Floppy iris syndrome: A drug-related complication of cataract surgery

, Barton L. Ramsey III, MD; Jennifer Childers, MS, PA-C May 07, 2012

Older patients who are about to undergo cataract removal should be asked to provide a complete medication history, one that includes drugs no longer being taken.
 

Localized, dull abdominal pain in 
an otherwise asymptomatic woman

April 16, 2012

Isolated abdominal tenderness in the absence of other abnormal physical examination 
and laboratory findings eventually leads to diagnosis of a rare and benign condition.
 

Vomiting and periumbilical pain from an unexpected source of infection

, Bettie Coplan, MPAS, PA-C April 09, 2012

The triad of abdominal pain, fever, and vomiting in this 11-year-old girl led the pediatrician to refer her to the emergency department (ED) for evaluation of possible appendicitis.
 

Renal artery stenosis: A correctable cause of resistant hypertension

, Paul M. Zack, MD; Abdulfatah Osman, MD March 12, 2012

A patient whose blood pressure had previously been well-controlled on a beta-blocker 
and an ACE inhibitor experiences rising BP levels and dyspnea on exertion.
 

Is this persistent tumor the cause of Bell palsy or something more severe?

, Glen M. Bowen, MD; Shawn Grimes, MPT; Randy G. Moon, PhD; Mark A. Hyde, MMS, PA-C February 21, 2012

Clinicians must take care to eliminate a number of entities before confirming a diagnosis 
of Bell palsy. A thorough examination and palpation help to confirm the condition.
 

Seizures induced by hot water in an 
otherwise healthy 18-month-old boy

February 13, 2012

Over several days, ordinary bathing causes a child to go limp and develop periorbital 
and lip cyanosis that resolves when he is removed from the water.
 

C-reactive protein: A clinically useful biomarker in renal cell carcinoma

, Jennifer DeLong, PA; Viraj A. Master, MD, PhD January 16, 2012

Biochemical markers of inflammation, specifically CRP, serve as adjuncts to TNM staging 
to help identify patients at increased risk for recurrence of kidney cancer.
 

Immune thrombocytopenic purpura develops in a 67-year-old female

, Alison C. Essary, MHPE, PA-C December 19, 2011

After a careful diagnostic workup and a process of elimination, the patient's attempt to treat her leg cramps was revealed to be the most probable cause of her hemorrhagic lesions.
 

Rhinocerebral mucormycosis: A rare fungal infection linked to diabetes

, December 05, 2011

Although usually prevented by the immune system, this disease is common in patients who are immunocompromised. As in this case, early detection and treatment are key.
 

Fusobacterium otitis causes a case of 
hydrocephalus and fatal meningitis

Erin N. Arrington; M. Michael Behnia, MD November 15, 2011

A delay in the administration of antimicrobial therapy resulted in lethal complications. To reduce the high morbidity and mortality rates, clinicians must begin early treatment.
 

What caused the medical emergency in this patient with type 1 diabetes?

, November 04, 2011

Even though patients in diabetic ketoacidosis commonly present with hyperglycemia, 
normal blood glucose levels don't allow you to rule out this diabetic emergency.
 

Tachycardia and an enlarged cardiac silhouette in an adolescent male

, P. Nelson Le, MD, FAAP October 24, 2011

An 18-year-old with a complicated history presents with a worsening upper respiratory tract infection. A chest radiograph identified a severe heart condition as the cause.
 

Abdominal pain in an elderly patient with an extensive surgical history

, Sonia James, RN, MA, ACNP-BC, CCRN October 10, 2011

One of the first steps to diagnosis was ruling out ischemia due to an earlier surgical procedure. CT with and without contrast helped confirm the cause of this man's worsening discomfort.
 

A rare cause of hip pain characterized by an inability to walk or bear weight

September 26, 2011

With no history of trauma, a middle-age man experiences severe pain in his left hip and 
buttock. After common conditions are excluded, an unusual diagnosis is finally made.
 

