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Nail-Patella SyndromeThis 33-year-old Guatemalan man presented to a medical mission camp with generalized bilateral knee pain and inability to extend his leg without pain. The 4-ft 11-in patient had mild scoliosis, increased elbow carrying angles, and hypoplastic patellae. He had had dysplasia of the nails with triangular lunulae since birth. The fingernails were absent on the first and second digits of both hands. His mother had had similar physical findings. He had not had regular medical care.
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Sarcoid UveitisA 44-year-old black man presented to our office with insidious onset of blurred vision. He had no significant past medical history but complained of dyspnea on exertion. On examination, the left pupil was irregular and fixed. A chest film demonstrated bilateral hilar adenopathy. Laboratory findings included normal purified protein derivative test results and elevated angiotensin-converting enzyme levels; pulmonary function studies appeared normal.
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Lichen Planus: Quick TipsA 27-year-old man presented with intensely pruritic, violaceous, flat-topped papules on the lateral aspect of his left leg. He reported that the lesions developed a few weeks after the area was severely scraped in an accident several months earlier.
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Statin-Drug Interactions: Update on the Most Common and Clinically SignificantStatins (HMG-CoA reductase inhibitors) are the most effective drugs in the management of elevated low-density lipoprotein cholesterol (LDL-C) levels. Recent large clinical trials continue to demonstrate the remarkable efficacy of these agents, including improved outcomes.
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The “Statin-Intolerant” Patient: Alternative Strategies for Primary CareIn patients deemed statin-intolerant, lifestyle changes and alternative classes of drugs should be pursued to lower LDL-C.
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What Is Causing Headache and Neck Stiffness in This Patient?A 41-year-old African American man presented with the chief complaint of a constant, dull headache for 3 days. The headache had a gradual onset and was associated with nausea and mild neck stiffness that was not relieved by acetaminophen. The man denied experiencing visual disturbances, fever, night sweats, weight loss, cough, shortness of breath, emesis, or weakness. He had no recent history of trauma or sick contacts.
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Docs on Board With CDC Opioid GuidanceMost respondents to a SERMO survey supported mandatory registration and use of Prescription Drug Monitoring Programs.
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Clostridium difficile: New Guidelines Confront Hypervirulent StrainRecurrent C difficile requires pulse vancomycin therapy; fecal microbiota transplant shows promise.
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Osteoporosis:What to Tell Patients About Prevention and TreatmentOsteoporosis is no longer consideredage- or sex-dependent, although prevalencevaries by sex and race. Postmenopausalwhite women suffer almost75% of all hip fractures and havethe highest age-adjusted rate of fracture.Thanks to progress in our understandingof causes and treatments, thisdisease is largely preventable, and significantimprovements in morbidityand mortality are possible. The beststrategy for prevention and treatmentuses a team approach that involves thepatient, physician, health educators, dietitians,and physical therapists.
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Solitary Rectal Ulcer SyndromeA 34-year-old woman who has had constipation and episodes of obstipation for at least 5 years recently passed blood and mucus rectally and has a rectal prolapse. Colonoscopy revealed an ulcer on the anterior rectal wall, approximately 4 cm from the anus.
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Avoid Caffeine to Stop the FlowBefore you prescribe an anticholinergic for patients with urinary frequency or urge incontinence, advise them to cut out all caffeine. Complete avoidance--rather than just decreased intake--often results in an immediate improvement in symptoms.
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Emerging Treatments for Rheumatoid Arthritis: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.
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Podcast: Status of the Polypill in Prevention of Cardiovascular DiseaseFindings of the TIPS-2 study, announced at the recent 2012 World Congress of Cardiology, put the promise of the polypill-a simplified, one-size-fits-all approach to prevention of cardiovascular morbidity-back on the table for international discussion. Here, Dr Christopher Cannon puts the TIPS-2 results in perspective.
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Antidepressant-Induced Sexual Dysfunction: Five Management StrategiesSelective serotonin reuptake inhibitors and other second-generation antidepressants have become common therapeutic options for the management of depression. Although these agents are effective and generally well tolerated, they frequently cause sexual adverse effects that can impact patients’ quality of life, thus ultimately leading to nonadherence to therapy in many cases.
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Gastrointestinal Involvement of Systemic AmyloidosisThe authors present a case of AL amyloidosis with rare GI involvement and an equally rare presenting symptom.
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Blood Pressure Measurement:ABSTRACT: The most common errors in measuring blood pressure (BP) are using the incorrect cuff size, not having the patient relax for 5 minutes before the measurement, and deflating the cuff too quickly. Observer bias may compound technical errors. When patients use the proper procedure, home BP measurements may be more reproducible than office measurements. Brachial artery-based monitors are more accurate than finger- or wrist-based instruments. To ensure that patients measure their BP correctly, observe their technique with their own monitors. Counsel patients to measure their BP at predetermined times and to have their monitors validated periodically.
