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What You Forgot About the Neurologic Exam, Part 2:ABSTRACT: Asymmetry-whether of strength, reflexes, or sensory function-is an important localizing finding in the neurologic evaluation. Asymmetric deficits of strength may indicate an acute CNS lesion. Symmetric hyperreflexia or hyporeflexia alone is not diagnostic; compare reflexes between sides of the body and between upper and lower extremities. The extensor plantar response (Babinski reflex) suggests an upper motor neuron lesion. During the sensory examination, look for asymmetry and determine whether both light touch and pinprick sensation are intact. Simultaneous stimulation with 2 sharp objects on opposite sides of the body-done to detect extinction of response on 1 side-can uncover subtle sensory deficits.
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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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Personalized Medicine: A New Medical ParadigmRecent advances in diagnostic testing have increased the likelihood that our current model of medical treatment will soon be supplanted, at least in part, by personalized medicine. With this change in the medical paradigm will come numerous benefits and opportunities for patients, caregivers, drug developers, diagnostics firms, and MCOs.
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Too Much for the Computer: Complete Heart Block in an Elderly WomanA 92-year-old woman presented with signs and symptoms of heart failure, including marked bilateral lower extremity edema, jugular vein distention, and difficulty in breathing at rest. Her medical history was significant for hyperthyroidism, chronic asthmatic bronchitis, and senile dementia. Medications included oral methimazole, 10 mg/d, and oral theophylline, 200 mg/d.
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Lhermitte-Duclos DiseaseLhermitte-Duclos disease is a rare, slow-growing, benign lesion of the cerebellum and is considered a hamartomatous tumor of the cerebellar cortex.
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Splenic InfarctionA 53-year-old woman presented with sudden onset of left upper quadrant abdominal pain. She had a history of atrial fibrillation, hypertension, and congestive heart failure.
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Many Physicians Ignore This RuleIt is often easier to ignore the rule about having a qualified medical interpreter in the room for non-English speaking patients. What do you do?
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Pasteurella Pneumonia Associated With Cutaneous TraumaCommunity-acquired pneumonia is a frequent cause ofhospital admission in adults. It usually results from infectionwith pathogens such as Streptococcus pneumoniae, Haemophilusinfluenzae, Mycoplasma, and Chlamydia, among others. In a fewcases, pneumonia develops from infection with unusualpathogens, such as Pasteurella multocida, a gram-negativeorganism commonly found in the mouths of cats and dogs.We report a case of P multocida pneumonia associated with skintrauma caused by cat scratches in a woman with a history ofchronic obstructive pulmonary disease. [Infect Med. 2008;25:487-489]
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Wheezing in a 52-Year-Old Woman With a History of Colon CancerA 52-year-old woman was admitted tothe hospital with progressive shortnessof breath of 2 days’ duration. Bronchialasthma had been diagnosed 6 monthsearlier; inhaled corticosteroids, bronchodilators,and leukotriene antagonistswere prescribed. Despite aggressivetreatment, the patient’s dyspneaand wheezing worsened.
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Clinical ChallengeHerpes zoster occurs in 10% to 20% of the general population as a result of reactivation of the varicella-zoster virus (VZV) and is generally benign. It occurs more frequently in persons with cellular immunodeficiency and older age. The association between herpes zoster and HIV was confirmed early in the course of the HIV epidemic by numerous studies. Zoster was noted to precede AIDS in high-risk groups. Both the incidence and complication rate of herpes zoster are increased in HIVinfected patients.
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Lifestyle Medicine: AHA's Statement Calling for Lifestyle Counseling TrainingPatients take lifestyle recommendations seriously, but not many physicians offer them. Why not? Do you?
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Benzocaine-induced methemoglobinemia in bronchoscopyBenzocaine-induced methemoglobinemia has been a well-documented illness that is usually simple to cure but can be life-threatening if not recognized. As the use of "scope" procedures becomes more commonplace, the early recognition of hypoxemia resulting from methemoglobinemia is essential. The authors report a case of benzocaine-related methemoglobinemia following bronchoscopy.
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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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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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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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Sex Ratio of Multiple SclerosisThe worldwide sex ratio of MS has been substantially changing over the last century. Environmental factor/s appear to be at work in a sex-specific manner.
