Surgical and nonsurgical management of gallstones.

Cholelithiasis, or gallstones, is one of the most common and costly of all the gastrointestinal diseases. The incidence of gallstones increases with age. At-risk populations include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. Most patients are asymptomatic; gallstones are discovered incidentally during ultrasonography or other imaging of the abdomen. Asymptomatic patients have a low annual rate of developing symptoms (about 2% per year). Once symptoms appear, the usual presentation of uncomplicated gallstones is biliary colic, caused by the intermittent obstruction of the cystic duct by a stone. The pain is characteristically steady, is usually moderate to severe in intensity, is located in the epigastrium or right upper quadrant of the abdomen, lasts one to five hours, and gradually subsides. If pain persists with the onset of fever or high white blood cell count, it should raise suspicion for complications such as acute cholecystitis, gallstone pancreatitis, and ascending cholangitis. Ultrasonography is the best initial imaging study for most patients, although additional imaging studies may be indicated. The management of acute biliary colic mainly involves pain control with nonsteroidal anti-inflammatory drugs or narcotic pain relievers. Oral dissolution therapy is usually minimally successful and used only if the patient cannot undergo surgery. Laparoscopic cholecystectomy remains the surgical choice for symptomatic and complicated gallstones, with a shorter hospital stay and shorter convalescence period than open cholecystectomy. Percutaneous cholecystostomy is an alternative for patients who are critically ill with gallbladder empyema and sepsis.

Management of influenza.

Influenza is a contagious airborne viral illness characterized by abrupt onset of symptoms. Fever, myalgia, headache, rhinitis, sore throat, and cough are commonly reported symptoms. The diagnosis should be made clinically, and the decision to begin antiviral therapy should not be delayed for laboratory confirmation of influenza. The 2009 pandemic influenza A (H1N1) virus is expected to continue to circulate during the 2010-2011 season, but it is not certain whether it will replace or cocirculate with seasonal influenza A subtypes that have been circulating since 1977. The 2009 H1N1 virus is largely resistant to adamantanes, but it is sensitive to neuraminidase inhibitors such as oseltamivir. Neuraminidase inhibitors have modest effectiveness in reducing influenza-related symptoms in patients at low risk of complications. Patients at high risk of complications, including pregnant women, should be treated with antiviral agents, preferably within 48 hours of symptom onset. Family physicians should follow guidelines from the World Health Organization and the Centers for Disease Control and Prevention when treating patients with influenza or influenza-like symptoms.

Sudden painless unilateral vision loss caused by branch retinal artery occlusion: implications for the primary care physician.

We report a case of sudden onset visual loss caused by branch retinal artery occlusion. Systematic search for the cause of branch retinal artery occlusion revealed Factor V Leiden mutation and antiphospholipid antibody syndrome as the cause. Implications for diagnosis and management are discussed.

The Man With "Pseudo-Occlusion" Syndrome: A Case Report.

We present a case of a patient with acute colonic pseudo obstruction (Ogilvie's Syndrome) in a 63-year-old Hispanic male with multiple co morbidities, sent from the Nursing Home for evaluation of progressive abdominal distention. Clinical examination and diagnostic workup confirmed massive colonic dilatation, without mechanical obstruction.

Brief, recurrent, and spontaneous episodes of loss of consciousness in a healthy young male.

INTRODUCTION: Lyme disease is caused by bacterial spirochete Borrelia burgdorferi and is transmitted by Ixodes scapularis and Ixodes pacificus ticks, which get infected while feeding on the reservoir host of the bacteria.1 About 248,074 cases of Lyme disease were reported by the US Centers for Disease Control and Prevention from 1992-2006.2 Over 95% of these cases are reported from the Northeastern and upper Midwestern United States.3 Carditis is usually a clinical manifestation/complication of Lyme disease and is seen in approximately 5% of untreated cases.4. CASE PRESENTATION: A 32-year-old male Hispanic from Chile presented with brief episodes of loss of consciousness and awareness of irregular heart beat, and denied any history of tick bite. The patient was found to have a heart rate of 40 beats per minute and fluctuating variable atrioventricular blocks. A transvenous pacemaker was placed with good capture. The diagnosis was made with serological testing and gallium scanning. Treatment with antibiotics and continuous cardiac monitoring resulted in remarkable symptomatic improvement of the patient. CONCLUSION: Absence of history or evidence of tick bite must not rule out the possibility of Lyme carditis in a patient with a transient heart block. Prompt recognition of this reversible cause of heart block is essential for avoiding implantation of an unnecessary, permanent pacemaker.

Concomitant leiomyosarcoma of the right kidney and squamous cell carcinoma of the cervix - an unusual clinical presentation.

We report a case of right-sided leiomyosarcoma of the kidney with concomitant poorly differentiated squamous cell carcinoma of the cervix diagnosed one month after radical nephrectomy in a previously healthy female patient. This is the first reported case of concomitant leiomyosarcoma of the kidney and squamous cell carcinoma of the cervix, and the diagnosis, clinical presentation, prognosis, and treatment are discussed.