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High-Grade Ductal Carcinoma In SituFor 6 weeks, a 68-year-old woman had had sharp pain in the left breast that radiated to the left arm and back. The pain was worse on palpation; ibuprofen provided only mild relief. She denied nipple discharge, skin discoloration, and fever. She had no family history of breast cancer. Results of a biopsy of the left breast 6 years earlier were benign. Her most recent mammogram, 4 weeks earlier, was negative.
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Systemic Inflammation and Use of Diet to Stem DiseaseThe popular media recently took a look at the connection between systemic inflammation and the many human diseases it’s responsible for. A lengthy article in the Wall Street Journal focused on the role of daily diet in the development and modulation of inflammation and noted the clinical use of biomarker C-reactive protein to measure inflammation levels. Harvard cardiologist Christopher Cannon offered tips on eating to beat inflammation and shed pounds at the same time from his new book titled The Complete Idiot’s Guide to the Anti-Inflammation Diet. Alarming health news paired with a new book on diet can create a perfect storm of questions from you patients.
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Low Back Pain: Management of the Psychosocial ComponentBack pain is second only to upper respiratory tract infection as the most frequently reported illness in the United States; up to 20% of Americans experience back pain each year.
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Spontaneous Internal Carotid Artery DissectionA 36-year-old man who had collapsedand sustained a bruised right shoulderwas brought to the emergency departmentwith acute emesis, cephalgia,blurred vision, aphasia, and righthemiparesis. He was confused but ableto follow simple commands.
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Penicillin- and Carbapenem-Induced Neurotoxicity: How to Reduce the RiskPenicillin-induced neurotoxicity was first recognized by Johnson and Walker in 1945 after intraventricular administration of benzylpenicillin.1,2 Subsequently, the β-lactams have been shown to have a higher rate of CNS effects than other classes of antibiotics.3,4
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Older Man With Exertional Dyspnea and Leg SwellingA 74-year-old man with a history ofatrial fibrillation presents to hisprimary care physician with dyspneaof 4 days’ duration. The dyspnea developedwhile he was walking as partof his recovery from back surgery forspinal stenosis 1 month earlier. Hebecame progressively short of breathand was unable to carry out his exerciseprogram.
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Achalasia in a Previously Healthy Young ManFor 3 weeks, a previously healthy 24-year-old man had repeated episodes of nonbloody, nonbilious emesis. He denied dysphagia, but he did report a 40-lb (18-kg) weight loss and heartburn.
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Renal Infarction in the Setting of Undiagnosed Paroxysmal Atrial FibrillationAcute renal infarction most often causes flank pain associated with nausea, vomiting, abdominal pain and, less frequently, fever.
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Prevention of Opportunistic Infections in the Solid Organ Transplant RecipientThe successful management of immunosuppression followingsolid organ transplant requires a delicate balance betweenpreventing allograft rejection and minimizing the risk ofinfection. Strategies that may reduce the risk of de novoopportunistic infection and emergence of latent infectionduring the early posttransplant period-specifically infectioncaused by Cytomegalovirus, opportunistic fungi such as Aspergillus and Candida, and bacteria such as Pneumocystisjiroveci and Mycobacterium tuberculosis-are presented in thisreview. [Infect Med. 2008;25:403-415]
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Case In Point: Fever and a chest wall mass in a young manCoccidioides immitis is a di-morphic fungus that causes pulmonary disease with a variety of clinical and radiographic presentations. Miliary pulmonary disease is very uncommon and is found almost exclusively in immunocompromised patients. The authors describe the case of an immunocompetent patient who had disseminated coccidioidomycosis with a miliary pulmonary disease pattern. Obtaining a careful travel history and considering regional fungal infections was integral to making a prompt diagnosis.
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Nasal Perforation From Chronic Cocaine AbuseCocaine abuse is associated with many dermatological manifestations, vasculitides, and infections. Consider this diagnosis in patients with unexplained chronic skin lesions, an ambiguous medical history, previous examinations that found no source of symptoms, labile affect, and delusional behavior.
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Sulfonylurea-Induced Hypoglycemia: The Case Against GlyburideSince it came onto the market in 1983, glyburide has been one of the most popular sulfonylureas. The American Diabetes Association (ADA) recommends the use of these agents as part of a stepwise approach to treating type 2 diabetes mellitus.
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Primary Adrenal InsufficiencyFor 2 weeks, a 43-year-old white female had worsening nausea and multiple episodes of vomiting. Her symptoms began with increased malaise and decreased appetite. The emesis was unrelated to meals and was sometimes accompanied by mild abdominal distention. She had occasional fevers but denied any recent contact with ill persons. She also reported a 12-lb weight loss, decreased energy level, and an increased tan complexion over the past several months.
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Pneumomediastinum as First Presentation of Hypersensitivity PneumonitisSpontaneous pneumomediastinum with subcutaneous emphysema is rare. Alveolar rupture allows air to enter the pulmonary interstitium and penetrate the mediastinum.
