Dual antiplatelet therapy in coronary artery disease: A case-based approach
Current guidelines support dual antiplatelet therapy with aspirin and clopidogrel (Plavix) in a number of clinical scenarios, ie, in ST-segment-elevation myocardial infarction (MI), non-ST-elevation MI, and percutaneous coronary intervention. The guidelines are based on strong evidence from several large randomized clinical trials over the last 10 years. The authors present several cases to show how to put this evidence into day-to-day clinical practice.
Paraneoplastic Nephrotic Syndrome in Patients with Lung Cancer
Here, the authors report 4 cases of nephrotic syndrome associated with lung cancer, in 1 of which urinary protein and oedema were improved by steroid therapy. Based on their experience, the authors suggest that in patients with paraneoplastic nephrotic syndrome histologically diagnosed as having minimal change disease, it is important not only to treat the cancer itself but also to use steroids as early as possible.
Complete Full ReportA 52-Year-Old Woman With Disabling Peripheral Neuropathy
Journal of the American Medical Association
Ms Q is a 52-year-old woman who has had progressive polyneuropathy in the setting of diabetes for the past 8 years. Ms Q's major disability is that of increasingly severe neuropathic pain and cramps that have been poorly responsive to a variety of therapies, including gabapentin and topiramate. The diagnosis of and differential diagnosis for diabetic polyneuropathy are reviewed herein. In general, treatment options for diabetic polyneuropathy remain primarily symptomatic. Improving the metabolic profile through weight loss, exercise, and if necessary, medications may help slow neuropathy progression. Many medications are effective in reducing pain, and newly developed ones, such as pregabalin and duloxetine, while specifically marketed for diabetic neuropathy, are likely to be no better and are considerably more expensive than older ones. -Lipoic acid appears to be effective as well.
Complete Full TextA 59-year-old woman with atypical chest pain
Journal of the American College of Cardiology
Congenital coronary anomalies affect 1% of the population. The single coronary artery variant has been well described (1). We describe a new anomalous coronary artery variant in which a single coronary artery originating from the right coronary cusp courses the entire atrioventricular groove, encircling the heart like a necklace, or collier [French]. Computed tomographic coronary angiography was performed in a 59-year-old woman with atypical chest pain.
Complete Full Text and PicturesA 35-year-old Asian man with jaundice and markedly high aminotransferase levels
Cleveland Clinic Journal of Medicine
A 35-year-old man who was born in Vietnam presents to the emergency department of a local hospital because he has had jaundice for 5 days and fatigue, malaise, and anorexia for 2 weeks. He also has nausea and mild epigastric and right upper quadrant abdominal pain. He denies having fevers, chills, night sweats, vomiting, diarrhea, melena, hematochezia, or weight loss.
His medical history is remarkable only for perinatally acquired hepatitis B virus (HBV) infection, for which he never received antiviral therapy. He does not take any prescribed, over-the-counter, or herbal medications.
He lives in the Midwest region of the United States and works full-time as a physician in private practice. He is married and has two children.
He has not travelled recently. He has no pets at home and has not been exposed to any.
He has never smoked. He drinks alcohol socially but has never used recreational drugs.
Complete Full TextHow to Reverse an Antithrombotic Agent
Emergency Medicine Journal
A stable patient with a supratherapeutic international normalized ratio (INR) level and a hemorrhaging patient on clopidogrel both present the acute care provider with the same difficult challenge: determining the most appropriate way to reverse an antithrombotic medication.
The ubiquity of antithrombotic agent use and the range of serious health problems that call for it are sobering things to stop and think about.
We havepatients with atrial fibrillation or venous thromboembolism taking anticoagulants such as warfarin and enoxaparin, patients with a history of acute coronary syndromes (ACS) or cerebrovascular disease on antiplatelet agents such as aspirin and clopidogrel, patients being treated with fibrinolytics for acute myocardial infarction or (in carefully selected cases) a cerebrovascular accident, and more. Given the high-risk nature of many of these conditions, it is essential for us to have a solid understanding of the actions of antithrombotic agents and of what is involved in reversing them.