Immune (idiopathic) thrombocytopenic purpura in a 21-year-old student

, September 12, 2011

Diagnosis of the adult form and the pediatric form of ITP may be based less on the calendar than on individual patient presentation.
 

Recurrent pneumonia and fevers in a child with congenital heart disease

August 15, 2011

Sound clinical judgment coupled with diagnostic testing reveal a much more serious cause of a 6-year-old girl's seemingly nondiagnostic symptoms of recurrent fever and cough.
 

An adolescent hockey player suffers a rare injury in an uncommon location

August 01, 2011

Various radiographic views found no injury, but limited range of motion and pain persisted.
 

Recurrent lesion on the right ala nasi and an odontogenic cyst in a soldier

July 18, 2011

Being able to diagnose basal cell carcinoma syndrome is crucial to any provider, but a 
thorough history can sometimes unmask a rare and more involved condition.
 

Progressive weakness and inability to walk in a healthy 28-year-old male

July 11, 2011

The weakness was so severe that the patient could not get out of bed despite having intact sensation in his feet, and friends had to help transport him to the emergency department.
 

Polydactyly in a young boy: A cause of teasing and local tribal suspicion

, June 27, 2011

During a medical civic action program in Ethiopia, a 10-year-old male with polydactyly arrived with his father for surgical removal of his extra digits, the cause of much taunting and grief.
 

Transverse myelopathy mimicking conus medullaris syndrome

, Michael Roscoe, PhD, MPAS, PA-C June 07, 2011

A generally healthy man with a history of migraine headaches and diplopia awakens with sudden onset of numbness below the waist, erectile dysfunction, and difficulty urinating.
 

Polycythemia rubra vera: An unlikely cause of severe pulmonary embolism

, Mary Jane Gallahan, PA-C, PhD? May 30, 2011

An elderly woman presented with mild pain in her leg and shortness of breath. The results of CT and laboratory testing led to the diagnosis of a rare myeloproliferative disorder.
 

An atypical case of ARB-associated angioedema of the small intestine

, May 09, 2011

A patient with a history of hypertension and myasthenia gravis reports worsening bouts of nausea, vomiting, and diarrhea.
 

A rare but serious cause of spinal cord compression in an adolescent female

, Eddy Garrido, MD, FRCS, FACS April 25, 2011

A young woman presents for evaluation after falling down the stairs a few times and developing midthoracic back pain.
 

Acute peroneal tendon tear: Extreme pain indicative of more than a sprain

April 11, 2011

The patient's injury was diagnosed as an ankle sprain, but worsening pain and MRI findings indicated a more serious diagnosis.
 

Miller Fisher variant of Guillain-Barré syndrome in an HIV-infected patient

, Miguel Valdes-Sueiras, MD; Pam Jongthavorn, NP; Shilpa Sayana, MD; Homayoon Khanlou, MD March 07, 2011

Symptom overlap makes Miller Fisher syndrome hard to distinguish, but the presence of antiganglioside antibodies can verify a diagnosis.
 

Atypical femoral stress fracture in a woman on alendronate therapy

February 07, 2011

Both the patient's bone mineral density and fracture risk assessment were improving when she noted intensifying pain in her left thigh.
 

Isolated compartment syndrome of the extensor carpi ulnaris muscle

February 01, 2011

After a cast is placed for a metacarpal fracture of the right forearm, a man presents with extreme pain in the dorsal aspect of the arm.
 

A misleading resting ECG in a patient with left bundle branch block

, M.J. Gallahan, PhD, PA-C? January 24, 2011

A female patient who experienced pain when she exerted herself had normal ECG findings. 
Although rare, exercise may cause LBBB.
 

A rare pelvic neoplasm is discovered 
during a routine evaluation

, Kevin Cunningham, PA-C; Melanie Kim, PA-C January 10, 2011

Ultrasonography performed to check the position of an intrauterine device revealed an angiomyxoma, a benign but aggressive tumor.
 

