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- 2009
November 12, 2009
Renal-Artery Stenosis
Lance D. Dworkin, M.D., and Christopher J. Cooper, M.D.
N Engl J Med 2009;361:1972-1978A 73-year-old former smoker with a history of hypertension and dyslipidemia presents to the emergency department with shortness of breath. His blood pressure is 160/75 mm Hg, heart rate 60 beats per minute, and respiratory rate 24 breaths per minute. Chest auscultation reveals diffuse rales, and there is 1+ pitting edema. The serum creatinine level is 1.4 mg per deciliter (124 {mu}mol . . .October 29, 2009
Postexposure Prophylaxis for HIV Infection
Raphael J. Landovitz, M.D., and Judith S. Currier, M.D.
N Engl J Med 2009;361:1768-1775A 24-year-old man presents to an outpatient clinic, reporting that 36 hours previously he had receptive anal intercourse without the use of a condom with an anonymous male partner who was known to have had sex with other men. The patient is known to the clinical practice and has had several negative tests for human immunodeficiency virus (HIV) infection, most recently 6 . . .October 15, 2009
Bacterial Diarrhea
Herbert L. DuPont, M.D.
N Engl J Med 2009;361:1560-1569A 47-year-old man reports a 1-week history of diarrhea, with grossly bloody stools for the past 5 days. He reports no history of travel, contacts with sick persons, or underlying gastrointestinal disease. How should he be evaluated and treated for an infectious cause of his illness?Foodborne bacterial diarrhea is an emerging health threat that is attributable to the increased consumption of . . .
September 17, 2009
Screening for Colorectal Cancer
David A. Lieberman, M.D.
N Engl J Med 2009;361:1179-1187A healthy 76-year-old woman presents as a new patient for primary care. She reports having one daily bowel movement and no rectal bleeding. She has no family history of colorectal cancer. She reports having negative stool card tests during gynecologic examinations, most recently at 65 years of age. Would you advise this patient to undergo colon-cancer screening, and if so, what test . . .September 3, 2009
Should Coronary Calcium Screening Be Used in Cardiovascular Prevention Strategies?
Robert O. Bonow, M.D.
N Engl J Med 2009;361:990-997A 52-year-old man requests a coronary-artery calcium (CAC) scan for assessment of his risk of coronary events after seeing an advertisement from a local facility that offers the test. He has no symptoms of cardiac disease, has never smoked, and is not overweight, but he does not exercise regularly. His father, who was a heavy smoker, had a fatal myocardial infarction at . . .August 20, 2009
Infection Associated with Prosthetic Joints
Jose L. Del Pozo, M.D., Ph.D., and Robin Patel, M.D.
N Engl J Med 2009;361:787-794A 62-year-old woman with osteoarthritis presents with a 7-month history of progressively worsening left hip pain radiating to the groin, 8 months after undergoing total left-hip arthroplasty. The pain has not responded to nonsteroidal antiinflammatory drugs. Physical examination reveals a sinus tract overlying her left hip. Her leukocyte count is 8000 per cubic millimeter, and the C-reactive protein (CRP) level is 15.5 mg per liter. A radiograph shows loosening of the prosthesis at the bone-cement interface. Synovial-fluid aspirate shows 15×103cells per cubic millimeter (89% neutrophils); cultures of an aspirate from the hip grow Staphylococcus epidermidis. How should her case be managed?The numbers of primary total hip and total knee arthroplasties have been increasing over the past decade, with nearly 800,000 such procedures performed in the United States in 2006 (Figure 1A).1 Procedures to replace the shoulder, elbow, wrist, ankle, temporomandibular, metacarpophalangeal, and interphalangeal joints are less commonly performed.
Prosthetic joints improve the quality of life, but they may fail, necessitating revision or . . .
August 6, 2009
Neurologic Prognosis after Cardiac Arrest
G. Bryan Young, M.D.
N Engl J Med 2009;361:605-611A 55-year-old man collapses while jogging through the park. A bystander finds him unconscious and without a pulse and initiates cardiopulmonary resuscitation (CPR) while an ambulance is summoned. On arrival in the emergency room, the patient is in ventricular fibrillation; the partial pressure of oxygen in arterial blood is 200 mm Hg, the pH is 7.25, and the bicarbonate level is 18 . . .July 23, 2009
Ectopic Pregnancy
Kurt T. Barnhart, M.D., M.S.C.E.
N Engl J Med 2009;361:379-387A healthy 29-year-old woman who has been trying to conceive presents with vaginal spotting for the past 5 days and intermittent crampy abdominal pain in her left lower quadrant for the past 3 days. Although she normally has regular menstrual cycles, her last menstrual period was 6 weeks and 2 days before presentation. She has had a spontaneous vaginal delivery and an . . .July 9, 2009
Screening for Ovarian Cancer
Daniel L. Clarke-Pearson, M.D.
N Engl J Med 2009;361:170-177A 56-year-old woman presents to her physician, requesting screening for ovarian cancer. She reports the recent death of a friend from ovarian cancer at the age of 65 years. The patient has no family history of ovarian or breast cancer. The physical examination, including pelvic and rectal examination, is normal. Should the physician recommend screening for ovarian cancer?Ovarian cancer accounts for . . .
