All News

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."

ABSTRACT: Consider hyperthyroidism in patients who complain of anxiety or nervousness and palpitations. The diagnosis can be confirmed by measurement of thyroid-stimulating hormone, free thyroxine, and free triiodothyronine levels. Graves' disease is the most common cause of hyperthyroidism; more women are affected than men. A radioiodine uptake test and thyroid scan can distinguish among the various causes of hyperthyroidism. Reserve fine-needle aspiration and biopsy for patients with palpable thyroid nodules. Radioiodine ablation is the treatment of choice for most patients. Some patients, such as children, pregnant women, and patients with large goiters, may be candidates for total or partial thyroidectomy. Antithyroid medications-propylthiouracil and methimazole-are appropriate for patients with mild hyperthyroidism, pregnant women, and children and adolescents with Graves' disease.

ABSTRACT: Because of concerns raised by recent studies about the safety of hormone replacement therapy, attention has shifted to alternative therapies for prevention of osteoporosis. Resistance training has been shown to strengthen skeletal muscles, increase bone mineral density (BMD), and reduce fractures. Low-impact aerobic exercises, such as walking, improve cardiovascular fitness but do not create enough stress to increase BMD or muscle mass. A basic resistance training regimen consists of 5 or 6 weight-bearing exercises performed 2 or 3 times a week. Results can be seen in 4 to 6 weeks.

ABSTRACT: Urinary incontinence is a widespread disorder that remains underdiagnosed, underreported, and undertreated. Nevertheless, it is highly treatable. Components of the initial office evaluation include a focused history taking, physical examination, a postvoid residual urine volume measurement, and urinalysis. Behavioral interventions are first-line therapy. These include bladder training, pelvic floor muscle training, biofeedback therapy, and caregiver-dependent interventions. The antispasmodics oxybutynin and tolterodine are the most commonly used agents for urge incontinence. Stress incontinence can be treated with pseudoephedrine or topical vaginal estrogen. Imipramine may be helpful in cases of nocturnal or mixed incontinence. Overflow incontinence caused by an anatomic obstruction may be treated with an α-blocker.

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.

Over the previous 6 months, a59-year-old man had experienced lethargy,fatigue, poor appetite, cold intolerance,and abdominal distention. Hisvital signs were normal; physical examinationrevealed periorbital andpretibial edema, distant heart sounds,and delayed reflexes.

The mother of a 7-year-old girl noticed the rapid progression of a lesion on her child’s right hand over 3 weeks. Within several days of its initial appearance, the very small, nontender, and nonpruritic lesion had grown in circumference and “looked like a wart,” according to the mother. Application of over-the-counter preparations failed to resolve the lesion. A week before the office visit, the lesion “started growing straight up.”

The father of a 28-year-old man accompanied his son to the emergency department (ED) for evaluation of a “worm infestation.” About 6 weeks earlier, the patient had diarrhea for 2 days and claimed to have seen worms in his stool.

While jogging in a park, a 45-year-old man tripped and fell on his outstretched hand. As he fell, he tried to catch himself on a nearby park bench but was unsuccessful. He felt that his shoulder was out of place, and he was unable to adduct his arm from its erect position. A witness called for an ambulance, and the man was taken to the emergency department.

ABSTRACT: The presence of blood in the urine is a significant finding that calls for prompt evaluation. Gross hematuria usually indicates a serious problem; its correlation with malignancy-typically a transitional cell carcinoma-is fairly high. Microscopically detectable blood is less likely to signal a major underlying condition; a finding of 0 to 3 red cells per high-power field is probably innocent. The workup for gross and microscopic hematuria focuses on disturbances of urinary tract function and includes a history and physical examination, urinalysis, radiologic imaging, urine cytology, and cystoscopy. The presence of hematuria, proteinuria, and renal insufficiency warrants referral to a nephrologist. A search for the cause of microscopic hematuria is much less likely than a workup for gross hematuria to uncover a life-threatening condition. If the hematuria persists, repeat the urinalysis and cytology every 6 months until the problem resolves or 3 years have passed.

ABSTRACT: Most hypertensive patients require lifestyle modification and multiple-drug therapy to achieve current blood pressure (BP) goals of less than 140/90 mm Hg and less than 130/80 mm Hg for those with diabetes mellitus or renal disease. For patients older than 65 years, the recommended initial antihypertensive is a thiazide diuretic. If a diuretic does not adequately control BP or is contraindicated, base the selection of an antihypertensive medication on comorbid conditions. For example, a ß-blocker may benefit a patient with coronary artery disease, while an angiotensin-converting enzyme inhibitor may help forestall renal disease in a patient with type 2 diabetes mellitus. The adage "start low and go slow" is appropriate to help avoid side effects and ensure compliance; however, most elderly patients eventually require standard dosages of medications to adequately control BP.

A 40-year-old womanwith HIV infection has had an occasionallypruritic facial rash for severalmonths. The rash is not associatedwith any systemic symptoms.

A 52-year-old man complains of nausea, fever, and malaise following a 2-day diarrhealillness that developed at the end of a family vacation in New England.Two family members suffered a similar illness, characterized by watery diarrhea.Symptoms developed in all who were affected within 24 hours of eatinghamburgers at a local restaurant.

Painful blue toes developed in a 72-year-old woman with coronary artery andperipheral vascular disease after she underwent angiography.

A 32-year-old African American man presented with an asymptomatic rash of 10 years’ duration.The patient reported that eruption abated during the winter.

A 34-year-old white woman presentswith a 4-month history of diarrhea,with bulky, foul-smelling stools; flatulence;diffuse abdominal discomfort;and episodic nausea and vomiting. Shehas lost 13.5 kg (30 lb) during this period.The patient has had no fever, andher medical, family, and travel historyare unremarkable.

For several months, a 70-year-old woman had had dysphagia,mild dyspnea on exertion, and the Raynaud phenomenon.Her skin was waxy and edematous; 2- to 10-mm pinkishspots had appeared on her fingers, palms, and oral mucousmembrane over the past 2 weeks. These disappearedcompletely with pressure. Subcutaneous calcific depositswere present on the extensor surfaces of the forearms.

A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.