Wolff-Parkinson-White syndrome is the most common form of ventricular preexcitation and affects 1... more Wolff-Parkinson-White syndrome is the most common form of ventricular preexcitation and affects 1-3 per 1,000 persons worldwide. Many patients remain asymptomatic throughout their lives; however, approximately half of the patients with Wolff-Parkinson-White syndrome experience symptoms secondary to tachyarrhythmias, such as paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and, rarely, ventricular fibrillation and sudden death. Patients with Wolff-Parkinson-White syndrome may present with a multitude of symptoms such as unexplained anxiety, palpitations, fatigue, light-headedness or dizziness, loss of consciousness, and shortness of breath. We report the case of a patient who presented with a plethora of symptoms related to generalized anxiety along with several confounding factors such as psychosocial stressors, chronic fatigue secondary to high physical and mental demands at work, a strong family history of anxiety, and a history of substance abuse. Keeping cardiac dysrhythmia within his differential diagnosis allowed for accurate diagnosis and treatment.
Morphea, also known as localized scleroderma, is an uncommon idiopathic inflammatory disorder lea... more Morphea, also known as localized scleroderma, is an uncommon idiopathic inflammatory disorder leading to the development of sclerotic plaques in the skin. The disorder preferentially affects females. The pathogenesis of morphea is not well-understood. The disorder is likely to have an autoimmune basis; environmental and genetic factors may also play a role in its etiology. Morphea has a variety of clinical presentations. Lesions of morphea typically begin as inflammatory plaques or patches that evolve into firm sclerotic lesions. Involvement may be limited to the dermis or may extend to underlying subcutaneous fat, muscle, or bone. The identification of characteristic clinical findings is often sufficient for the diagnosis of morphea. A biopsy can be a useful tool when the diagnosis is in question or to obtain information on the depth and intensity of the disease, and it should always extend at least into the subcutaneous fat. Morphea may cause joint contractures and other impairments secondary to tissue sclerosis and can be very debilitating cosmetically and functionally.
Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin... more Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin lesions. It is often a paraneoplastic manifestation of internal malignancy. Hence, early recognition of this disorder is important. Although not all dermatomyositis are associated with malignancies, the ones with such association regress with the treatment of associated malignancy. In clinical practice, symptoms of muscle weakness can be vague, and skin lesions can be dismissed as sunburn. We present a case of an elder adult female who presented with dermatomyositis as a paraneoplastic syndrome secondary to an underlying Mullerian malignancy.
Giant ovarian cysts, which are described in the literature as measuring more than 10 cms in size ... more Giant ovarian cysts, which are described in the literature as measuring more than 10 cms in size in their largest diameter, are rare in occurrence. With the availability of multiple imaging modalities and routine physical examinations, it has become even rarer to find such cases. Ovarian serous cystadenomas, which are benign tumors arising from the ovarian epithelium, represent the most common type.
We present a case of a 58-year-old female who came to establish primary care in our clinic. She reported ongoing symptoms of constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding for the past few months. The patient reported taking over-the-counter medications for her predominant gastrointestinal symptoms with no improvement at all.
Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) of the pelvis revealed the presence of giant bilateral ovarian masses measuring more than 17 X 10cms each. Further testing revealed highly elevated levels of tumor markers cancer antigen 125 (CA-125) and human epididymis protein 4 (HE-4). The patient subsequently underwent total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Her histopathology report revealed the presence of bilateral benign cystadenomas.
From a primary care physician's perspective, this case highlights the importance of possible rare pathologies that can present with symptoms of a completely unrelated organ system. Even with the rarity of these cases, a clinician may encounter such a case in their everyday practice. Patients can endorse a plethora of vague complaints, often masquerading other entities seen commonly in the clinic.
Ewing’s sarcoma is the second most common malignant bone tumor in children, with the worst outcom... more Ewing’s sarcoma is the second most common malignant bone tumor in children, with the worst outcomes seen in patients over the age of 20. However, the onset of the disease is much less common in people over the age of 30. This case represents the diagnostic dilemma posed by an otherwise “straight forward” case of back pain. Keeping the differential diagnosis sufficiently broad to include bone malignancies, so as not to delay diagnosis and treatment, provides the best chance at a positive outcome.