A 48-year-old man with uncontrolled diabetes
Cleveland Clinic Journal of Medicine
A 48-year-old white man who has had diabetes mellitus for 6 years presents to the outpatient clinic because his blood sugar levels have been rising for the past week. He had recently just dicontinued his metformin because low sugar a few weeks ago. What is the most likely cause of his poor control?
Progressively increasing painless swelling in the left knee of an 8 year old
The Internet Journal of Orthopedics
Multiple enchondromatosis is a rare developmental disorder characterised by large rounded masses or columns of cartilage in the metaphysis of certain bones, particularly the long bones1. It is defined by the presence of at least three enchondromas. It is characterised by asymmetric distribution of lesions and an extreme clinical variability. Multiple enchondromatosis may cause devastating disfigurement and even adversely affect the growth and function of an extremity. Radiographs show typical changes and are generally diagnostic. There is no medical treatment for enchondromatosis. Surgical intervention is indicated in case of complications (pathological fractures, growth defect, malignant transformation).We hereby report a case of multiple enchondromatosis in an 8 yrs old child with growth disturbances.
Complete Full TextWhen and how to image a suspected broken rib
Cleveland Clinic Journal of Medicine
Radiographic confirmation of rib fracture is often clinically irrelevant in patients who appear to have no complications or associated injuries. However, it is essential in a number of cases, especially when the clinical presentation and history raise suspicion of complications such as organ damage, or if the patient has other risk factors or conditions for which the precise information would help in management decisions. The authors discuss when to order imaging and which imaging test to order.
A 69 y/o white man who is scheduled for a routine herniorrhaphy must cancel because of an abnormal preoperative blood count
05/11/2009
A 69-year-old Caucasian man is scheduled to have a routine herniorrhaphy. However, this is cancelled because of an abnormal blood count obtained preoperatively.
- White blood cell count is 75,000 90% mature lymphocytes and 10% neutrophils.
- Hemoglobin is 15.4 gms%
- Hematocrit 47%
- Platelet count 244,000
Because of the abnormal blood count the patient is referred to you.
Management of Incidental Hepatitis C Virus Infection
NEJM
04/30/2009
A 25-year-old black woman is referred to your clinic for management of an incidental positive result on a hepatitis C virus (HCV) antibody test. She had decided to donate blood because her mother had recently become ill and required a transfusion. Three weeks after her donation, she received a telephone call and was told that her donated blood could not be used because her HCV antibody test was positive. She was encouraged to see her primary care physician to determine whether anything further should be done.
Woman With Neck Pain
ANNALS OF EMERGENCY MEDICINE
04/24/2009
A
44-year-old woman presented to the emergency department with neck pain.
She reported that 1 week ago she “tweaked” her neck while coughing and
during the intervening days had undergone physical therapy with massage
for this mild, isolated neck pain. One hour before her ED arrival, the
pain suddenly increased in severity, associated with vomiting and
diffuse headache. The physical examination was notable for an inability
of the left eye to abduct past the midline
Conjunctivitis with Ocular Nodules in the Northern Amazon
EMERGING INFECTIOUS DISEASES
04/17/2009
On October 26, 2006, local ophthalmologists notified the State Health Secretariat in Tocantins, located in the northern Amazon region of Brazil, of an unusual outbreak of conjunctivitis with ocular nodules of unknown etiology among children. Of all of the children most of them presented the following physical signs: conjunctival injection or inflammation, nodules on sclera, or conjunctival or corneal opacities with anterior uveitis identified during ophthalmologic examination (including by slit-lamp and microscopy).
A Man with a Rash
Annals of Emergency Medicine
03/26/2009
A 53-year-old man presented with a 5-day history of a diffuse scaly rash and reported a sore throat and fever 2 weeks earlier. Distinctively after the rash onset, he began presumptively receiving penicillin V potassium for streptococcal pharyngitis because of a culture-positive family contact. The patient reported worsening of the rash despite therapy. Our physical examination was remarkable for a pink maculopapular scaly rash, most prominent on the trunk and extremities, sparing the palms and soles. His antistreptolysin O titer level was 571 IU/mL (reference range <200 IU/mL).