Eagle syndrome: A rare cause of 
dysphagia and head and neck pain

, December 20, 2010

A male patient presented with an unusual 
combination of symptoms, including sharp pain, jaw spasms, and chronic headaches.
 

A chigger bite activates a dormant 
infection in an outdoorsman

December 06, 2010

The patient attributed pain and swelling of two fingers to a chigger bite, but the real cause of his symptoms remained a mystery.
 

Alcoholic hepatitis in a patient with 
a history of daily beer consumption

Jolene Siple, PharmD, BCPS; Lynnette Klaus, PharmD; Kathryn S. Voll, PharmD November 01, 2010

Even after limiting his drinking, the patient was so nauseated that he couldn't keep down even one beer, and he reported darkening urine.
 

Thymoma: An uncommon cause of persistent anterior wall chest pain

, October 18, 2010

Previously diagnosed as costochondritis, chest pain that persisted despite treatment prompted a search for an alternate diagnosis.
 

Multiple potential infectious causes of hematuria complicate this diagnosis

, Jennifer DeLong, PA-C; Viraj A. Master, MD, PhD, FACS October 11, 2010

Gross hematuria triggers an in-depth evaluation that demonstrates how important it is for clinicians to keep multiple possibilities in mind.
 

New-onset status epilepticus develops after a motor vehicle collision

, Vivek K. Vadehra, MD; Alluru S. Reddi, MD, PhD September 29, 2010

Despite suffering no head trauma, the patient began to experience new-onset 
seizures from an unexpected and surprising source.
 

Abnormal protein deposition causes symptoms of dyspnea and fatigue

September 13, 2010

Light chain amyloid deposition can occur in any organ but the brain, disrupting the tissue architecture and interfering with organ function.
 

BRCA gene testing in a woman with a family history of cancer

Terry D. Kober, PA-C; Miranda M. Collins, MEd, MPAS, PA-C August 16, 2010

The case of a woman at risk of breast cancer illustrates the importance of taking action; how a recent law protects all patients.
 

Rapidly growing abdominal tumor in a toddler

Holly L. Green, PA-C; Michael E. Rytting, MD; Charles S. Cox Jr, MD August 09, 2010

Worsening abdominal distention, intermittent vomiting, a palpable mass, and decreased activity signaled a life-threatening malignancy.
 

Evolving purple lesions and nodules on the abdomen and forearm

July 19, 2010

An elderly man complains of plum-colored lesions, some of which had worsened and some of which had spontaneously regressed.
 

Mediastinal mass in a patient with a history of bypass surgery

June 14, 2010

Nonproductive cough and pleuritic chest pain with a history of chronic obstructive pulmonary disease lead to a surprising diagnosis.
 

Painful subcutaneous abdominal mass in a woman with a history of cesarean section

June 07, 2010

Years of worsening pain in a surgical scar proved baffling until an MRI revealed a soft-tissue mass in an uncommon location.
 

A rare combination of uveitis, salivary gland swelling, and cranial nerve palsy in a febrile woman

Jason Evanchan, DO; Timothy J. Barreiro, DO, FCCP, FACOI; David Gemmel, PhD May 17, 2010

Bilateral swollen parotid glands trigger an evaluation and imaging studies that uncover ocular, neurologic, and pulmonary abnormalities.
 

Acute respiratory illness leads to 
the discovery of renal disease

Tamara Moutsatson, DO; Ahmad Hakemi, MD; Keir Todd, MEd, PA-C; Manjit Grewal, MD; John Lopes, MS, DHSc, PA-C May 13, 2010

The patient presented with a sore throat, runny nose, and a cough. When his condition worsened despite treatment, further workup revealed chronic nephropathy.
 

Dizziness induced by acute noise exposure

Carrlene Donald, MMS, PA-C; David Barrs, MD; Joseph Hoxworth, MD April 12, 2010

This patient had left-sided autophony, aural fullness, and episodes of vertigo triggered by a loud noise that lasted from a few seconds to a few minutes.
 