The purpose of our case report is to generate awareness among the providers about the rising abus... more The purpose of our case report is to generate awareness among the providers about the rising abuse of loperamide, which is a readily available nonprescription medication for its opiate-like actions and the risk of severe cardiac complications as a consequence of the same. It is currently becoming a significant concern among the healthcare fraternity due to its increasing abuse owing to its opioid agonistic activity. Our patient was a 32-year-old female who presented to the ED with ventricular dysrhythmias and persistent, prolonged QT interval secondary to excessively high doses of over-the-counter (OTC) loperamide abuse. More and more cases of loperamide abuse and its cardiotoxic potential are being reported in the literature, highlighting the increasing incidence of this problem.
Anxiety disorders are highly prevalent in the primary care setting and are responsible for
signif... more Anxiety disorders are highly prevalent in the primary care setting and are responsible for significant morbidity as well as a loss of productivity. Evaluation by mental health specialists and behavioral specialists can sometimes be confounded with problems of availability, accessibility, and the patient’s hesitancy to talk to new providers due to lack of prior relationship and trust. Primary care providers already have the advantage of being available for their patients, and have built years of trust behind them to strengthen this relationship. The biggest problems which confront primary care are the time constraints as well as the presence of multiple medical demands. This leads to a constant need for tools that facilitate early recognition and diagnosis of mental health disorders while also providing judicious utilization of clinic time. This article attempts to review the use of two of these popular tools: Generalized Anxiety Disorder scale-2 (GAD-2) and GAD-7 in the primary care setting.
Candida parapsilosis osteomyelitis is a rare diagnosis. Candidal infection can occur via
hematoge... more Candida parapsilosis osteomyelitis is a rare diagnosis. Candidal infection can occur via hematogenous or local spread. A localized swelling around a bony structure should raise clinical suspicion. Diagnosis is made by a combination of imaging modalities and biopsy. Anecdotal case reports have been reported in medical literature and treatment guidelines are very limited. Treatment modality includes a combination of surgical debridement and antifungal therapy.
Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often... more Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often goes undiagnosed. OSA is characterized mainly by anatomical obstruction or partial collapse of upper airways during sleep. The obstruction is multifactorial, and a lesser-known fact is that damage to the pharyngeal plexus during head and neck procedures or placement of hardware in the cervical area can lead to narrowing or collapse of the upper airway. We present such a case of a 59-year-old female who developed new-onset OSA after undergoing anterior cervical discectomy and fusion (ACDF). The severity of OSA worsened with the progression of her rheumatoid arthritis (RA) in the cervical region. This case report aims to raise awareness of such an association among clinicians to enable them to screen appropriate patients for sleep-disordered breathing and treat them accordingly.
Stevens-Johnson Syndrome: A Perplexing Diagnosis, 2020
Stevens-Johnson syndrome/toxic epidermal necrolysis is a spectrum of mucocutaneous
reactions that... more Stevens-Johnson syndrome/toxic epidermal necrolysis is a spectrum of mucocutaneous reactions that can occur due to drug reactions, infections with Mycoplasma pneumonia, human immunodeficiency virus (HIV), cancer, and genetics. Stevens-Johnson syndrome involves less than 10% of the body surface, while toxic epidermal necrolysis involves greater than 30%. The most common site of the lesions is mucocutaneous surfaces such as the eyes and oral cavity. Our patient was a 44-year-old female who presented to the emergency department with concerns for pain in her eyes, hands and feet, rash, and sore throat. Her rash worsened during the initial hospitalization. This case emphasizes the importance of pattern recognition of Stevens-Johnson syndrome, as this is a rare but serious condition that must be recognized and treated appropriately. The reaction is most commonly due to medications; however, a thorough history and physical exam are vital to diagnosing this potentially fatal condition.
Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces
dermatitidis, of... more Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces dermatitidis, often found in endemic regions of Midwestern America. It can be found in forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and long bones have been most frequently reported. Disseminated infection to the genitourinary system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining a detailed medical and social history is important for making a diagnosis. Culturing a specimen will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based budding with a double-contoured cell wall). In mild to moderate disease without dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases, patients with CNS involvement or in immunocompromised individuals, amphotericin B is the preferred initial drug of choice. We present an interesting case of a 42-year-old African-American male with no significant past medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces osteomyelitis.
