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Paget's Disease of BoneA serum alkaline phosphatase (ALP) level three times higher than normal, found on routine laboratory examination, prompted further evaluation of a 57-year-old man. At admission, his temperature was 36.8°C (98.2°F), blood pressure was 120/85 mm Hg, pulse rate was 90 beats per minute, and respiration rate was 19 breaths per minute. The physical examination was unrevealing, and the patient's personal and family medical histories were unremarkable.
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Pulmonary nocardiosis mimicking empyema necessitatisNocardia asteroides is a rarecause of pulmonary or disseminatedinfection in immunocompetentpersons. Pleuralcompromise is common, butempyema necessitatis is veryrare. The authors describe anapparently immunocompetentpatient with N asteroides infectionwho had chest wallcompromise mimicking empyemanecessitatis.
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Epidermoid Cysts Treated With Phosphatidylcholine InjectionsEpidermoid cysts may be treated with intralesional injections of phosphatidylcholine to avoid potential recurrence, eliminate scarring, and reduce cost.
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Stevens-Johnson SyndromeA 37-year-old man presented to the emergency department with painful, burning, blistering skin lesions. The lesions started 3 days earlier on the face and spread to the trunk and extremities. Ten days before presentation, the patient had received a diagnosis of AIDS.
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An update on advances in interventional bronchoscopyAbstract: Because of recent advances, more patients may potentially benefit from a variety of interventional bronchoscopic techniques. Nd:YAG laser phototherapy is the most widely used modality and is the treatment of choice for patients with endobronchial malignancies who have large-central airway obstruction. Cryotherapy may be superior to Nd:YAG phototherapy for more distal airways lesions because of the lower risk of airway perforation, but it may be suboptimal for bulky airways disease that requires quick relief of obstruction. Brachytherapy relieves symptoms, such as cough, dyspnea, and hemoptysis, in many patients who have locally invasive airway malignancies. Endobronchial ultrasonography appears to be a safe and sensitive method for staging lung cancer. In select patients with emphysema, a 1-way endobronchial valve can be used to reduce lung volumes. Bronchial thermoplasty is being studied as a potential treatment for asthma. (J Respir Dis. 2006;27(10):415-428)
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Cutaneous Metastasis of Prostatic AdenocarcinomaThis lesion had appeared in the right groin of a 60-year old man and had slowly enlarged over a month (A). Two years before this evaluation, he had undergone total prostatectomy with lymph node dissection for prostate carcinoma. Metastatic disease was found in a resected lymph node, and he underwent multiagent chemotherapy.
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A Young Woman With Sudden Loss of Vision in One EyeA 17-year-old sexually active young woman presented with sudden loss of vision in the left eye 2 weeks before presentation.
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Woman With Acromegaly Presenting as Unilateral Vision LossA 36-year-old woman presented to the emergency department with loss of vision in the right eye that had initially involved the peripheral field and progressed over 2 months to the central and nasal fields. During this period, she also had headaches, vomiting, and generalized weakness. She had had amenorrhea for 1 year.
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New Treatments for Early and Late COPD: Part 1, PreventionABSTRACT: The key factor in reducing morbidityand mortality in patients with chronicobstructive pulmonary disease (COPD)continues to be smoking cessation. Newerformulations of nicotine replacementtherapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and maybe appropriate for highly dependent smokers.Bupropion has been shown to improvesmoking cessation rates, either when usedalone or with a nicotine patch. Both theinfluenza and pneumococcal vaccines arerecommended to reduce the morbidity andmortality associated with respiratory infectionsin patients with COPD.
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COPD: How to Manage Early and Late DiseaseThe goals of therapy in chronic obstructive pulmonary disease are to ameliorate symptoms, improve daily function, preserve lung function, identify and reduce exacerbations and, if possible, decrease mortality. A comprehensiveapproach that includes prevention, early identification, and pharmacotherapy-and oxygen therapy, pulmonary rehabilitation, and/or surgery when appropriate-can optimize patient outcomes.
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Paralytic IleusThis obstruction is caused by a failure of intestinal peristalsis; there is no evidence of mechanical obstruction. Paralytic ileus is common after abdominal surgery, especially if anticholinergic drugs are given preoperatively and/or narcotics are used postoperatively. It usually lasts 2 to 3 days. Paralytic ileus may also be caused by peritonitis; ischemia or surgical manipulation of the bowel; retroperitoneal hemorrhage; spinal fracture; systemic sepsis; shock; hypokalemia; uremia; pharmacologic agents (eg, vincristine, loperamide, and calcium channel blockers); diabetic ketoacidosis; and myxedema.