A rare presentation of metastatic breast cancer in a woman with apparent cholangiocarcinoma

Holly L. Johnson, MPAS, PA-C? March 08, 2010

Jaundice and intermittent abdominal pain were the only clues to a primary breast cancer that manifested without the usual symptoms.
 

Exploratory laparotomy for a pancreatic pseudocyst uncovers an adrenal mass instead

Castigliano M. Bhamidipati, DO; Matthew Smeds, MD February 08, 2010

In the patient with an abdominal mass, good communication, collaboration, and an evidence-based approach are essential.
 

Common signs and symptoms, and a diagnosis that is often overlooked

Bettie Coplan, MPAS, PA-C December 14, 2009

Celiac disease should be considered in anyone who presents with suspicious gastrointestinal symptoms or with associated conditions.
 

Bilateral shoulder pain developing after a hypoglycemic seizure

Captain Christopher L. Furbee, PA-C, MPAS; Colonel David A. Brown, MD December 07, 2009

Posterior shoulder dislocations are hard to diagnose because of their rarity. Your ability to interpret the appropriate radiographs is key.
 

Poor medication history plus slow symptom onset delays a diagnosis

Todd Wilkin, MPA, PA-C; LaDonna S. Hale, PharmD; Richard A. Claiborne, MD October 14, 2009

The best way to identify this type of adverse drug reaction is to obtain and document a complete and accurate medication history.
 

Referral to a dietitian uncovers why this woman cannot lose weight

Louise Lee, MHA, PA-C October 12, 2009

This eating disorder is probably often missed in primary care because the condition is so difficult for providers to recognize.
 

FAP: Recognizing the importance of family history and genetic testing

Mike Deeter, PA-C September 14, 2009

A young woman with a family history of abdominal scars presents with hematochezia, diffuse abdominal pain, and anemia.
 

Stone-induced ruptured calyx in a patient with a horseshoe kidney

Capt Donald Adams, MPAS, APA-C; Col Michael W. Restey, MD, USAF (Ret), MC; Kevin Dwyer, MD; Maj Elena Schlenker, MSHS, CPRN, USAF, NC August 31, 2009

A soldier in Afghanistan reports bloody urine, dysuria, and diffuse abdominal pain, leading to discovery of a congenital anomaly.
 

An elusive tumor in a man who has evidence of prostate cancer metastasis

Brendan Patrick Boyer, PA-C; Martin James Boyer, DO August 10, 2009

Conventional imaging studies failed to locate the metastasis in a patient with an elevating PSA level. Scintigraphy revealed the tumor.
 

The risk of tramadol abuse and dependence: Findings in two patients

James D. Stoehr, PhD; Alison C. Essary, MHPE, PA-C; Chrissi Ou; Rob Ashby, MD, PLC; Michel Sucher, MD, FASAM, FACEP July 13, 2009

Tramadol dependence is controversial, but these cases provide a blueprint for recognizing and treating similar patients in your practice.
 

Sudden onset of substernal chest pain in a college student at rest

David F. Irvine, DHSc, RPA-C; Wilson Crone, MD, PhD June 08, 2009

Despite its name, spontaneous pneumomediastinum may be associated with a number of factors.
 

Bacteremia, vertebral diskitis, and osteomyelitis in a man with cirrhosis

Ryann Morrison, MS, PA-C; Jaan Naktin, MD, FACP May 11, 2009

Snow shoveling accounts for a man's back pain but not the shaking chills and fever.
 

Laparoscopic Roux-en-Y bariatric gastric bypass in an adolescent

Cristina Hochwalt, PA-C, MPAS; Rita Anderson, MD, PhD April 03, 2009

An obese teenager's gastric bypass results not only in weight loss and a healthier lifestyle but also in resolution of her type 2 diabetes.
 

A patient with unexplained fevers and persistent fatigue

March 10, 2009

Cases that involve prolonged fever for which no cause can be identified are challenging. This one illustrates the deductive reasoning required of an excellent clinician.
 

