Authors
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Dike Drummond, MD - Brief BioDike Drummond, MD, is a Mayo-trained family doctor, professional coach, author, speaker and trainer whose sole professional focus is addressing the modern burnout epidemic in physicians.
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Paget's DiseaseA 74-year-old man, who had been aware of a gradual increase in hat size over the past 3 years, complained of a mild headache and backache. His serum phosphatase level was 1,475 U/L (upper normal limit, 120 U/L). Skull films showed calvarial enlargement caused by thickening of the cortical tables, radiolucency in the frontal and occipital regions, and patchy osteosclerosis that produced a cotton-wool appearance.
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Acid-Base Problem SolvingA 34-year-old man has had Crohn disease for 12years. He presented initially with ileitis and has had 3surgeries for obstructive complications. Ileum resectionhas resulted in bile salt and fat malabsorption. Recently,the Crohn disease has spread to the large bowel. For thelast 2 years, he has also had seronegative spondyloarthropathy-another complication of Crohn disease.
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Chest Pain: Is It Life-Threatening, or Benign?Ruling out coronary artery disease is the first step in assessing chest pain.
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Case In Point: Recognizing allergic bronchopulmonary aspergillosisA 28-year-old man presented with chest pain, hemoptysis, and wheezing. He had a history of intermittent shortness of breath that occurred at least 3 times a year in the past 3 years; fever; and loss of appetite associated with headache, vomiting, and weakness. His medical history also included asthma, chronic gastritis, and more than 5 episodes of pneumonia since 1996. A test for hepatitis C virus (HCV) had yielded positive results.
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Man With Reflux Symptomsand Esophageal Papular LesionsA 51-year-old man with a 12.5-pack-year smoking history had symptomssuggestive of gastroesophageal reflux disease for 6 weeks.
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Subcutaneous Emphysema After ThoracoscopyA 38-year-old woman with a history of injection drug use presented with progressive pain in the left arm and neck and fever (temperature, up to 38.8°C [102°F]) of 9 days' duration. Physical findings included subcutaneous crepitus, erythema, and swelling of the left arm, chest, and neck. White blood cell count was 27,000/µL with 91% neutrophils. Chest radiographs showed gas in the subcutaneous and soft tissue of the neck, arm, and chest . Necrotizing fasciitis was suspected.
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Case In Point: Does this woman with cough and dyspnea really have CHF?A 47-year-old African American woman presented to the hospital after a 5-day history of cough and shortness of breath. The patient also described worsening cough with yellow sputum production over that same time but denied any fevers, chills, nausea, vomiting, abdominal pain, and urinary symptoms. Her condition began to rapidly deteriorate on arrival to the emergency department (ED).
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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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The Dyslipidemia of Type 2 Diabetes: When and How to TreatABSTRACT: Low-density lipoproteins are the most common atherogenic particles in diabetic dyslipidemia; therefore statins, which dramatically reduce low-density lipoprotein (LDL) cholesterol, are first-line therapy for patients with diabetes. These agents produce equivalent relative risk reductions in those with and without diabetes but confer greater absolute risk reduction because of the increased incidence of ischemic cardiovascular events in those with diabetes. The LDL cholesterol goal for patients with diabetes who do not have coronary heart disease is below 100 mg/dL. For secondary prevention, the goal is below 70 mg/dL. High-dose statin therapy may be required to achieve these goals. Fibric acids are a reasonable initial option for patients with triglyceride levels above 200 mg/dL and high-density lipoprotein (HDL) cholesterol levels below 40 mg/dL; in such patients they reduce risk as effectively as statins. Intermediate-release niacin raises HDL cholesterol levels; the effect is enhanced when niacin is combined with a statin.
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What's New in the Treatment of Hypertension?An oral renin inhibitor, aliskiren, recently became available. Does it have any advantages over angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs)?
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Girl With Palpable Purpura and EcchymosesTen days after ballet practice, a 9-year-old girl noticed a nonpruritic, petechial rash on her lower legs. Swelling of the ankles and knees was also apparent. The patient was afebrile, otherwise healthy, and had no abdominal pain. There was no family history of blood dyscrasias. The patient was taking no medications.
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Is It a Seizure? Differentiating Epileptic Seizures from Nonepileptic EventsEarly differentiation of epileptic from nonepileptic seizures is important. Clues that suggest epilepsy are a history of febrile seizures (particularly if prolonged), past brain injury from trauma or infection, and epilepsy in first-degree relatives.
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Managing CA-MRSA Infections: Current and Emerging OptionsMethicillin-resistant Staphylococcus aureus (MRSA) must be recognized now as one of the most common causes of infections acquired in the community. The majority of these infections involve the skin and soft tissue structures and confer significant morbidity on those affected.
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Older Woman With Dyspnea and Large Abdominal EcchymosisTHE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.
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Acute Suppurative Thyroiditis in a Patient With Aplastic AnemiaAcute suppurative thyroiditis (AST) is a rare inflammatorycomplication in patients with hematological malignancy.Infection spreads to the thyroid from a distant site throughthe bloodstream or the lymphatics. Defects such as persistentthyroglossal duct and pyriform sinus fistula are associatedwith the development of AST. Ultrasonography, bariumswallow testing, CT, and fine-needle aspiration are usedfor diagnosis. Treatment includes the administration ofparenteral antibiotics, drainage, and excision. We describea patient with aplastic anemia and bacteremic AST.[Infect Med. 2008;25:339-342]
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Scrub Typhus: Two Cases Presenting as Abdominal PainScrub typhus, which is caused by Orientia tsutsugamushi, has various systemic manifestations, including GI symptoms. We describe one patient with scrub typhus who presented with symptoms that suggested acute appendicitis and another who presented with symptoms of acute cholecystitis.
