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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.

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Tuberculin-type hypersensitivity is characterized by marked spongiotic dermatitis with intraepidermal and subepidermal vesiculation and scattered eosinophils.

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Advances in the understanding of multiple sclerosis (MS) have translated into aggressive treatment regimens that enhance patients' quality of life. In this article, we discuss the therapeutic options, especially treatments that are directed toward the underlying immunologic mechanisms of the disease. Because of its direct effect on quality of life, aggressive management of symptoms is emphasized.

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Emphysematous pyelonephritis (EPN) is a rare but life-threatening infection characterized by widespread necrosis and production of gas within the kidney.

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Because bariatric surgery has traditionally been associated with a high incidence of complications, it has been used primarily for superobese patients. A large body of evidence suggests that laparoscopic adjustable gastric banding is a much safer procedure that is also very effective. This procedure offers an additional option to patients who might benefit from bariatric surgery when diet, exercise, and pharmacologic approaches have failed. Here we address questions primary care physicians often ask about the procedure.

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ABSTRACT: Unless the cause of back pain is obvious, order anteroposterior and lateral radiographs of the spine, a complete blood cell count, erythrocyte sedimentation rate, and urinalysis. If you suspect infection, tumor, or bony abnormalities, obtain an MRI or CT scan. MRI has surpassed bone scanning as the gold standard for diagnosing spinal infections, because it confirms a specific anatomic diagnosis. Spondylolysis and spondylolisthesis are 2 of the most common causes of back pain in adolescents; the diagnosis is made with plain radiographs, which show slippage on the later-al view in patients with spondylolisthesis and fracture through the pars interarticularis on the oblique views in those with spondylolysis.

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A 24-year-old woman was concerned about a protruding epigastrium mass that had grown since it was first noted 4 months earlier. She had no abdominal pain, nausea, or vomiting.

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ABSTRACT: Although the widespread use of prostate-specific antigen (PSA) testing has led to an increase in the number of cancers detected, controversies about the benefits of screening persist. No conclusive evidence has yet emerged that PSA screening reduces the mortality associated with prostate cancer. Thus, mass screening is not universally endorsed. The American Urologic Association and the American Cancer Society recommend that digital rectal examination and PSA testing be offered annually to men 50 years and older with an estimated life expec- tancy of 10 years or more. High-risk patients (those with a positive family history or those of African American descent) are advised to begin screening at age 45. The decision to screen is based on the patient's preference following a thorough discussion of the benefits and limitations of PSA testing. Refer to a urologist any patient with a PSA greater than 4.0 ng/mL. Also, be alert for high PSA velocity changes in patients undergoing annual screening, and refer those with a PSA velocity of more than 0.75 ng/mL/y.

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A 22-year-old woman presented to her primary care physician’s office with right lower quadrant and suprapubic abdominal pain. She stated that the pain had begun earlier that day; she had no symptoms on awakening that morning.

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A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.

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A 35-year-old woman presented to the emergency department (ED) with vague abdominal complaints. The patient had a complex medical history that included diverticulosis and relapsing polychondritis. Initially, her polychondritis was limited to involvement of the ears and nose. Within the past few years, however, her polychondritis flares had been associated with progressive dyspnea, which prompted intermittent and then long-term use of high-dose oral corticosteroids.

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Would you consider oral steroids for a patient with acute radiculopathy due to a herniated disc? What's the clinical evidence of benefit?

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abstract: In the past, constrictive pericarditis was most often caused by tuberculosis. Today, however, it is more likely to be preceded by injury or trauma, infection, or previous cardiac surgery. Most patients with constrictive pericarditis present with dyspnea and have elevated jugular venous pressure. Other potential symptoms and signs include peripheral edema, abdominal fullness, hepatomegaly, ascites, and chest pain. Electrocardiography demonstrates nonspecific ST-segment and T-wave changes and generalized T-wave inversion or flattening. In many cases, chest radiography and CT reveal pericardial calcification, and echocardiography shows increased pericardial thickness and calcification. Treatment may include NSAIDs, corticosteroids, antibiotics, angiotensin-converting enzyme inhibitors, and diuretics. Surgery is the treatment of choice for chronic disease, and pericardiectomy is typically effective. (J Respir Dis. 2007;28(2):49-56)

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A 51-year-old man with a long history of alcohol abuse and heavy cigarette smoking presented to our hospital with worsening of a chronic cough, which had become productive of thick green sputum and was associated with posttussive emesis. He denied fevers and chills but had a recent and unintentional weight loss of about 5 kg. He had a history of squamous cell carcinoma of the right tonsil, which remained in remission for more than 4 years after chemotherapy, radiation therapy, and resection. There was no recent history of travel or any occupational exposures or known contacts with tuberculosis or animals (wild or domestic).

