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Phrenic Nerve ParalysisPhrenic nerve paralysis can present with chest wall pain, cough, and exertional dyspnea mimicking cardiac dyspnea. Fluoroscopy is the most reliable way to document diaphragmatic paralysis, and the sniff test confirms that abnormal hemidiaphragm excursion is due to paralysis rather than unilateral weakness.
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Allergic Reactions: Anaphylaxis Presenting as MacroglossiaThree days after having eaten fish, a 66-year-old woman with a known allergy to fish and a history of schizophrenia was brought to the emergency department because of macroglossia--a presentation of anaphylaxis.
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Case In Point: Recognizing allergic bronchopulmonary aspergillosisA 28-year-old man presented with chest pain, hemoptysis, and wheezing. He had a history of intermittent shortness of breath that occurred at least 3 times a year in the past 3 years; fever; and loss of appetite associated with headache, vomiting, and weakness. His medical history also included asthma, chronic gastritis, and more than 5 episodes of pneumonia since 1996. A test for hepatitis C virus (HCV) had yielded positive results.
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Pseudomyxoma PeritoneiA 67-year-old man presented with right lower quadrant pain of 3 days' duration. CT findings suggested acute appendicitis with ascites and omental caking. Laparotomy revealed a ruptured appendix, which was removed, and numerous gelatinous deposits throughout the abdomen.
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Emphysematous Pancreatitis in a 61-Year-Old ManEmphysematous pancreatitis is a rare form of necrotizing pancreatitis. Free air within the pancreatic parenchyma is typically attributed to infection.
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Congenital Nevomelanocytic NevusThis darkly pigmented lesion on the left arm of a 27-year-old man had been present since birth and had slowly enlarged over the past 2 months. Two days earlier, another physician had diagnosed a wart and treated the lesion with liquid nitrogen, which caused erythema of the surrounding skin.
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Chemical Colitis From Hydrogen Peroxide EnemaA 61–year–old man presented to the emergency department with diffuse lower abdominal pain, nausea, and severe diarrhea (20 episodes within the past 12 hours). His symptoms began the night before and had gradually worsened. He denied fever. His medical history was significant for hypertension.
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Older Woman With Dyspnea and Large Abdominal EcchymosisTHE CASE: A 77-year-old woman who has had shortness of breath and intermittent left flank pain for the past 2 to 3 days is brought by her family for evaluation. The dyspnea worsens when she lies down. She denies chest pain, back pain, and syncope. She has also had mild nonbloody diarrhea of 2 days’ duration but no vomiting or oral intake intolerance.
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Superior Mesenteric Vein ThrombosisA 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.
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Anal Pain: Office Diagnosis and TreatmentPatients almost always believe that their anorectal problems are caused by hemorrhoids, regardless of the nature of their symptoms. They are often dismayed when we insist that they must come to the office for an examination before we can prescribe any treatment.
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Fever and Rash: Infection or Kawasaki Syndrome?Kawasaki syndrome (KS) is a common and serious disorderthat most often affects children aged 1 to 8 years but mimicsa range of other diseases of childhood. Diagnosis of KS isbased on physical examination findings coupled with theexclusion of other causes. To provide optimal care for patients,it is important to be aware of the differential diagnosis of KS.We report a case of a 4-year-old boy who presented withpersistent fever and cervical lymphadenitis; later, mucousmembrane changes, rash, and conjunctival injectioncharacteristic of KS developed. [Infect Med. 2008;25:320-322]
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Ventricular Septal Defect Following MyocarditisA previously healthy 55-year-old woman complained of fever, weakness, and generalized malaise for the past 3 to 4 weeks. She had been treated with ciprofloxacin, amoxicillin, and azithromycin for 21 days with no resolution of her symptoms. Five days before she was hospitalized, multiple nonspecific constitutional complaints developed.
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Clinical Evolution in Asthma and COPDNew approaches discussed at CHEST 2015 ranged from the impact of bariatric surgery on asthma control to endobronchial valve placement in COPD.
