effective for urticaria. Medications that modulate neurologic function, including gabapentin, are effective for recalcitrant pruritus and less sedating than oral antihistamines.2 Treatment of comorbid depression or anxiety can also improve the symptoms and burden of pruritus.Patients without a dermatologic, neurologic, or psychiatric cause for pruritus should be asked about the presence of fevers, chills, night sweats, and/or unintended weight loss, as well as undergoing a full review of systems to assess for localizing symptoms. Physical examination would include palpation of the lymph nodes, spleen, and liver. Testing for a metabolic or neoplastic source of pruritus should be considered for patients with chronic, generalized pruritus who lack a primary skin disease.3 Systemic evaluation of these patients can include malignant neoplasm and thyroid, renal, hepatic, and infectious diseases. 4 Thus, it is important to remember the association of chronic pruritus and internal systemic diseases but to limit screening to the patients without recognizable skin disease.
LESS IS MORE
Competing Mortality in Cancer Screening
A Teachable Moment
Story From the Front LinesA 70-year-old man saw his primary care clinician and ex pressed concern about his lung cancer risk after learning a friend had recently died of it. The patient had had an 80-pack-year history, and had quit 7 years previously. His physician ordered a screening chest computed tomographic (CT) scan, which demonstrated a spiculated 12-mm lung nodule that was new when compared with scans done previously for other reasons. This prompted a positron emission tomographic scan, which showed metabolic activity, raising the suspicion for lung cancer. He was referred to a pulmonary-nodule clinic. The man presented to the pulmonary clinic in a wheel chair while receiving continuous oxygen. His medical history revealed severe diastolic heart failure; chronic obstructive pulmonary disease; obesity (his body mass index, calculated as weight in kilograms divided by height in meters squared, was 54); diabetes mellitus with microvascular complications, including stage III chronic kidney disease; and peripheral neuropathy. Additional medical history included several recent falls attributed to progressive neuropathy and deconditioning. These considerations were discussed with the patient and ultimately, invasive diagnostic testing was discouraged. A conservative plan that included a repeated CT scan in 4 months was mutually agreed on. Two months after this visit, the patient was admitted and treated for pneumonia. While recovering in the hospital, his primary team noted that this nodule had not undergone workup and he had another CT scan, which demonstrated interval growth. He was scheduled for an outpatient CT-guided biopsy.Prior to the biopsy, the patient was rehospitalized for pneumonia, this time requiring intensive care unit admission. His medical history was addressed at a multidisciplinary thoracic tumor conference. He was not a surgical candidate, and attempts to biopsy...