Treatment of restless legs syndrome with iron infusion therapy

Vicki Gorder, PA-C, MPAS; Susan Kuntz, PhD; March 09, 2009

This 52-year-old woman's case reaffirms the importance of a careful history in evaluating a patient with symptoms of RLS.
 

A serum sickness-like reaction to a commonly used acne drug

Angela M. Bettge, MPAS, PA-C; Gary N. Gross, MD February 19, 2009

Patients with acne often take oral antibiotics to control the condition. This 39-year-oldpatient experienced a rare, serious adverse effect that resolved only after hospitalization.
 

What condition caused the cyclical decompensation in this child?

Tracy M. Deutsch, MS, PA-C February 10, 2009

Mitochondrial cytopathy refers to a group of disorders. A lack of unique symptoms makes the diagnosis difficult.
 

An unusual diagnosis for persistent leg pain in an adolescent girl

Pamela Y. Young, RPA-C January 01, 2009

This condition should be in the differential diagnosis for any patient presenting with extremity pain.
 

Measuring the optic nerve sheath diameter in a head-injured man

Peter Lindbloom, MPAS, PA-C December 01, 2008

Measuring optic nerve sheath diameter does not involve radiation exposure and can be done quickly at the bedside during the evaluation of a patient with head injuries.
 

Severe stress in an elderly woman causes a temporary "broken" heart

CPT Jonathan D. Monti, MPAS, PA-C; LTC Michael D. Eisenhauer, MD, FACC, FACP, FSCAI November 01, 2008

This novel cardiac syndrome has clinical features that mimic those of acute myocardial infarction. The typical patient is a postmenopausal woman.
 

An unusual cause of low back and hip pain in a 20-year-old female

George A. Barbee, DSc, PA-C, CPT, SP October 01, 2008

Case Report - This patients symptoms turned out to be from an uncommon conditionbut one that should always be considered in the evaluation of abdominal pain in adults.
 

The history holds the key in this gardener with a skin infection

Tara A. Lykowski, MMS, PA-C; Emil R. Orpilla, MMS, PA-C; Richard J. Hayek, MD September 01, 2008

Staphylococci and streptococci are the most common causes of skin infections—but when the patient is immunocompromised, keep other causative organisms in mind as well.
 

A worrisome, increasingly painful breast mass in an adolescent female

Valerie J. Schaffer, MHS, PA-C; David Coniglio, MPA, PA-C August 01, 2008

A breast mass in a young woman presents a challenge to clinicians. The differential diagnosis and diagnostic studies of choice may differ from those used for an adult patient.
 

Pericardial effusion and developing tamponade in a 30-year-old man

Kristen Frank, BS; Fred Weber, MD, JD July 01, 2008

The cause sometimes remains unclear, but cardiac tamponade is potentially fatal. A rapid diagnosis and appropriate treatment are essential to saving the patient.
 

Severe hyponatremia develops in a runner following a half-marathon

Beth Glace, MS; Christine Murphy, PA-C June 01, 2008

It's essential to know how to distinguish dehydration from fluid overload in endurance athletes,because the treatment for one can greatly worsen the other.
 

Acute HIV infection comes with a missed opportunity

Bettie Coplan, PA-C May 01, 2008

If you miss acute HIV infection, you miss a chance to prevent transmission of HIV as well. Patients are highly infectious, so a quick diagnosis is essential.
 

Fever, nausea, and vomiting in a student from Thailand

April 01, 2008

A detailed history, with an emphasis on any recent travel, is especially important when you are evaluating a patient who presents with a fever without a clear cause. The patient is a 20-year-old woman who presented to the emergency department complaining of nausea and vomiting for the past 5 days. The patient reported a decrease in appetite, loose bowel movements, and mild generalized abdominal pain after vomiting.
 

An uncommon diagnosis in a young woman with knee pain

James R. Borchers, MD; Rose A. Backs, PA-C, ATC; Christopher C. Kaeding, MD February 01, 2008

Active adults often complain of knee pain and swelling, and PAs should consider less common causes of these symptoms when the diagnosis remains unclear.
 

