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A 52-year-old woman presented to her primary care physician complaining of a nonproductive cough and dyspnea on exertion. These symptoms had a subacute onset over 4 weeks before her initial visit. She denied fever, sputum production, hemoptysis, chest pain, palpitations, abdominal pain, nausea, vomiting, and diarrhea. She did not have any known sick contacts.

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The FDA would have broad public support for a behind-the-counter (BTC) classification for drugs. According to the results of a telephone survey conducted by Leo J. Shapiro & Associates, 67% of respondents said they would welcome the convenience of obtaining a drug without a prescription and after counseling by a pharmacist, even while they recognize that their insurance plan would not cover the cost of the BTC medication.

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A 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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A 97-year-old woman with a history of hypertension and a paraesophageal hiatal hernia presented with abdominal distention and shortness of breath. Three days earlier, she had fallen and sustained a hairline pelvic fracture; she was evaluated in the emergency department and given narcotics for the pain. Subsequently, the patient's abdomen became increasingly distended, and she had no bowel movement for 3 days.

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The case presented here illustratesthe diagnostic challengesand potential severity of a fungalinfection.

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For 2 months, a 22-year-old uncircumcised man noticed an asymptomatic, erythematous, static lesion on the glans penis. He had applied an over-the-counter “jock-itch” ointment for 2 weeks but to no avail. The young man was otherwise healthy and denied having dysuria or a history of sexually transmitted disease.

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Worsening painful ulcers on both legs prompted a 62-year-old woman to seek medical attention. She had a history of rheumatoid arthritis (RA), demonstrated by the markedly deformed interphalangeal joints in her thumbs (A), and scleroderma-polymyositis overlap syndrome.

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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)

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The weight of some of my patients exceeds the upper limit of our office scales. Rather than invest in a more expensive scale for this small group of patients, we placed 2 scales side by side.

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Clostridium difficile infections account for most cases of antibiotic-associated colitis.1 However, there is increasing evidence that Klebsiella oxytoca infection contributes to the development of C difficile–negative antibiotic-associated hemorrhagic colitis. Most cases have been reported in France,2-12

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Coronary angiography was performed in a 54-year-old man with low-level stable angina. He had undergone percutaneous transluminal coronary angioplasty (PTCA) 3 months earlier. The angiogram showed tight stenosis of the proximal left anterior descending artery. The lesion was successfully dilated during a second PTCA, and a stent was placed using a flexible catheter.

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A 39-year-old man with HIV infection was being treated with antiretroviral therapy. He now sought help for multiple 2- to 3-cm violaceous papules on his right hip and the right lower abdominal area. A biopsy specimen showed intense, atypical lymphocytoid and monocytoid cells with prominent nucleoli, hyperchromatism, and bruised nuclei.

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For 6 months, a 69-year-old man has experiencedpain in his right shoulder; hetakes NSAIDs for relief. During the lastmonth, the pain has worsened, weaknessand tingling have developed in his righthand, and the skin on the right side ofhis face has become dry. The patient alsoreports a 1-month history of melanoticstools. He had smoked 1 pack of cigarettesa day for 50 years before quittinglast year

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ABSTRACT: Patients with rheumatoid arthritis (RA) often havepulmonary manifestations, such as interstitial lung disease.The most common cause of upper airway obstruction is cricoarytenoidarthritis. Patients often complain of a pharyngeal foreign-body sensation or hoarseness, but some present with severestridor. Bronchiolitis obliterans is characterized by a rapidonset of dyspnea and dry cough, with inspiratory rales andsqueaks on examination. This presentation, particularly in middle-aged women with seropositive disease, distinguishes bronchiolitisobliterans from other pulmonary manifestations ofRA. High-resolution CT may be more sensitive than pulmonaryfunction tests for detecting small-airways disease, and it frequentlyshows moderate to severe air trapping on expiratoryimages. (J Respir Dis. 2008;29(8):318-324)

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An 80-year-old woman has a 3-month history of increasing dysphagia (withboth solids and liquids), fatigue, and dyspnea on exertion. She has also involuntarilylost 50 lb during the same period. She reports no abdominal pain orchange in bowel function.

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A 31-year-old man presents with a2-week history of a constant, dull acheand hearing loss in the right ear. Healso complains of intermittent sharppains that are usually followed bydrainage through the external auditorycanal. Another practitioner diagnosedacute otitis media with tympanic membraneperforation, for which he prescribeda 10-day course of amoxicillin.The patient completed the regimen buthas obtained no relief.

