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Rheumatoid Nodules in a 65-Year-Old WomanA 65-year-old woman, who was confined to a wheelchair because of severe rheumatoid arthritis, was concerned about nodules that had erupted on her fingers and hands during the previous 3 weeks. Her medical history included colon cancer, chronic renal insufficiency, anemia, and hypertension. The nonpruritic nodules were painful when they began to form under the skin; however, once they erupted, the pain disappeared.
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Contraception article:Despite major advances in contraception that occurred during the 20th century, about 49% of pregnancies in the United States are unintended. More than half of these pregnancies end in abortion.
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What Next For This Patient?A patient who is allergic to penicillin was bitten on his wrist by a dog. What is the first test you order?
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A case of miliary TB complicated by ARDS and pancytopeniaWe 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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Multiple Aorto-Cavitary FistulasInfective endocarditis (IE) starts as a vegetation on the valvular structures. The infection can extend to the adjacent periannular areas and erode into nearby cardiac chambers, leading to an aorto-cavitary fistula (ACF).1,2
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COPD in women, part 2: Treatment considerationsAbstract: Smoking cessation is still the most important intervention in patients with chronic obstructive pulmonary disease (COPD), regardless of sex. There is some evidence that nicotine replacement therapy may be less effective in women than in men. However, women may derive greater benefits from a sustained quit attempt. For example, one study found that compared with men, women who were sustained quitters had a greater initial rise and a slower age-related decline in forced expiratory volume in 1 second. Men and women do not appear to differ in their response to bupropion or to the various types of bronchodilators. A number of factors contribute to the increased risk of osteoporosis in women with COPD. Both smoking and the degree of airflow obstruction have been identified as important risk factors for osteoporosis. Women may be particularly susceptible to the effects of smoking on bone metabolism. Immobility and decreased physical activity have also been shown to accelerate bone loss. (J Respir Dis. 2006;27(3):115-122)
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Is Your Room an Asthma “Nightmare”?If your bedroom or other rooms in your home look a lot like this one,you may be living in an asthma "nightmare"-an environment full ofpotential causes of asthma attacks.
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Elderly Man With Sudden Back and Abdominal PainAn 84-year-old man with back and abdominal pain ofrecent onset arrives at the emergency department(ED) of a small community hospital at 5 AM. Sudden,severe back pain awakened him from sleep 2 hours earlier.The patient has had back pain for 12 hours and intermittentcolicky pain in the suprapubic region for the past2 hours.
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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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Preventing Hypertension: Do Primary Care Providers Practice What They Prescribe?A key finding: a primary physician’s healthy lifestyle behaviors may be linked to his or her recommendations for hypertension prevention.
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Mucinous CystadenomaA 53-year-old perimenopausal woman presented to the emergency department with throbbing lower abdominal pain and distention. The pain started 5 days earlier and worsened with sitting and walking; she also experienced increasing dyspnea. She had noticed increasing abdominal girth about 5 months earlier. Since then, she had gained 5 to 10 lb, despite dieting. The patient reported a 22-pack-year history of smoking but no alcohol use. She was taking over-the-counter painkillers and allergy medications. Her family history was notable for a brother who died of laryngeal cancer.
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Prophylactic Oseltamivir for Prevention of Nosocomial Influenza A Virus InfectionThe effectiveness of oseltamivir in preventing nosocomialinfluenza (influenza Avirus infection) during an influenzaepidemic was carried out in several wards of a universityhospital. Asurvey conducted during the 2005 influenza seasonidentified 30 staff members (nurses and doctors) and 3hospitalized patients who met the case definition for influenza.Adefinitive influenza diagnosis was made in 17 staff members(57%) and in 2 inpatients (66%) based on the results of a rapiddiagnostic test. Most of the 30 symptomatic staff membershad been vaccinated for influenza. Symptomatic staff memberswere sent home for 1 week, and the infected inpatients wereisolated. Oseltamivir (75 mg/d for 5 days) was administered to99 staff members and 2 inpatients who had close contact withthe infected patients. Although a relatively large number of thestaff had an influenza virus infection, the use of oseltamivirmay have effectively prevented a nosocomial outbreak.[Infect Med. 2008;25:49-50a]
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Older Woman With Abdominal PainFor 2 weeks, a 67-year-old obese woman has had episodes of diffuse, nonradiating abdominal pain that last for several hours and are slightly relieved by famotidine/antacid. She rates the pain as 7 on a scale of 1 to 10.
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Cerebellar Blastomycotic AbscessesA comatose 29-year-old woman was brought to the emergency department. Her family reported that she had been well until 4 days earlier, when headache and fever developed. She went to another hospital at that time and was told she had an abscessed tooth. She was given erythromycin, and the tooth was extracted the following day. The patient's headache and fever worsened; a sore throat also developed, and a rash appeared on her trunk, arms, and legs. The family denied any HIV risk factors, unusual medical history, recent travel, and exposure to persons with infectious diseases.