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Share the Burden of Uncertainty With PatientsWe have to let patientsknow that theimpact of mammography isnot that large-especiallyin women aged 40 to 49years. We simply do notknow whether early detectionof breast cancer leadsto improved outcomes inthis age group.
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Medical Training for the 1%Internal medicine doctors train predominantly in our high-tech academic medical centers, yet most will provide outpatient care. Here, Dr Andrew Morris-Singer frames one of modern health care’s greatest disconnects.
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A rare complication of empyema: Thoracic aorta perforationThis case represents an unusualcomplication of cellulitiscaused by methicillin-resistantStaphylococcus aureus.
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A Neurologist on a Medical MissionHealth expectations and standards of safety in this part of the world are clearly different from what most of us are used to. But it is my impression that “laying on of hands” offers encouragement and hope.
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Renal Infarction: An Unusual Complication of Cocaine AbuseA 63-year-old African American man presented with severe epigastric pain of 1 day's duration. The pain was sharp and continuous and radiated toward the left flank. There were no aggravating or relieving factors or previous similar episodes.
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What You Forgot About the Neurologic Exam, Part 2:ABSTRACT: Asymmetry-whether of strength, reflexes, or sensory function-is an important localizing finding in the neurologic evaluation. Asymmetric deficits of strength may indicate an acute CNS lesion. Symmetric hyperreflexia or hyporeflexia alone is not diagnostic; compare reflexes between sides of the body and between upper and lower extremities. The extensor plantar response (Babinski reflex) suggests an upper motor neuron lesion. During the sensory examination, look for asymmetry and determine whether both light touch and pinprick sensation are intact. Simultaneous stimulation with 2 sharp objects on opposite sides of the body-done to detect extinction of response on 1 side-can uncover subtle sensory deficits.
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Chronic Diarrhea:Chronic diarrhea presents difficulties for clinicians as well as for patients. Because the differential diagnosis is enormous, management can be challenging. In this article, we present a strategy for quickly narrowing the differential based on a simple analysis of stool characteristics. We then describe an appropriate workup for each of the basic types of diarrhea.
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Orbital Pseudotumor Disguised as Orbital Cellulitis and SinusitisA 58-year-old man with a past medical history of chronic sinus disease and hypothyroidism presented with left periorbital pain and erythema that worsened despite outpatient treatment with topical antibiotics. An outpatient CT scan showed pansinusitis and orbital stranding. The diagnosis was orbital cellulitis and sinusitis.
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Concurrent Management of Achalasia and Morbid ObesityThe development of a standardized treatment that simultaneously addresses achalasia and obesity is becoming more imperative as obesity becomes epidemic in the US. Here’s a case in point.
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Chronic Tophaceous GoutThese joint deformities occurred in a 61-year-old man with chronic tophaceous gout. The patient had had joint pain and swelling since he was 40 years old; the symptoms began in 2 fingers and were initially mild. He did not seek medical attention. Within 5 to 10 years, joint abnormalities had developed in the fingers and then in the left elbow and right ankle. The toes were not affected. He had no family history of joint pain or swelling. Serum uric acid level was 9.7 mg/dL.
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Disseminated Histoplasmosis in a Woman With History of Polymyositis and Possible DermatomyositisFor 3 days, a 28-year-old woman with a history of polymyositis and possible dermatomyositis had fever, chills, and nonproductive cough. She complained of rash, joint pain, and progressive immobility because of severe muscle weakness. For the past 6 years, she had been taking prednisone (60 mg/d), hydroxychloroquine (200 mg bid), and tramadol (100 mg q6h prn for pain).
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Congenital RanulaA 1-day-old neonate was brought for evaluation of a mass on the floor of her mouth. The swelling was fluctuant and had a bluish tint. No bruit was detected. There was mild tongue elevation but no airway obstruction. Other than this swelling, physical examination findings were normal. The infant was born at term and was breast-feeding.
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What Do These Images Reveal?A 64-year-old woman complainsof neck fullness that has increased inthe last few months. She has occasionaldyspnea but denies fever, cough, andhemoptysis. Hypertension is well-controlledwith propranolol.
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Middle-aged Man With Chest PainFor 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.
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Blue Rubber Bleb Nevus SyndromeBRBNS is a rare GI disorder characterized by distinctive cutaneous and GI venous malformations that can lead to occult or massive GI bleeding.
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Gram-Negative Bacteria as Cause of Foot IntertrigoFor a year, a 31-year-old man had asymptomatic, malodorous discoloration of the toe web spaces. He stated that his feet perspire heavily in the boots he is required to wear for work.
