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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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Small-Bowel Metastatic MelanomaAn 83-year-old man with a history of hypertension, hyperlipidemia, and diverticulosis was hospitalized because of painless hematochezia of 1 day's duration. Two years earlier, he had undergone surgical excision of a superficial spreading melanoma on his right thigh.
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What Is the Cause of Macrocytosis and Dyspnea in an Older Man?A 78-year-old man presented to theemergency department with a 3-weekhistory of progressive shortness of breathand cough with blood-streaked, yellowishsputum. The patient had dyspnea onexertion limited to 2 blocks, 2-pilloworthopnea, paroxysmal nocturnal dyspnea,and nocturia. Neither fever norchills were present. He had lost 7.2 kg(16 lb) during the last year.
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Breast Abscess After Nipple PiercingA 29-year-old sailor presented with a painless, enlarging, reddish, mobile lump under his left nipple. Four months earlier, while on deployment in the South Pacific, he had his nipples pierced on a whim.
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Space-Age Concussion Assessment Tool Has a Long Way to GoMIAMI -- With the Super Bowl upon us, the long-term effects on some former National Football League players of repeated concussions, including premature Alzheimer's disease-like symptoms, have been the subject of two front-page articles in The New York Times this week. Here from the MedPage Today archives is a major 2005 report on football concussions at all levels of competition.
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Surfer's EarA 35-year-old man, a sea and white-water kayaking instructor, complained of pain and congestion in the right ear. Otoscopy revealed bilateral external auditory canal stenosis with impacted cerumen and otitis externa on the right.
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Wood Smoke, Indoor Air, and AsthmaIn many parts of the country-and for people of all ages-a turn of the calendar to the winter months means more time spent indoors. For patients with asthma, however, an evening spent in front of a crackling fire may simply serve as a trigger for an attack.
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Association Between Sleep Disorders and GERD Explored at ACG MeetingMention GERD and most of patients probably think of heartburn. But the GERD story does not begin and end with the esophagus. The connection between GERD and laryngeal, pharyngeal, and pulmonary symptoms is the focus of a seminar, “An Eye and Nose Opening Experience-Chronic Complications of GERD,” at the upcoming American College of Gastroenterology Annual Scientific Meeting, October 31 to November 2 in Washington, DC.
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Clinical InvestigationThe CDC estimates that more than 850,000 people are living with HIV/AIDS in the United States today,1 with African Americans and Latinos being disproportionately affected.2 Over the past decade, the Latino population in the United States has been growing. In fact, in 2002 for the first time, Latinos surpassed African Americans as the largest US minority group. However, the term "Latino" is applied to a very heterogeneous group from different countries and different cultures.3 In addition, a large proportion of Latinos is undocumented in the United States and thus marginalized from the health care system.
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In COPD, Controlling Acute Exacerbations Remains Key to SurvivalCOPD exacerbations severe enough to require hospitalization are a red flag for mortality. Preventing or delaying the second after a patient is discharged, and each successive exacerbation, is crucial to extending lifespan.
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Orthotopic UreteroceleA 67-year-old woman was admitted to the hospital with fever, chills, unilateral flank pain, dysuria, and urinary frequency and urgency. Her past medical history included several febrile relapses of infection.
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ICD-10 Uptake Poll: Week 1You knew it was coming; you prepared and prepared; you had meetings, you stayed late; you were ready. So, how'd it go?
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Arterial blood gas analysis: A 3-step approach to acid-base disordersThe foundation of arterial blood gas (ABG) analysisconsists of determining whether the patient has acidosis or alkalosis;whether it is a respiratory or metabolic process; and,if respiratory, whether it is a pure respiratory process. If the patient'spH and PCO2 are increased or decreased in the same direction,the process is metabolic; if one is increased while theother is decreased, the process is respiratory. In a number ofclinical situations, pulse oximetry is preferred to ABG analysis.However, pulse oximetry may not be accurate in patients whoare profoundly anemic, hypotensive, or hypothermic. Whilevenous blood gas (VBG) analysis does not provide any informationabout the patient's oxygenation, it can help assessthe level of acidosis or alkalosis. VBG analysis may be particularlyuseful in patients with diabetic or alcoholic ketoacidosis.(J Respir Dis. 2008;29(2):74-82)
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Bronchoalveolar Carcinoma in a 58-Year-Old ManA 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.
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Breast Abscess After Nipple PiercingA 29-year-old sailor presented with a painless, enlarging, reddish, mobile lump under his left nipple. Four months earlier, while on deployment in the South Pacific, he had his nipples pierced on a whim.
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Woman With Abdominal Pain and ObstipationA 63-year-old woman presents to the emergency department with a 3-day history of abdominal pain, nausea, and obstipation. The pain is located in the left lower quadrant and is sharp, constant, and nonradiating.