Fatal Anaphylaxis to Contrast a Reality: A Case Report., 2019
Contrast media (CM) are widely used in imaging techniques to enhance the differences between body... more Contrast media (CM) are widely used in imaging techniques to enhance the differences between body tissues on images. Less than one percent of patients receiving low osmolar nonionic contrast media can develop anaphylaxis, including a severe anaphylactic shock. The precise mechanism of this is mostly unknown but postulated to be due to the release of histamine by triggering mast cells or IgE-related mechanisms.
We described the case of a 45-year-old female with a past medical history of severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and anxiety and with no known allergies to contrast media who had an unpredictable fatal anaphylactic reaction to non-ionic contrast dyes and suffered a cardiac arrest while getting the scan done. The unpredictability of a negative past medical history of adverse reactions to these dyes and the considerable variability in the pretreatment regimens for patients with the previous adverse response to these dyes further confounds the whole picture. As primary care providers, we are usually the first link of the patient to healthcare access. Therefore, we feel the great need to generate awareness of this rare but life-threatening emergent condition and be well prepared to deal with it.
Erythema Ab Igne: A Mottled Rash on theTorso., 2020
Erythema ab igne (EAI) is a typical example of an environmental-induced dermatosis secondary to o... more Erythema ab igne (EAI) is a typical example of an environmental-induced dermatosis secondary to overexposure of a particular part of the skin to heat. Once a familiar entity in the precentral heating era, it seems to be making a comeback with prolonged usage of electronic devices close to the body surface as well as usage of alternative methods of pain relief being sought by patients. We describe a case of a 39-year-old female who presented to our clinic with a mottled reticulate rash on her back after five years of using heating pads for her chronic backache.
Daith piercing is a form of body piercing that involves the crux of the ear’s helix. While daith ... more Daith piercing is a form of body piercing that involves the crux of the ear’s helix. While daith piercing has been used as an esthetic piercing since the 1990s, it is gaining popularity in the general population as an alternative treatment in chronic headaches, especially migraines. Despite its use, the evidence is currently lacking. Postulated hypotheses include vagal neuromodulation vs. placebo effect. We present a case of a 47-year-old female patient suffering from refractory cluster headache who underwent daith piercing. We aim to raise awareness among the general practitioners of this health-related practice prevalent in the community.
Wolff-Parkinson-White syndrome is the most common form of ventricular preexcitation and affects 1... more Wolff-Parkinson-White syndrome is the most common form of ventricular preexcitation and affects 1-3 per 1,000 persons worldwide. Many patients remain asymptomatic throughout their lives; however, approximately half of the patients with Wolff-Parkinson-White syndrome experience symptoms secondary to tachyarrhythmias, such as paroxysmal supraventricular tachycardia, atrial fibrillation, atrial flutter, and, rarely, ventricular fibrillation and sudden death. Patients with Wolff-Parkinson-White syndrome may present with a multitude of symptoms such as unexplained anxiety, palpitations, fatigue, light-headedness or dizziness, loss of consciousness, and shortness of breath. We report the case of a patient who presented with a plethora of symptoms related to generalized anxiety along with several confounding factors such as psychosocial stressors, chronic fatigue secondary to high physical and mental demands at work, a strong family history of anxiety, and a history of substance abuse. Keeping cardiac dysrhythmia within his differential diagnosis allowed for accurate diagnosis and treatment.
Morphea, also known as localized scleroderma, is an uncommon idiopathic inflammatory disorder lea... more Morphea, also known as localized scleroderma, is an uncommon idiopathic inflammatory disorder leading to the development of sclerotic plaques in the skin. The disorder preferentially affects females. The pathogenesis of morphea is not well-understood. The disorder is likely to have an autoimmune basis; environmental and genetic factors may also play a role in its etiology. Morphea has a variety of clinical presentations. Lesions of morphea typically begin as inflammatory plaques or patches that evolve into firm sclerotic lesions. Involvement may be limited to the dermis or may extend to underlying subcutaneous fat, muscle, or bone. The identification of characteristic clinical findings is often sufficient for the diagnosis of morphea. A biopsy can be a useful tool when the diagnosis is in question or to obtain information on the depth and intensity of the disease, and it should always extend at least into the subcutaneous fat. Morphea may cause joint contractures and other impairments secondary to tissue sclerosis and can be very debilitating cosmetically and functionally.
Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin... more Dermatomyositis (DM) is an idiopathic condition characterized by inflammation of muscles and skin lesions. It is often a paraneoplastic manifestation of internal malignancy. Hence, early recognition of this disorder is important. Although not all dermatomyositis are associated with malignancies, the ones with such association regress with the treatment of associated malignancy. In clinical practice, symptoms of muscle weakness can be vague, and skin lesions can be dismissed as sunburn. We present a case of an elder adult female who presented with dermatomyositis as a paraneoplastic syndrome secondary to an underlying Mullerian malignancy.
Giant ovarian cysts, which are described in the literature as measuring more than 10 cms in size ... more Giant ovarian cysts, which are described in the literature as measuring more than 10 cms in size in their largest diameter, are rare in occurrence. With the availability of multiple imaging modalities and routine physical examinations, it has become even rarer to find such cases. Ovarian serous cystadenomas, which are benign tumors arising from the ovarian epithelium, represent the most common type.
We present a case of a 58-year-old female who came to establish primary care in our clinic. She reported ongoing symptoms of constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding for the past few months. The patient reported taking over-the-counter medications for her predominant gastrointestinal symptoms with no improvement at all.
Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) of the pelvis revealed the presence of giant bilateral ovarian masses measuring more than 17 X 10cms each. Further testing revealed highly elevated levels of tumor markers cancer antigen 125 (CA-125) and human epididymis protein 4 (HE-4). The patient subsequently underwent total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Her histopathology report revealed the presence of bilateral benign cystadenomas.
From a primary care physician's perspective, this case highlights the importance of possible rare pathologies that can present with symptoms of a completely unrelated organ system. Even with the rarity of these cases, a clinician may encounter such a case in their everyday practice. Patients can endorse a plethora of vague complaints, often masquerading other entities seen commonly in the clinic.
Ewing’s sarcoma is the second most common malignant bone tumor in children, with the worst outcom... more Ewing’s sarcoma is the second most common malignant bone tumor in children, with the worst outcomes seen in patients over the age of 20. However, the onset of the disease is much less common in people over the age of 30. This case represents the diagnostic dilemma posed by an otherwise “straight forward” case of back pain. Keeping the differential diagnosis sufficiently broad to include bone malignancies, so as not to delay diagnosis and treatment, provides the best chance at a positive outcome.
The purpose of our case report is to generate awareness among the providers about the rising abus... more The purpose of our case report is to generate awareness among the providers about the rising abuse of loperamide, which is a readily available nonprescription medication for its opiate-like actions and the risk of severe cardiac complications as a consequence of the same. It is currently becoming a significant concern among the healthcare fraternity due to its increasing abuse owing to its opioid agonistic activity. Our patient was a 32-year-old female who presented to the ED with ventricular dysrhythmias and persistent, prolonged QT interval secondary to excessively high doses of over-the-counter (OTC) loperamide abuse. More and more cases of loperamide abuse and its cardiotoxic potential are being reported in the literature, highlighting the increasing incidence of this problem.
Anxiety disorders are highly prevalent in the primary care setting and are responsible for
signif... more Anxiety disorders are highly prevalent in the primary care setting and are responsible for significant morbidity as well as a loss of productivity. Evaluation by mental health specialists and behavioral specialists can sometimes be confounded with problems of availability, accessibility, and the patient’s hesitancy to talk to new providers due to lack of prior relationship and trust. Primary care providers already have the advantage of being available for their patients, and have built years of trust behind them to strengthen this relationship. The biggest problems which confront primary care are the time constraints as well as the presence of multiple medical demands. This leads to a constant need for tools that facilitate early recognition and diagnosis of mental health disorders while also providing judicious utilization of clinic time. This article attempts to review the use of two of these popular tools: Generalized Anxiety Disorder scale-2 (GAD-2) and GAD-7 in the primary care setting.
Candida parapsilosis osteomyelitis is a rare diagnosis. Candidal infection can occur via
hematoge... more Candida parapsilosis osteomyelitis is a rare diagnosis. Candidal infection can occur via hematogenous or local spread. A localized swelling around a bony structure should raise clinical suspicion. Diagnosis is made by a combination of imaging modalities and biopsy. Anecdotal case reports have been reported in medical literature and treatment guidelines are very limited. Treatment modality includes a combination of surgical debridement and antifungal therapy.
Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often... more Obstructive sleep apnea (OSA) is the most common variant of sleep-disordered breathing that often goes undiagnosed. OSA is characterized mainly by anatomical obstruction or partial collapse of upper airways during sleep. The obstruction is multifactorial, and a lesser-known fact is that damage to the pharyngeal plexus during head and neck procedures or placement of hardware in the cervical area can lead to narrowing or collapse of the upper airway. We present such a case of a 59-year-old female who developed new-onset OSA after undergoing anterior cervical discectomy and fusion (ACDF). The severity of OSA worsened with the progression of her rheumatoid arthritis (RA) in the cervical region. This case report aims to raise awareness of such an association among clinicians to enable them to screen appropriate patients for sleep-disordered breathing and treat them accordingly.
Stevens-Johnson Syndrome: A Perplexing Diagnosis, 2020
Stevens-Johnson syndrome/toxic epidermal necrolysis is a spectrum of mucocutaneous
reactions that... more Stevens-Johnson syndrome/toxic epidermal necrolysis is a spectrum of mucocutaneous reactions that can occur due to drug reactions, infections with Mycoplasma pneumonia, human immunodeficiency virus (HIV), cancer, and genetics. Stevens-Johnson syndrome involves less than 10% of the body surface, while toxic epidermal necrolysis involves greater than 30%. The most common site of the lesions is mucocutaneous surfaces such as the eyes and oral cavity. Our patient was a 44-year-old female who presented to the emergency department with concerns for pain in her eyes, hands and feet, rash, and sore throat. Her rash worsened during the initial hospitalization. This case emphasizes the importance of pattern recognition of Stevens-Johnson syndrome, as this is a rare but serious condition that must be recognized and treated appropriately. The reaction is most commonly due to medications; however, a thorough history and physical exam are vital to diagnosing this potentially fatal condition.
Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces
dermatitidis, of... more Blastomycosis is an uncommon disease caused by the dimorphic fungus, Blastomyces dermatitidis, often found in endemic regions of Midwestern America. It can be found in forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and long bones have been most frequently reported. Disseminated infection to the genitourinary system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining a detailed medical and social history is important for making a diagnosis. Culturing a specimen will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based budding with a double-contoured cell wall). In mild to moderate disease without dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases, patients with CNS involvement or in immunocompromised individuals, amphotericin B is the preferred initial drug of choice. We present an interesting case of a 42-year-old African-American male with no significant past medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces osteomyelitis.
Fatal Anaphylaxis to Contrast a Reality: A Case Report., 2019
Contrast media (CM) are widely used in imaging techniques to enhance the differences between body... more Contrast media (CM) are widely used in imaging techniques to enhance the differences between body tissues on images. Less than one percent of patients receiving low osmolar nonionic contrast media can develop anaphylaxis, including a severe anaphylactic shock. The precise mechanism of this is mostly unknown but postulated to be due to the release of histamine by triggering mast cells or IgE-related mechanisms.
We described the case of a 45-year-old female with a past medical history of severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and anxiety and with no known allergies to contrast media who had an unpredictable fatal anaphylactic reaction to non-ionic contrast dyes and suffered a cardiac arrest while getting the scan done. The unpredictability of a negative past medical history of adverse reactions to these dyes and the considerable variability in the pretreatment regimens for patients with the previous adverse response to these dyes further confounds the whole picture. As primary care providers, we are usually the first link of the patient to healthcare access. Therefore, we feel the great need to generate awareness of this rare but life-threatening emergent condition and be well prepared to deal with it.
Erythema Ab Igne: A Mottled Rash on theTorso., 2020
Erythema ab igne (EAI) is a typical example of an environmental-induced dermatosis secondary to o... more Erythema ab igne (EAI) is a typical example of an environmental-induced dermatosis secondary to overexposure of a particular part of the skin to heat. Once a familiar entity in the precentral heating era, it seems to be making a comeback with prolonged usage of electronic devices close to the body surface as well as usage of alternative methods of pain relief being sought by patients. We describe a case of a 39-year-old female who presented to our clinic with a mottled reticulate rash on her back after five years of using heating pads for her chronic backache.
Daith piercing is a form of body piercing that involves the crux of the ear’s helix. While daith ... more Daith piercing is a form of body piercing that involves the crux of the ear’s helix. While daith piercing has been used as an esthetic piercing since the 1990s, it is gaining popularity in the general population as an alternative treatment in chronic headaches, especially migraines. Despite its use, the evidence is currently lacking. Postulated hypotheses include vagal neuromodulation vs. placebo effect. We present a case of a 47-year-old female patient suffering from refractory cluster headache who underwent daith piercing. We aim to raise awareness among the general practitioners of this health-related practice prevalent in the community.
