September 17th 2024
New data shows that favorable CV health in the first trimester is associated with a 35% to 62% lower risk of HDP regardless of level of genetic risk.
Erectile Dysfunction in Patients With Hypertension:
October 1st 2004ABSTRACT: The prevalence of erectile dysfunction (ED) is higher among men with hypertension than among normotensive men. Sexual dysfunction is a common side effect of many antihypertensive medications and can lead to noncompliance. Treatment-related ED is more often associated with diuretics and ß-blockers and is less common with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. If ED complicates therapy, consider switching to an antihypertensive agent with fewer sexual side effects. However, if compelling reasons exist for the use of a particular antihypertensive agent (eg, a ß-blocker in a patient with previous myocardial infarction), several options for the treatment of ED are available. Phosphodiesterase-5 inhibitors have been shown to be safe and effective in men who are receiving antihypertensive therapy.
Diabetic Neuropathy: Early Clues, Effective Management
October 1st 2004ABSTRACT: The early signs of diabetic neuropathy can be detected during a routine clinical examination. Inspect patients' feet for deformities and sensory loss, which indicate risk of ulceration. Prolonged poor glycemic control, alcohol abuse, and obesity increase the risk of amputation. Autonomic dysfunction, which can lead to sexual dysfunction and gastropathy, can be detected by measurement of heart rate and blood pressure. A resting heart rate of about 100 beats per minute and a decrease of about 30 mm Hg in systolic blood pressure within 2 minutes of standing are abnormal findings. Electromyography and nerve conduction studies confirm the diagnosis. Improved metabolic control is the main goal of treatment. Analgesics, neuromodulators, and tricyclic antidepressants are effective for managing pain. In patients with autonomic neuropathy, treat the associated symptoms.
Posterior Shoulder Dislocation
September 1st 2004A 53-year-old man with type 2 diabetes mellitus and hypertension presented to the emergency department with pain in his left upper chest and back, neck, and shoulder. The pain increased with passive and active range of motion testing and decreased at rest. His physical examination was unremarkable except for restricted left shoulder movement and generalized tenderness in the left shoulder area.
Congestive Heart Failure Update: New Cardiac Peptides in Diagnosis and Treatment
September 1st 2004ABSTRACT: The Studies of Left Ventricular Dysfunction (SOLVD) trials demonstrated that early intervention in congestive heart failure (CHF) improves survival. However, early CHF is mainly a clinical diagnosis based on New York Heart Association criteria and, until recently, no easy and inexpensive screening test existed. There are now several such tests that employ radioimmunoassays (RIAs) to measure cardiac peptides in a single plasma sample; results help determine the likelihood that CHF is present but do not definitively establish the diagnosis. The vessel dilator RIA is the most specific and sensitive for differentiating persons with mild CHF from healthy ones; intravenous administration of this cardiac peptide hormone has beneficial hemodynamic, diuretic, and natriuretic properties in persons who have CHF. Brain natriuretic peptide (BNP) measured by fluorescence immunoassay is useful in the emergency department, because a result may be obtained in as little as 15 minutes. This assay may indicate CHF; further tests are recommended to define the diagnosis. BNP increases with other causes of dyspnea, including pulmonary hypertension, pulmonary emboli, and renal failure, so it is not specific for CHF. BNP also increases with age, and measured values are higher in women than in men.
Autosomal Dominant Polycystic Kidney Disease in a 30-Year-Old Man
August 2nd 2004A 30-year-old man presentedwith severe left flankpain radiating to his abdomenand gross hematuriaof 5 to 10 days’ duration.He also reported a 4- to 6-monthhistory of nausea with intermittentvomiting, anorexia, and progressiveweight loss. He took no medicationsand had no allergies.
ECG Challenge: Nausea and Weakness in a Woman With Multiple Diseases
August 1st 2004A 60-year-old woman with hypertension, diabetes mellitus, and intermittentatrial fibrillation presents with nausea, diaphoresis, dizziness, and globalweakness that has lasted 1 hour. She denies chest pain, dyspnea, syncope,vomiting, diarrhea, blood loss, and headache; there is no vertigo. Medicationsinclude acetaminophen, digoxin, diltiazem, glipizide, hydrochlorothiazide,irbesartan, metformin, pioglitazone, and warfarin.
Whats Wrong With This Picture?: Middle-aged Woman With Chest Pain and Dyspnea
July 1st 2004A 48-year-old woman with a historyof hypertension and mildasthma has been transferred to themedical service because of an abnormalpostoperative ECG. She hadbeen admitted 2 weeks earlier to thegynecology-oncology service for localrecurrence of a previously resecteduterine sarcoma and underwent laparotomyfor debulking of the pelvicmass and resection of the rectosigmoidcolon. She did well until postoperativeday 14, when sudden chestpain and dyspnea developed.
Secondary Prevention in Patients With Unstable Angina and Non-ST-Segment Elevation MI:
July 1st 2004ABSTRACT: Guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction have been updated following results from pivotal controlled trials. The new American College of Cardiology/American Heart Association guidelines stress risk factor modification and long-term management. Medications that have been shown to reduce the incidence of future cardiovascular events in patients with acute coronary syndromes include antiplatelet agents, statins, ß-blockers, and angiotensin-converting enzyme inhibitors. Other long-term management strategies include smoking cessation, achievement and maintenance of optimal weight, daily exercise, appropriate diet, and control of hypertension and diabetes.
