In The Clinic: Obstructive Sleep Apnea

The American College of Physicians has an excellent series called “In the Clinic,” presenting topics to inform the delivery of effective, evidence-based, cost-conscious primary care.  Today, we present their thoughts on the management of obstructive sleep apnea –  a common condition that we encounter almost daily in our practice. You know the patient needs a sleep study, but which patient? Can you do anything to prevent the development of OSA or reduce its morbidity? Check out the ACP website for guidance (click the image below to link to the article):


ACP In The Clinic: Obstructive Sleep Apnea

Hypersensitivity Pneumonitis mini-review

Clinical Presentation

Although symptoms occasionally develop after just a few weeks of contact with the allergen, most cases of hypersensitivity pneumonitis occur following months or years of continuous or intermittent inhalation of the inciting agent.

  • Acute: fever, chills, myalgia, headache, coughing, chest tightness, dyspnea, and leukocytosis
  • Chronic: gradual onset of exertional dyspnea, fatigue, coughing, sputum production, anorexia, and weight loss. Bibasilar crackles are typically audible and finger clubbing may be present



  • CXR: reticular pattern, honeycombing; sometimes are more severe in the upper lobes
  • CT: ground-glass opacity, air trapping, and centrilobular nodules, traction bronchiectasis
  • BAL: lymphocytic lavage


  • Remove the offending agent.
  • 40–60 mg of prednisone daily and taper

Best Practices: Are we actually doing them? Should we even bother?

This week, NPR posted an interesting segment titled, “Why Many Doctors Don’t Follow Best Practices”, about why some physicians don’t follow nationally-recognized guidelines despite rigorous research and studies. The segment refers to research by Dr. Catherine Chen from UCSF about preoperative testing for medical clearance in Medicare patients undergoing cataract surgery. Despite studies showing preoperative testing does not decrease adverse events or improve outcomes, her study in this month’s NEJM showed that this practice was still occurring frequently and seemed to be based on physician practice patterns rather than patient characteristics. Should we all follow “best practices”? Or we not taking into account other factors that may not be addressed in these best practices? Check out NPR’s segment by clicking on the link and listening to the segment below!

Why Many Doctors Don’t Follow Best Practices

Case Challenge #13

History of Present Illness

A previously healthy 20-year-old white male presents with high fever (up to 40°C, unresponsive to anti-inflammatory drugs), appetite loss, nausea and vomiting, persistent headache and a feeling of significant malaise for 5 days. He was diagnosed at an outside hospital with an atypical infection and had received azithromycin for 3 days, without any improvement.

Denies travel, IV drug use, new sexual partners or tattoos. He has no animal exposure.

Past History

He does not use tobacco products or alcohol and has not taken any medications. Family history is negative. Several episodes of tonsillitis and tonsillar abscess as a child.

Physical Exam
  • T: 38.3°C, BP: 80/50mmHg,  P: 100 bpm, O2 sat 92%.
  • Bilateral conjunctival chemosis
  • L cervical lymphadenopathy
  • Cracked, red lips and tongue, dry mucus membranes
  • Tachycardia with S3 and S4 gallop
  • Faint macular skin rash of his trunk, edema of palms and soles, desquamation of fingertips
  • Examinations of his lungs, abdomen, neurological and musculoskeletal systems were normal.
  •  WBC: 13.2 (91% neutrophils), Hematocrit 33%, Platelets 541
  • Creatinine normal
  • ESR 127; CRP 30; LDH 263
  • All blood tests for autoimmune diseases were negative
  • Blood and urine cultures negative
  • The results of a chest X-ray, an electrocardiogram and a transthoracic echocardiogram were normal.

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