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Cutaneous Leishmaniasis (“Baghdad Boil”)A 33-year-old active-duty soldier who had been in Iraq for 6 months presented with a depressed lesion on his left lateral elbow of several months’ duration. It was neither healing nor enlarging. (The yellowish tint to the skin in the photograph was from a topical iodine solution.)
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Hydrocele in a Sterilized ManScrotal enlargement and pain of rapid onset prompted a 28-year-old man to seek medical attention.The testicle was displaced posterior and inferior in the engorged scrotum and wasdifficult to palpate.
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CollagenomasDuring a skin cancer screening, a 45-year-old male soldier was noted to have bilateral subcutaneous nodules on the dorsa of his feet. The patient reported that the nodules had remained unchanged since they first appeared in his early 20s and were asymptomatic. He had no other lesions.
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Clinical Observations on West Nile Virus InfectionsIn 2004, 391 cases of West Nile virus (WNV) infection werereported in Arizona. This represented an epidemic thatchallenged area clinicians. We treated 34 patients with WNVinfection and reviewed their medical records. They werehospitalized at 3 community hospitals during the epidemic.These patients represented 9% of all WNV infection casesreported in Arizona. Meningitis was diagnosed in 13 patients,encephalitis in 12, fever of unknown origin in 5, transversemyelitis in 3, and carditis in 1. Respiratory failure requiringmechanical ventilation developed in 6 patients. Five of thesickest patients were empirically treated with interferon alfa 2band ribavirin. The epidemic and associated clinical challengesprompted evaluation of the available diagnostic and treatmentstrategies to optimize care of very ill patients. The consensusamong clinicians was that they were poorly prepared todiagnose and treat WNV infection in hospitalized patients.All patients survived hospitalization, although 4 patientsdied after discharge because of factors attributable to WNVinfection. [Infect Med. 2008;25:430-434]
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Cocaine-Induced StrokeBrain infarcts among crack cocaine users may be secondary to large cerebral artery vasospasm with secondary intravascular thrombosis (with or without distal embolization).
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Metallic Corneal Foreign Body With Rust RingTwo days after "heading" a soccer ball, a 17-year-old boy presented to the emergency department with progressive pain and a foreign-body sensation in his left eye. Visual acuity was 20/20 in the right eye and 20/25 in the left eye. The pupils were equally round and reactive; full extraocular movements of both eyes were noted. The left eye had conjunctival injection and a 1-mm foreign body on the medial cornea with a surrounding halo of discoloration--typical of a metallic corneal foreign body. A Seidel test (which demonstrates streaming of fluorescein dye from the aqueous humor when illuminated with UV light) revealed no evidence of corneal perforation; there were noareas of fluorescein dye uptake.
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The Right Amount of Exercise Is ...... any amount at all. A new American College of Cardiology report says even minimal exercise helps lower risk of cardiovascular disease.
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Pearls From Steven Nissen, MD: On Statin Denial and Cult DietsDr Steven Nissen says statins and climate change share similar public opinion problems and suggests counter tactics.
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Elevated Hematocrit in Man Receiving HemodialysisA 50-year-old man with end-stage renal disease secondary to long-standing hypertension had an elevated hematocrit and progressively increasing hemoglobin levels. For the past 7 years, he had been receiving hemodialysis 3 times a week. He denied headache, flushing, easy bruising, bleeding, nausea, vomiting, chest pain, dyspnea, and other symptoms. He was not receiving exogenous erythropoietin.
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Diabetic Myonecrosis: A Rare Complication of Type 2 DiabetesA 50-year-old African American woman with type 2 diabetes mellitus and hypertension was admitted with constant bilateral knee and thigh pain and swelling of both knees, all of 1 week’s duration. The pain was not relieved with hydrocodone/acetaminophen and had caused weakness and subsequent falls.
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FOOSH Injury of the ElbowFOOSH injuries associated with acute onset of pain at the elbow suggest fracture of the radial head, proximal ulna, or humeral condyle or soft tissue injury.
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Vertebral Compression Fracture and OsteoporosisNo double-blind, randomized controlled studies of the effectiveness of vertebroplasty have been performed. However, this reflects less the effectiveness or safety of the procedure than it does the difficulty involved in conducting randomized controlled trials of any treatment for a pain disorder.
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Pulmonary hypertension in the elderly, part 2: TreatmentABSTRACT: The treatment of pulmonary arterial hypertension(PAH) is directed at the underlying cause, such as diastolicheart failure or chronic thromboembolic disease. Patients withidiopathic PAH or PAH associated with connective-tissue diseasewho have World Health Organization (WHO) functionalclass II or III PAH should receive a trial of oral bosentan, ambrisentan,and/or sildenafil; inhaled iloprost is an alternative oran additive agent. If patients fail to respond to these interventionsor if they have WHO functional class IV PAH, considersubcutaneous or intravenous treprostinil or epoprostenol. Theuse of these latter agents is much more complicated and maybe difficult to initiate in elderly patients. (J Respir Dis. 2008;29(12):468-474)
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Older Woman With Recent Abdominal Pain and FullnessOn her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.