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Chronic Venous Insufficiency in Left Leg of 70-Year-Old ManTortuous, dilated varicosities; multiple smaller caliberabnormal perforating vessels; and chronic brawnyedema of chronic venous insufficiency (CVI) were seenon a 70-year-old man’s left leg (A). He reported that theedema and discoloration had worsened over the last15 years. The brawny edema stopped just above theankle, indicating that compression by the patient’s sockcontrolled the signs and symptoms of CVI.
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Interdigital Pilonidal SinusIn the web space of his left hand, a 50-year-old barber had a painful cystlike lesion. The lesion had recurred intermittently, despite oral antibiotic treatment and warm compresses. The patient's father, also a barber, had a similar, more severe condition, which eventually required surgical intervention.
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Questioning Medicine: The Vitamin D CrazeThe verdict is in: there’s not enough evidence to support screening of asymptomatic individuals for low vitamin D. Here: a look behind the curtain.
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Two Cases of Rhythm DisturbanceFor 2 days, a 49-year-old man with hypertension and hypercholesterolemiahas experienced light-headedness and fatigue.Based on the presenting ECG, what is the most likely cause of hissymptoms?A. Accelerated junctional rhythm.B. First-degree atrioventricular (AV) block.C. Mobitz type I (Wenckebach) second-degree AV block.D. Mobitz type II second-degree AV block.E. Third-degree AV block (complete heart block).
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Concurrent Management of Achalasia and Morbid ObesityThe development of a standardized treatment that simultaneously addresses achalasia and obesity is becoming more imperative as obesity becomes epidemic in the US. Here’s a case in point.
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Nasal Septal AbscessA 63-year-old man with myelodysplasia presented with oral thrush, intranasal dryness, and congestion that developed 2 months earlier. Intranasal saline rinse and sleeping with the head elevated temporarily relieved the nasal symptoms.
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Bilateral Nodular FasciitisAsymptomatic, enlarging growths had been present on the bottom of a 56-year-old woman’s feet for 3 years. The nodules initially arose-first on the left foot, then on the right-at the sites of blisters on the insteps after the patient had taken a long hike in uncomfortable boots.
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Scrotal Lesions:The differential diagnosis of intrascrotal pathology includes a myriad of benign and malignant entities. Timely detection is imperative to reduce the morbidity associated with many of these disease processes.
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Asthma:ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.
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Kaposi's Sarcoma in the Sigmoid ColonA 2-week history of diarrhea mixed with bright red blood was the presenting complaint of a 40-year-old man who was seropositive for HIV. Stool studies and culture results were negative for microorganisms. Colonoscopy demonstrated only the raised vascular lesion seen here in the sigmoid colon, which may have been responsible for the bleeding.
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Antihypertensive Treatment: How to Maximize Results for Your PatientsQ:Many of my patients appear to have white-coathypertension: their pressure is elevated whenmeasured in my office-but normal when measured athome. Am I ignoring significant hypertension if I do nottreat these patients? Or am I overtreating if I do treat?
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Melanoma of the Foot: Often OverlookedSeen here is an ulcerated tumor with irregular borders on the left foot of a 37-year-old man. He said the tumor had developed several years ago.
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Mild Traumatic Brain Injury:Traumatic brain injury may occur without visible head injury; it manifests as confusion, focal neurologic abnormalities, an altered level of consciousness, or subtle changes on neuropsychological testing. The initial evaluation includes assessment of the patient's airway and respiratory, circulatory, and neurologic status.
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New Advances in Antiretroviral TherapyIt is estimated that approximately 33.2 million persons worldwide were living with HIV infection in 2007.1 With the development of effective antiretroviral treatment strategies, HIV infection has now become a manageable chronic disease.2 Despite advances in treatment, drug resistance, long-term adverse effects, and high adherence requirements represent ongoing challenges to durable viral suppression.
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Unexplained Chest Pain:ABSTRACT: Once you have excluded a cardiac origin of chest pain, focus the evaluation on esophageal, psychiatric, musculoskeletal, and pulmonary causes. Gastroesophageal reflux disease (GERD) and esophageal motility disorders are the most common causes of unexplained chest pain (UCP). If you suspect an esophageal disorder, empiric antisecretory therapy is the most cost-effective initial approach. If the patient remains symptomatic, order a 24-hour esophageal pH study with symptom analysis while the patient receives maximal acid suppression. Once GERD is excluded, the patient may be treated for visceral hyperalgesia with low-dose tricyclic antidepressants or standard doses of selective serotonin reuptake inhibitors. Panic disorder-the most common psychiatric disorder in patients with UCP-is often associated with atypical symptoms, such as palpitations and paresthesias, and other psychiatric disorders. If you suspect panic disorder, one approach is to give the patient a short-term, nonrefillable prescription for a benzodiazepine and refer him or her for psychiatric evaluation.
