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Situs Inversus TotalisThe parents of a 2-year-old boy with a 3-day history of fever took him to the emergency department. The child's temperature fluctuated between 38°C (100.4°F) and 39°C (102.2°F). As part of the workup, chest films were taken.
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Under what circumstances is outpatient therapy possible? Using low molecular weight heparins to treat venous thromboembolism key words: Deep venous thrombosis, Pulmonary embolism, Heparin, Anticoagulant therapyabstract: Low molecular weight heparins (LMWHs) have proved to be as safe and effective as unfractionated heparin for the treatment of venous thromboembolism. They have the advantage of not requiring frequent measurement of activated partial thromboplastin time and subsequent dosage adjustments. Patients who have deep venous thrombosis can be treated with once- or twice-daily subcutaneous doses. Hospital admission is necessary for patients with risk factors for major bleeding complications, for those with symptomatic pulmonary embolism, or when noncompliance is likely. Symptomatic proximal deep venous thrombosis and asymptomatic pulmonary embolism may be managed on an outpatient basis if there are no contraindications. Although heparin-induced thrombocytopenia occurs less frequently with LMWHs than with unfractionated heparin, the platelet count must still be monitored during therapy. (J Respir Dis. 2007;28(4):132-138)
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Puzzling Rash in an Older WomanA 73-year-old woman presents with apainless, nonpruritic rash of recent onseton her right lower ankle. She has nofever, chills, nausea, vomiting, malaise,or other systemic complaints. Her medicalhistory includes fibromyalgia, osteoarthritis,stable angina, and anxiety;there is no history of connective tissuedisease.
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MorpheaTwo enlarging, dry, tender lesions had developed on the right breast of a 62-year-old woman 2 years before she sought medical consultation. The patient had no other symptoms; she was taking metoprolol succinate for cardiac arrhythmias.
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Photo Finish: Acute Dx: What Cause of Sudden Illness?A 56-year-old man presents with diffuse erythema. He has not changed his routine or eaten anything unusual. The rash initially appeared the previous night as asymptomatic erythema on the face and body. On awakening in the morning, the patient noticed that the erythema had spread over most of his body and had become pruritic. Over-the-counter diphenhydramine did not relieve the symptoms.
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Intussusception in the Adult Patient: Rare, OminousMost adult intussusceptions are caused by structural lesions, lead points for many of which are malignant neoplasms.
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Primary synovial sarcoma presenting as an endobronchial massEndobronchial primary synovialsarcoma is an extremelyrare pulmonary tumor. We reportthe case of a 58-yearoldman who presented witha right-sided endobronchialmass, which was diagnosed asprimary synovial sarcoma onthe basis of histological appearanceand immunohistochemicalstaining. To the bestof our knowledge, this is onlythe third case report of endobronchialprimary synovialsarcoma.
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Woman With a Protuberant AbdomenA 69-year-old woman with a protuberant abdomen presents with intermittent, painless vaginal bleeding of 2 weeks' duration. The patient has not seen a physician in years. Her abdominal girth began to increase 8 years ago.
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Elderly Man With HypothermiaOn a warm August day, a 79-year-old man is hospitalized because of progressive lethargy over the past week. Previously, he was alert and able to converse. He has no chest pain, dyspnea, or cough. His history includes hypertension of unknown duration, chronic obstructive pulmonary disease, and a recent hospitalization for pneumonia.
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Eye on Ocular Disorders: Isolated Abducent Nerve PalsyA 65-year-old woman presented withdouble vision of 2 days’ duration.The diplopia mainly occurred whenshe looked toward her right. She deniednausea, vomiting, vision loss,headache, change in mental status,facial pain, weakness in the extremities,and sinus infection. She had nohistory of head trauma or systemicmalignancy.
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Recognizing tracheobronchomalaciaAbstract: Tracheobronchomalacia is a form of expiratory central airway collapse characterized by softening of the airway wall cartilaginous structures. Symptoms often mimic asthma and chronic obstructive pulmonary disease. Pulmonary function test results may suggest a diagnosis, but findings are neither sensitive nor specific. Bronchoscopy and novel dynamic radiographic studies contribute to the diagnosis and help differentiate true malacia from other forms of expiratory central airway collapse. Treatment options include medication; noninvasive ventilatory support; interventional bronchoscopy with airway stent insertion; and open surgical procedures, such as tracheostomy, tracheal resection, and tracheoplasty. (J Respir Dis. 2006;27(8):327-335)
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Juvenile DermatomyositisThe diagnosis of juvenile dermatomyositis can be challenging when proximal muscle weakness develops without characteristic skin manifestations. In this patient, rash appeared 2 months after the onset of muscle weakness. As a result, the initial diagnosis was viral myositis, which led to delayed therapy.
