Febrile seizures: risks, evaluation, and prognosis.

Febrile seizures are common in the first five years of life, and many factors that increase seizure risk have been identified. Initial evaluation should determine whether features of a complex seizure are present and identify the source of fever. Routine blood tests, neuroimaging, and electroencephalography are not recommended, and lumbar puncture is no longer recommended in patients with uncomplicated febrile seizures. In the unusual case of febrile status epilepticus, intravenous lorazepam and buccal midazolam are first-line agents. After an initial febrile seizure, physicians should reassure parents about the low risk of long-term effects, including neurologic sequelae, epilepsy, and death. However, there is a 15 to 70 percent risk of recurrence in the first two years after an initial febrile seizure. This risk is increased in patients younger than 18 months and those with a lower fever, short duration of fever before seizure onset, or a family history of febrile seizures. Continuous or intermittent antiepileptic or antipyretic medication is not recommended for the prevention of recurrent febrile seizures.

Practice patterns in the evaluation and management of dementia by primary care residents, primary care physicians, and geriatricians.

With the aim of determining if specialty type or the amount of geriatric training during primary care residencies correlated with the rate of and comfort with dementia identification and management in patients 65 years and older, physician practice patterns were compared through a web-based survey. The survey was sent to family medicine, internal medicine, and geriatric physicians in Dallas County and the HealthTexas Provider Network as well as third-year family medicine and internal medicine residents in Texas. Chi-square analyses revealed no relationship between the quantity of geriatric training and either dementia screening rates or comfort with dementia diagnosis. However, there was a significant difference in these areas based on specialty: more geriatricians reported asking senior patients about memory problems and being very comfortable in making a diagnosis of dementia, while fewer family medicine and internal medicine physicians reported being very comfortable in making the dementia diagnosis. Most physicians surveyed supported instituting routine screening and evaluation of senior patients during residency training. Further research is needed to determine if brief screening modalities, enhanced training, and institution of national guidelines would result in earlier identification and management of dementia in primary care.

Postsplenectomy reactive thrombocytosis.

Thrombocytosis is frequently encountered as an incidental laboratory finding. The most common etiology is reactive (secondary) thrombocytosis due to infections, trauma, surgery, or occult malignancy. Even though thrombocytosis is benign and self-limiting in most cases, it can result in hemorrhage or thrombosis. The hypercoagulable state is characterized by episodes of thrombosis and can be due to inherited or acquired conditions. Extreme thrombocytosis may result in thrombotic events such as acute myocardial infarction, mesenteric vein thrombosis, and pulmonary embolism. It is important for physicians to be familiar with the complications associated with thrombocytosis. Postsplenectomy reactive thrombocytosis has an incidence of about 75% to 82%. Thrombosis in association with elevated platelet count after splenectomy is well recognized, with an incidence of approximately 5%. This case report describes a 61-year-old patient who underwent emergent splenectomy and presented 1 week later with acute ST segment elevation myocardial infarction. Severe thrombocytosis, which was not present prior to splenectomy, was noted, and a diagnosis of reactive thrombocytosis was initially made. Involvement of the right coronary artery led to emergent percutaneous transluminal coronary angioplasty. Essential thrombocytosis was considered when treatment with hydroxyurea failed to lower the platelet count. A review of arterial and venous thrombosis in patients with severe thrombocytosis is presented, and the approach to the management of such patients is discussed.

Discovering the elusive underlying cause of a bilateral effusion combined with ascites.

A 77-year-old Asian man presented to the emergency department with bilateral pleural effusion and ascites accompanied with generalized weakness, dyspnea, tachycardia, and tachypnea. After an extensive workup that ruled out heart failure, pulmonary embolism, pneumonia, and malignancy-including extensive laboratory tests, electrocardiograms, chest x-ray, computed tomographic angiogram, computed tomography scans of the abdomen and pelvis, colonoscopy, thoracentesis, paracentesis, and exploratory laparoscopy-an elusive peritoneal tuberculosis was successfully identified. This case suggests that clinicians should consider extrapulmonary tuberculosis in their practice, given increasing immigration and the variety of populations present in our society. When tuberculosis is suspected, a negative smear for acid-fast bacillus, a lack of granulomas on histopathology, and failure to culture Mycobacterium tuberculosis do not exclude the diagnosis. Exploratory laparoscopy or minilaparotomy has a high level of sensitivity and specificity so should be considered.

Acute pericarditis.

Although acute pericarditis is most often associated with viral infection, it may also be caused by many diseases, drugs, invasive cardiothoracic procedures, and chest trauma. Diagnosing acute pericarditis is often a process of exclusion. A history of abrupt-onset chest pain, the presence of a pericardial friction rub, and changes on electrocardiography suggest acute pericarditis, as do PR-segment depression and upwardly concave ST-segment elevation. Although highly specific for pericarditis, the pericardial friction rub is often absent or transient. Auscultation during end expiration with the patient sitting up and leaning forward increases the likelihood of observing this physical finding. Echocardiography is recommended for most patients to confirm the diagnosis and to exclude tamponade. Outpatient management of select patients with acute pericarditis is an option. Complications may include pericardial effusion with tamponade, recurrence, and chronic constrictive pericarditis. Use of colchicine as an adjunct to conventional nonsteroidal anti-inflammatory drug therapy for acute viral pericarditis may hasten symptom resolution and reduce recurrences.