June 25, 2009
Alpha1-Antitrypsin Deficiency
Edwin K. Silverman, M.D., Ph.D., and Robert A. Sandhaus, M.D., Ph.D.
N Engl J Med 2009;360:2749-2757A 60-year-old white man presents for evaluation of progressive dyspnea. He is a former smoker with a 20-pack-year smoking history and a 10-year history of diagnosed chronic obstructive pulmonary disease (COPD). There is no family history of COPD. Severe airflow obstruction is seen on spirometry, with a forced expiratory volume in 1 second (FEV1) that is 40% of the predicted value. . . .June 11, 2009
Prenatal Screening for Aneuploidy
Deborah A. Driscoll, M.D., and Susan Gross, M.D.
N Engl J Med 2009;360:2556-2562A 37-year-old woman, gravida 1, seeks prenatal care at 8 weeks' gestation. Her family history and medical history are unremarkable. What would you advise regarding her risk of fetal chromosomal abnormalities such as Down's syndrome and her options for prenatal screening and diagnosis?Aneuploidy, a deviation from the normal number of 46 chromosomes in humans, is associated with significant morbidity and mortality, . . .
May 28, 2009
Chronic Venous Insufficiency and Varicose Veins
Seshadri Raju, M.D., and Peter Neglen, M.D., Ph.D.
N Engl J Med 2009;360:2319-2327A 52-year-old receptionist presents with an ulcer on her ankle that has persisted for a year. The use of narcotic analgesics once or twice a day and elevation of the leg reduce the pain. She does not have a history of diabetes and does not smoke. Physical examination reveals an ulcer, approximately 5 cm in diameter, above the medial malleolus. The ulcer . . .May 14, 2009
Fungal Nail Disease
David de Berker, M.R.C.P.
N Engl J Med 2009;360:2108-2116A 68-year-old man reports changes in his left big toenail. It has been discolored distally for the past 2 years. It has become thickened and difficult to cut and is painful when the man is walking in certain shoes. He is otherwise well. On physical examination, the nail appears thickened, has crumbling yellow material beneath, and is more discolored distally than proximally. . . .April 30, 2009
Asthma in Pregnancy
Michael Schatz, M.D., and Mitchell P. Dombrowski, M.D.
N Engl J Med 2009;360:1862-1869A 23-year-old nonsmoking woman (gravida 1, para 0) presents at 11 weeks' gestation with an 8-year history of asthma, which has worsened over the past year. She reports asthma symptoms requiring albuterol two or three times per day and interfering with sleep two or three nights per week. A corticosteroid inhaler was prescribed before pregnancy, but she has been afraid to use . . .April 16, 2009
Molar Pregnancy
Ross S. Berkowitz, M.D., and Donald P. Goldstein, M.D.
N Engl J Med 2009;360:1639-1645A healthy 37-year-old woman presents at 10 weeks of pregnancy with vaginal bleeding. Physical examination shows that the uterine size is appropriate for gestational age. The level of serum human chorionic gonadotropin (hCG) is 22,000 mIU per milliliter. Ultrasonography does not show an identifiable fetal heartbeat. After receiving a clinical diagnosis of missed abortion, the patient undergoes evacuation of the uterus; pathological . . .April 2, 2009
Evaluation and Management of Enuresis
W. Lane M. Robson, M.D.
N Engl J Med 2009;360:1429-1436The parents of an 8-year-old boy bring him to the pediatrician's office for evaluation of nightly bed-wetting. On half the nights, his urine soaks through a pair of absorbent disposable underpants into the sheets. He often does not void during school hours, and when he returns home after school, he usually rushes to the bathroom. He arrives home thirsty after school, and . . .March 19, 2009
Carbon Monoxide Poisoning
Lindell K. Weaver, M.D.
N Engl J Med 2009;360:1217-1225A 39-year-old female executive has a several-month history of fatigue, headache, and memory lapse. Multiple specialists have performed evaluations, but no diagnosis has been established. During a period of feeling worse than usual, she called a friend, who arrived at the residence to find the woman semicomatose and called 911. The patient was given supplemental oxygen and transported to the emergency department, . . .March 5, 2009
Graves' Ophthalmopathy
Luigi Bartalena, M.D., and Maria Laura Tanda, M.D.
N Engl J Med 2009;360:994-1001A 40-year-old woman who recently received a diagnosis of Graves' disease comes for a follow-up visit. She has been taking methimazole, at a dose of 10 mg daily, and is now euthyroid, but for the past 3 months, she has had bothersome eye symptoms, including redness, tearing, grittiness, photophobia, diplopia at the extremes of gaze, and ocular pain with eye movements. She . . .February 19, 2009
Epistaxis
Rodney J. Schlosser, M.D.