The potential role of spiral computed tomography in acute gastrointestinal bleeding
Journal of the Royal College of Surgeons
Posted 03.17.2009
We present four cases of profuse gastrointestinal (GI) bleeding where the site
of haemorrhage was demonstrated using multi-slice computed tomography (MSCT),
with concordant findings at laparotomy and pathological examination. A review of
the current literature is undertaken and the role of spiral computed tomography
as a method of sourcing the bleeding point is discussed in relation to other
management modalities.
Unilateral cotton wool spots: An important clue
Cleveland Clinic Journal of Medicine
Posted 03.09.09
A 54 year old man with sudden visual loss in the left eye. The left eye and left periorbital area have been painful for the past 5 days. Funduscopic examination of the left eye reveals multiple cotton wool spots in the peripapillary area. The visual acuity is 20/200. The right eye appears normal, with normal vision.
An
89-year-old Woman with Hip Pain
EMERGENCY MEDICINE MAGAZINE
Posted 3.03.09
An 89-year-old woman presents to your emergency department after a
fall. She is complaining of left hip pain and is unable to bear weight.
You obtain the radiographs above.
A 64-year-old man was referred to our hospital with a history of painless, gradually growing lump in his left breast.On physical examination, nontender, irregular surface, demarcated elastic firm tumor (6 cm 3 7 cm in size) was palpable in the medial area of his left breast (Image1A). Fine needle aspiration cytology of the tumor cells showed that lymphocytic cells with prominent nucleoli were dispersed as single cells.
Surgical management of primary
aortoesophageal fistula secondary to thoracic aneurysm
An endoscopy showing a large clot with a well circumscribed, sharply marginated mucosal defect with pulsatile extrinsic compression presumed to be an ulcer or a fistula
Aortoesophageal fistula, secondary to thoracic aortic aneurysm, is an uncommon cause of gastrointestinal bleeding that is uniformly fatal without surgical intervention. These may be primary fistulas, in cases of thoracic aortic aneurysm without previous repair, or secondary fistulas occurring after surgical repair of thoracic aortic aneurysm. Surgical treatment has been successful in a small number of cases of primary aortoesophageal fistula, secondary to thoracic aortic aneurysm, but techniques used have varied. We report a successful repair of primary aortoesophageal fistula, secondary to descending thoracic aortic aneurysm, and review the evolution of management since the three previously reported successful repairs at our institution.
Intestinal endometriosis-A rare
cause of colonic perforation
Posted 02.07.2009
Endometriosis is the ectopic growth of viable endometrium outside the uterus, affecting approximately 7% of females. It commonly affects pelvic structures including the bowel. Perforation of the colon by endometriosis is very rare and the patients generally present with an asymptomatic or painful pelvic mass, often in the left iliac fossa. Our patient presented acutely unwell and her symptoms were more suggestive of pyelonephritis or diverticulitis. We therefore report an unusual cause of acute abdomen. The purpose of the following case report is to elucidate certain diagnostic and therapeutic problems of the disease, concerning both surgeons and gynaecologists.
Secondary Syphilis in a HIV
positive patient masquerading as Reiter's Syndrome A 28 year-old male of African descent presented with urethritis,
arthritis and keratoderma |
Acute Glaucoma after Dilated Eye
Exam in a Patient With Hyphema, Retinal Detachment, and Vitreous
Hemorrhage 
A 55-year-old man presented to the emergency department (ED) with complaints of decreased visual acuity and right eye pain after his airbag deployed during a motor vehicle collision. Examination revealed normal vital signs, right eye redness with tearing, a circumferential hyphema of the right eye not involving the pupil, and abrasions over the right eyebrow. The upper and lower lids were both swollen, but could be retracted for an exam. Visual acuity was 20/20 in the left eye, and 20/200 in the right eye. Slit-lamp exam additionally revealed multiple small corneal abrasions. The retina could not be visualized by funduscopic exam. ED bedside ultrasound with a high-frequency linear probe was used to visualize the globe.
A persistently swollen lip
A 44-year-old man is referred for evaluation of asymptomaticswelling of the lower lip that has persisted for 10 months. He has been treated unsuccessfully with oral antihistamines for suspected chronic angioedema. He has no other symptoms and appears to be well otherwise. He has no history of applied irritants or local trauma, and his medical history is unremarkable.
Posted 01.13.2009
