Der Internist
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Upper gastrointestinal symptoms are among the most common reasons for medical consultation and represent a challenge for general practitioners in the outpatient care setting. History taking, symptom evaluation and physical examination are the crucial steps toward establishing an initial working diagnosis. The subsequent abdominal ultrasound and laboratory analyses are essential tools for the differential diagnosis.
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A systematic survey of the symptoms of back pain in terms of the triggering event and onset, nature of the pain and the extent to which pain dynamics can be influenced (lying or standing, under stress, nocturnal pain, localized percussion tenderness, B symptoms, etc.), as well as a structured clinical examination (segment height, radiance, projection, reflex status, sensitivity, and motor function), allows an initial and therefore orienting classification of back pain as non-specific or specific. Thus, in the primary care setting, many patients can be treated extremely effectively and economically from a cost perspective. The more precise the initial findings are, the more effective the measures taken are in general. ⋯ In addition to non-pharmacological measures (initial rest and starting home exercises early on, promoting everyday mobility, physiotherapy, manual therapy, etc.), a wide range of pharmacological treatment alternatives is available. In the further course of treatment, it may be necessary to consult medical specialists in the fields of radiology, orthopedics, neurology, neurosurgery, rheumatology, psychotherapy, and psychiatry, among others. Treatment is managed by the primary care provider, who should also receive and re-evaluate all findings during the course of the disease.
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Back pain is a common reason for consulting a general practitioner. For 80% of patients, the back pain is nonspecific. Specific back pain has a determinable cause that needs to be rapidly identified. ⋯ In addition to laboratory diagnostics, structured morphological imaging is necessary. Causes of specific back pain include: fractures, infections, radiculopathy, tumors, axial spondylarthritis, as well as extravertebral causes. The diagnosis, treatment and continuous follow-up of the patient with specific back pain is interdisciplinary and requires close communication with the relevant specialists.
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Case Reports
[Weight loss, diarrhea and dystrophic alterations of the fingernails in an 80-year-old male patient].
Cronkhite-Canada syndrome (CCS) is a rare noninherited condition characterized by gastrointestinal polyposis, alopecia, onychodystrophy, hyperpigmentation, weight loss and diarrhea. We report the case of an 80-year-old patient presenting with weight loss, diarrhea and dystrophic changes of the fingernails. The symptoms began 3 months prior to the admission. ⋯ Together with the ectodermal changes a CCS was diagnosed and treatment with corticosteroids, intravenous nutrition and proton pump inhibitors was initiated. In the further course of the hospital stay a moderately reduced left ventricular function was diagnosed and the patient had to be temporarily monitored in the intensive care unit due to a prolonged QTc time. In the follow-up 3 months later the patient showed good clinical and endoscopic response to the treatment with cessation of the diarrhea, weight gain of 8 kg and regrowth of the fingernails and head hair; however, the left ventricular function remained moderately impaired.
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A 19-year-old female patient was admitted to hospital for further diagnostics and treatment of a febrile infection. The cause was found to be a bronchopulmonary infection due to methicillin-sensitive Staphylococcus aureus (MSSA), which led to an infective endocarditis with mitral valve infestation and two splenic abscesses. ⋯ Even during the physical examination there was a suspicion of Cushing's syndrome, which was confirmed by laboratory and radiological investigations and is associated with a general immune deficiency. Remarkable was that the initially difficult to adjust high blood pressure became normalized after transsphenoidal resection of the pituitary adenoma.