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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.
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Pay Attention to How Doctors TalkSlang is a window into the healthcare culture, this physician-author says.
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Boy With Extraordinarily High Blood Lead LevelsA 9-year-old asymptomatic boy was referred to our tertiary care facility with a blood lead level (BLL) of 59 μg/dL. A diagnosis of attention deficit hyperactivity disorder, which was managed with amphetamine/dextroamphetamine, had been made when the patient was 6 years old.
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Raynaud Phenomenon as a Manifestation of Systemic DiseaseThe young female presented with a 1-month history of violaceous papules, petechiae, and healing ulcerations on the distal digits of both hands and feet.
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Sexually Transmitted Diseases: Recognizing Telltale Skin Lesions Disseminated Gonococcal InfectionTelltale skin lesions of syphilis, gonorrhea, human papillomavirus infection, and Haemophilus ducreyi infection.
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Giant Bullous EmphysemaA 54-year-old man presented to the ED with palpitations identified as atrial flutter and RVR. Medical history included stage IV renal-cell carcinoma, end-stage COPD, NYHA class IV heart failure, and recent pulmonary embolism. A CT scan of the thorax was ordered.
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Chronic Cough in Children: An OverviewThe prevalence of chronic cough is reported to be 5% to 7% in preschoolers and 12% to 15% in older children. Diagnosis and management can present challenges.
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Economic Evaluation of a Prior Authorization Program for Biologic Response ModifiersSpecialty medications constitute the fastest-growing segment of drug spending under the pharmacy benefit. This study evaluated the impact of a specialty pharmacy prior authorization (PA) program on prescription drug costs for biologic response modifiers (BRMs) used in the treatment of persons with rheumatoid arthritis, juvenile rheumatoid arthritis, Crohn disease, ankylosing spondylitis, psoriatic arthritis, psoriasis, and other spondyloarthropathies. A retrospective, case-control, one-to-one matching approach based on patient age, sex, and client characteristics was used. Case clients were enrolled in the specialty pharmacy PA program from January 1 through December 31, 2005. The control group consisted of clients who were not enrolled in the program during this time. The average costs per eligible member per month (PMPM), for the total, plan, and member were $1.32, $1.29, and $0.03, respectively, in the case group, and $1.44, $1.41, and $0.03, respectively, in the control group. Clients who implemented the specialty pharmacy PA program for BRMs saved an estimated total cost of $0.12 PMPM. Implementing a specialty pharmacy PA program reduced BRM costs. (Drug Benefit Trends. 2008;20:26-31)
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Colorectal Cancer Screening: Which Tests, How Often?ABSTRACT: Screening options for colorectal cancer (CRC) include colonoscopy every 10 years, annual fecal occult blood testing, flexible sigmoidoscopy every 5 years, or double contrast barium enema every 5 years. In white patients at average risk, screening should begin at age 50; in African American patients, at age 45. Colonoscopy is preferred to sigmoidoscopy because it can detect proximal neoplasms and has the longest protection interval. High-risk patients include those with a family history of CRC or adenomas. These persons should begin colonoscopic screening at age 40, or 10 years earlier than the age at which CRC or adenomas were diagnosed in a first-degree relative. Other high-risk patients are those with a personal history of CRC, a genetic syndrome, or inflammatory bowel disease. In patients with CRC, the first follow-up colonoscopy is performed 1 year after surgery. If results are normal, the interval can be extended to every 3 years.
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Multiple Symmetric LipomatosisThe multiple, symmetrically distributed, soft, nontender swellings on the shoulders and torso of a 56-year-old Hispanic man are characteristic of multiple symmetric lipomatosis (MSL), also known as Madelung disease or Launois- Bensaude syndrome.
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Severe Hypersensitivity Reaction to Antituberculosis MedicationsA66-year-old white man with tuberculosis of the shoulderjoint had a severe hypersensitivity reaction to antituberculosismedications. Symptoms included development of pulmonaryinfiltrates, hepatic dysfunction, renal insufficiency, andneutropenia. The patient improved after the medicationswere withdrawn. [Infect Med. 2008;25:287-291]
