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The Mysterious Case of the Boy who BarkedA 14-year-old with an odd facial rash has vocal outbursts at school, especially when teased and at home when stressed. What’s wrong? Your Dx?
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Hematemesis Secondary to a Bronchogenic CystA 24-year-old man with an unremarkable medical history presented to the emergency department with abdominal pain and hematemesis of 3 days' duration. His symptoms were postprandial, and each episode yielded up to half a cup of blood without clots. He denied using NSAIDs or alcohol. He had had an episode of hematemesis 2 years earlier that resolved spontaneously, for which he had not sought treatment. His vital signs were normal, and his physical examination was notable only for moderate epigastric tenderness without rebound or guarding.
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Aspirin-exacerbated respiratory disease: An easy-to-overlook diagnosisAbstract: Patients who have aspirin-exacerbated respiratory disease (AERD) usually experience upper and lower respiratory tract symptoms about 1Z|x to 2 hours after taking aspirin or another NSAID that inhibits the enzyme cyclooxygenase-1. In addition to symptoms such as nasal congestion, rhinorrhea, paroxysmal sneezing, periorbital edema, laryngospasm, and intense flushing, patients may have severe--often life-threatening--exacerbations of asthma. AERD occurs in about 10% to 20% of patients with asthma and in about 30% of asthmatic patients with nasal polyposis. However, AERD also occurs in patients who do not have any of these predispos- ing conditions. In patients with AERD, aspirin desensitization can improve asthma control, reduce the need for corticosteroids, and reduce the need for sinus surgery. (J Respir Dis. 2006;27(7):282-290)
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A rare complication of empyema: Thoracic aorta perforationThis case represents an unusualcomplication of cellulitiscaused by methicillin-resistantStaphylococcus aureus.
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Renal Artery Stenosis Complicating Essential HypertensionA 73-year-old man who had a history of long-standing essential hypertension, congestive heart failure, mild renal insufficiency, atrial fibrillation, and a mitral valve replacement presented with refractory hypertension. His medications included labetalol, irbesartan, and furosemide.
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The Dangers of ATVsAn all-terrain vehicle-ATV-is described by the American National Standards Institute as one that "travels on low pressure tires, with a seat that is straddled by the operator, and with handlebars to be used for steering."1 By this definition, an ATV is designed for interactive riding by a single operator. Drivers are able to shift their weight freely in all directions depending on the situation and terrain. According to ATV safety standards and recommendations, children younger than 6 years are never to be on an ATV of any size-alone or with someone else.
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Multiple Myeloma With a Gastric PlasmacytomaTwo 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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3 Things Your COPD Patients May Not Tell You"I'm having trouble catching my breath." "I can't pay for my inhaler." "I'm just so sad." They may not tell us, so we need to ask. Here's my experience.
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Foreign-Body Retrieval: Diamonds in the RugaeProgressive weakness, confusion, and decreased oral intake preceded hospital admission for this 73-year-old man with a history of Parkinson dementia and resection for esophageal adenocarcinoma. The real problem, seen here, was revealed on a chest x-ray film.
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The Charcot Foot: A Missed Diagnosis Can Cost a LimbThis enigmatic, destructive, and deforming condition most often affects persons who have diabetes.
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Nonadherence to therapy is often the culprit Difficult-to-control asthma, part 2: Optimizing therapy key words: Asthma, Allergic rhinitis, GERD, Rhinosinusitisabstract: Common causes of poorly controlled asthma include nonadherence to long-term inhaler therapy; environmental exposures; and uncontrolled comorbidities, such as allergic rhinitis. Adherence can be limited by many factors, including inadequate patient education, medication cost, prior failed treatment, poor physician-patient relationship, unrealistic expectations for therapy, and depression. For patients who have a poor perception of their symptoms, emphasizing the "disconnect" between symptoms and pulmonary function can help motivate them to monitor themselves with a peak flow meter and to adjust their medication accordingly. For patients with allergic triggers, instituting allergen-specific environmental controls can decrease symptoms and urgent care visits for asthma. Chronic rhinosinusitis and gastroesophageal reflux disease can also contribute to difficult-to-control asthma, and treatment of these comorbidities can help reduce asthma symptoms. (J Respir Dis. 2007;28(9):365-369)
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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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Progressive Pulmonary Symptoms in an Elderly WomanResults of a physical examination and CT scan of the chest offer clues to this patient's diagnosis.