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Electronics Before Bed: When Does It Affect Sleep?A big concern is that sleep affects memory performance and concentration, much-needed skills in the classroom.
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Anorectal Complaints: Office Diagnosis and Treatment, Part 2Anorectal abscesses and fistulae, pilonidal disease, rectal prolapse, pruritus ani, and anal masses are discussed, with an emphasis on diagnosis and treatment of these conditions in the primary care office setting.
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The Mediterranean Diet in Primary Cardiovascular PreventionPatients who consumed a Mediterranean-style diet had a 30% reduction in major cardiovascular events compared with patients who ate a diet low in saturated fat.
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Handle With Care: The Dangers of Cervical Spine Fracture in Patients With Ankylosing SpondylitisPatients with ankylosing spondylitis areat increased risk for fractures (particularlyextension fractures of the cervicaland thoracolumbar spine) and spinalcord injury. Fractures in these patientsare extremely unstable; in fact, they areamong the most complication-prone ofall cervical spine injuries likely to beseen in the primary care setting.
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The Dizzy Patient: How You Can HelpMost primary care practitioners approach the patient who complains of dizziness with some trepidation. This is chiefly because the differential diagnosis involves multiple organ systems and a wide variety of disorders. In this article, I offer a rational, straightforward, and cost-effective approach that uses only minimal, selective diagnostic testing.
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Toxic Epidermal NecrolysisA 43-year-old woman presented to the emergency department with a 4-day history of worsening erythema, swelling, and pruritus that developed on the face and progressed to the abdomen, back, and lower legs. In the past 2 to 3 days, fluid-filled blisters had arisen, followed by skin sloughing; the patient also reported subjective fevers. Another physician had prescribed naproxen for back pain 6 days earlier. The patient had a history of asthma, with rare inhaler use, and depression, for which she had taken citalopram for 2 years.
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Reaction to QuinineThe sudden onset of a petechial rashon the upper and lower extremities,ecchymosis of the tongue, and anepisode of epistaxis prompted a78-year-old woman to seek medicalevaluation. She reported having takenone of her husband’s quinine pills aday earlier to alleviate leg cramps.The patient was otherwise in goodhealth and took no other medications.
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Small-Bowel Metastatic MelanomaAn 83-year-old man with a history of hypertension, hyperlipidemia, and diverticulosis was hospitalized because of painless hematochezia of 1 day's duration. Two years earlier, he had undergone surgical excision of a superficial spreading melanoma on his right thigh.
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Skin Cancer:ABSTRACT: Prevention of skin cancer requires photoprotection (eg, the use of a sunscreen with both UVB and UVA protection) and regular monitoring of the skin for suspicious lesions. Encourage patients to examine all areas of their skin, including the interdigital and genital regions, for unusual macules, papules, and nodules. Teach patients the "ABCDE" warning signs of melanoma (asymmetry, border irregularity, color variegation, diameter greater than 0.5 cm, evolving lesion). Office skin examinations are recommended for patients with risk factors for skin cancer and for those with obvious sun damage. Correct lighting, preferably daylight, and cross-illumination are crucial. Palpation may be helpful in detecting lesions such as actinic keratoses, which have a gritty, sandpaper-like surface.
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How to Use a Coronary Artery Calcium Score: Is a Statin Needed?The decision to prescribe a statin to prevent ASCVD may require considering factors in addition to global CVD risk. A short case illustrates use of the CAC score.
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HCV Testing Still LagsHepatitis C virus is the leading indication for liver transplant in the US. Is it time for state-mandated HCV testing?
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Vin Rose UrineA 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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Common Shoulder Problems: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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Metastatic Squamous Cell CarcinomaShortly 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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Clinical Consultation: Could your patient's flu-like illness really be inhalation anthrax?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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Diagnostic Nucleic Acid Testing for Invasive Fungal InfectionsOver 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.
