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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.
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Renal Colic:ABSTRACT: In patients with renal colic, the location of the urinary tract obstruction largely determines the nature of the symptoms (eg, an obstruction in the distal ureter typically produces boring pain that radiates to ipsilateral groin, testicle, or labium). The initial evaluation includes urinalysis, a complete blood cell count, and a renal function panel. A full metabolic evaluation is warranted if the patient has risk factors for or a family history of stone disease, a history of bilateral stone disease, or chronic recurrent urinary tract infection, or if nephrocalcinosis is found on radiographic studies. Noncontrast CT is the imaging study of choice; it is nearly 100% accurate for detecting stone disease. Analgesia and volume expansion are the mainstays of management.
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Pulmonary nocardiosis mimicking empyema necessitatisNocardia asteroides is a rarecause of pulmonary or disseminatedinfection in immunocompetentpersons. Pleuralcompromise is common, butempyema necessitatis is veryrare. The authors describe anapparently immunocompetentpatient with N asteroides infectionwho had chest wallcompromise mimicking empyemanecessitatis.
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Bronchoscopy Clinic: A patient with "worsening asthma"A 45-year-old man was referred to our pulmonary clinic for progressive dyspnea and worsening asthma. His shortness of breath had been worsening over the past 2 years. He denied fever, weight loss, and other systemic complaints.
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Erysipelas in a 60-Year-Old ManA 60-year-old man presented with redness, swelling, and pain on his right lower leg of 3 day's duration. He recalled being scratched by underbrush while hiking in the woods a few days earlier; the patient denied other recent trauma or insect bites.
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Case In Point: A case of bilateral hilar lymphadenopathyThe authors describe a rare cause of diffuse thoracic lymphadenopathy--Cogan syndrome. This case was remarkable for the temporal development of extensive lymphadenopathy independent of other hallmark symptoms and signs of this syndrome. In the appropriate clinical setting, Cogan syndrome should be considered in the differential diagnosis of thoracic lymphadenopathy.
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Autosomal Dominant Polycystic Kidney Disease in a 38-Year-Old WomanAutosomal dominant polycystic kidney disease (ADPKD) is common. Presenting symtpoms include hypertension, hematuria, proteinuria, and renal insufficiency.
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Sleep Problems Disturb Children With Autism Spectrum DisorderWith proper assessment and treatment, primary care physicians can help improve their sleep habits and quality.
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HIV/AIDS and Starfish: "It Makes A Difference to This One"Millions of years of life have been saved by antiretroviral therapy. For more lives to be saved, for more years of life to be gained, patients and doctors need to be aware of the risk of HIV infection and to be amendable to screening.
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Introducing a New CONSULTANT Series "Primary Care Procedures: A Photo Guide"When should buried stitches be used in closing a laceration? Which tools are best for removing a popcorn kernel lodged in a 2-year-old's nose? How do you determine the appropriate site for a shoulder injection? These are just some of the questions that will be answered in our new feature, "Primary Care Procedures: A Photo Guide," which launches in this issue on page 1035.
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Oroesophageal Candidiasis in a Patient With AIDSTopical treatment for oral candidiasis is not as effective when there is esophageal involvement. Topical treatments include nystatin, amphotericin B solution, and miconazole tablets. Systemic therapy given orally includes the azoles, of which fluconazole remains the most effective commonly prescribed. Voriconazole is effective against some resistant strains of Candida. Echinocandins, a newer class of drugs, inhibit cell wall synthesis.
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Type 2 Diabetes: After the Diagnosis, Resist InertiaDiabetes is a progressive disease and takes advantage of inaction. How would you manage our patient Mrs Davis?
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Esophageal Foregut Cyst Presenting as Suprahilar MassA chest roentgenogram from a 42-year-old man with asthma, primary hypoparathyroidism, and pectus excavatum showed a left suprahilar mass-like density.
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Drug Interactions With Azole Antifungals: Focus on Fluconazole and ItraconazoleAzole antifungals are widelyused to treat numerousinfections.1 Manywell-documented, clinicallysignificant drug interactionsare associated with these agents1,2
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Migraine Management during the Holidays: How to Help Patients Identify, Manage TriggersCommon triggers, such as stress, travel, and disrupted routines, can impact patients with migraine this holiday season. Practical strategies and short-term preventive measures to help, here.
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Primary Care Compensation: Incomes are Up, Job Satisfaction Not So MuchWhat does primary care compensation look like these days? Would you choose primary care all over again? Here: key highlights that shed light from a Medscape Physician Compensation Report.
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65-year-old man with nonpruritic yellowish lesions on his eyelidsA 65-year-old man consults his primary care physician because of concern about nonpruritic yellowish lesions on his eyelids. He says they have been present for the past few years but have recently become more numerous.
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Help for Osteoarthritis Pain: Exercises to Stretch and Strengthen the Hip, Thigh, and KneeExercise is a key part of your care plan. It promotes strength and flexibility, helps you maintain a healthy weight, reduces pain, and improves overall mobility and quality of life.
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Second-Degree Burn From IontophoresisHalf way through a 15-minute iontophoresis treatment for de Quervain tenosynovitis of the right wrist, a 42-year-old woman felt exquisite pain but completed the session. After the therapist returned to the room and removed the electrodes, a light gray circular mark about 5 mm in diameter was noted on the skin. The epidermis was gone, and the underlying dermis was also injured. Within 6 hours, a tender, dark red-brown lesion developed.
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Melanoma of the ScalpA 60-year-old African American woman presented with an asymptomatic, nonpruritic lesion on the left temporal scalp that bled intermittently. She had noticed the lesion after she used a hair relaxant 5 to 6 months earlier. Since then, the lesion had slowly enlarged. She had a history of type 2 diabetes mellitus and hypertension. She denied alcohol consumption and tobacco use.