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Primary care providers are thefirst responders for many childrenwho are clearly manifestingemotional and psychologicalreactions to the recentterrorist attacks and ongoing threatsof terrorism and war. You can facilitatetimely and appropriate referral tomental health services for such childrenand their parents. Bear in mind,however, that many children and parentswho would benefit from supportiveservices and/or counseling will notbe self-identified. Thus, all cliniciansneed to maintain a heightened awarenessfor trauma-related symptoms,such as somatization, and help thesefamilies begin to address the underlyingpsychological issues.

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A 45-year-old man presents with a 4- to 5-year history of an intermittent, asymptomatic, red, circular rash on his trunk. Trials of antifungal creams have not been successful. The patient is otherwise healthy and takes no medications.

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The "sat fat" fires are flaming once again. Yale nutrition researcher David Katz weighs in.

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A 43-year-old woman with chronic hip pain presents with an asymptomatic eruption on the hip of several months' duration. She has been using a heating pad at night for pain relief because NSAIDs have not been effective.

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ABSTRACT: The Studies of Left Ventricular Dysfunction (SOLVD) trials demonstrated that early intervention in congestive heart failure (CHF) improves survival. However, early CHF is mainly a clinical diagnosis based on New York Heart Association criteria and, until recently, no easy and inexpensive screening test existed. There are now several such tests that employ radioimmunoassays (RIAs) to measure cardiac peptides in a single plasma sample; results help determine the likelihood that CHF is present but do not definitively establish the diagnosis. The vessel dilator RIA is the most specific and sensitive for differentiating persons with mild CHF from healthy ones; intravenous administration of this cardiac peptide hormone has beneficial hemodynamic, diuretic, and natriuretic properties in persons who have CHF. Brain natriuretic peptide (BNP) measured by fluorescence immunoassay is useful in the emergency department, because a result may be obtained in as little as 15 minutes. This assay may indicate CHF; further tests are recommended to define the diagnosis. BNP increases with other causes of dyspnea, including pulmonary hypertension, pulmonary emboli, and renal failure, so it is not specific for CHF. BNP also increases with age, and measured values are higher in women than in men.

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Six months after testing positive for HIV in 10 bands, a 24-year-old homosexual man presented with a macular rash on his palms and soles. He first noticed the lesions 2 weeks earlier; they were not pruritic or painful. He also had a brighter, more inflamed rash in the groin and antecubital fossae that was presumed to be a yeast infection and was treated with fluconazole. He had no other symptoms.

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Salivary gland enlargement, most commonly involving one or both parotid glands, is sometimes seen in association with HIV infection. Enlargement of the parotid gland may be due to diffuse infiltrative lymphocytosis syndrome; lymphoepithelial cysts; or malignant tumors, such as squamous cell carcinoma, Kaposi sarcoma, and Hodgkin and non-Hodgkin lymphomas.1,2 Non–HIV-related causes of parotid enlargement include acute and chronic viral infection, granulomatous disease, malnutrition, alcoholism, and diabetes mellitus.3,4 Here we report the case of a 41-year-old HIV-infected man with fat maldistribution syndrome associated with type 2 diabetes and hyperlipidemia. Sialadenosis developed presumably as a result of HIV infection and hypertriglyceridemia.

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For several weeks, a 78-year-old woman had an intensely pruritic, diffuse, raised, slightly scaly, erythematous rash that persisted despite the use of several over-the-counter topical medications (such as hydrocortisone and clotrimazole cream). Since her last visit about 3 months earlier for a blood pressure reading, she had been well except for 2 episodes of night sweats. For several years, she had been taking levothyroxine and reserpine/hydrochlorothiazide; about 6 months ago, valsartan/hydrochlorothiazide had been prescribed.

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The family of a 49-year-old Chinese man brings him to the hospital after he becomes confused and disoriented. For about a week, the patient has had cough, cold symptoms, dizziness, and occasional vomiting.

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abstract: There is increasing evidence that close monitoring and early intervention lead to better outcomes in patients with cystic fibrosis. At each office visit, spirometry should be performed and sputum culture specimens should be obtained; if the patient cannot produce sputum, a throat culture can be done instead. New respiratory symptoms or other evidence of worsening lung disease should prompt antibiotic therapy, increased airway clearance, and adjunctive anti-inflammatory medication as appropriate. Close attention should be paid to the patient's diet, appetite, stooling pattern, and growth measurements. Adolescents should be given additional information about their medications and adjunctive therapies to encourage them to take on a larger role in their own care. (J Respir Dis.2006;27(7):298-305)