N Engl J Med 2009;360:784-789A 61-year-old man presents to the emergency room with left-sided epistaxis that has continued for 1 hour. He estimates having lost approximately 1/2 cup of blood and reports no history of nasal obstruction, epistaxis, trauma, bleeding diathesis, or easy bruising. He has a history of hypertension. Medications include atenolol and baby aspirin. How should this patient be evaluated and treated?Epistaxis is . . .
February 5, 2009
Primary Ovarian Insufficiency
Lawrence M. Nelson, M.D.
N Engl J Med 2009;360:606-614A 30-year-old woman presents with a history of no menses since she stopped taking oral contraceptives 6 months ago in order to conceive. She had undergone puberty that was normal in both timing and development, with menarche at 12 years of age. At 18 years of age, she started taking oral contraceptives for irregular menses. She reports stress at work. Her weight . . .January 22, 2009
Seborrheic Dermatitis
Luigi Naldi, M.D., and Alfredo Rebora, M.D.
N Engl J Med 2009;360:387-396A 35-year-old man reports itching, redness, and scaling in his scalp, eyebrows, and external auditory canal. He has tried several over-the-counter dandruff shampoos, with only temporary relief, and he is increasingly embarrassed by this problem. Physical examination reveals greasy scaling on the scalp and erythema with yellowish scales in the nasolabial creases. How should his case be managed?Seborrheic dermatitis is a . . .
January 8, 2009
Vitiligo
Alain Taieb, M.D., and Mauro Picardo, M.D.
N Engl J Med 2009;360:160-169A healthy 25-year-old brunette woman reports a 12-month history of skin depigmentation. She first noticed patches of skin whitening on her hips; her physician prescribed an imidazole cream for a presumed fungal infection, but there was no improvement. After a vacation at the beach, she noticed additional depigmented patches on her elbows, shins, upper eyelids, and lower chin. A dermatologist made a . . .- 2008
December 25, 2008
Acute Pulmonary Embolism
Stavros Konstantinides, M.D.
N Engl J Med 2008;359:2804-2813A 62-year-old man presented with a 5-day history of progressively worsening dyspnea and orthopnea after returning from a 3-day business trip to the Far East. On physical examination, the heart rate was 102 beats per minute, and the blood pressure 110/60 mm Hg. The arterial oxygen saturation was 86% while the patient was breathing ambient air. The neck veins were distended. There . . .December 11, 2008
Prevention and Treatment of Seasonal Influenza
W. Paul Glezen, M.D.
N Engl J Med 2008;359:2579-2585In February 2007, fever developed in a previously healthy 15-year-old girl, with a peak temperature of 102°F (38.9°C) and mild upper respiratory congestion. The next day she was seen by her primary care physician. A rapid screening test for group A streptococcus was negative, and oseltamivir was prescribed. After two doses, she continued to have fever and also had nausea and emesis, . . .November 27, 2008
Primary Retinal Detachment
Donald J. D'Amico, M.D.
N Engl J Med 2008;359:2346-2354A 57-year old man noted flashing lights in his right eye, followed two days later by a cluster of dark floaters that mildly interfered with his vision. He initially ignored these symptoms, but over the course of the next week, he noted a progressive loss of the nasal visual field in that eye, beginning inferiorly and spreading superiorly, with an eventual striking loss of central acuity that prompted him to seek ophthalmologic evaluation. Examination of the fundus with the pupil dilated showed a retinal detachment involving the temporal retina, including the macula, with peripheral retinal tears at the 10:30 and 11:30 positions. How should his case be managed?Rhegmatogenous retinal detachment, which refers to detachment due to round holes, tears, or breaks in the retina, is an important cause of visual symptoms and visual loss (Figure 1). The development of rhegmatogenous detachment typically involves the convergence of three factors: posterior vitreous detachment, one or more full-thickness breaks in the retina, and the passage of fluid from the vitreous cavity through . . .
November 13, 2008
Anterior Cruciate Ligament Tear
Kurt P. Spindler, M.D., and Rick W. Wright, M.D.
N Engl J Med 2008;359:2135-2142A female high-school soccer athlete reacts to a defender, plants her leg, cuts to the left without contact, feels her leg give out, hears a pop, and has acute pain. She is unable to walk off the field or return to play. That evening her knee progressively swells. The next day she presents for evaluation. How should her case be managed?The passage in 1972 of Title IX legislation, which guarantees equal access to athletic programs for both sexes at any high school or college receiving federal funds, has led to an exponential rise in the number of female participants in sports. Although this has resulted in many benefits, including the promotion of physical fitness and the fostering of team-building behavior, it has . . .
October 16, 2008
Gastroesophageal Reflux Disease
Peter J. Kahrilas, M.D.
N Engl J Med 2008;359:1700-1707A 53-year-old man, who is otherwise healthy and has a 20-year history of occasional heartburn, reports having had worsening heartburn for the past 12 months, with daily symptoms that disturb his sleep. He reports having had no dysphagia, gastrointestinal bleeding, or weight loss and in fact has recently gained 20 lb (9 kg). What would you advise regarding his evaluation and treatment?Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics.1 In the United States, it is estimated that 14 to 20% of adults are affected, although such percentages are at best approximations, given that the disease has a nebulous definition and that such estimates are based on the prevalence of self-reported chronic heartburn.2 A current definition of . . .