An uncommon isolated fracture of the capitate bone

December 01, 2007

Initial radiographs may miss a capitate fracture entirely, increasing the risk that the patient will develop avascular necrosis, arthritis, or non-union.
 

Hemangioblastoma without von Hippel-Lindau disease

November 01, 2007

Tumors account for only 1% of cases in which the patient presents with dizziness. This patient turned out to be a member of that rare group.
 

Prompt recognition of a rare type of infectious arthritis

October 01, 2007

Most clinicians have never seen this type of infectious arthritis. Fortunately, this patient received a rapid diagnosis and ultimately underwent successful treatment.
 

Disseminated GC infection without urogenital symptoms

Ryanne Coulson, PA-C, MPAS; Nalini Rao, MD, FACP, FSHEA; Mark Freeman, MBA, MEd, PA-C September 01, 2007

Disseminated gonococcal infection is rare—and significantly more rare in men than in women.The patient described in this case proves that exceptions do exist.
 

Papulosquamous rash in a man with HIV disease

W. Patrick Bowden, MMS, RPA-C; Cynthia H. Miller, MD August 01, 2007

A 41-year-old Colombian male visited an urgent care facility complaining of a chronic, nonproductive cough. he was tested positive for HIV. One month later, the patient came to the emergency department with a cough, a fever, and malaise. He was noted to have a generalized papulosquamous rash over most of his body.
 

A rare, opportunistic disease in a patient with AIDS

July 01, 2007

PML is a demyelinating disease that affects immunosuppressed patients. PML associated with AIDS is difficult to treat, and the prognosis for those afflicted is generally poor.
 

Meningitis in an infant: All that's aseptic is not viral

June 01, 2007

Meningeal tuberculosis is the most common CNS manifestation of tuberculosis. Children younger than 5 years are among the groups who are most affected.
 

The nuts and bolts of peanut bolts of peanut allergy

Alex T. Vu, MD; Minh-Tri Duong, PharmD April 01, 2007

The principles for successful management of peanut allergy include patient education, treatment of the acute reaction, and appropriate follow-up care.
 

An unusual rash in an elderly man

March 01, 2007

This disease is presumed to be transmitted between humans most commonly by droplet nuclei, as the nasal mucosa is frequently involved. It has also been documented in wild armadillos and might be transmitted from armadillo to human.
 

Merkel cell carcinoma: A rare, aggressive cancer of the skin

February 01, 2007

Epidemiologic data indicate that Merkel cell carcinoma is increasing in prevalence. Part of the reason is thought to be an aging population with lifestyles that have included increased sun exposure.
 

Implementing a continuous insulin infusion protocol on a cardiac surgical service A PA's perspective

June 01, 2006

The author describes how one rural hospital used aggressive glucose control with continuous IV insulin to reduce complications and death among surgical patients, whether they had diabetes or not.
 

Case report:Subcutaneous emphysema in a 61-year-old man

Sarah E. Smith, PA-C; Fred Weber, MD, JD February 01, 2006

Subcutaneous emphysema can have many different causesa challenge because a precise diagnosis and correction of underlying pathology are required for proper treatment.
 

Case report: For facial swelling, look below the belt

Kristopher M. Murphy, PA-C; Brent Savelli, MD; Karen Newell, PA-C October 01, 2005

An atypical presentation of a patient with a ruptured diverticulum highlights a concern of corticosteroid use—and demonstrates once again how in medicine, things arent always what they're supposed to be.
 

Case report :A foreign body in the urethra

Daniel S. McPartlin, PA-C; Adam P. Klausner, MD; Tristan T. Berry, MD September 01, 2005

Almost every imaginable object has been inserted into the urethra. This case report describes the presentation and management of this unusual phenomenon.
 

Case report: Classic Kaposi’s sarcoma

Ellen Joffe, PA-C; Louis D. Dubilier, MD July 01, 2005

Classic KS usually appears between ages 50 and 70 years and has a relatively benign, indolent course for 15 years or longer. Treatment usually controls the disease quite well.
 

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