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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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Anorexia Nervosa-Associated Raynaud PhenomenonEvaluation of intermittently discolored, cold fingers was sought by a 39-year-old woman with long-standing anorexia nervosa. The patient had never smoked and was not taking any vasoconstrictive drugs.
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Bell's Palsy in a 75-Year-Old WomanFor 36 hours, a 75-year-old woman had experienced weakness of the right side of the face. She was unable to close the right eye and drooled from the right side of the mouth. There was no weakness, numbness, or tingling of the extremities. The patient's medications included insulin for type 2 diabetes, furosemide and spironolactone for hypertension, aspirin, alendronate, calcium, vitamin D, and tramadol for occasional pain from osteoarthritis.
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Cancer of the PenisA 38-year-old man presented with a fleshy lesion beneath the tip of his penis. He had discovered it about 18 months before the initial evaluation. A second similar lesion resembling a “cauliflower” had appeared several weeks after the first. Both lesions had grown and had begun to bleed during intercourse.
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Can You Identify These Lesions?Erythematous patches and papules on the knuckles; a slowly enlarging papule on a finger; a painful ulcer on the thumb; rough, thickened skin around the metacarpophalangeal joints; symmetric, soft, tan papules....
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Gastric Outlet Obstruction Shown in Barium Swallow StudyAn 88-year-old woman was brought to the emergency department after she choked on a piece of meat. She had dysphagia of many years’ duration and progressive weight loss over the past 5 years.
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Exercises to Prevent RecurrenceMany patients who experience anepisode of severe low back pain willhave a recurrence at some time in theirlife. Therefore, it is usually prudent toprescribe a long-term exercise programto minimize the pain and frequency ofrecurrences. Such a program should include3 types of activities:
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Intraductal PapillomasSolitary intraductal papillomas are tumors of the major lactiferous ducts. They occur most frequently in women 30 to 40 years of age, and frequently present with nipple discharge.
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Acute Mesenteric IschemiaA 52-year-old man presented to theemergency department (ED) with a12-hour history of cramping abdominalpain, nausea, vomiting, andwatery, brown diarrhea. Mid upperquadrantpain had begun suddenlythe night before, 1 hour after the patienthad lifted heavy bags of rocks.The GI symptoms persisted with varyingintensity throughout the night.
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End-of-Life Discussions: The Art of Delivering Bad NewsAn 84-year-old woman with progressive stenosis of the cervical spinal canal, type 2 diabetes mellitus, hyperlipidemia, gastroesophageal reflux disease, hypertension, and stable angina presents to her primary care physician after an appointment with the orthopedist who is monitoring her chronic degenerative joint disease.
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How Can You Tell Medication Use From Medication Abuse?Accepting the gatekeeper role requires scrutinizing and sometimes confronting the patient at the gate; it's getting a lot more complicated.
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High-Grade Ductal Carcinoma In SituFor 6 weeks, a 68-year-old woman had had sharp pain in the left breast that radiated to the left arm and back. The pain was worse on palpation; ibuprofen provided only mild relief. She denied nipple discharge, skin discoloration, and fever. She had no family history of breast cancer. Results of a biopsy of the left breast 6 years earlier were benign. Her most recent mammogram, 4 weeks earlier, was negative.
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Low Bone Mass in Early-Stage Multiple SclerosisLow bone mass may manifest early in MS: this finding calls for an active approach to optimize bone health.
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Two Cases of Episodic, Asymptomatic, Erythematous EruptionsA 31-year-old white woman presents with an erythematous skin eruption of 2 weeks' duration that consists of papules on the cheeks and several disk-shaped papules and plaques on the back, posterior neck, and right upper anterior chest.
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Accidental Ocular Installation of “Stomahesive”A 63-year-old woman with Crohn disease who had a colostomy accidentally instilled a stoma care product (Stomahesive) into her right eye.
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Diabetic Foot Problems: Keys to Effective, Aggressive PreventionABSTRACT: A 4-pronged approach that includes patient education, skin and nail care, appropriate footwear, and proactive surgeries can effectively prevent diabetic foot problems. Teach patients with diabetes to examine their feet daily to detect new onset of redness, swelling, breaks in the integrity of the skin, blisters, calluses, and macerated areas. Have them follow a daily foot care regimen that includes warm water soaks and lubrication, and have them keep toenails properly trimmed. Recommend that patients select shoes that fit properly and have sufficient padding and toe box space; have them use inserts, lifts, orthoses, or braces--as recommended-to correct abnormal gait patterns. Finally, if deformities develop, simple proactive surgical procedures can correct these problems before they result in the development of wounds.