October 2, 2008
Autosomal Dominant Polycystic Kidney Disease
Jared J. Grantham, M.D.
N Engl J Med 2008;359:1477-1485Shortly after being elbowed in the flank during a pickup basketball game, a 35-year-old healthy man has severe, colicky abdominal pain followed by gross hematuria. He is hospitalized, and a renal ultrasound scan reveals bilateral polycystic kidneys and liver cysts, previously unknown to the patient. The blood pressure is 160/100 mm Hg. The serum creatinine concentration is 0.9 mg per deciliter (80 {mu}mol per liter). The pain subsides in 2 days with analgesics, rest, and fluids; the gross hematuria resolves in 4 days, although microscopic hematuria persists. How should his case be further evaluated and managed?Autosomal dominant polycystic kidney disease is an inherited systemic disorder with major renal manifestations and, in some cases, abnormalities in the liver, the pancreas, the brain, the arterial blood vessels, or a combination of these sites.1 The disease affects approximately 300,000 to 600,000 Americans of either sex, and without racial predilection. Each child of an affected parent has a 50% chance of . . .
September 18, 2008
Food Allergy
Gideon Lack, M.D.
N Engl J Med 2008;359:1252-1260A 3-year-old boy with a recent history of hives and wheezing after eating chocolate mousse is evaluated. At 18 months of age, contact urticaria developed after he put his hand into a cake mix containing egg. He also has a history of chronic rhinitis, nocturnal cough, severe eczema, and a previous hospitalization for recurrent wheezing. How should this child be evaluated and . . .September 4, 2008
Hereditary Angioedema
Bruce L. Zuraw, M.D.
N Engl J Med 2008;359:1027-1036A 19-year-old woman presents to the emergency department with light-headedness, severe abdominal pain, and intractable nausea and vomiting that began 12 hours earlier. The patient reports previous episodes of abdominal pain and swelling of her hands and feet that have been attributed possibly to food allergies, which have recently become more frequent. There is no associated urticaria. Her only medication is an . . .August 21, 2008
Idiopathic Sudden Sensorineural Hearing Loss
Steven D. Rauch, M.D.
N Engl J Med 2008;359:833-840A healthy 58-year-old woman answers the telephone and realizes that her hearing is diminished on the left side. She notices aural fullness and loud tinnitus in the affected ear. Later that day she has several hours of mild vertigo that clears by the following morning. Over the next few days, repeated self-administered ear cleaning with the use of an over-the-counter kit does . . .August 7, 2008
Malaria Prevention in Short-Term Travelers
David O. Freedman, M.D.
N Engl J Med 2008;359:603-612A family of three persons is planning a safari to southern Africa. The itinerary includes 3 days in Cape Town, South Africa, 3 days in Kruger National Park, South Africa, and 3 days in Victoria Falls, Zambia. The 31-year-old husband takes no medications currently, but he recently discontinued fluoxetine, which he had taken for depression. His 29-year-old wife, who won the trip . . .July 24, 2008
Hypoparathyroidism
Dolores Shoback, M.D.
N Engl J Med 2008;359:391-403A 58-year-old man is found on laboratory testing to have a serum calcium level of 6.0 mg per deciliter (1.5 mmol per liter) (normal range, 8.5 to 10.5 mg per deciliter [2.1 to 2.6 mmol per liter]), an albumin level of 3.9 g per deciliter, and a phosphorus level of 6.0 mg per deciliter (1.94 mmol per liter) (normal range, 2.5 to . . .July 10, 2008
Initial Management of Epilepsy
Jacqueline A. French, M.D., and Timothy A. Pedley, M.D.
N Engl J Med 2008;359:166-176A 29-year-old woman presents for evaluation. The previous evening, her husband, who was in the next room, heard unusual sounds and found her lying on the bed looking dazed. She was confused for a few minutes but quickly returned to normal. On questioning, she recalls an unwitnessed event about 1 month previously; at that time, she awoke feeling mildly confused, had sore . . .June 26, 2008
Acute Calculous Cholecystitis
Steven M. Strasberg, M.D.
N Engl J Med 2008;358:2804-2811A previously well 42-year-old woman presents with severe pain in the right upper quadrant, which started 15 hours earlier. She has previously noted episodic pain in that location that lasted for up to 2 hours but has not sought medical advice. She has had one episode of vomiting with the current attack. On physical examination, her temperature is 38.5°C, and the heart rate is 95 beats per minute. She has tenderness and guarding in the right upper quadrant. How should her condition be evaluated and treated?Acute calculous cholecystitis is a complication of cholelithiasis, a condition that afflicts more than 20 million Americans annually1 and results in direct costs of more than $6.3 billion.2 Most patients with gallstones are asymptomatic. Of such patients, biliary colic develops in 1 to 4% annually,3,4,5 and acute cholecystitis eventually develops in about 20% of these symptomatic patients if they are left untreated.
June 12, 2008
Graves' Disease
Gregory A. Brent, M.D.