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The keys to diagnosing interstitial lung disease: Part 3Abstract: Important components of the workup for interstitial lung disease (ILD) include the history and physical examination, chest radiography, high-resolution CT (HRCT), pulmonary function testing and, in some cases, bronchoalveolar lavage (BAL) and/or biopsy. Pulmonary function tests usually show a restrictive ventilatory impairment. However, some patients have a mixed restrictive/obstructive pattern; in fact, almost 50% of patients with sarcoidosis have airflow obstruction at presentation. HRCT has an increasingly important role in the assessment of ILD. In some cases, the results may obviate the need for biopsy. BAL can help confirm the diagnosis of ILD; it also can identify conditions such as infection or hemorrhage or suggest an alternative diagnosis. Surgical lung biopsy has the advantage of yielding samples of lung tissue that are usually diagnostic, especially if HRCT is used to target lung regions. (J Respir Dis. 2005;26(11):466-478)
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Who Needs Beta-Blockers? Analysis Raises QuestionsA new analysis of data from a large international registry finds that use of beta-blockers in patients with and without a history of coronary artery disease does not reduce cardiovascular events.
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Approved Treatments for Osteoporosis and What’s in the PipelineAlong with the release of revised guidelines, several pharmacological therapies have become available or are under investigation to help improve outcomes in patients with osteoporosis.
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Diabetic Nephropathy: Early Clues, Effective ManagementNephropathy develops in about 30% of patients with diabetes. Screen for albuminuria at the time type 2 diabetes is diagnosed and within 5 years of diagnosis of type 1 diabetes.
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Cryptococcal Meningitis: Review of Current Disease ManagementThe incidence of cryptococcal infections in the HIV-infectedpopulation has diminished because of the effectiveness of anti retroviraltherapy, whereas the incidence in non–HIV-infectedhosts has grown. Despite improvements in antifungal therapy,successful outcomes in the management of cryptococcalmeningitis are dependent on a high index of clinical suspicion,appropriate use of diagnostic assays, early and aggressiveantifungal therapy, and recognition of complications such asincreased intracranial pressure and immune reconstitutionsyndromes. Published guidelines for the care of patients withcryptococcal meningitis are available and may be adapted toindividual patient requirements. Basic and clinical studies areneeded to further define the components of immune protection,optimal therapy in special patient populations, and the recognitionand treatment of complications of cryptococcal meningitis.[Infect Med. 2008;25:11-23]
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Erythema Chronicum Migrans in Lyme DiseaseA 34-year-old man experienced fever and arthralgia several days after appearance of the rash.
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Rate-Related Septal Infarct PatternA 64-year-old asymptomatic woman with a 10-year-history of hypertension was referred for blood pressure control. She had no other significant medical history. The patient denied exertional chest discomfort or dyspnea. Her medications included atenolol, lisinopril, and hormone replacement therapy.
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Osteoporosis CircumscriptaSkull x-ray films were taken after this 62-year-old nursing home resident fell and hit his head. The radiographs revealed only a sharply demarcated radiolucent area, mainly over the right parietal bone. Osteoporosis circumscripta was diagnosed.
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DDW: A Multimedia Special ReportWASHINGTON -- This special report from Stanton M. Paddock, a MedPageToday contributing photographer, presents Ted Bader, M.D., of University of Oklahoma, discussing infection of Hepatitis C in Vietnam veterans.
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Middle-Aged Woman With Numerous Skin LesionsA 54-year-old woman presents for an initial consultation. She has multiple chronic disorders, including type 2 diabetes mellitus and hypertension, for which she takes various medications-none of which are new.
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DermatomyositisThis inflammatory myopathy is believedto be related to immune-mediatedmuscle damage. An increased incidenceof malignancy is associatedwith dermatomyositis (DM), especiallyin patients older than 50 years.
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Elderly Woman With Facial Edema and Erythema, and Tattoo on ForearmAn 87-year-old woman who recently moved to an assisted living facility from her home is seen for evaluation of facial edema and erythema after a bee or wasp sting sustained 2 days earlier. Patient denies pain, pruritus, or visual changes. She took one dose of diphenhydramine shortly after the event and has noticed that the edema, which affected primarily the right side of the face, near the sting, has improved.
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Sudden-Onset, Discrete, Painful Lesions in a 39-Year-Old ManA 39-year-old man sought evaluation ofnewly erupted skin lesions on his arms.Ten days earlier he had fallen on hisforearms, but no bruises appeared atthat time.
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Fracture After Fall in a Middle-Aged African American WomanA 58-year-old African American woman comes for a follow-up visit after sustaining a fracture of the right radius, which occurred when she tripped on loose carpeting and broke her fall with an outstretched hand.
