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Rosacea is a common, chronic facial skin disease; features include erythema, papules, pustules, telangiectasias, flushing, phymatous changes, and ocular manifestations. Management includes avoidance of triggers, skin care measures, and treatments that target various features.
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A 76-year-old man was admitted to the hospital because of weakness and fever. Seventeen days earlier, he had presented with fatigue, weight loss, and guaiac-positive stool. Within 12 hours after admission, altered mental status developed. A diagnostic test was performed.
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The proportion of a health system’s resources that it devotes to primary care — including clinician incomes, performance payments, case-management activities, and health information technologies — could be used for assessing its orientation toward high-value care.
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Hone Your Skills: Videos, Images, Cases
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images in clinical medicineNovember 9, 2017 | Y.-B. Joo and K.‑S. ParkA 58-year-old woman had a history of medical and acupuncture treatment for rheumatoid arthritis. Plain radiographs of the hands showed severe joint deformities, with short gold threads surrounding the joints.
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videos in clinical medicineOctober 12, 2017 | M. Pasquier and OthersThis video reviews the indications and contraindications for and the techniques involved in carotid sinus massage, a noninvasive diagnostic test used to detect carotid sinus hypersensitivity and, in emergencies, to diagnose or treat paroxysmal supraventricular tachycardia.
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Interactive Medical CaseSeptember 21, 2017 | K. Romano and OthersThis interactive feature presents the case of a 26-year-old woman with a 1-week history of worsening pleuritic chest pain.
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images in clinical medicineNovember 9, 2017 | A.F. Egan and K.C. CahillA 26-year-old man presented with compartment syndrome after prolonged immobilization of his left arm. Delayed decompression restored perfusion to ischemic muscles.
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images in clinical medicineFebruary 25, 2016 | P. Nepal and D. KumarA 43-year-old man presented with dysuria and intermittent hematuria. Similar episodes had occurred several times in the preceding 6 months, with episodes of rectal bleeding. CT revealed hydroureteronephrosis of the right ureter and kidney, with mural calcifications.
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images in clinical medicineFebruary 25, 2016 | R. Asoklis and K. MalyskoA 58-year-old man presented with recurrent facial flushing and redness, foreign-body sensation, and blurred vision in both eyes. Examination revealed telangiectasia with hyperemia of the eyelid margins, conjunctival hyperemia, and neovascularization of the cornea in both eyes.
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interactive medical caseAugust 13, 2015 | C.M. Rariy and OthersThis interactive feature presents the case of a 24-year-old man with abnormal and agitated behavior.
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videos in clinical medicineJuly 10, 2014 | S. Manzano and OthersUrethral catheterization permits direct drainage of the urinary bladder and is often performed in pediatric practice. This video demonstrates catheterization of the urinary bladder in the female infant or child.
Clinical Pearls
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How common is neuroinvasive disease among patients with West Nile virus infection?
Case 34-2017 — A 76-Year-Old Man with Fever, Weight Loss, and Weakness
November 9, 2017 | J.L. Lyons and OthersWest Nile virus remains the most common arbovirus in New England; it causes symptomatic infection in approximately 10% of affected persons. Of the symptomatic persons, only 10% have progression to neuroinvasive disease. Such progression is more common in older patients or those with immunodeficiency. West Nile encephalitis is associated with an in-hospital mortality of approximately 20%.
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What factors are associated with increased mortality among patients with West Nile virus neuroinvasive disease?
Case 34-2017 — A 76-Year-Old Man with Fever, Weight Loss, and Weakness
November 9, 2017 | J.L. Lyons and OthersAccording to the available literature, prognosis in West Nile virus neuroinvasive disease, particularly West Nile virus encephalitis, is related to several factors. An age of more than 50 years and coexisting medical illnesses, factors that affect general health, are associated with increased morbidity and mortality. Coma at presentation and cranial neuropathy are each associated with brain-stem dysfunction and portend worse outcomes. Acute flaccid paralysis has historically been associated with a mortality as high as 50%, in large part because of neuromuscular respiratory failure. However, the degree of recovery in West Nile virus neuroinvasive disease is highly variable.
NEJM Journal Watch Covers Other Key Research
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Summary and Comment
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November 2, 2017 | Daniel D. Dressler, MD, MSc, SFHM, FACP
Reviewing: Ann Intern Med 2017 Oct 24U.S. Department of Veterans Affairs and U.S. Department of Defense suggest using glycosylated hemoglobin target ranges to guide diabetes therapy.