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A covert cause of hypoxemia: Intravascular pulmonary lymphomaWe describe a patient with intravascularpulmonary lymphomawho presented withprogressive dyspnea and hypoxemiawith normal chest radiographicfindings. After anunrevealing noninvasive evaluation,a high-grade B-cellintravascular lymphoma wasdiagnosed by bronchoscopywith transbronchial biopsy.Treatment with a modifiedCHOP regimen resulted in resolutionof the patient’s hypoxemiaand exercise limitation.Although intravascular pulmonarylymphoma rarely presentswith pulmonary symptoms,it should be consideredin the differential diagnosis ofpatients presenting with hypoxemiaand normal chest radiographicfindings.
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Coronary Artery Calcium Scoring: 7 Questions for Primary CareHow current are you on CAC and its place in CVD risk assessment? This short quiz will reveal your score.
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Shoulder Pain That Prevents a Painter From WorkingA 55-year-old right-handed house painter has had a constant dull ache in his right shoulder for 3 weeks. The pain worsens when he steers his car or elevates his arm, and the inability to raise his arm above his head interferes with his work.
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Acute Suppurative Thyroiditis in a Patient With Aplastic AnemiaAcute suppurative thyroiditis (AST) is a rare inflammatorycomplication in patients with hematological malignancy.Infection spreads to the thyroid from a distant site throughthe bloodstream or the lymphatics. Defects such as persistentthyroglossal duct and pyriform sinus fistula are associatedwith the development of AST. Ultrasonography, bariumswallow testing, CT, and fine-needle aspiration are usedfor diagnosis. Treatment includes the administration ofparenteral antibiotics, drainage, and excision. We describea patient with aplastic anemia and bacteremic AST.[Infect Med. 2008;25:339-342]
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Scrub Typhus: Two Cases Presenting as Abdominal PainScrub typhus, which is caused by Orientia tsutsugamushi, has various systemic manifestations, including GI symptoms. We describe one patient with scrub typhus who presented with symptoms that suggested acute appendicitis and another who presented with symptoms of acute cholecystitis.
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Boy With Frequent, Severe Unilateral HeadachesA 14-year-old boy presents with frequent severe headaches characterized by sharp, throbbing pain behind his left eye and left temple.
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Timely, Appropriate Follow-up Is CriticalThe scientific literatureon screeningmammography can be confounding.This poses a continuingdilemma for bothpatients and clinicians. Nevertheless,objective analysisof the available data canprovide reasonable guidelinesfor the primary careclinician who must decidewhether screening mammographyhas benefit foran individual patient.
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Pulmonary Arteriovenous Malformation in a Woman With Severe Mitral Valve StenosisAn 86-year-old woman presented with a 1-week history of worsening dyspnea, wheezing, and orthopnea. She denied chest pain, cough, or fever. She did not smoke cigarettes. Her oxygen saturation was 86% on 2 L/min via nasal cannula.
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Occupational Prepatellar BursitisFor 2 months, a 29-year-old man had pain and circular, soft swelling (7 x 7 cm in diameter) over the anterior left knee, superficial to the patellar ligament. Pain was minimal and associated with extension and flexion.
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Middle-Aged Man With Wedge-Shaped Growths in Both EyesA 45-year-old man of Hispanic ancestry presents for evaluation of what he describes as a "growth in both eyes." This growth has been present for some time; however, it has recently become more prominent. The patient has had mild redness and irritation in both eyes, but he denies any change in vision.
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How to Improve Outcomes in African Americans and Hispanics With AsthmaIn general, asthma-related morbidity and mortality are greatest among members of ethnic minority groups who live in the inner cities; about 5000 deaths occur in these populations each year in the United States.
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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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Octogenarian With Low Back Pain and an Enlarged SkullAn 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.
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Hyperpigmented Macules: Lines of BlaschkoLines of Blashko may represent normal embryonic movements of the skin during embryogenesis.
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A Young Boy With Painful, Erythematous Nodules on Lower ExtremitiesA 5-year old boy presented with these nonpruritic nonsupurrative painful erythematous nodules on his lower extremities. The rash had appeared about 1 week after the onset of a dry hacking cough.
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Replacing the ACA: A Battle was Won, But the War Isn't OverAmerican College of Physicians leaders call for steady opposition to the administration's proposed replacement of the Affordable Care Act.
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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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Various Manifestations of Rheumatic Disorders: Case 6 Progressive Systemic SclerosisFor several months, a 70-year-old woman had had dysphagia,mild dyspnea on exertion, and the Raynaud phenomenon.Her skin was waxy and edematous; 2- to 10-mm pinkishspots had appeared on her fingers, palms, and oral mucousmembrane over the past 2 weeks. These disappearedcompletely with pressure. Subcutaneous calcific depositswere present on the extensor surfaces of the forearms.