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A 47-year-old woman who recently completed adjuvant chemotherapy for colon cancer has painless cervical lymphadenopathy of 1 to 2 cm. She has no fever, sore throat, cough, or unexplained weight loss, and she denies exposure to ill persons or animals.

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A focus on the known clinically significant drug-drug interactions of phenytoin.

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Benzocaine-induced methemoglobinemia has been a well-documented illness that is usually simple to cure but can be life-threatening if not recognized. As the use of "scope" procedures becomes more commonplace, the early recognition of hypoxemia resulting from methemoglobinemia is essential. The authors report a case of benzocaine-related methemoglobinemia following bronchoscopy.

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Dipeptidyl peptidase-4 inhibitors, of the incretin class of antidiabetes drugs, are weight neutral, avoid hypoglycemia, and result in an average reduction in HbA1c of 0.5% to 1.0%

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A 7-year-old boy with a history of atopic dermatitis presented with an intensely pruritic linear rash on his upper extremity. His mother reports that the rash has been “growing” despite use of topical corticosteroid creams.

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Urinary incontinence is common--especially among older adults--but underdiagnosed. Many persons with this disorder are reluctant to discuss it with their physicians; often, only direct questioning can uncover the problem.

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Apreviously healthy 47-year-old woman presents with an ascending, nonpruritic rash of 3 days’ duration on her legs. She reports that the rash began on her ankles following a day of gardening. She does not recall any recent insect bites and denies chest pain, dyspnea, abdominal pain, fever, arthralgia, arthritis, cough, and hemoptysis. She has never had a similar rash before. The patient’s only medication is an oral antihistamine for seasonal allergies. She has no known drug allergies.

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Graves disease presents commonly with exophthalmos and stare and striking pretibialmyxedema.

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Coccidioides 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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Abstract: High-resolution CT (HRCT) can play an important role in the assessment of bronchiolitis. Direct signs of bronchiolitis include centrilobular nodules, bronchial wall thickening, and bronchiolectasis. Indirect signs include mosaic perfusion, hyperlucency, mosaic or diffuse airtrapping, vascular attenuation, and increased lung volumes. Expiratory HRCT scans are considered an essential part of the workup, because airtrapping may be evident only on these scans. In infectious cellular bronchiolitis, the centrilobular nodules typically have a branching, or "tree-in-bud," appearance, whereas in hypersensitivity pneumonitis, these nodules have a round or nonbranching pattern. The HRCT signs of constrictive bronchiolitis include mosaic perfusion, mosaic airtrapping, vascular attenuation, bronchiolectasis, and bronchiectasis; centrilobular nodules are usually absent. (J Respir Dis. 2005; 26(5):222-228)

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Plague is caused by Yersiniapestis, a gram-negative, nonmotile,nonsporulating bacillus.It is a zoonotic disease, and rodentsare the primary reservoir.Plague can present as bubonic,pneumonic, or primary septicemic disease.Y pestis is usually transmitted tohumans via the bites of infected fleas,causing the bubonic form of the disease.Primary septicemic and secondarypneumonic disease are muchless common. Primary pneumonicdisease results from aerosol exposureto an infected animal or human withplague pneumonia; however, it too hasbecome uncommon as a natural event.Nonetheless, primary pneumonicplague, or a similar illness, is the mostlikely manifestation following a bioterroristattack.1,2 Despite the substantialinvestment by the former Soviet Unionin this agent as a potential weapon,there is little experience from whichto predict the clinical consequencesof intentional aerosolization of thisorganism.

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Your patient with atrial fibrillation (AF)is hemodynamically stable and youhave successfully established rate control.Your next step is to weigh therisks and benefits of attempting to restoresinus rhythm. In up to one half ofpatients, AF of recent onset convertsspontaneously to normal sinus rhythmwithin 24 hours. Thus, in some cases,the most appropriate approach maybe to control the ventricular response,identify and treat comorbid conditions,initiate anticoagulation, and closelymonitor the patient.

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The recent signing of health reform legislation signals a watershed event in the delivery of health care in our country. It is the culmination of a tangled legislative battle, but it ignores 3 of the 4 pillars of health reform. In this article, I describe these pillars, and then outline where recent legislation falls short.