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Plantar Fasciitis: Office ManagementABSTRACT: Heel pain that occurs with the first several steps in the morning and diminishes as walking continues is the classic symptom of plantar fasciitis. Assessment of risk factors, such as improper footwear, a change in physical activities, and a new running surface, is important. Radiographs are rarely useful. Plantar fasciitis is generally self-limited; symptoms typically take 6 to 18 months to resolve. Conservative measures may include relative rest, stretching, strengthening, shoe modifications, orthoses, night splints, NSAIDs, and ice therapy. A corticosteroid injection may be warranted in resistant cases. If extensive conservative treatment is unsuccessful, referral to an orthopedic surgeon may be indicated.
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Right Bundle-Branch Block After Pacemaker ImplantationThe morning after an 88-year-old woman with symptomatic second-degree type I (Wenckebach) atrioventricular block underwent placement of a dual chamber pacemaker without complication, she awoke with uncomfortable pulsations in her abdomen. The pacing thresholds and impedance had remained unchanged since implantation.
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A Case of "Refractory Asthma"A 43-year-old African American woman presented to the emergency department with severe dyspnea, wheeze, and cough productive of white sputum. Three years earlier, she had been given a diagnosis of asthma based on symptoms of wheeze and cough; her treatment regimen included intermittent use of albuterol.
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An Elderly Man With a Lung Mass and Neurologic SymptomsA 71-year-old man was admitted to the MICU for weaning from mechanical ventilation. The history revealed a global decline over the previous 3 to 4 weeks predominated by cognitive impairment, mood swings, somnolence, and limb weakness. No respiratory symptoms were noted.
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Salter-Harris II Fracture of the Distal PhalanxA 10-year-old boy stubbed his toe while running upstairs barefoot. He presented with tenderness, swelling, and ecchymosis of the left great toe and bleeding in and around the nail fold (A). Radiographs of the left foot revealed a Salter-Harris II fracture of the distal phalanx (B).
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Autosomal Dominant Polycystic Kidney Disease in a 38-Year-Old WomanAutosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.
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Pneumomediastinum as First Presentation of Hypersensitivity PneumonitisSpontaneous pneumomediastinum with subcutaneous emphysema is rare. Alveolar rupture allows air to enter the pulmonary interstitium and penetrate the mediastinum.
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Acute Ischemic Stroke: REFERENCES: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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Young Man With a Mildly Pruritic Generalized RashA 29-year-old Ukrainian man presents with a mildly pruritic generalized rash, which started 4 days earlier as a widespread eruption. The patient has no contacts who have a similar rash.
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Autosomal Dominant Polycystic Kidney Disease in a 38-Year-Old WomanAutosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.
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Intoxication with street drugs: Cocaine and amphetaminesCocaine and amphetamine intoxication continue to be common causes of emergency department and hospital admissions.
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Differentiating colonization from infection can be difficult Nontuberculous mycobacterial infections: Diagnosis and treatment key words: Pulmonary infections, Nontuberculous mycobacteria, Mycobacterium avium complex, Rapidly growing mycobacteriaabstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)
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Skin Disorders in Older Adults: Papulosquamous and Bullous Diseases, Part 1Certain papulosquamous and bullous diseases are more common in older adults than in younger persons. For example, bullous pemphigoid typically affects those in the fifth through seventh decades of life. Grover disease, or transient acantholytic dyskeratosis, is most common in white men older than 65.
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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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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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Tracheal Stenosis: An Uncommon Cause of DyspneaA 75-year-old woman presented with worsening dyspnea of about 6 to 8 months' duration. Her symptoms were initially associated with exercise, after about 30 minutes on the treadmill, and now were present at rest. Her breathing pattern had changed to "panting" to improve airflow during minimal activity.
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Heart Disease and SyncopeSyncope is defined as a sudden, brief loss of consciousness and postural tone followed by spontaneous complete recovery. It accounts for 3% of emergency department visits and 1% of hospital admissions.
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An unusual case of malignant invasive thymomaMalignant thymoma is an indolent tumor arising from the thymic epithelial cells located in the anterior mediastinum. These tumor cells spread via regional metastasis or invade surrounding structures, including the pleural space.
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Tight Skin in a Patient With DiabetesThis patient with long-standing insulin-dependent diabetes has difficultyclosing his hand because of “tight skin.” Diabetes is the cause: this findingoccurs more often in persons with microvascular complications, such asretinopathy and nephropathy. The condition may occur even in patients withwell-controlled diabetes.
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Disseminated Mycobacterium avium-intracellulare complex InfectionA39-year-old man with a history of AIDS and nonadherence to highly active antiretroviral therapy (HAART) presented with frontal headache and scalp pain of 2 weeks' duration. These symptoms were accompanied by nausea, weight loss, and generalized weakness. Physical examination revealed a small, tender scalp lump, 2 × 2 cm over the left parietal area. The findings from the rest of the examination were unremarkable.
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Cocaine-Induced StrokeBrain infarcts among crack cocaine users may be secondary to large cerebral artery vasospasm with secondary intravascular thrombosis (with or without distal embolization).
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Hyponatremic Encephalopathy Induced by “Ecstasy”Ecstasy ingestion should be high on the list of differential diagnoses for young patients who present with acute, unexplained encephalopathy.
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Mites and HTLV-1 at the Crux of a 10-Year Itch and Plaque-Like LesionsImmunosuppression that is associated with human T-cell lymphotropic virus 1 (HTLV-1) infection predisposes to hyperinfective strongyloidiasis.1,2
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Chest Film Clinic: What caused persistent cough and dyspnea in this patient?A 65-year-old woman presented to her primary care physician with a 3-month history of worsening cough, now productive of copious blood-tinged secretions. She also reported a recent onset of fever and dyspnea. She denied any chest pain, chills, night sweats, and weight loss.
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Catscratch Disease Presenting as Acute Respiratory DistressSuperficial adenopathy is the most common symptom ofcatscratch disease (CSD) attributed to Bartonella henselaeinfection. More complicated adenopathy with pulmonaryinvolvement can occur. We report a case of a 15-year-oldboy with pleural symptoms related to B henselae–associatedCSD. [Infect Med. 2008;25:248-250]
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Disseminated Intravascular Coagulation as an Unusual Presentation of Acute Retroviral SyndromeMultiple atypical presentations of acute retroviral syndromehave been reported in the literature, but rarely has acute retroviralsyndrome been associated with disseminated intravascularcoagulation (DIC). We detail a case of a 19-year-old manadmitted to the hospital with initially unexplained severe DICthat on workup was found to be secondary to acute retroviralsyndrome. [Infect Med. 2008;25:24-28]
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Case In Point: Exfoliative dermatitis: A presenting sign of lung cancerA 53-year-old man presented with a 3-day history of bilateral pain in the lower extremities. He also had a 3-month history of thickening and desquamation of skin, with associated itching, and a 5-lb (2.27-kg) weight loss. The skin changes initially appeared on the hands and subsequently became generalized.
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Boerhaave SyndromeAn 85-year-old white woman was brought to the emergency department (ED) with acute, severe left posterolateral chest wall pain of several hours' duration. The nonradiating pain was accompanied by shortness of breath. She denied palpitations, diaphoresis, syncope, or dizziness.
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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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Sézary SyndromeA 55-year-old woman with no significant medical history reported that diffuse erythematous, patchy, purpuric skin lesions over most of her body had been present for the past year. Applications of an over-the-counter corticosteroid cream helped control the pruritus but did not clear the skin lesions.
