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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.
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Trash Feet and Mobile Thrombus/AtheromaFour months after coronary artery bypass surgery, a 77-year-old man began to suffer severe pain in his feet. Multiple necrotic areas developed on the toes.
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Erythema Multiforme MinorErythromycin had been prescribed for a 15-year-old boy who complained of flulike symptoms. Twenty-four hours after starting the medication, he awakened with painful ulceration of his mouth and lips. The erythromycin was discontinued, and hydroxyzine (25 mg, three times daily) was started for possible macrolide sensitivity. His condition worsened over the next 3 days, however, and he was hospitalized when the severe oral pain made it impossible for him to tolerate food or drink. At no point had he any nausea, vomiting, diarrhea, fever, or chills.
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Exercise for Patients with Osteoarthritis: A Phased Approach to PlannngABSTRACT: Exercise can be an effective way to stabilize or slow the degenerative process of osteoarthritis-provided convenient, safe, and enjoyable activities are selected and achievable goals are set. Implement an osteoarthritis exercise plan in phases, and progress gradually from one phase to the next; this will help both you and your patient anticipate difficulties and gauge progress. The first phase-the initial evaluation-includes gathering baseline data, targeting an area of the body to focus on first, and identifying potential contraindications to activities. Subsequent phases include range of motion exercises (stretching), isometric and isotonic strengthening exercises, and recreational or functional activities. Encourage patients to continue stretching exercises throughout the program.
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Pleural EffusionCongestive heart failure and cirrhosis are the most common causes of transudative pleural effusions, while pneumonia and malignancy are responsible for the majority of exudative effusions. Plain chest films are valuable in confirming the presence of an effusion, providing clues to the cause, and directing the method of pleural fluid sampling. Thoracentesis is safe and simple, and it is diagnostic in about 75% of cases. Pleural biopsy is indicated for unexplained exudative effusions, most of which are found to result from malignancy or tuberculosis. Medical thoracoscopy, if available, is the procedure of choice for patients with these effusions. Thoracoscopy permits visually directed pleural biopsies and allows for therapeutic intervention at the time of diagnosis, obviating the need for subsequent invasive procedures.
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First Comes Pain, Then Comes InsomniaGood physical and social functioning may help avert insomnia in older people with musculoskeletal pain.
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Older Woman With Ankle and Chest InjuryA 69-year-old woman is broughtto the emergency department(ED) after a head-on collision in whichshe sustained injury to the right sideof the chest and the left ankle in additionto a laceration on her left forearm.She possibly had a transient loss ofconsciousness, but in the ED she canrecall all the events of the car accident.She complains of pain in the chestand ankle.
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The Dangers of ATVsAn all-terrain vehicle-ATV-is described by the American National Standards Institute as one that "travels on low pressure tires, with a seat that is straddled by the operator, and with handlebars to be used for steering."1 By this definition, an ATV is designed for interactive riding by a single operator. Drivers are able to shift their weight freely in all directions depending on the situation and terrain. According to ATV safety standards and recommendations, children younger than 6 years are never to be on an ATV of any size-alone or with someone else.
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Chinese Physicians More Burned Out Than US PhysiciansThink you have it bad? Consider the Chinese.
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How to Grow a Happy DoctorClinician mental health advocate Pamela Wible, MD, has drafted The 10 Commandments for Medical Educators. Your comments welcomed.
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Acute EpiglottitisA 74-year-old nursing home resident was admitted to the hospital with shortness of breath and stridor. Radiographic examination of the neck revealed the “thumb sign” of a swollen epiglottis (Figure, white arrow); the black arrow indicates the normal posterior wall of the pharynx. Acute epiglottitis was diagnosed.
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Are Expensive Diabetes Drugs Worth It?The good news is that a few diabetes drugs now show valid cardioprotective benefits; the bad news is the drugs are unaffordable for many.
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Bronchoalveolar Carcinoma in a 58-Year-Old ManA 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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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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Primary Biliary CirrhosisA 50-year-old woman had a 6-month history of severe generalized itchiness and fatigability. There was no associated fever, abdominal pain, or joint pain. A cholecystectomy had been performed 20 years earlier. She had no family history of hypercholesterolemia or liver disease.
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Double Aortic Arch in an Infant With Persistent StridorDouble aortic arch-a vascular ring anomaly in which both embryonic aortic arches persist and encircle the trachea and esophagus-is rare.
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Erythema ab Igne in a 66-Year-Old Black WomanThis 66-year-old black woman presented with a 2-year history of a painless skin eruption. She stated that her skin had “changed overnight” while she was caring for her mother who had been hospitalized.
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Bilateral Painless Swelling of the Neck in a 40-Year-Old ManOn palpation, the swelling was non-tender, soft, and mobile but did not feel fluid-filled. Here, view ultrasound findings and propose your diagnosis.
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Vulvar MelanosisDuring a routine examination, macular dermatitis with irregular borders was noted on the genitalia of an otherwise healthy 41-year-old woman. The right labia minora featured a 7-cm dark pigmented macular area; a similar area measuring 10 cm was observed on the left upper labia minora.
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Gastrointestinal Involvement of Systemic AmyloidosisThe authors present a case of AL amyloidosis with rare GI involvement and an equally rare presenting symptom.
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Medication Nonadherence and the Risks of Hospitalization, Emergency Department Visits, and Death Among Medicare Part D Enrollees With DiabetesThe authors are affiliated with the University of Mississippi School of Pharmacy, in University, Miss. Dr Yang is assistant professor in the department of pharmacy administration.
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Back Extension Exercises for Patients With OsteoporosisExercises that help strengthen themuscles that support the spinemay be especially helpful duringthe postmenopausal years. Theback extension series illustratedin Figures 1 through 5 is anexample of progressively moredifficult exercises that can beperformed several times perweek. These exercises can alsobe performed individually inconjunction with resistance andweight-bearing routines.
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The 10 Most Common Prescribing Errors: Tips on Avoiding the PitfallsNumerous factors contribute to the medication errors that kill up to 98,000 patients each year. Unnecessarily high dosages can result in increased side effects with only a small therapeutic benefit, especially in elderly patients. Lack of patient information-such as a history of allergies or adverse drug reactions-is another cause of error and injury. Communication failures include the use of ambiguous abbreviations, misinterpretation of verbal orders, and lack of timely response to a patient's medication-related symptoms. Dosing errors are common in children because of variability in dosage expressions in drug references. Remedies for prescribing errors are described in detail here.
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AIDS-Related PsoriasisA 29-year-old man presented with a complaint of venereal warts and a long history of mild psoriasis, which he had treated with fluocinolone. He returned 3 months later complaining of chest congestion of 10 days' duration; it had been treated with ciprofloxacin at an urgent care facility.
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Rebound Headache: Keys to Effective TherapyWhich of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.
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Osteoarthritis of the Knee and Hip:For patients with osteoarthritis, nonpharmacologic treatment can be an effective adjunct to drug therapy. Patient education is essential; both community-based and independent self-care programs are available. Weight loss can improve function and alleviate symptoms; however, it is more effective when dietary modification is accompanied by increased physical activity.
