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Parkinson Disease: REFERENCES: EVIDENCE-BASED MEDICINE: RELEVANT GUIDELINES:ABSTRACT: Signs that strongly suggest Parkinson disease (PD) include unilateral hand tremor, slowed or decreased movement, and gait changes. Postural alterations include leaning forward or asymmetric shoulder height; the arm may not swing when the patient walks, or it may be held flexed at the elbow. Patients may report increasing difficulties in occupational and social functioning. Mimics of PD include essential tremor, normal pressure hydrocephalus, other neurodegenerative diseases, and drug-induced parkinsonism. Most patients report such nonmotor symptoms as sleep disturbances, visual difficulties, bowel and bladder problems, fatigue, depression, and anxiety. Cognitive impairment in many patients takes the form of slowing of memory and difficulty with visual spatial tasks and executive function. A more realistic treatment goal than tremor eradication is improved overall mobility.
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Primary Hodgkin Lymphoma Masquerading as a Klatskin TumorA 56-year-old man presented to the emergency department with a 1-week history of dark-colored urine and acholic stools followed by 3 days of intermittent right upper quadrant abdominal pain and overt jaundice. He had been healthy and did not smoke or drink alcohol. His family history was unremarkable. He recently lost 15 lb and experienced early satiety and intermittent night sweats.
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Orogastric Tubes to Prevent Nasopharyngeal InjuryIn patients with chronic liver disease or coagulation disorders, nasogastric tubes may result in significant nasopharyngeal trauma and uncontrolled bleeding. In such patients, use an orogastric tube instead.
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Fever With Bacteremia in Children:ABSTRACT: Occult bacteremia now occurs in only 1 of 200 children who present with acute fever (temperature of 39°C [102.2°F] or higher) and white blood cell counts of 15,000/µL or more. The most likely cause of bacteremia remains Streptococcus pneumoniae; when there is no evidence of toxicity, such bacteremia is generally a benign, self-limited event. Because of the extremely low yield, blood cultures are no longer routinely warranted in children aged 3 to 36 months who have no obvious source of infection, and empiric treatment of occult bacteremia is no longer appropriate. Almost all cases will spontaneously resolve with a low rate of subsequent focal infection. If a child remains febrile and worsens clinically, further diagnostic evaluation and possible empiric treatment with antibiotics pending results of cultures may be considered.
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Ironic ExorciseAfter drinking a cup of coffee in the lounge of St Gimmick Hospital, Dr Schmeckman accompanied one of his students, Mollie Jeanette, who was beginning her rotation through the hospital’s infectious diseases service, to the microbiology laboratory.
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What’s New in Perinatal Psychopharmacology?To treat or not to treat? The risks and benefits of perinatal treatment for mental illness should be understood by all primary care clinicians.
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Genentech Restricts Sales of Less Costly Agent for Macular Degeneration TreatmentSAN FRANCISCO -- Retinal specialists who use Genentech's bevacizumab (Avastin) off-label, instead of ranibizumab (Lucentis), to treat macular degeneration will soon find that their sources for the drug have dried up.
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Clinical Consultation: Is scuba diving off-limits for patients with asthma or COPD?Under what circumstances would asthma or chronic obstructive pulmonary disease (COPD) be a contraindication to scuba diving? What precautions should patients with either asthma or COPD take if they are determined to go diving?
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Posterior Shoulder DislocationA 53-year-old man with type 2 diabetes mellitus and hypertension presented to the emergency department with pain in his left upper chest and back, neck, and shoulder. The pain increased with passive and active range of motion testing and decreased at rest. His physical examination was unremarkable except for restricted left shoulder movement and generalized tenderness in the left shoulder area.
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Case In Point: What caused diffuse alveolar hemorrhage in a patient with gout?Allopurinol, commonly used to treat patients with gout, has been known to cause hypersensitivity reactions. We report a case of drug-induced delayed multiorgan hypersensitivity syndrome secondary to allopurinol use. To the best of our knowledge, this is the first reported case of diffuse alveolar hemorrhage in a patient presenting with allopurinol-induced rash with eosinophilia and systemic symptoms.
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Case In Point: Cystic fibrosis in an elderly womanThe diagnosis of cystic fibrosis (CF) is typically made in childhood. However, there is increasing evidence that a mild and atypical form of this disease can present in adulthood. The author describes a patient who received the diagnosis of CF when she was 74 years old.
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New Lymphadenopathy in a Woman With a History of Colon CancerA 47-year-old woman who recently completed adjuvant chemotherapy for colon cancer has painless cervical lymphadenopathy of 1 to 2 cm. She has no fever, sore throat, cough, or unexplained weight loss, and she denies exposure to ill persons or animals.
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COPD and mood disorders, part 2:Sleep problemsSleep complaints are common in patients with chronic obstructive pulmonary disease (COPD). Many patients complain of morning tiredness, early awakenings, difficulty in falling asleep, restlessness, and daytime sleepiness. Functional status may eventually be impaired by the resulting chronic fatigue that is compounded by dyspnea.
