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Managing COPD, part 2: Acute exacerbationsAbstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)
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Using ultrasonography in the diagnosis and management of pleural diseaseABSTRACT: The increasing availability of bedside ultrasonographyallows for more timely diagnosis and treatment of pleuraleffusion while limiting the patient's exposure to radiation. Thedynamic signs characteristic of pleural effusions includerespirophasic changes in the shape of the fluid collection, floatingmovements of atelectatic lung, and the plankton sign. Ultrasonographyalso is an efficient means of excluding pneumothoraxwhen rapid diagnosis is needed or after interventionssuch as central line placement, lung or pleural biopsy, or thoracentesis.The diagnosis of a pneumothorax relies on the absenceof dynamic signs such as "lung sliding." Static signs, suchas the comet tail artifact, or consolidated lung parenchyma orlung tissue that contains a solid mass, also can be useful in excludingpneumothorax. Ultrasonography can be used to guidefine-needle aspiration and core biopsies of pleural nodules,pleural thickening, and subpleural lung masses. (J Respir Dis.2008;29(5):200-207)
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Worsening Neurological Symptoms in an Older Man With History of Rectal CancerA 65-year-old man, who was lost to follow-up after abdominal-perineal resection for rectal adenocarcinoma 9 months earlier, presents with progressively worsening neurological symptoms, including bilateral hearing loss, dizziness, gait disturbance, ataxia, and blindness in the right eye.
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Dyspnea and chronic bronchitis in a man with ulcerative colitisThe authors report a case of idiopathic eosinophilic pneumonia in a man with sclerosing cholangitis and ulcerative colitis associated with features of sarcoidosis.
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Transient ST Elevations and Conduction Delay After Traumatic Fracture of the SternumA 25-year-old man with no significant medical history was attempting to move a heavy container when he lost control and became pinned between the container and a concrete pole.
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Bronchoscopy Clinic: Emerging options for managing foreign-body aspirationEndobronchial foreign bodies can be life-threatening, but once they are detected, they can usually be removed, leading to prompt resolution of symptoms. Chest radiography and CT scanning can be helpful in some cases, but bronchoscopy is necessary for definitive diagnosis and treatment.
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Sweet SyndromeA 66-year-old woman was hospitalized because of severe anemia secondary to myelodysplastic syndrome. She had had associated fatigue and throbbing pain in both legs for several days.
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Child With Appendicitis-like Symptoms9-year-old girl was seen in the emergency department (ED) with a 5-day history of non-bilious, non-projectile emesis, decreased appetite, and persistent right lower quadrant pain following an appendectomy 5 days earlier.
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Takotsubo Cardiomyopathy in a Man With a Gunshot WoundA 48-year-old African American man with no significant medical history sustained a gunshot wound to the face and shoulder.
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Subcapsular Hematoma of LiverIntermittent right upper quadrant abdominal pain prompted a 42-year-old woman to seek medical consultation. Ultrasonographic examination of the abdomen revealed cholelithiasis; percutaneous gallstone dissolution was performed.
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Update on Therapy for HistoplasmosisHistoplasmosis is caused by the dimorphic fungus Histoplasma capsulatum, which is endemic to the Ohio and Mississippi river valleys. It is associated with a variety of manifestations, and its severity ranges from asymptomatic infection to severe disseminated illness.
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ECG Changes in HyperkalemiaA succinct review of hyperkalemia . . . its various causes, clinical manifestations and consequences, ECG findings, and treatment approaches.
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A Differential Diagnosis of Drug-Induced Aseptic MeningitisDrug-induced aseptic meningitis should be included in thedifferential diagnosis of viral/aseptic meningitis. Cliniciansshould use historical clues in patients presenting with signs andsymptoms of viral meningitis to aid in the differentiation ofdrug-induced aseptic meningitis from other causes of asepticmeningitis. Viruses are the most common cause of asepticmeningitis, with enteroviruses being the most common amongviruses in cases presenting as aseptic meningitis. Ibuprofen iscurrently the most common cause of drug-induced asepticmeningitis. Drug-induced aseptic meningitis is a benign conditionwithout long-term sequelae. The diagnosis of druginducedaseptic meningitis is made by establishing a causalrelationship between the use of the drug and the onset of signsand symptoms, supported by negative tests for infectiouscauses of symptoms and rapidity of resolution after the drugis discontinued. [Infect Med. 2008;25:331-334]
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'Not your father's MRSA': What you need to know -- and do -- about community-associated MRSAThe notoriously adaptable and increasingly common pathogen requires a new approach including routine I&D and culturing of infected tissues; the use of more-potent antibiotics, but only when needed; and a focus on hygiene in patients with recurrent infections.
