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How to handle the difficult airway, part 2Abstract: The laryngeal mask airway (LMA) and intubating LMA are valuable alternatives in patients in whom intubation has failed and who need oxygenation and ventilation immediately. The dual-lumen, dual-cuffed airway tube is effective in a variety of settings and can tolerate ventilation at pressures as high as 50 cm H2O; it is contraindicated in awake patients who have intact airway reflexes, caustic ingestions, and upper airway obstruction from a foreign body or pathology. Surgical airways are lifesaving techniques when intubation is unsuccessful or impossible through the mouth or nose. It may be particularly appropriate in patients with laryngeal or facial trauma, upper airway obstruction, or oropharyngeal injury. When patients aged 12 years and older cannot be ventilated by mask or intubated with traditional methods, surgical or needle cricothyrotomy is the procedure of choice. (J Respir Dis. 2005;26(7):298-302)
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Child With Appendicitis-like Symptoms9-year-old girl was seen in the emergency department (ED) with a 5-day history of non-bilious, non-projectile emesis, decreased appetite, and persistent right lower quadrant pain following an appendectomy 5 days earlier.
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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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Pain Management for Osteoarthritis: Guideline ToplinesGet a topline review of OA pain management recommendations from the Osteoarthritis Research Society International and the American College of Rheumatology/Arthritis Foundation.
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Managing Diabetes to Prevent Cardiovascular Disease: A Guideline QuizDiabetes is a primary risk factor for atherosclerotic cardiovascular disease. Find out how well you know the guideline recommendations for reducing that risk with the first of 4 quizzes.
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Topics in Cardiometabolic Disease: Hypertension Guideline QuizCardiometabolic disease affects 1 out of every 2 Americans today. This first of 4 quizzes tests your knowledge of how to manage hypertension, heart failure, and renal disease.
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Metformin Ups Survival in T2DM and CirrhosisContinuing metformin after a diagnosis of cirrhosis can significantly decrease the risk of death in patients with diabetes, a new study suggests.
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Lymphoepithelial Cysts in a Patient With HIV: Is HAART the Answer?Lymphoepithelial cysts of the parotid gland may be diagnostic of HIV infection; they are typically bilateral, benign, and associated with lymphadenopathy.
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Concurrent Management of Achalasia and Morbid ObesityThe development of a standardized treatment that simultaneously addresses achalasia and obesity is becoming more imperative as obesity becomes epidemic in the US. Here’s a case in point.
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What caused this patient's cough and mild hemoptysis?The authors describe a previously healthy patient who required surgical resection of a large mucoid tumor lined with atypical columnar epithelium. The diagnosis was mucinous cystadenocarcinoma, a rare type of pulmonary cancer that is difficult to identify.
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MDIs, Spacers, and Dry Powder Inhalers: What Patients Are Likely to Do WrongInhaled medications are the cornerstoneof therapy for most of themore than 30 million Americanswho have asthma or chronic obstructivepulmonary disease(COPD). Unfortunately, many ofthese patients use aerosol deliverydevices incorrectly.
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HIV-Related Oral Lesions: Clues for Early DiagnosisA 30-year-old man with a 15 packyear smoking history presented for a follow-up evaluation of an asymptomatic whitish lesion on the tongue of 4 months’ duration. The lesion had not responded to oral therapy with either nystatin or fluconazole. The patient was distressed about the lesion’s appearance and his inability to remove it with a toothbrush.
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Behçet's DiseaseThis is a multisystem disorder characterized by oral and genital aphthae. Other symptoms include a myriad of cutaneous findings; variable systemic features include uveitis, synovitis, meningoencephalitis, and large- and smaller-vessel vascular disease.
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How Do Medical and Pharmacy Directors Perceive the Value of New Cancer Drugs?A total of 50 health care professionals, including 25 health plan medical directors, 20 health plan pharmacy directors, and 5 pharmacy directors for pharmacy benefit management companies were surveyed regarding their perceptions of the value of 3 novel cancer therapies. The physicians and pharmacists were asked to estimate the monthly average wholesale price of each therapy, overall survival benefit of bevacizumab for treatment of persons with advanced colorectal cancer and erlotinib for treatment of persons with non–small-cell lung cancer, and progression-free survival benefit of sunitinib malate for treating persons with advanced renal cell carcinoma. Most respondents overestimated drug costs and underestimated survival benefit associated with these treatments. Mean incremental cost-effectiveness ratio for all drugs studied was approximately $170,000/quality-adjusted life-year (QALY). Cost-effectiveness ratios were lower than the $300,000/QALY cited by oncologists in another study but significantly higher than those for many other costly interventions. Our study findings reflect the need for a better understanding of the value of the clinical benefits of novel cancer therapies in an environment of product innovation but with resource constraints. (Drug Benefit Trends. 2009;21:120-130)
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Transient ST Elevations and Conduction Delay After Traumatic Fracture of the SternumA 25-year-old man with no significant medical history was attempting to move a heavy container when he lost control and became pinned between the container and a concrete pole.