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Aortic Valve AbscessA 75-year-old woman with a bioprosthetic aortic valve, who had undergone surgical repair of an aortic root aneurysm 9 months earlier was hospitalized with fever, headache, and altered mental status of 1-day's duration.
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Serratia marcescens Pneumonia in an HIV-Infected PatientFor 3 days, a 45-year-old woman with HIV infection who was noncompliant with her antiretroviral medications had cough, yellowish sputum, fever, and dyspnea. She denied hemoptysis, weight loss, or recent hospitalization. She had a long history of heavy smoking and alcohol and intravenous drug abuse.
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Acute lymphoblastic leukemia presenting with an acute fibrinous and organizing pneumoniaThe authors report a case of adult-onset acute lymphoblastic leukemia (ALL) presenting with a right upper lobe infiltrate associated with acute fibrinous and organizing pneumonia (AFOP), which resolved spontaneously during the course of chemotherapy.
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Acute Pericarditis in an 8-Year-Old GirlThe mother of an 8-year-old girl sought medical care for her daughter who had complained of intermittent chest pain for 3 days. The patient denied nausea, vomiting, and diarrhea. There was no shortness of breath, chills, fever, or diaphoresis. Her travel history included 2 trips to Mexico within the past year; the most recent trip ended 3 months before the pain started.
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Chest Pain: 10 Common Myths and MistakesABSTRACT: Atypical clinical presentations in the quality, intensity, and radiation of pain are common in patients with acute coronary syndromes. Women with an acute myocardial infarction (AMI) are more likely to have atypical symptoms, such as dyspnea, than men. A history of acute anxiety or a psychiatric diagnosis does not preclude the possibility of an acute coronary event in a patient with chest pain. The clinical response to a GI cocktail, sublingual nitroglycerin, or chest wall palpation does not reliably identify the source of pain. Over-reliance on tests with poor sensitivity, such as the ECG, or on the initial set of cardiac biomarkers will miss many patients with MI. Serial troponin levels obtained at 3- to 6-hour intervals are recommended to evaluate the extent of myocardial damage. Coronary angiography that detects mild non-obstructive disease does not exclude the possibility of sudden plaque rupture and acute coronary occlusion.
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Middle-aged Man With Chest PainFor 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.
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Pharmacists’ Perceptions of Drug Reimbursement Rates and Processing Times Among Managed Care PlansThe effect of payment delays on the normal functioning of community pharmacy operations has been documented. We undertook a study to evaluate and compare pharmacists’ perception regarding reimbursement rates and processing time for prescription drug claims processed for Medicare Part D, Medicaid, and commercial managed care plans.
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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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Fibromyalgia Syndrome: Can It Be Treated?Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.
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CuppingAn acute exacerbation of asthma brought this 52-year-old Russian emigré to the emergency department (ED). Examination revealed the well-demarcated round erythema and ecchymosis on the patient's back. This circular pattern was created by cupping performed 2 days earlier by the patient's wife in an effort to treat her husband's asthma.
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Yolk Sac Tumor in the Anterior Mediastinum: A Rare CaseInitially treated empirically for acute bronchitis, this patient came to the ED with a 6-week history of worsening cough, dyspnea, fevers, weakness, and a 20-lb weight loss.
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Pott DiseaseFor 3 months, a 43-year-old Bolivian woman had worsening thoracic and lumbar pain associated with tingling and tightness in the anterior upper and lower abdominal area, and numbness in the lower extremities. Her symptoms also included difficulty in walking (with frequent falls from imbalance), occasional urinary incontinence for the past few weeks, occasional afternoon low-grade fevers, and poor appetite with an associated 10-lb weight loss within the past 4 months.
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Mesenteric Venous ThrombosisA 63-year-old man with a history of hypertension and gastroesophageal reflux disease presented with progressive, sharp mid-abdominal pain of 3 weeks' duration.
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Metabolic Acidosis in a Woman With Stable HIV/AIDSAn asymptomatic 42-year-old woman who has HIV/AIDS presents for aroutine check-up. She denies abdominal pain, nausea, vomiting, diarrhea,paresthesias, and muscle weakness.