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Perifolliculitis Abscedens Et SuffodiensFor about 10 years, a 26-year-old man had recurring cystic lesions on his scalp that would periodically enlarge, shrink, and occasionally drain. One lesion had been excised by another physician, but it later recurred. The patient had been taking minocycline (100 mg) daily for this condition.
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Beau LinesTransverse depressions like the one shown here appeared on all the other nails of this 68-year-old man several weeks after he had suffered a myocardial infarction.
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In Sickle Cell Disease, What Cause of Acute Respiratory Symptoms?A young woman experienced acute onset of high fever, productive cough, and right-sided pleuritic pain. She was not in sickle cell crisis. Do the images here shed light on cause of symptoms?
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Erythema ab Igne in a 66-Year-Old Black WomanThis 66-year-old black woman presented with a 2-year history of a painless skin eruption. She stated that her skin had “changed overnight” while she was caring for her mother who had been hospitalized.
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Worsening Respiratory Symptoms in an Adult MaleThe patient presents 6 weeks after a prolonged hospitalization for pancreatitis. More details and the office spirometry tracing here.
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Mediastinal Adenopathy in a Middle-Aged Man: How to Proceed?A PET/CT scan shows uptake of tracer consistent with malignancy in the left lower lobe and mediastinal nodes. What would be your next step?
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Patients Aren't the Only Worried Ones in the Exam RoomAt what point in a medical career do we allow identification with the sick and dying we treat to inform who we are?
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Migraines: 6 Things a Neurologist Wants PCPs to KnowWhen a patient presents to their primary care physician with a headache, it's not always diagnosed as the migraine it is. These 6 tips from a neurologist can help.
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Pulmonary nocardiosis mimicking empyema necessitatisNocardia asteroides is a rarecause of pulmonary or disseminatedinfection in immunocompetentpersons. Pleuralcompromise is common, butempyema necessitatis is veryrare. The authors describe anapparently immunocompetentpatient with N asteroides infectionwho had chest wallcompromise mimicking empyemanecessitatis.
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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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Mesenteric Venous ThrombosisA 63-year-old man with a history of hypertension and gastroesophageal reflux disease presented with progressive, sharp mid-abdominal pain of 3 weeks' duration.
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Obstructive sleep apnea syndrome, part 2: Reviewing the treatment choicesAbstract: The management options for persons with obstructive sleep apnea-hypopnea syndrome (OSAHS) include lifestyle changes, continuous positive airway pressure (CPAP), oral appliances, and surgery. Lifestyle modifications work best in persons with mild OSAHS and may include weight loss and cultivation of good sleep habits, such as not sleeping supine. Before initiating CPAP therapy, polysomnography is recommended to determine the best airway pressure for the patient. Although the benefits of CPAP have been well documented, compliance remains an issue; some difficulties may be alleviated through patient/partner education and close follow-up. Oral appliances, which work by mechanically enlarging or stabilizing the upper airway, are preferred by some patients; however, they are less effective than CPAP at reducing the apnea-hypopnea index. Surgical interventions to alleviate upper airway obstruction can be used in select patients. (J Respir Dis. 2006;27(5):222-227)
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Juvenile DermatomyositisThe diagnosis of juvenile dermatomyositis can be challenging when proximal muscle weakness develops without characteristic skin manifestations. In this patient, rash appeared 2 months after the onset of muscle weakness. As a result, the initial diagnosis was viral myositis, which led to delayed therapy.
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Scrotal Calcinosis in Normocalcemic Primary HyperparathyroidismA 32-year-old man with no significant medical history presents with multiple scrotal lesions that he claims have been present for 2 years. They are non-tender and he reports no overt symptoms. The full case, here.
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Unmasking Mental Health Disorders in Primary Care PracticePrimary care physicians treat the majority of patients in this country who have mental health disorders. But how well prepared are we for these patients when they present to our offices?
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Primary PyomyositisA 59-year-old woman presents with right-sided, nonradiating, “aching” chest pain that has been continuous and increasing in severity for the past 3 days. It began as a tightness that gradually became more painful; it is aggravated by palpation and movement and has not been relieved by acetaminophen.