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Lemierre Syndrome: A Forgotten DiseaseSymptoms closely resemble "strep" throat but suspicion for Lemierre should run high when pharyngitis and fever persist.
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Neurotic ExcoriationA 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.
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Case In Point: Does this woman with cough and dyspnea really have CHF?A 47-year-old African American woman presented to the hospital after a 5-day history of cough and shortness of breath. The patient also described worsening cough with yellow sputum production over that same time but denied any fevers, chills, nausea, vomiting, abdominal pain, and urinary symptoms. Her condition began to rapidly deteriorate on arrival to the emergency department (ED).
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Update on Cause and Management of Catscratch DiseaseMore than 22,000 persons in the United States are affected bycatscratch disease (CSD) annually. Despite the discovery of thecausative organism more than a decade ago, much is still unknownabout this illness. Recent data suggest that ticks, as wellas cats, may transmit the disease to humans. Immunofluorescenceassay is proving to be the most efficient and noninvasivetechnique for diagnosing CSD. Among available antimicrobials,azithromycin has proved to be especially useful, although randomized,double-blind, placebo-controlled trials are warrantedto define the best treatment method for patients with CSD.[Infect Med. 2008;25:242-246, 250]
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Superior Mesenteric Vein ThrombosisA 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.
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Ovarian Hyperstimulation SyndromeWith assisted reproduction widespread, all physicians, including primary care providers, should be familiar with presenting symptoms of OHSS.
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Neurotic ExcoriationA 42-year-old woman sought medical advice for a facial rash of 4 weeks' duration. She denied any drug allergies, changes in her routine, or use of new laundry products.
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Case In Point: Middle-Aged Man With Worsening Cough and DyspneaA 52-year-old man with hypertension and hyperlipidemia presents to the emergency department with a 5-month history of cough and dyspnea.
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MalariaDuring a flight from Houston to New York, a 46-year-old man had fever, chills, rigors, and body aches. After he landed, he sought treatment at a local hospital. The patient was on his way back to Liberia, where he works. He had been at home in Houston for several weeks. In the emergency department, he complained only of subjective fever.
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Perianal Crohn's DiseaseA 56-year-old man complained of perianal swelling and discomfort. He reported a history of diarrhea and mucus discharge from the rectum with intermittent rectal bleeding. A colonoscopy confirmed the diagnosis of Crohn's disease of the rectum and sigmoid colon.
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Villous Adenoma in a 61-Year-Old ManEndoscopic evaluation of a 61-year-old man hospitalized with a 4-month history of rectal bleeding, mucus discharge, and change in bowel habits revealed this large, sessile villous adenoma.
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Strangulated Rectal ProlapseIncarcerated rectal prolapse is uncommon and seen mainly in elderly female patients. If ischemia is present, perineal proctosigmoidectomy is the only remaining treatment option.
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What to Include in the Workup of an Elevated Hemoglobin Concentration and Hematocrit?Q:My patient has an elevated hemoglobin concentration and hematocrit; however, the reticulocyte count, ferritin level, results of hemoglobin electrophoresis, and total iron-binding capacity are normal. What is the next step after common causes of an elevated hemoglobin concentration and hematocrit, such as chronic obstructive pulmonary disease, have been ruled out?
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Appendicitis: Jump to Make the DiagnosisDiagnosing the cause of abdominal pain in a child can be difficult. When I suspect appendicitis, I ask the patient to jump down from the exam table. If this causes no pain, the diagnosis is most likely not appendicitis. Pain indicates rebound tenderness, and further workup is likely needed.
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Osler NodesOsler nodes may accompany bacteremia without endocarditis, septic endarteritis, typhoid fever, gonococcemia, systemic lupus erythematosus, and nonbacterial thrombotic endocarditis.