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Post-Test on Rheumatoid Arthritis in Primary CareUse this short test to gauge how much you’ve learned about a condition that needs more primary care involvement.
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Abdominal EcchymosisAn elderly obese female presents with abdominal bruising following a motor vehicle accident. Can you ID the cause?
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Fixed Drug Eruption Provoked by PhenolphthaleinA hyperpigmented macule on the submental surface disturbed this 56-year-old man.
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Thyroid Problems May Spell Trouble for Diabetes RiskLow thyroid function predisposes to weight gain, which may partly explain the association with higher risk of diabetes.
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Hyperglycemia Predicts Adverse Outcomes in Patients With Intracerebral HemorrhageSeveral poster presentations this week confirm that hyperglycemia is a risk factor for poor outcomes in patients with intracerebral hemorrhage (ICH).
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A Painless, Rapidly-growing Nodule in a 74-year-old WomanThe solitary, keratotic lesion has grown quickly over one month. Infection? Neoplasia? What else is in your differential diagnosis?
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Respiratory symptoms may develop years after IBD diagnosis What are the pulmonary manifestations of inflammatory bowel disease? key words: Inflammatory bowel disease, Ulcerative colitis, Crohn disease, Bronchiectasis, BOOP, Interstitial pneumonitisabstract: Inflammatory bowel disease (IBD) can have a variety of extraintestinal manifestations, including pulmonary disease. Bronchial involvement is the most common, but other manifestations include upper airway disease; parenchymal involvement, such as bronchiolitis obliterans with organizing pneumonia (BOOP) and interstitial lung disease; and serositis, including pleural effusions and pericarditis. Patients with BOOP may present with fever, dyspnea, cough, and pleuritic chest pain. Chest radiographs show bilateral patchy airspace opacities or a diffuse process; CT scans often demonstrate the opacities to be pleural-based. Corticosteroids appear to be effective in the management of certain pulmonary manifestations of IBD, such as BOOP and pulmonary infiltrates with eosinophilia. (J Respir Dis. 2007;28(6):227-234)
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Popular Android BP Apps Useless, HarmfulEditors at Medpage Today have been scouting for health apps that make dubious--even dangerous--claims. Here's an update on BP apps.
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Hand Deformities and Heart Problems: A Case ReportPatients who present with congenital hand deformities in association with cardiac disorders require a detailed evaluation.
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Intrathecal Methotrexate: A Treatment Option for Patients With Progressive Multiple Sclerosis?Could intrathecally administered methotrexate be a viable treatment option for your patients with progressive forms of multiple sclerosis?
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Infant in Shock With Respiratory FailureThe patient had right submandibular swelling with inflammation and induration up to the nape of neck. Ultrasonography showed multiple enlarged lymph nodes with soft tissue swelling. What's your diagnosis?
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Battle Over Statins Highlights Two Camps Within MedicineThe "statin war" is about ossified ideologies and asks medicine's most primal question-"what is the role of medicine in society?"
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Man With Severe Dyspnea, Fever, and CoughA46-year-old white man is hospitalized with increasing dyspnea of 3weeks’ duration. He has a history of stable chronic obstructive pulmonarydisease secondary to heavy smoking (2 packs of cigarettes a day for 27years, discontinued 6 years previously) and uses inhaled bronchodilators.
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Gouty Tophi of the PinnaeA 33-year-old man presented with joint pain and general malaise of about 2 weeks' duration and small yellowish lesions on the pinnae of the ears of about 6 months' duration. He had no urinary symptoms or conjunctivitis and was not taking any medications. His grandfather had been treated for gout.
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A Woman With Delirium From Diabetic KetoacidosisMucormycosis, an angioinvasive yeast infection of the Mucorales order of the class of Zygomycetes, often grows in patients with diabetes mellitus, especially in the presence of diabetic ketoacidosis.
