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Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.

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ABSTRACT: The diagnosis of asthma in older persons may becomplicated by a number of factors, including atypical presentationsand comorbid conditions, such as chronic obstructivepulmonary disease and congestive heart failure (CHF). Ahigh index of suspicion for the diagnosis of asthma is warrantedin patients with isolated dyspnea or cough. The diagnosisshould be based on demonstration of reversible airwayobstruction on pulmonary function tests. Additional tests thatmay be useful in the initial evaluation include chest radiography,arterial blood gas analysis, and standard electrocardiography.CT may help exclude pulmonary embolism and certainneoplasms that can masquerade as asthma. High-resolutionCT scans are valuable when pulmonary function testresults are consistent with interstitial lung disease. When thediagnosis is uncertain, measurement of brain natriuretic peptidecan help distinguish between obstructive lung disease andCHF. (J Respir Dis. 2008;29(10):391-396)

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Selective 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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Parents of young children know that colds are extremely common, especially from fall until spring. Colds account for a large number of pediatric office visits and telephone calls-particularly during "cold season."

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A 6-year-old girl was evaluated in the emergency department for a leg rash that had spread to the buttocks. The lesions first appeared earlier in the day and worsened hourly. The child's mother reported that her daughter was in good health until a low-grade fever, nonproductive cough, sore throat, and headache developed 5 days earlier. The youngster also complained of neck pain with movement.

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A comatose 82-year-old woman is brought to the emergency department. Her husband reports that after dinner she began to have difficulty in speaking, lost consciousness, and fell to the floor. He tried to rouse her, but was unsuccessful and called for an ambulance.

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ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.

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A 37-year-old woman presented with weakness, fatigue, and lethargy. Her only other complaint was heavy menses.

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A 14-year-old girl came to the officewith severe hip pain, which occurredafter she attempted a cheerleadingmaneuver on a trampoline. She reportedthat she was bouncing as highas she could and landed on the trampolinewith her left knee flexed andher right hip extended. On impact,she felt a “pop” that was immediatelyfollowed by right hip pain.

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A 76-year-old man reported a 3-month history of an asymptomatic, raised, reddened lesion on his penis. The patient had type 2 diabetes mellitus. In 1994, a basal cell carcinoma had been excised from his chest and, 3 years later, a squamous cell carcinoma was excised from his left temple.

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Cryptococcus 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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A 67-year-old woman with insulin-dependent diabetesmellitus and uncontrolled hyperglycemia complained offatigue and malaise. For 2 years, a draining ulcer hadbeen present on the bottom of her left foot.

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A seasoned rheumatologist provides a list of distinctive clues to a diagnosis of fibromyalgia that you won't find in the guidelines.

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This case highlights the importance of detecting HIV infection in its earliest stages. Each year, 40,000 new cases of HIV infection are diagnosed in the United States; however, very few of these are identified at the acute infection stage. Diagnosis of primary HIV infection is important because it improves the patient's chances for a good outcome, reduces the risk of transmission, and provides epidemiologic data on virus strains in the community.

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Clad only in shorts, T-shirt, and helmet, a 21-year-old man was involved in a motorcycle accident. He sustained “road rash”-diffuse multiple body abrasions, lacerations, and contusions-particularly on the extremities. Abrasions about the chest wall and abdominal region were also noted. Other injuries included a closed right clavicle shaft fracture and a nondisplaced open fracture of the dorsal aspect of the right olecranon.

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Employers and their employees are facing tough times in today’s economy. To stay competitive, employers must scrutinize all areas of business for cost-cutting opportunities, including health care benefits. Consumers, too, face challenges. In October, a Kaiser Family Foundation poll reported that the percentage of consumers who skipped dosages or split pills in the past year to save on medication costs had increased to 22%, up from 19% in April. The percentage of consumers who reported not filling their prescriptions rose from 23% to 27% over the same 6-month period.1

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Several hours after he had installed ceramic tile, a 33-year-old man experienced muscle spasms and felt pressure in his right shoulder. He denied previous injury to the area.

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This enigmatic, destructive, and deforming condition most often affects persons who have diabetes.

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A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs (Figure 1). Over the past 3 to 4 weeks, he has had malaise, nonproductive cough, and a decline in mental status but no fever, headache, nausea, light-headedness, hemoptysis, or melena.