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Medical Problems of the Athlete:As the world of sport has embraced the participation of women and girls, the incidence of health problems that pertain specifically to premenopausal female athletes has increased significantly. One of these is the female athlete triad, which consists of 3 interrelated medical conditions associated with athletic training
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Disseminated Echinococcosis Involving the Pulmonary ArteryDisseminated echinococcal disease can present complex management issues that require a multidisciplinary approach to care. We describe a patient with hydatid disease who had multiple cysts in the liver, lungs, and pulmonary artery that were caused by Echinococcus granulosus infection.
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Cryptococcal cavitary pneumonia in an immunocompetent patientCryptococcus neoformansmost commonly infects personswith an underlying T-cellimmunodeficiency. It hasbeen nicknamed the "sugarcoatedkiller" because it cancause a devastating disseminatedillness in immunosuppressedpatients. C neoformansrarely causes primaryinfection in an immunocompetentpatient. We present acase of pulmonary cryptococcosisthat occurred in an otherwisehealthy man.
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Infant With a "Tail"A 6-cm midline tail-like soft tissue appendage was noted on the back of this newborn infant at the level of L5. An epithelialized mid-sacrum dimple was also present inferior to the appendage. The infant otherwise appeared to be normally developed.
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Invasive pulmonary aspergillosis, part 2: TreatmentABSTRACT: In general, the management of invasive pulmonaryaspergillosis is based on antifungal therapy and reversal of immunosuppression.Voriconazole is the preferred treatment inmost cases. Liposomal preparations of amphotericin B, caspofungin,and posaconazole are alternatives in patients whocannot tolerate voriconazole or have refractory aspergillosis.Prophylaxis in high-risk patients has gained popularity withthe availability of oral extended-spectrum azoles; posaconazoleis approved for prophylaxis in patients with acute leukemia,myelodysplastic syndrome, and graft versus host disease.(J Respir Dis. 2008;29(11):429-434)
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When should you suspect asbestos-related pulmonary disease?Abstract: A number of factors complicate the diagnosis of asbestos-related pulmonary diseases. Most persons who have had heavy exposure to asbestos are now aged at least 65 years and, therefore, are more likely to have other respiratory problems, such as chronic obstructive pulmonary disease, that may be difficult to differentiate from asbestosis. An accurate assessment of exposure history is particularly challenging because of poor recall of events by patients and because critical variables, such as fiber type, size, and length, can be difficult to evaluate. High-resolution CT (HRCT) has better sensitivity and specificity for asbestos-related pleural disease and neoplasms than does chest radiography. However, HRCT findings in patients with asbestosis are relatively nonspecific. Bronchoalveolar lavage and lung biopsy can provide definitive information about the extent of asbestos exposure. (J Respir Dis. 2005;26(11):499-510)
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Bacterial ArthritidesGonococcal infection is the leading cause of bacterial arthritis in adults.
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A Comparison of the Clinical Effectiveness and Cost-Effectiveness of Treatments for Moderate to Severe PsoriasisThis study investigated the clinical effectiveness and cost-effectiveness of treatments for moderate to severe psoriasis from a managed health care systems perspective. An analysis was conducted of randomized clinical trials evaluating biologic and oral systemic medications and phototherapy for patients with moderate to severe psoriasis.
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ChondrosarcomaA firm mass projected from the deltoid muscle region of a 24-year-old man's right shoulder.
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In Multiple Sclerosis, Motivational Interviewing Can Improve Exercise ExperiencePhysical inactivity is more common among patients with multiple sclerosis (MS) than the general public-even though studies have shown that exercise can reduce the frequency and intensity of MS symptoms. Here's a motivational technique that may help.
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Today's approach to the treatment of heparin-induced thrombocytopeniaAbstract: Failure to recognize heparin-induced thrombocytopenia (HIT) can lead to devastating thrombotic events, including pulmonary embolism and stroke. In most cases, the problem develops within 5 to 14 days after a first-time exposure to heparin. HIT can occur with either unfractionated heparin or low molecular weight heparin (LMWH), but the incidence is much lower with LMWH. When HIT is suspected clinically, a functional assay and immunoassay should be performed. However, treatment should not be delayed while waiting for laboratory confirmation. All forms of heparin should be eliminated, and treatment with an alternative anticoagulant should be initiated to prevent new thromboembolic events. Argatroban and lepirudin are the direct thrombin inhibitors that have been approved for the treatment of HIT. Because of the risk of warfarin-induced venous limb gangrene or skin necrosis, warfarin should be avoided in patients with acute HIT until their platelet counts have recovered and they are improving clinically. (J Respir Dis. 2006;27(6):248-259)
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Acute Gouty Arthritis and Gouty TophusA 5-day history of pain and swelling in the right third finger (A) were the complaints of a 76-year-old man. A few days earlier, another physician had prescribed indomethacin, 25 mg tid, but it had not helped, and the patient believed that his condition had worsened. He had had an attack of gout 5 years before but had not been taking any maintenance medication. The distal interphalangeal (DIP) joint of the affected finger was now erythematous and tender, with chalky subcutaneous deposits. A diagnosis of acute gouty arthritis and gouty tophus was made.
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Cystic Hygroma in a Young GirlA 21-month-old previously healthy child is brought to the pediatrician's office because of increasingly labored breathing that began the night before. The father reports that the child has had fever, congestion, nonproductive cough, and irritability for 2 days and that she is slightly hoarse.