N Engl J Med 2008;358:2594-2605A 23-year-old woman presents with palpitations. Over the past 6 months, she has reported loose stools, a 10-lb (4.5-kg) weight loss despite a good appetite and food intake, and increased irritability. She appears to be anxious and has a pulse of 119 beats per minute and a blood pressure of 137/80 mm Hg. Her thyroid gland is diffusely and symmetrically enlarged to . . .May 29, 2008
Precocious Puberty
Jean-Claude Carel, M.D., and Juliane Leger, M.D.
N Engl J Med 2008;358:2366-2377The parents of a 6-year-old girl bring her to a pediatrician because of breast development. Her medical history is unremarkable. The parents are of average height, and the mother reports first menstruating when she was 11 years old. At physical examination, the girl is 125 cm tall (in the 97th percentile for her age), weighs 28 kg, and has a body-mass index . . .May 15, 2008
Rotator-Cuff Failure
Frederick A. Matsen III, M.D.
N Engl J Med 2008;358:2138-2147A 63-year-old woman presents with a 2-year history of progressive weakness and discomfort in her right shoulder, especially when she puts dishes on the top shelf in her kitchen. She is otherwise healthy and has had no injuries. Her physician diagnosed "bursitis" and gave her four subacromial corticosteroid injections; the first two seemed to relieve her symptoms temporarily, but the last two . . .May 1, 2008
Nonsurgical Management of Obesity in Adults
Robert H. Eckel, M.D.
N Engl J Med 2008;358:1941-1950A 44-year-old woman desires weight reduction. Her history is notable for hypertension, snoring, daytime somnolence, and osteoarthritis. Her father was obese and had type 2 diabetes. On physical examination, her weight is 215 lb (98 kg), her body-mass index (BMI) (the weight in kilograms divided by the square of the height in meters) 32.7, her waist circumference 40 in. (102 cm), and . . .April 17, 2008
Irritable Bowel Syndrome
Emeran A. Mayer, M.D.
N Engl J Med 2008;358:1692-1699A 28-year-old woman presents with a 7-month history of recurrent, crampy pain in the left lower abdominal quadrant, bloating with abdominal distention, and frequent, loose stools. She reports having had similar but milder symptoms since childhood. She spends long times in the bathroom because she is worried about uncontrollable discomfort and fecal soiling if she does not completely empty her bowels before leaving the house. She feels anxious and fatigued and is frustrated that her previous physician did not seem to take her distress seriously. Physical examination is unremarkable except for tenderness over the left lower quadrant. How should her case be evaluated and treated?Irritable bowel syndrome (IBS), characterized by chronically recurring abdominal pain or discomfort and altered bowel habits, is one of the most common syndromes seen by gastroenterologists and primary care providers, with a worldwide prevalence of 10 to 15%.1 In the absence of detectable organic causes, IBS is referred to as a functional disorder, which is defined by symptom-based diagnostic criteria known as . . .
April 3, 2008
Osteoporosis in Men
Peter R. Ebeling, M.D.
N Engl J Med 2008;358:1474-1482A 65-year-old asymptomatic man is concerned about his risk of osteoporosis. His mother died after a hip fracture at 74 years of age. The patient has no history of fractures but has lost 7.6 cm (3 in.) in height; he does not smoke and has never taken corticosteroids. He drinks two glasses of beer (16 oz, or about 0.5 liter, each) per . . .March 20, 2008
Hormonal Contraception in Women of Older Reproductive Age
Andrew M. Kaunitz, M.D.
N Engl J Med 2008;358:1262-1270A healthy, lean 46-year-old woman who is a nonsmoker requests advice about contraception. She notes that her menstrual periods are less regular than previously, and she also reports intermittent bothersome hot flashes. She is in a new relationship after a divorce, and she is sexually active. She asks if she can begin to use an oral contraceptive. What would you advise?During . . .
March 6, 2008
Urinary Stress Incontinence in Women
Rebecca G. Rogers, M.D.
N Engl J Med 2008;358:1029-1036A 45-year-old woman reports losing urine with coughing, laughing, or sneezing since the birth of her last baby. She has been unable to lose the 25 lb (11 kg) that she gained after her pregnancy 6 years ago. She voids every 3 hours and reports no urinary urgency or nocturia. Her incontinence keeps her from participating in her exercise class, and she . . .February 21, 2008
Lumbar Spinal Stenosis
Jeffrey N. Katz, M.D., M.Sc., and Mitchel B. Harris, M.D.
N Engl J Med 2008;358:818-825A 72-year-old woman with hypertension presents with a 4-month history of lower back discomfort that radiates to both buttocks and lateral thighs. Previously, she had walked 2 miles (3.2 km) a day; now she has difficulty walking 2 blocks and standing up for more than 15 minutes at a time. Her physical examination is notable only for a slightly stooped posture and . . .February 7, 2008
Neurogenic Orthostatic Hypotension
Roy Freeman, M.B., Ch.B.
