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Serum Digoxin Concentrations: Do You Know the Current Upper Limit in Heart Failure?For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.
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What Is Causing This Patient’s Acute Left-Sided Weakness?A 56-year-old woman with type 2 diabetes mellitus and hypertension presented with acute left-sided weakness and altered mental status, for which she was hospitalized. The patient, who was obese, was in her usual state of well-being until 2 months before this presentation, when she noted a gradual onset of generalized weakness. She received a diagnosis of severe hypokalemia that was refractory to oral potassium supplementation. The outpatient workup of the cause of her hypokalemia was in progress.
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Pulmonary function testing: Applying techniques in infantsAbstract: As in adults and older children, pulmonary function testing in infants may help detect certain obstructive or restrictive diseases. However, different techniques and equipment must be used. The most commonly performed noninvasive tidal breathing test involves use of a face mask with a pneumotachograph; an alternative method is respiratory inductive plethysmography. Ratios derived from volume-time and flow-time tracings can help identify patients with obstructive lung disease, who have a shorter time to peak expiratory flow:expiratory time ratio than do healthy persons. Instead of spirometry, the rapid thoracic compression technique can be used to measure expiratory flow and construct a flow-volume curve. This method, which is performed with the patient under sedation, increases flow rates over tidal flow values and enhances the ability to detect abnormal airway function. (J Respir Dis. 2006;27(4):158-166)
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Case In Point: Massive, fatal hemoptysis in a patientwith AIDS and B-cell lymphomaA 49-year-old man presented to theemergency department (ED) andcomplained of fever and cough thatproduced bloody sputum for 1 day.He had AIDS and recently receiveda diagnosis of large B-cell lymphoma.His most recent CD4+ cellcount was 24/µL. He had optedagainst receiving highly active antiretroviraltherapy and prophylaxisfor opportunistic infection.
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Managing the Patient With an Abnormal Liver Test: Part 1, Persistent Aminotransferase ElevationsIdentifying the cause of a persistent, asymptomatic aminotransferase elevation can be challenging. The possible diagnoses are many and varied. To narrow the differential, begin with a detailed history.
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A Woman With Delirium From Diabetic KetoacidosisMucormycosis, an angioinvasive yeast infection of the Mucorales order of the class of Zygomycetes, often grows in patients with diabetes mellitus, especially in the presence of diabetic ketoacidosis.
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Pellagra I a 45-Year-Old Man#onc_figure_border{ width: 175px; float:right; display:block;clear:right; border-left: 1px solid #a5a5a5; padding: 2px 0px 10px 10px; margin: 0px 0px 0px 10px;}
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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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Recurrent Fever of Unknown Origin Responsive to PrednisoneThere are no guidelines for the workup for classic FUO. Diagnostic modalities are guided by the spectrum of differentials as well as local prevalence of disease.
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Refractory Ulcer:What to Do Next?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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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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Stroke: Update on New Therapies- and the Implications for Primary CareCurrently, the only approved therapy for acute ischemic stroke is tissue plasminogen activator (tPA), initiated within 3 hours of stroke onset. New patient selection criteria are emerging that may improve the effectiveness and safety of thrombolysis. For example, evidence of extensive early ischemia on CT may predict a poor outcome regardless of whether tPA is administered. New imaging techniques, such as diffusion MRI, perfusion MRI, and MR angiography, may be able to identify salvageable tissue and distinguish it from irreversibly damaged tissue. Such findings may allow the 3-hour window for tPA therapy to be extended in certain patients. Other approaches to ischemic stroke therapy that are being studied include intra-arterial thrombolysis, new thrombolytic agents, platelet aggregation inhibitors, endovascular interventional techniques (alone and in combination with pharmacologic thrombolysis), and neuroprotective therapy with various agents to ameliorate the consequences of ischemia in brain tissue.
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Lithium-Drug InteractionsBipolar disorder (also known as manic-depressive illness) affects nearly 6 million adults in the United States.1 This psychiatric disorder was first described at the time of Hippocrates and is currently one of the most prevalent and severe mental illnesses in our society.