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Summary and Comment
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November 2, 2017 | Paul S. Mueller, MD, MPH, FACP
Reviewing: BMJ 2017 Sep 20In a meta-analysis, pain resolution occurred about 11 hours sooner when patients received single-dose dexamethasone.
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Case Records of the Massachusetts General Hospital
Case 34-2017 — A 76-Year-Old Man with Fever, Weight Loss, and Weakness
Presentation of Case. Dr. Benjamin R. Robbins (Psychiatry): A 76-year-old man was admitted to this hospital in the late summer because of weight loss, generalized weakness, and fever. The patient had been well until 3 weeks before admission, when he began to have decreased energy and poor appetite,…
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Clinical Problem-Solving
Circling Back for the Diagnosis
Foreword. In this Journal feature, information about a real patient is presented in stages (boldface type) to an expert clinician, who responds to the information, sharing his or her reasoning with the reader (regular type). The authors’ commentary follows. Stage. A 28-year-old man presented to the…
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Review Article
Nutritional Management of Chronic Kidney Disease
Chronic kidney disease, defined as evidence of structural or functional renal impairment for 3 or more months, is generally progressive and irreversible, affecting multiple metabolic pathways. Altered protein and energy homeostasis, abnormal protein catabolism, acid–base derangements, and hormonal…
Clinical Practice
Rosacea
Foreword. This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author’s clinical recommendations. Stage. A 36-year-old…
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Images in Clinical Medicine
HIV Infection Manifesting as Proximal White Onychomycosis
Figure 1.
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Perspective
Primary Care Spending Rate — A Lever for Encouraging Investment in Primary Care
Why doesn’t the United States invest more in primary care? A large body of evidence suggests that greater investment in primary care is good for patients and health systems. Greater use of primary care has been associated with lower costs, higher patient satisfaction, fewer hospitalizations and…
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Images in Clinical Medicine
Pigmented Macule — A Skin Manifestation of Invasive Breast Cancer
Figure 1.
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Correspondence
Liposuction for Swelling in Patients with Lymphedema
To the Editor: Lymphedema is a progressive, noncurable condition that is caused by anomalous development of the lymphatic system or trauma to lymphatic vasculature. The disease most commonly affects the limbs because of injury to or removal of lymph nodes. Fluid accumulates in the interstitial…
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Case Records of the Massachusetts General Hospital
Case 33-2017 — 22-Month-Old Conjoined Twins
Presentation of Case. Dr. Allan M. Goldstein: A pediatric surgeon at this hospital was contacted by a nonprofit organization to evaluate the possibility of surgical separation of conjoined twin girls. The twins were born by spontaneous vaginal delivery in East Africa. Because of the anticipated…
Review Article
Fertility Preservation in Women
In recent years, the demand for fertility preservation for oncologic and nononcologic reasons, as well as personal reasons, has increased dramatically, and meeting this demand will prove a major challenge in the coming years. Currently, embryo cryopreservation and mature-oocyte cryopreservation…
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Case Records of the Massachusetts General Hospital
Case 32-2017 — A 64-Year-Old Man with Dyspnea, Wheezing, Headache, Cough, and Night Sweats
Presentation of Case. Dr. Amulya Nagarur: A 64-year-old man was evaluated in the emergency department of this hospital because of dyspnea, wheezing, headaches, cough, and night sweats. Approximately 6 years before this presentation, the patient had received a diagnosis of fibromyalgia, which had…
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Review Article
Evaluation and Management of Lower-Extremity Ulcers
Lower-extremity ulcers are very common, with an estimated prevalence of 1 to 2% among U.S. adults, and they have a major effect on public health. Lower-extremity ulcers are divided into two groups — leg ulcers and foot ulcers — because of differences in causes, pathogenesis, and treatment. Even…
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Perspective
The Power of Regret
When we consider regret in medicine, we typically think of the feeling that follows a poor clinical outcome. For example, a friend in his late 60s had prostatitis. He did not like taking pills and after reading up on treatment options, he insisted on a once-a-day regimen with a fluoroquinolone…
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Perspective
A Devastating Delay — Zika and the Implementation Gap
The epidemic of Zika in the Americas and the virus’s effects on fetal development have jolted the U.S. medical community and the broader public. Zika’s relatively recent emergence has necessitated rapid research on its virology and pathogenesis, transmission, clinical manifestations, and diagnosis.…
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