of atrophy of the left thenar eminence that had developed within the past 2 weeks. He denied hand weakness. The patient had had symptoms of bilateral carpal tunnel syndrome for more than 12 years. His main symptom was numbness of the fingertips, which made buttoning his shirt and pants pocket difficult. He also had difficulty with fine manipulation, such as picking up paper clips.

ABSTRACT: First steps in the treatment of irritable bowel syndrome (IBS) are dietary modification, smoking cessation, and other lifestyle changes. Treatment of mild symptoms includes increased soluble dietary fiber and osmotic laxatives for constipation, antispasmodics for cramping, and over-the-counter antidiarrheals. For moderate disease, serotonergic agents work primarily in the intestine to relieve the global symptoms of IBS. Alosetron decreases gut motility and visceral sensitivity in women with chronic, severe diarrhea-predominant IBS who have not responded to conventional therapies. Tegaserod relieves pain, bloating, and constipation in women with constipation-predominant IBS. Psychotherapy, hypnotherapy, biofeedback, and other nonpharmacologic modalities may also be helpful for patients with IBS. Antidepressants are reserved for refractory symptoms; they can be combined with other modalities if needed.

ABSTRACT: The complexities of chronic nonmalignant pain and the contributions of psychosocial and environmental factors require assessment and treatment strategies that may go far beyond the use of analgesics. The first step is to rule out serious underlying conditions; determine the chronicity, quality, location, and intensity of the pain; assess aggravating environmental factors; and evaluate the patient's level of functioning. The pharmacologic regimen may include oral or topical analgesics, antidepressants, muscle relaxants, nerve stabilizers, and/or opioids. A comprehensive plan includes alternative modalities, such as physical and occupational therapy, stress management, relaxation techniques, and the treatment of comorbid conditions, including anxiety, depression, and sleep disorders. The optimal opioid regimen consists of methadone or a sustained-release opioid combined with a short-acting opioid for breakthrough pain.

ABSTRACT: The cardinal feature of irritable bowel syndrome (IBS) is abdominal pain or discomfort associated with altered bowel habits. Because no serologic marker or structural abnormality exists, the diagnosis is based on clinical findings. A systematic symptom-based approach, including the Rome II criteria, ensures diagnostic accuracy. Determine whether a specific event-such as gastroenteritis, antibiotic use, or a food-borne illness-precipitated the IBS symptoms. Be alert for warning signs of cancer, infection, or inflammatory bowel disease, such as fever or unexplained weight loss. Only minimal laboratory testing is required; however, further evaluation may be warranted if a patient does not respond to treatment or loses weight, if the dominant symptom changes, or if other "red flags" are identified.

ABSTRACT: Prompt treatment of herpes zoster with an antiviral such as acyclovir does not prevent post-herpetic neuralgia, but it can reduce the pain and duration of the disorder, particularly in older patients. Agents used to treat post-herpetic neuralgia include gabapentin, tricyclic antidepressants, lidocaine patches, capsaicin, and opioids. Effective treatment often requires the use of multiple medications. When you select a regimen, consider whether your patient is at heightened risk for adverse drug effects and whether he or she has comorbid disorders, such as depression, that might be amenable to treatment with the same medication used for post-herpetic neuralgia. Patients with intense pain and dysfunction are more likely to have a protracted disease course; early, aggressive intervention is warranted in this setting. For patients who continue to have disabling pain despite treatment, consider intrathecal corticosteroid or lidocaine injections or referral to a pain management center or specialist.

ABSTRACT: To assess a child for overweight, begin by calculating his or her body mass index (BMI). Note that BMI is used differently in children than it is in adults. A child's BMI is plotted on a growth curve that reflects that child's age and gender. This yields a value-BMI-for-age-that provides a consistent measure across age groups. Children whose BMI-for-age is between 85% and 95% are at risk for becoming overweight. Any child whose BMI-for-age is 95% or more is considered overweight. The 2 main factors associated with overweight in children are poor eating habits and decreased physical activity. Recommend that children have at least 5 servings of fruits and vegetables a day. Children should engage in moderate physical activity for at least 60 minutes on most days of the week, and TV viewing and computer activities should be limited to no more than 2 hours a day.

A 32-year-old woman presents with weight loss of 6.4 kg (14 lb) during the past 8 months and diarrhea of recentonset. Menstruation had ceased 10 weeks earlier. She appears anxious, with pressured speech. Physical examination detectsbaseline sinus tachycardia, sweaty palms, and a diffusely enlarged thyroid gland. Laboratory tests reveal a thyroid-stimulatinghormone (TSH) level of 0.00 µU/mL (normal, 0.45 to 4.5 µU/mL), a free thyroxine (FT4) level of 4.8 ng/dL (normal,0.61 to 1.76 ng/dL), and a positive thyroid-stimulating immunoglobulin (TSI) level with high titer.