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A retrospective review of administrative claims data was conducted to identify health plan members with asthma who were persistent with their controller medications and those who were not persistent. Utilization of health care services and associated costs were measured for both groups. Non-persistent use of controller medications resulted in more asthma-related emergency department visits and home health services whereas persistent controller use was associated with more physician office and outpatient visits. Mean asthma-related medical costs per member were greater in the non-persistent cohort ($577.62) than in the persistent cohort ($323.03). These findings support the need for targeted interventions to address non-persistence in a managed Medicaid population.(Drug Benefit Trends. 2009;21:112-118)

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ABSTRACT: Undiagnosed or persistent Helicobacter pylori infection and surreptitious or unrecognized NSAID use are the most common causes of refractory peptic ulcers. The use of antibiotics, bismuth, or proton pump inhibitors (PPIs) suppresses the H pylori bacterial load and may obscure the diagnosis. H pylori infections have also become more difficult to cure because of increased antibiotic resistance. For refractory infection, select an antibiotic based on in vitro susceptibility testing. When this is not available, combination therapy with a PPI, tetracycline, metronidazole, and bismuth is often effective. To detect surreptitious or inadvertent NSAID use, review the drug history in detail. When there is any doubt about such use, check platelet cyclooxygenase function.

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Dr Schommer is professor, University of Minnesota College of Pharmacy, Minneapolis. Cindy Chen, Jagannath Muzumdar and Siting Zhou are doctoral candidates at the University of Minnesota College of Pharmacy.

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A 17-year-old sexually active young woman presented with sudden loss of vision in the left eye 2 weeks before presentation.

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An acute exacerbation of asthma brought this 52-year-old Russian emigré to the emergency department (ED). Examination revealed the well-demarcated round erythema and ecchymosis on the patient's back. This circular pattern was created by cupping performed 2 days earlier by the patient's wife in an effort to treat her husband's asthma.

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We present a case of a 35-year-old man with fever and pancytopenia, who had rapid progression to acute respiratory distress syndrome (ARDS), multiorgan failure, and disseminated intravascular coagulopathy secondary to disseminated tuberculosis (TB). Although both sputum and bronchoalveolar lavage (BAL) fluid smears were negative for acid-fast bacilli, the polymerase chain reaction (PCR) assay on the BAL fluid was positive for Mycobacterium tuberculosis. This case emphasizes the need to include TB in the differential for ARDS and the value of PCR testing of BAL fluid, especially in high-risk patients.

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Two weeks after being treated for a fracture of the left humerus and several palpable breast lesions, a 63-year-old African American woman was hospitalized for generalized weakness and confusion. She had a history of type 2 diabetes mellitus, hypertension, coronary artery disease, chronic kidney disease, and low-grade B-cell lymphoma (which had been in remission for 2 years).

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Abstract: Although excessive daytime sleepiness is most often simply the result of inadequate sleep, other causes must be considered as well. Common causes of daytime sleepiness include obstructive sleep apnea/hypopnea syndrome (OSAHS) and medication side effects. The differential diagnosis also includes narcolepsy and restless legs syndrome (RLS). In many cases, the answers to a few simple questions can provide the necessary clues to the diagnosis. Loud snoring is associated with OSAHS, while sudden muscle weakness triggered by intense emotion is consistent with narcolepsy. Referral for sleep evaluation is indicated to evaluate for OSAHS, narcolepsy, RLS, and idiopathic hypersomnia. Methods of measuring daytime sleepiness include the Multiple Sleep Latency Test and the Epworth Sleepiness Scale. (J Respir Dis. 2005;26(6):253-259)

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A methodical approach to diagnosis usually reveals the cause of fever. In patients with simple fever, a careful history taking and physical examination combined with basic laboratory and imaging studies (complete blood cell count with differential, urinalysis, and possibly a chest film and blood cultures) usually yield the diagnosis. In patients with prolonged fever whose cause remains undiagnosed after extensive examination (fever of unknown origin), repeat the history taking and physical examination; also order routine laboratory studies, an HIV test, a tuberculin skin test, 3 sets of blood cultures, and chest films. In addition, abdominal CT scanning is often useful. Further testing at this point may include fluorodeoxyglucose positron emission tomography, technetium-tagged white blood cell scanning, transesophageal echocardiography, liver biopsy, bone marrow examination, and/or temporal artery biopsy. Exploratory laparotomy is rarely indicated.