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A 17-year-old girl presented to the emergency department with abdominal pain, nausea and vomiting, and diarrhea approximately 9 hours after swallowing 25 tablets (200 mg each) of iron sulfate in a suicide attempt. Her vital signs were within normal limits. She was mildly lethargic; stool was hemoccult-positive.

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Our goal here is to help you master the shoulder examination. We review the basics of the examination, and we evaluate emerging concepts in the diagnosis of the more common shoulder conditions.

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Shortly after arriving from Puerto Rico, a 59-year-old man presented with right-sided frontal head pain and decreased vision in his right eye. He was concerned about a “sore” that first developed 9 months earlier on his head. The patient denied fever, chills, and syncope.

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In 2001, 11 US residents contracted inhalation anthrax as a result of the deliberate mailing of 4 letters containing anthrax spores. Five died as a result. Several of these patients presented to physicians before becoming fatally ill, but their illness was misdiagnosed as influenza.1

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Over the past 2 decades, there has been an alarming increase in opportunistic fungal infections with an associated rise in morbidity and mortality. This trend has been attributed to the growing number of patients who are immunocompromised because of bone marrow or solid organ transplant, immunosuppressive drugs, AIDS, and hematological malignancies. Advances in trauma and critical care medicine that lead to longer survival of more patients with immunocompromising conditions also play a role.

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Atropy of the paravertebral musculature--the "spine sign"--in this 64-year-old man offers clues to the genesis of the coronary artery disease for which he had undergone a coronary artery bypass graft (CABG) and to the cause of his severe post-CABG anterior chest pain.

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Palpitations and dizziness prompted a previously healthy 21-year-old cable lineman from southeastern Pennsylvania to seek medical attention. An ECG showed first-degree heart block. The young man was scheduled for outpatient cardiology consultation, but his symptoms worsened and he presented to an emergency department with chest pain and fever 2 days later. Further evaluation revealed that for the past 3 weeks he had myalgia; arthralgia; fatigue; and an expanding, erythematous, nonpruritic rash on his trunk and extremities. He did not recall any tick bites.

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ABSTRACT: Establishing the time of symptom onset is essential to selecting the appropriate therapy. Intravenous tissue-type plasminogen activator (t-PA), administered within 3 hours of symptom onset, is the only FDA-approved treatment for acute ischemic stroke. Intra-arterial and combined intra-arterial-intravenous thrombolytic therapy may be considered for patients whose condition does not improve or who present within 3 to 6 hours of symptom onset. Other options for treating acute ischemic stroke are balloon angioplasty with or without stenting (for symptomatic patients with more than 50% intracranial stenosis in whom medical therapy has failed) and mechanical clot retrieval (for those with an NIH Stroke Scale score greater than 10 who present after the 3-hour window for intravenous t-PA and can be treated within 8 hours of symptom onset or who present within 3 hours of symptom onset but in whom intravenous thrombolysis is contraindicated).

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ain management is a commonand challenging aspect of caringfor elderly patients. The principlesthat guide therapeutic pain managementin these persons are differentfrom those used in the treatmentof younger persons.

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Immunocompromised hosts are at high risk for opportunisticinfections caused by endemic fungi such as Cryptococcus,Histoplasma, and Coccidioides. Moulds other than Aspergillusalso are being implicated in opportunistic fungal infections inimmunocompromised patients. Infections attributed toZygomycetes and Fusarium and Scedosporium species are beingreported with increased frequency. Because infection with theseorganisms cannot be distinguished from aspergillosis onradiographic imaging or histological examination, culture isrequired to confirm the diagnosis. Therapeutic success mayhinge on correct identification of the infectious organism.

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Two weeks earlier, a 25-year-old woman had sustained a thermal burn to the right forearm. About 1 week after the injury, the eschar sloughed off and she applied an over-the-counter antibiotic ointment (neomycin) to the wound site.

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Research shows that pediatricians are at higher risk than other physician groups for financial loss as they transition to ICD-10. Here, 8 areas you can focus on now.

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An 89-year-old woman is seen for an erosion on the frontal area of the scalp. History is positive for actinic keratosis. What's your Dx?

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Abstract: Acute chest syndrome (ACS) is one of the most common causes of death and hospitalization among patients with a sickle hemoglobinopathy. The clinical presentation is characterized by the appearance of a new infiltrate on a chest radiograph, with 1 or more new symptoms, including fever, cough, chest pain, and dyspnea. Additional findings include leukocytosis, hypoxemia, and auscultatory signs of consolidation. The differential diagnosis includes pneumonia, pulmonary infarction, fat embolism syndrome, pulmonary edema, and bone infarction. Treatment of ACS involves supportive care, empiric antibiotic therapy, and red blood cell transfusion when indicated. The decision of whether to use simple or exchange transfusions depends on the severity of illness and the risk of acute respiratory failure. Currently, hydroxyurea is the only FDA-approved drug designated as a preventive therapy. (J Respir Dis. 2005;26(12):529-534)

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A 45-year-old man of Hispanic ancestry presents for evaluation of what he describes as a "growth in both eyes." This growth has been present for some time; however, it has recently become more prominent. The patient has had mild redness and irritation in both eyes, but he denies any change in vision.

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Two weeks before admission, he had visited the emergency department (ED) because of the headache. Migraine was diagnosed and ibuprofen had been prescribed. The headache persisted despite NSAID therapy, and the patient returned to the ED 2 days later.

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A 58-year-old man presents with exertionaldyspnea of 6 weeks’ duration, adry cough for 2 weeks, and decreasedappetite. He denies fever, chills, sputumproduction, hemoptysis, cigarette smoking,and significant weight loss. Thepatient, a retired electrician, was exposedto asbestos 20 years earlier.

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In the United States, it has been estimated that 7.8% of the total population has diabetes. In 2007, the direct medical expenditures for diabetes were about $116 billion and the total direct and indirect costs were $174 billion, according to the CDC.1

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Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)

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A 10-year-old boy presented with right hip pain and a limp. The patient was taking no medications and had no personal or family history of disease. He denied a history of trauma.

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A 75-year-old woman with a bioprosthetic aortic valve, who had undergone surgical repair of an aortic root aneurysm 9 months earlier was hospitalized with fever, headache, and altered mental status of 1-day's duration.

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Vaccination rates in adults are lower than those in children, but the consequences of lack of immunization in adults are just as significant. Barriers to adult immunization include patients’ lack of knowledge or misconceptions about vaccines and health care providers’ failure to recommend vaccination.1

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Attacks of muscle weakness associated with this condition can range in severity from mild deficit to complete paralysis. Episodes may alternate with periods of normal muscle function.

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During the first quarter of a football game, a 17-year-old athlete noticed that his right (dominant) arm was swollen and heavy. Two days earlier, he had fired a shotgun right-handed multiple times while hunting.