N Engl J Med 2008;358:615-624A 65-year-old man reports a 6-month history of dizziness, light-headedness, weakness, and fatigue while upright. He takes no medication and has no personal or family history of neurologic disease. On physical examination, his supine blood pressure is 160/100 mm Hg, with a heart rate of 72 beats per minute; on standing, his blood pressure falls to 70/40 mm Hg, with no change . . .January 24, 2008
Croup
James D. Cherry, M.D., M.Sc.
N Engl J Med 2008;358:384-391Crouplike symptoms develop in a previously healthy 2-year-old girl at 11 p.m. She is seen in an emergency department 2 hours later with a barking cough and, when upset, inspiratory stridor. Her temperature is 36.1°C, respiratory rate 20 breaths per minute, heart rate 151 beats per minute, and oxygen saturation 94% while she is breathing ambient air. She has mild sternal retractions . . .January 10, 2008
Long-QT Syndrome
Dan M. Roden, M.D.
N Engl J Med 2008;358:169-176After the sudden death of a 13-year-old girl while she was playing basketball, her family comes to the clinic for medical evaluation (Figure 1). Her parents' resting electrocardiograms (ECGs) are normal, but her 9-year-old sister's ECG shows an abnormally long QT interval. There is a history of recurrent syncope in female relatives of the maternal grandmother, but there is no family history . . .- 2007
December 27, 2007
Localized Prostate Cancer
Patrick C. Walsh, M.D., Theodore L. DeWeese, M.D., and Mario A. Eisenberger, M.D.
N Engl J Med 2007;357:2696-2705A 68-year-old man presents with newly diagnosed prostate cancer. Over the past 3 years, his serum prostate-specific antigen (PSA) level has been slowly and steadily increasing (from 4.0 ng per milliliter to 4.3 ng per milliliter to 4.7 ng per milliliter). His digital rectal examination is normal; the prostate volume, estimated by means of ultrasonography, is 48 ml, and a needle-biopsy specimen . . .December 13, 2007
Erectile Dysfunction
Kevin T. McVary, M.D.
N Engl J Med 2007;357:2472-2481A 65-year-old man presents to an outpatient clinic, reporting that he can no longer maintain an erection sufficient for intercourse. His medical history includes well-controlled hypertension and stable coronary artery disease. He smokes a pack of cigarettes daily. His medications include atenolol and low-dose aspirin (81 mg daily). On physical examination, his body-mass index (the weight in kilograms divided by the square . . .November 29, 2007
Late-Life Depression
Jurgen Unutzer, M.D., M.P.H.
N Engl J Med 2007;357:2269-2276A 71-year-old man, whose wife died 6 months previously, presents with foot pain from diabetic neuropathy, poor sleep, lack of energy, and increasing frustration about his inability to "keep his diabetes under control." On examination, he also notes lack of interest in usual activities, decreased appetite, a weight loss of 4.5 kg (10 lb) over the past 3 months, and intermittent thoughts . . .November 15, 2007
Diverticulitis
Danny O. Jacobs, M.D., M.P.H.
N Engl J Med 2007;357:2057-2066A previously healthy 45-year-old man presents with severe lower abdominal pain on the left side, which started 36 hours earlier. He has noticed mild, periodic discomfort in this region before but has not sought medical treatment. He reports nausea, anorexia, and vomiting associated with any oral intake. On physical examination, his temperature is 38.5°C and his heart rate is 110 beats per . . .November 1, 2007
Assessment of Patients' Competence to Consent to Treatment
Paul S. Appelbaum, M.D.
N Engl J Med 2007;357:1834-1840A 75-year-old woman with type 2 diabetes mellitus and peripheral vascular disease is admitted with a gangrenous ulcer of the plantar aspect of her left foot. A surgical consultation results in a recommendation for a below-the-knee amputation, but the patient declines the procedure on the grounds that she has lived long enough and wants to die with her body intact. Her internist, . . .October 18, 2007
Hair Loss in Women
Jerry Shapiro, M.D.
N Engl J Med 2007;357:1620-1630A 45-year-old white woman presents with a 1-year history of scalp-hair loss. She was hospitalized with appendicitis 14 months ago. She has been a vegetarian for 20 years. She takes no medications. Her father was bald. On physical examination, she has diffuse, nonscarring hair thinning with a widened part over the central portion of the scalp. How should this problem be evaluated . . .October 4, 2007
Osteoarthritis of the Hip
Nancy E. Lane, M.D.
N Engl J Med 2007;357:1413-1421A 70-year-old man reports a gradual onset of hip pain that has limited his activities for about a year. The pain initially occurred only with walking and was limited to the anterior hip area but now has spread to the side of the hip and is present at rest. He has no history of injury to the hip, back, or lower back . . .September 20, 2007
Gynecomastia
Glenn D. Braunstein, M.D.
N Engl J Med 2007;357:1229-1237During an evaluation for low back pain, a 67-year-old man is found to have gynecomastia on the right side that is nontender on palpation. Other than a body-mass index (the weight in kilograms divided by the square of the height in meters) of 32, the physical examination is normal. His medical history is notable only for hyperlipidemia; his only medication is a . . .September 6, 2007
Hypertriglyceridemia
John D. Brunzell, M.D.