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Irritable Bowel Syndrome: Rational TherapyABSTRACT: Irritable bowel syndrome (IBS) is characterized by abdominal pain or discomfort, bloating, and constipation or diarrhea; the pain is typically relieved by defecation. The diagnosis is not one of exclusion; it can be made based on the answers to a few key questions and the absence of "alarm" symptoms. Fiber therapy, the elimination of particular foods, and regulation of bowel function can help relieve symptoms. Tegaserod or polyethylene glycol can be used to treat IBS with constipation. Loperamide and alosetron are of benefit in IBS with diarrhea (although the latter carries a small risk of ischemic colitis). Low-dose tricyclic antidepressants may be used to treat the abdominal pain associated with IBS. Probiotic therapy or rifaximin may help reduce bloating. Psychological therapies seem to improve well-being in patients with IBS.
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A Better Way to Assess for Renal Insufficiency?A 72-year-old man with a history of rheumatic heart disease presented with pulmonary congestion and syncope. Results of the cardiac examination suggested mitral stenosis and atrial fibrillation with a controlled ventricular response. Two-dimensional echocardi-ography revealed a large, free-floating ball thrombus (T) in the dilated left atrium and demonstrated rheumatic and severely stenotic mitral valve leaflets.
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Achilles Tendon XanthomasA 51-year-old woman complained of mild pain in the Achilles tendon area of both feet. This was aggravated when she stood for prolonged periods and when she wore tight, high-heeled shoes. Physical examination results were unremarkable except for a disputable palpable thickness of the Achilles tendons, especially on the right foot.
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Is there a role for bronchoscopy in the workup of cough?• The evaluation of cough remains an important clinical problem for primary care physicians and pulmonologists alike. In the past 5 years, the American College of Chest Physicians,1 the British Thoracic Society,2 and the European Respiratory Society3 have published comprehensive guidelines to assist in standardizing the approach to cough evaluation. While determining the cause of cough can be vexing initially, prospective studies have shown that the cause can be established in more than 90% of patients.
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MalariaDuring a flight from Houston to New York, a 46-year-old man had fever, chills, rigors, and body aches. After he landed, he sought treatment at a local hospital. The patient was on his way back to Liberia, where he works. He had been at home in Houston for several weeks. In the emergency department, he complained only of subjective fever.
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Cutaneous T-Cell LymphomaThree months ago, a 50-year-old man who was otherwise in good health noticed a hard, round nodule on his left arm. Within 2 months, similar nodules appeared all over his trunk, head, arms, and legs. The reddish purple lesions, less than 2 cm in diameter, were painless and slightly pruritic.
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Lactic Acidosis in an Infant Receiving HIV ProphylaxisZidovudine is safe and effective in reducing transmission of HIV from mother to infant but rare serious side effects do occur. Is it worth the risk?
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A Patient With Nonresolving Pneumonia and ArthralgiasA 61-year-old man with arthritis and an 80-pack-year smoking history presented with fever, dyspnea, and productive cough of a week’s duration that did not respond to outpatient treatment with levofloxacin.
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Histoplasmosis mimicking metastatic carcinomaThe differential diagnosis forendobronchial lesions includesbut is not limited toneoplastic causes, benign tumors,infections, and foreignobjects. We report a case of anunusual cause of endobronchiallesions.
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Economic Burden Associated With Parkinson DiseaseThe objective of this study was to estimate the annual cost burden of Parkinson disease (PD) in the United States. Resource use and cost profiles were developed using all-payer statewide hospital discharge data from 6 states; emergency department visit, long-term–care, and national survey data; fee schedules; and published study findings. (Average direct and indirect costs per patient were calculated in 2007 US dollars.) The annual cost per patient was $21,626 (direct cost: $12,491). When applied to the US PD population (N = 500,000), the annual average cost was approximately $10.78 billion (direct costs, $6.22 billion; indirect costs, $4.56 billion). PD has substantial economic consequences for patients and their families, insurers, and society. (Drug Benefit Trends. 2009;21:179-190)
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Alcohol Again Tied to Lower Death RiskAnd, once again, light-to-moderate consumption appears protective while heavy and binge drinking increase risk for myriad diseases.
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Update on HPV InfectionAn estimated 20million Americansare currentlyinfectedwith humanpapillomavirus (HPV). Assuch, HPV is now the mostprevalent sexually transmitteddisease (STD) in thiscountry. Answers to commonquestions like the onesabove are therefore of particularinterest to physicians.The issue of when and howto use testing for HPV hasbecome especially crucial.
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Photo Dx: Achilles Tendon Rupture? Tendonitis? Bursitis? Something Else?Does an Achille’s tendon rupture, tendonitis, bursitis, or something else underlie sudden heel and lower leg pain?
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Cavitary lung disease and hemoptysis in a young manThe authors describe a patient who presented with episodic hemoptysis and other respiratory symptoms. His chest radiograph showed a diffuse reticulonodular pattern. Bronchoscopy led to the diagnosis of pulmonary blastomycosis.
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HIV-Associated LymphomaFor 2 months, a 30-year-old man with a history of cocaine abuse had had a painful gingival mass and difficulty in eating. Examination revealed a large, fungating mass in the anterior oropharynx that extended posteriorly up to the retromolar region. Posterior cervical lymph nodes were enlarged bilaterally, with no other peripheral lymphadenopathy.
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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).