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We present a case of a 58-year-old female who came to establish primary care in our clinic. She reported ongoing symptoms of constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding for the past few months. The patient reported taking over-the-counter medications for her predominant gastrointestinal symptoms with no improvement at all.
Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) of the pelvis revealed the presence of giant bilateral ovarian masses measuring more than 17 X 10cms each. Further testing revealed highly elevated levels of tumor markers cancer antigen 125 (CA-125) and human epididymis protein 4 (HE-4). The patient subsequently underwent total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Her histopathology report revealed the presence of bilateral benign cystadenomas.
From a primary care physician's perspective, this case highlights the importance of possible rare pathologies that can present with symptoms of a completely unrelated organ system. Even with the rarity of these cases, a clinician may encounter such a case in their everyday practice. Patients can endorse a plethora of vague complaints, often masquerading other entities seen commonly in the clinic.
significant morbidity as well as a loss of productivity. Evaluation by mental health
specialists and behavioral specialists can sometimes be confounded with problems of
availability, accessibility, and the patient’s hesitancy to talk to new providers due to lack of
prior relationship and trust. Primary care providers already have the advantage of being
available for their patients, and have built years of trust behind them to strengthen this
relationship. The biggest problems which confront primary care are the time constraints as well
as the presence of multiple medical demands. This leads to a constant need for tools that
facilitate early recognition and diagnosis of mental health disorders while also providing
judicious utilization of clinic time. This article attempts to review the use of two of these
popular tools: Generalized Anxiety Disorder scale-2 (GAD-2) and GAD-7 in the primary care
setting.
hematogenous or local spread. A localized swelling around a bony structure should raise clinical
suspicion. Diagnosis is made by a combination of imaging modalities and biopsy. Anecdotal
case reports have been reported in medical literature and treatment guidelines are very limited.
Treatment modality includes a combination of surgical debridement and antifungal therapy.
reactions that can occur due to drug reactions, infections with Mycoplasma pneumonia, human
immunodeficiency virus (HIV), cancer, and genetics. Stevens-Johnson syndrome involves less
than 10% of the body surface, while toxic epidermal necrolysis involves greater than 30%. The
most common site of the lesions is mucocutaneous surfaces such as the eyes and oral cavity.
Our patient was a 44-year-old female who presented to the emergency department with
concerns for pain in her eyes, hands and feet, rash, and sore throat. Her rash worsened during
the initial hospitalization. This case emphasizes the importance of pattern recognition of
Stevens-Johnson syndrome, as this is a rare but serious condition that must be recognized and
treated appropriately. The reaction is most commonly due to medications; however, a thorough
history and physical exam are vital to diagnosing this potentially fatal condition.
dermatitidis, often found in endemic regions of Midwestern America. It can be found in
forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird
feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as
pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the
bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and
long bones have been most frequently reported. Disseminated infection to the genitourinary
system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial
infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest
as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining
a detailed medical and social history is important for making a diagnosis. Culturing a specimen
will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium
hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based
budding with a double-contoured cell wall). In mild to moderate disease without
dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases,
patients with CNS involvement or in immunocompromised individuals, amphotericin B is the
preferred initial drug of choice.
We present an interesting case of a 42-year-old African-American male with no significant past
medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was
started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces
osteomyelitis.
We described the case of a 45-year-old female with a past medical history of severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and anxiety and with no known allergies to contrast media who had an unpredictable fatal anaphylactic reaction to non-ionic contrast dyes and suffered a cardiac arrest while getting the scan done. The unpredictability of a negative past medical history of adverse reactions to these dyes and the considerable variability in the pretreatment regimens for patients with the previous adverse response to these dyes further confounds the whole picture. As primary care providers, we are usually the first link of the patient to healthcare access. Therefore, we feel the great need to generate awareness of this rare but life-threatening emergent condition and be well prepared to deal with it.
We present a case of a 58-year-old female who came to establish primary care in our clinic. She reported ongoing symptoms of constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding for the past few months. The patient reported taking over-the-counter medications for her predominant gastrointestinal symptoms with no improvement at all.
Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) of the pelvis revealed the presence of giant bilateral ovarian masses measuring more than 17 X 10cms each. Further testing revealed highly elevated levels of tumor markers cancer antigen 125 (CA-125) and human epididymis protein 4 (HE-4). The patient subsequently underwent total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Her histopathology report revealed the presence of bilateral benign cystadenomas.
From a primary care physician's perspective, this case highlights the importance of possible rare pathologies that can present with symptoms of a completely unrelated organ system. Even with the rarity of these cases, a clinician may encounter such a case in their everyday practice. Patients can endorse a plethora of vague complaints, often masquerading other entities seen commonly in the clinic.
significant morbidity as well as a loss of productivity. Evaluation by mental health
specialists and behavioral specialists can sometimes be confounded with problems of
availability, accessibility, and the patient’s hesitancy to talk to new providers due to lack of
prior relationship and trust. Primary care providers already have the advantage of being
available for their patients, and have built years of trust behind them to strengthen this
relationship. The biggest problems which confront primary care are the time constraints as well
as the presence of multiple medical demands. This leads to a constant need for tools that
facilitate early recognition and diagnosis of mental health disorders while also providing
judicious utilization of clinic time. This article attempts to review the use of two of these
popular tools: Generalized Anxiety Disorder scale-2 (GAD-2) and GAD-7 in the primary care
setting.
hematogenous or local spread. A localized swelling around a bony structure should raise clinical
suspicion. Diagnosis is made by a combination of imaging modalities and biopsy. Anecdotal
case reports have been reported in medical literature and treatment guidelines are very limited.
Treatment modality includes a combination of surgical debridement and antifungal therapy.
reactions that can occur due to drug reactions, infections with Mycoplasma pneumonia, human
immunodeficiency virus (HIV), cancer, and genetics. Stevens-Johnson syndrome involves less
than 10% of the body surface, while toxic epidermal necrolysis involves greater than 30%. The
most common site of the lesions is mucocutaneous surfaces such as the eyes and oral cavity.
Our patient was a 44-year-old female who presented to the emergency department with
concerns for pain in her eyes, hands and feet, rash, and sore throat. Her rash worsened during
the initial hospitalization. This case emphasizes the importance of pattern recognition of
Stevens-Johnson syndrome, as this is a rare but serious condition that must be recognized and
treated appropriately. The reaction is most commonly due to medications; however, a thorough
history and physical exam are vital to diagnosing this potentially fatal condition.
dermatitidis, often found in endemic regions of Midwestern America. It can be found in
forested, sandy soils, decaying vegetation, rotting wood near water sources, and even in bird
feces. Most commonly, blastomycosis manifests as a pulmonary infection presenting as
pneumonia, or in severe cases, respiratory distress syndrome (ARDS). Dissemination to the
bone is less common but osteomyelitis of the lower thoracic and lumbar spine, ribs, skull, and
long bones have been most frequently reported. Disseminated infection to the genitourinary
system commonly manifests as prostatitis or epididymo-orchitis in men and as an endometrial
infection or tubo-ovarian abscess in women. In the nervous system, blastomycosis can manifest
as meningitis or with a cranial abscess. Having a high degree of clinical suspicion and obtaining
a detailed medical and social history is important for making a diagnosis. Culturing a specimen
will provide a definitive diagnosis. Sputum or tissue specimens stained in 10% potassium
hydroxide under microscopy will reveal the classic appearance of B. dermatitidis (broad-based
budding with a double-contoured cell wall). In mild to moderate disease without
dissemination, itraconazole is the treatment of choice. In severe, life-threatening cases,
patients with CNS involvement or in immunocompromised individuals, amphotericin B is the
preferred initial drug of choice.
We present an interesting case of a 42-year-old African-American male with no significant past
medical history who was admitted initially for suspicion of cellulitis/septic arthritis and was
started on broad-spectrum antibiotics. However, he was eventually found to have Blastomyces
osteomyelitis.
We described the case of a 45-year-old female with a past medical history of severe chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, and anxiety and with no known allergies to contrast media who had an unpredictable fatal anaphylactic reaction to non-ionic contrast dyes and suffered a cardiac arrest while getting the scan done. The unpredictability of a negative past medical history of adverse reactions to these dyes and the considerable variability in the pretreatment regimens for patients with the previous adverse response to these dyes further confounds the whole picture. As primary care providers, we are usually the first link of the patient to healthcare access. Therefore, we feel the great need to generate awareness of this rare but life-threatening emergent condition and be well prepared to deal with it.