N Engl J Med 2007;357:1009-1017A healthy 45-year-old man is found on routine screening to have hypertriglyceridemia. He is a nonsmoker, has a reasonable diet, consumes one alcoholic drink per week, and exercises regularly. He takes no medications. His father died at the age of 55 years in an automobile accident; his mother is healthy at 67 years of age, and he has two healthy older brothers. . . .August 23, 2007
Isolated Systolic Hypertension in the Elderly
Aram V. Chobanian, M.D.
N Engl J Med 2007;357:789-796A 68-year-old accountant visits his physician. He was told a year earlier that his blood pressure was somewhat elevated and was advised to reduce salt intake and increase physical activity. Otherwise he has been in good health and has no history or signs of cardiovascular or renal disease. On physical examination, his blood pressure is 178/72 mm Hg, with no clinically significant . . .August 9, 2007
Acute Ischemic Stroke
H. Bart van der Worp, M.D., Ph.D., and Jan van Gijn, F.R.C.P.
N Engl J Med 2007;357:572-579A 62-year-old man has sudden weakness of the left arm and leg and slurred speech. Except for untreated hypertension, his medical history is unremarkable. He is a current smoker with a smoking history of 45 pack-years. On arrival at the emergency department 1 hour 15 minutes after the onset of symptoms, he reports no headache or vomiting. His blood pressure is 180/100 . . .July 26, 2007
Skin and Soft-Tissue Infections Caused by Methicillin-Resistant Staphylococcus aureus
Robert S. Daum, M.D., C.M.
N Engl J Med 2007;357:380-390A 37-year-old man presents for the evaluation of localized swelling and tenderness of the left leg just below the knee. He suspects this lesion developed after a spider bite, although he did not see a spider. Examination of the leg reveals an area of erythema and warmth measuring approximately 5 by 7 cm. At the center of the lesion is a fluctuant . . .July 12, 2007
Management of an Inherited Predisposition to Breast Cancer
Mark Robson, M.D., and Kenneth Offit, M.D., M.P.H.
N Engl J Med 2007;357:154-162A healthy 33-year-old woman comes to establish care. She reports no breast symptoms, her age at menarche was 14, and she has no children. She notes a family history of early-onset breast cancer in her sister (whose condition was diagnosed at the age of 35 years and who is alive at 39 years), mother (diagnosed at 37 years and alive at 60 . . .June 28, 2007
Arteriovenous Malformations of the Brain
Robert M. Friedlander, M.D.
N Engl J Med 2007;356:2704-2712A 51-year-old woman presents with a generalized tonic-clonic seizure. After a brief postictal period, she recovers fully and does not report headache or other neurologic symptoms. She takes no medications and her medical history is unremarkable. Computed tomography of the head suggests a right occipital arteriovenous malformation, without evidence of hemorrhage. Computed tomographic angiography, magnetic resonance imaging, and magnetic resonance angiography of . . .June 14, 2007
Follow-up of Patients with Early Breast Cancer
Daniel F. Hayes, M.D.
N Engl J Med 2007;356:2505-2513An otherwise healthy 53-year-old woman is seen for routine care after completing treatment several months earlier for stage II estrogen-receptor-positive, HER2-positive breast cancer. The treatment consisted of lumpectomy, irradiation, adjuvant chemotherapy (doxorubicin and cyclophosphamide followed by paclitaxel), and trastuzumab. Her only current medication is an aromatase inhibitor. She is amenorrheic. She reports fatigue, hot flashes, arthralgias, and sexual difficulties and is concerned . . .May 31, 2007
Osteopenia
Sundeep Khosla, M.D., and L. Joseph Melton III, M.D., M.P.H.
N Engl J Med 2007;356:2293-2300A 55-year-old asymptomatic woman, who is 5 years postmenopausal, is concerned about osteoporosis, since her mother had a hip fracture at the age of 70 years. The patient has no personal history of fractures and has never taken corticosteroids. She does not smoke but does drink one to two glasses of wine a day. Her weight is 105 lb (48 kg), and . . .May 17, 2007
The Syndrome of Inappropriate Antidiuresis
David H. Ellison, M.D., and Tomas Berl, M.D.
N Engl J Med 2007;356:2064-2072A 62-year-old woman noted an unpleasant, sweet taste in her mouth. She otherwise felt well and was taking no medications. Because dysgeusia is a rare manifestation of hyponatremia, her serum sodium level was tested and was 122 mmol per liter. The serum osmolality was 250 mOsm per kilogram of water, the urinary osmolality 635 mOsm per kilogram of water, the urinary sodium . . .May 3, 2007
Superior Vena Cava Syndrome with Malignant Causes
Lynn D. Wilson, M.D., M.P.H., Frank C. Detterbeck, M.D., and Joachim Yahalom, M.D.