This 17-year-old presented with a 1-month history of weight loss, increased appetite, mild insomnia, hand tremor, palpitations, sweating, heat intolerance, and quick loss of temper. The number of daily bowel movements had increased from 1 to 2. There was no family history of thyroid disorders.

Because bariatric surgery has traditionally been associated with a high incidence of complications, it has been used primarily for superobese patients. A large body of evidence suggests that laparoscopic adjustable gastric banding is a much safer procedure that is also very effective. This procedure offers an additional option to patients who might benefit from bariatric surgery when diet, exercise, and pharmacologic approaches have failed. Here we address questions primary care physicians often ask about the procedure.

ABSTRACT: Acute scrotal pain, a high-riding testicle, and the absence of the cremasteric reflex on the affected side signal testicular torsion-a surgical emergency. The pain associated with torsion of the appendix testis is usually of gradual onset and is exacerbated by movement. The tenderness is often localized over the infarcted appendix, and the infarction may be visible through the scrotal skin (the "blue dot sign"). Pain associated with epididymitis is usually gradual in onset; the patient may complain of dysuria, increased frequency, and discharge, particularly if the causative pathogen is Chlamydia trachomatis or Neisseria gonorrhoeae. Hydroceles are smooth and nontender, and the scrotum transilluminates. If the scrotum does not transilluminate and compression of the fluid-filled mass toward the external ring completely reduces the mass, then a hernia is the more likely diagnosis. A patient with a varicocele typically complains of a sensation of heaviness and of "carrying a bag of worms."

Most sport-diving problems are mild and self-limited; however, serious or life-threatening situations can arise. In a previous article (CONSULTANT, June 2004, page 961), we addressed fitness and safety issues. In this article, we review the principal medical problems associated with sport diving.

ABSTRACT: Consider prophylactic therapy for patients with frequent (5 or more per month), severe migraine attacks; commonly used agents include β-blockers, calcium channel blockers, antidepressants, and antiepileptic agents. Daily or alternate-day use of aspirin or an NSAID may also be helpful, and limited data suggest angiotensin II receptor blockers may provide effective migraine prophylaxis. For treatment of acute migraine attacks, triptans have emerged as the most effective agents. Controlled clinical trials have demonstrated that all the triptans have similar efficacy. The optimal strategy for an acute migraine attack is to initially administer a therapeutic agent at a dose sufficient to relieve symptoms. Intervention during the early, mild stages of an attack is more likely to alleviate pain than intervention after moderate to severe symptoms occur.

An obese 61-year-old man who hadchronic obstructive pulmonary diseaseand sleep apnea heard a “pop”in his stomach while lifting a heavyweight; severe abdominal pain followed.He was short of breath thenext morning, and his physician empiricallyprescribed cephalexin.

A 39-year-old man complains of severe daily headaches that he describes as throbbing and "burning," with a sensationof pressure. He rates the severity of his pain as 8 to 10 on a 10-point visual analog scale (VAS) in which 10 isthe most severe. The mean duration of the headaches is 12 hours, and the mean frequency is 5 days per week. Betweenthe episodes of severe headache, he has constant "minor" headaches that are not as severe (mean severity, 3 to 5 on a10-point VAS). Within the past 5 months, he has never been totally free of headache.

Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.

Millions of Americans suffer from anxiety disorders. Many with panic disorder, social anxiety disorder, and/or generalized anxiety disorder present initially to their primary care clinician. Effective treatment is possible in a busy primary care setting; therapy involves patient education and pharmacotherapy. Once other potential causes of symptoms of an anxiety disorder have been ruled out, the first step is to reassure the patient that he or she has a psychological condition-a very common one-and that symptoms are not the result of an undiagnosed disease or "going crazy" or "losing control." Educate and inform patients that complete clinical remission is achievable, often with medication alone. Begin treatment on day 1 with a long-acting benzodiazepine-such as alprazolam XR or clonazepam-or with the anxiolytic agent buspirone; at the same time, start a selective serotonin reuptake inhibitor (SSRI). The anxiolytic agent allays acute somatic symptoms until the full effects of the SSRI are manifest (often 4 to 6 weeks). The anxiolytic can then be gradually tapered. Referral to a psychiatrist for psychotherapy may be indicated when a patient refuses or cannot tolerate drug therapy, or when response to therapy is inadequate.

Numerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

Is hypertension a frequent manifestation of thyroid disease?Which clinical clues suggest hypertension in persons with thyroiddysfunction?

The key factor in reducing morbidity and mortality in patients with chronic obstructive pulmonary disease (COPD) continues to be smoking cessation. Newer formulations of nicotine replacement therapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and may be appropriate for highly dependent smokers. Bupropion has been shown to improve smoking cessation rates, either when used alone or with a nicotine patch. Both the influenza and pneumococcal vaccines are recommended to reduce the morbidity and mortality associated with respiratory infections in patients with COPD.