Hypertension Q&A: When Is an urgency not an emergency
June 1st 2004Hypertensive crises encompass a spectrum of clinical situations thathave in common elevated blood pressure (BP) and progressive or impendingtarget organ damage. Each year more than 500,000 Americans (about1% of all persons with hypertension in the United States) have a hypertensivecrisis. In large urban areas, 25% of visits to the medical section of any givenemergency department (ED) are attributable to a hypertensive crisis.
Cutaneous T-Cell Lymphoma in a Woman With Pruritic, Erythematous Rash
April 16th 2004For several weeks, a 78-year-old woman had an intensely pruritic, diffuse, raised, slightly scaly, erythematous rash that persisted despite the use of several over-the-counter topical medications (such as hydrocortisone and clotrimazole cream). Since her last visit about 3 months earlier for a blood pressure reading, she had been well except for 2 episodes of night sweats.
Man With Nausea, Fever, and Rash Following a Diarrheal Illness
April 2nd 2004A 52-year-old man complains of nausea, fever, and malaise following a 2-day diarrhealillness that developed at the end of a family vacation in New England.Two family members suffered a similar illness, characterized by watery diarrhea.Symptoms developed in all who were affected within 24 hours of eatinghamburgers at a local restaurant.
Cutaneous Signs of Vascular Disorders: Small-Vessel Leukocytoclastic Vasculitis
April 2nd 2004A 70-year-old man who had just completeda course of trimethoprim-sulfamethoxazolefor a urinary tract infectionpresented with palpable purpuraand cutaneous erosions of acute onseton his legs (A). He also had massivescrotal edema and purpura (B).
Cutaneous Signs of Vascular Disorders: Idiopathic Leukocytoclastic Vasculitis
April 2nd 2004A 16-year-old girl was bothered byankle pain and “red spots” on herlower legs. These symptoms clearedin a few days without treatment. Sixweeks later, after returning from anall-day outing at a fair, she noticedthat the spots had reappeared (A)and hemorrhagic lesions had developedon the right ankle (B) and leftheel (C). After removing her shoes,the teenager felt severe pain in bothankles, particularly the right.
Cutaneous Signs of Vascular Disorders: Atrophie Blanche
April 2nd 2004A 57-year-old man with a history of venous stasis leg ulcerationwondered about the “white spots” on his leg. Thecondition is atrophie blanche, which manifests as smooth,ivory-white macules and plaques of sclerosis stippled withtelangiectasia that often are surrounded by mild to moderatepigmentation.
Cutaneous Signs of Vascular Disorders: Carotid–Cavernous Sinus Fistula
April 2nd 2004Redness, irritation, and diplopia developedover 2 to 3 weeks in a 55-yearoldman’s left eye (A). The injectionworsened and was unresponsive toeye drops. Ptosis, mild proptosis, andelevated intraocular pressure developed.A bruit was auscultated overthe affected eye.
Cutaneous Signs of Vascular Disorders: Polycythemia Vera
April 2nd 2004Four months after a patchy, macular,erythematous spot erupted on thedorsum of a 63-year-old woman’s leftfoot, the area became ulcerated,tender, and painful. The 1.2-cm ulcerwas covered by a hemorrhagic crustsurrounded by a cyanotic reticulardiscoloration of the skin.
Various Manifestations of Rheumatic Disorders: Case 5 Rheumatoid Nodules
March 2nd 2004A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.
Hypertensive Emergencies and Urgencies:
March 1st 2004To distinguish between hypertensive emergencies and urgencies and nonurgent acute blood pressure elevation, evaluate the patient for evidence of target organ damage. Perform a neurologic examination that includes an assessment of mental status; any changes suggest hypertensive encephalopathy. Funduscopy can detect papilledema, hemorrhages, and exudates; an ECG can reveal evidence of cardiac ischemia. Order urinalysis and measure serum creatinine level to evaluate for kidney disease. The possible causes of a hypertensive emergency include essential hypertension; renal parenchymal or renovascular disease; use of various illegal, prescription, or OTC drugs; CNS disorders; preeclampsia or eclampsia; and endocrine disorders. A hypertensive emergency requires immediate blood pressure reduction (although not necessarily to the reference range) with parenteral antibiotics. An urgency is treated with combination oral antihypertensive therapy.
A Woman With a Big Bump in the Mouth
January 2nd 2004A 67-year-old Hispanic woman is seen for routine physical examination. Has mild hypertension but no other known medical problems. Feels well. No weight loss. No reported difficulty with eating, speaking, or swallowing. Denies any discomfiture in the mouth. States that nothing has changed in her mouth “ever since I lost my baby teeth.” Does not smoke cigarettes nor drink alcohol.
Eye Signs of Systemic Disease: Case 5 Central Retinal Vein Occlusion
January 1st 2004An 87-year-old woman complained ofseeing a red tinge on the wallpaper inher house through her right eye. Thepatient had mild memory loss andmoderate hypertension, for whichshe took atenolol. She had quit smokingcigarettes many years earlier.
Eye Signs of Systemic Disease: Case 6 Diabetic Maculopathy
January 1st 2004During an annual eye examination, a 65-year-old womanwith a 5-year history of type 2 insulin-dependent diabetescomplained that her vision had slightly worsened in botheyes. Her best corrected visual acuity was 20/30 in botheyes.