N Engl J Med 2007;356:1862-1869A 58-year-old man presents with a 2-week history of progressive dyspnea on exertion, neck swelling, decreased appetite, and fatigue. There is no history of syncope or dysphagia. He smoked cigarettes until 5 years ago. The physical examination reveals a heart rate of 105 beats per minute, a respiratory rate of 20 breaths per minute, and superficial vascular distention over the neck, chest, . . .April 19, 2007
Fecal Incontinence in Adults
Arnold Wald, M.D.
N Engl J Med 2007;356:1648-1655A 53-year-old otherwise healthy woman presents with a 2-year history of intermittent fecal incontinence. Because of embarrassment, she has curtailed her social and professional activities. Physical activity often precipitates an episode, and she wears absorbent pads. She has occasional urinary incontinence when she coughs or sneezes. There is no history of gastrointestinal or rectal surgery and no neurologic symptoms. Physical examination reveals . . .April 5, 2007
Prophylaxis for Thromboembolism in Hospitalized Medical Patients
Charles W. Francis, M.D.
N Engl J Med 2007;356:1438-1444A 62-year-old man is admitted with fever, cough, and dyspnea. He is weak, appears to be dehydrated, and has purulent sputum. His temperature is 39.2°C, respirations 22, and blood pressure 128/69 mm Hg. There are crackles over the left lower lung field, and chest radiography shows a density in the left lower lobe that is consistent with pneumonia. Should thromboprophylaxis be provided? . . .March 22, 2007
Intermittent Claudication
Christopher White, M.D.
N Engl J Med 2007;356:1241-1250A 58-year-old, previously healthy mail carrier reports cramping pain in his right calf when he walks. The discomfort has progressively worsened over the past 6 months and now forces him to rest after walking half a block on level ground at a normal pace. The pain is interfering with his ability to perform his job. He has a normal right femoral pulse . . .March 8, 2007
Pediatric Strabismus
Sean P. Donahue, M.D., Ph.D.
N Engl J Med 2007;356:1040-1047A healthy 3-year-old boy presents with a 6-month history of strabismus in his left eye. The visible inward deviation of the eye began intermittently but is now constant. His visual acuity is 20/20 in the right eye but only 20/100 in the left eye. The physical examination is otherwise normal. How should he be treated?As evolution proceeded, the location of the . . .
February 22, 2007
Diabetic Gastroparesis
Michael Camilleri, M.D.
N Engl J Med 2007;356:820-829A 36-year-old man with a 20-year history of type 1 diabetes mellitus, background retinopathy, peripheral sensory neuropathy, and nephropathy presents with a history of several months of nausea and vomiting of undigested food and bile, during which time he lost 4 kg. On physical examination (performed 1 hour after the patient has eaten), his blood pressure is 130/80 mm Hg while he . . .February 8, 2007
The Incidentally Discovered Adrenal Mass
William F. Young Jr., M.D.
N Engl J Med 2007;356:601-610A 68-year-old woman is incidentally found to have a left adrenal mass, 2.8 cm in diameter, on abdominal computed tomography that was ordered to evaluate right lower abdominal discomfort (which has since resolved). Her medical history is notable only for hypertension that has been well controlled with hydrochlorothiazide, at a dose of 25 mg daily. She reports no sweating, palpitations, headache, weight . . .January 25, 2007
In Vitro Fertilization
Bradley J. Van Voorhis, M.D.
N Engl J Med 2007;356:379-386A 37-year-old woman who has never been pregnant and her 40-year-old husband have been attempting to conceive a child for the past 3 years. An infertility evaluation has shown no cause for the difficulty. She is ovulating regularly, and a hysterosalpingogram shows that her reproductive tract is anatomically normal. He has a normal sperm count; he has not fathered any children. They . . .January 11, 2007
Concussion
Allan H. Ropper, M.D., and Kenneth C. Gorson, M.D.
N Engl J Med 2007;356:166-172A 64-year-old woman slipped on an icy walk, falling forward and striking her forehead. She had a brief convulsion immediately after the fall, was unresponsive for less than 1 minute, and awakened with a severe generalized headache and nausea but no vomiting. In addition to being perplexed about the circumstances of the fall, she could not recall the previous few hours. She . . .- 2006
November 30, 2006
Management of Menopausal Symptoms
Deborah Grady, M.D., M.P.H.
N Engl J Med 2006;355:2338-2347A 51-year-old woman has frequent and distressing hot flushes that interfere with her work and sleep, and vaginal dryness that makes sexual intercourse with her husband uncomfortable. She is otherwise healthy. How should her case be managed?All healthy women transition from a reproductive, or premenopausal, period, marked by regular ovulation and cyclic menstrual bleeding, to a postmenopausal period, marked by amenorrhea . . .
October 5, 2006
Prevention of Meningococcal Disease
Pierce Gardner, M.D.
N Engl J Med 2006;355:1466-1473A previously healthy 18-year-old college freshman presented to an emergency department with acute onset of fever and headache. He was listless and in distress. His temperature was 40.0°C, his pulse was 140 per minute, his blood pressure was 70/40 mm Hg, and his respirations were 35 per minute. Petechiae were noted over his thorax. Meningococcal septicemia was suspected (and subsequently confirmed by . . .