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Pseudostrabismus (Pseudoesotropia)The parents of this 5-month-old boy were concerned that his eyes wereturned in toward the nose. The infant was otherwise healthy. Physical findingswere normal. In particular, when a light source was projected onto theeyes, the light reflex was centered in both eyes.
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Splenic InfarctionA 53-year-old woman presented with sudden onset of left upper quadrant abdominal pain. She had a history of atrial fibrillation, hypertension, and congestive heart failure.
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Heterozygous Familial HypercholesterolemiaA 56-year-old woman was referred for management of severe hyperlipidemia. Her family history included hypercholesterolemia and premature coronary artery disease.
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Eosinophilic Granuloma of the VulvaA 46-year-old woman sought treatment of vaginal pruritus of 6 months' duration. She also was bothered by generalized skeletal aching that was most prominent in her legs. The patient had a history of hypertension.
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Cerebellar Hemorrhage in Woman With History of HypertensionA 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.
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PylephlebitisAcute abdominal pain, fever, and chills prompted a 51-year-old man to visit his local hospital twice in one week. On both visits, a clinical and laboratory workup was negative. He then presented to a tertiary care center with worsening symptoms. His history included hypertension and tobacco and alcohol use.
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Calcification of the Mediastinum in an Asymptomatic WomanA 72-year-old woman presented for her annual physical examination. She had been treated for tuberculosis 20 years earlier. The patient did not smoke cigarettes; she denied fever, chills, and rigors.
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Acute Poisoning:We live in a world of toxins and potential toxins, and thus we are often just a misstep away from a toxic exposure and its consequences. Even that which is meant to cure can kill. All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy; exposure to the wrong dose of a medication (whether accidental or not) remains a common form of toxic exposure.
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Nonarteritic Anterior Ischemic Optic NeuropathyA 43-year-old white man presented to the emergency department with dyspnea, abdominal bloating, fever with chills, night sweats, decreased oral intake, and myalgia of 1 week's duration. He was found to have heart failure caused by systolic dysfunction. Viral myocarditis was the presumptive diagnosis after investigation for other causes.
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Multiple Myeloma Presenting With CHFDyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.
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Multiple Myeloma Presenting With CHFDyspnea, orthopnea, and weight loss sent a 40-year-old woman for medical consultation. Fifteen years earlier, the patient had been nephrectomized because of left kidney lithiasis. There was no history of other symptoms or diseases.
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Inflammatory Breast CancerA 40-year-old woman was concerned about an area of redness and tenderness on her left breast. Despite antibiotic therapy prescribed by another physician, the rash had progressed during the past month to erythema and nodules that involved the anterior chest and right breast.
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Pellagra I a 45-Year-Old Man#onc_figure_border{ width: 175px; float:right; display:block;clear:right; border-left: 1px solid #a5a5a5; padding: 2px 0px 10px 10px; margin: 0px 0px 0px 10px;}
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Pulmonary Embolism and Deep Venous ThrombosisFor 2 months, a 31-year-old woman had had dyspnea and dull, continuous retrosternal pain. She was admitted to the hospital, and a helical CT scan of the thorax identified a saddle pulmonary embolism. An ultrasonogram revealed deep venous thrombosis (DVT) in the left leg. Intravenous heparin was given; the patient was discharged, and warfarin was prescribed.
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Extrapulmonary tuberculosis, part 4: Skeletal involvementAbstract: Spinal tuberculosis is the most common form of osteoarticular involvement in patients with tuberculosis. Localized pain is a common presenting symptom. In patients who do not present until vertebral wedging and collapse have occurred, a localized knuckle kyphosis is obvious, especially in the dorsal spine. In some patients, a retropharyngeal abscess develops, causing dysphagia, dyspnea, and/or hoarseness. Peripheral joint tuberculosis is characterized by an insidious onset of slowly progressive, painful, and swollen monoarthropathy, most commonly affecting the hip or knee. The radiologic features include juxta-articular osteoporosis, peripheral osseous erosion, and gradual narrowing of the interosseous space. Treatment involves antituberculosis drugs; the indications for surgery are relatively limited. (J Respir Dis. 2005; 26(12):543-546)
