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Journal

Patient Care Online Vol 48 No 11: October 2008

Office Procedures

Visualizing ear wax while attempting to remove it can be
difficult. To make the process easier, I enlist the patient’s
help. When examining the left ear, I have the patient
grasp the ear with the right hand, at about the 2-o’clock
position.

Office Procedures

Atrial Fibrillation

Now that baby boomers have reached the age of Medicare eligibility, joint replacements are on the rise. Because patients who undergo hip or knee arthroplasty require anticoagulation, primary care physicians have a key role in the care of these persons— before as well as after surgery.

Atrial Fibrillation

A 93-year-old man with known Alzheimer dementia has his admission physical examination on transfer to a geropsychiatric hospital unit due to behavioral difficulties. A language barrier and his stoicism minimize communication, but his devoted wife translates and recounts that he is not in any physical discomfort. Has sometimes needed oxygen treatment in the past.

Atrial Fibrillation

It can be difficult to determine whether unusual, paroxysmal behavior represents a seizure or a nonepileptic event. Patients with sudden flailing movements or unresponsive staring may, in fact, be experiencing psychogenic events. Other types of pathological spells, such as syncope and migraine, can also be mistaken for epileptic seizures.

Atrial Fibrillation

HIV AIDS

A 59-year-old woman presents with right-sided, nonradiating, “aching” chest pain that has been continuous and increasing in severity for the past 3 days. It began as a tightness that gradually became more painful; it is aggravated by palpation and movement and has not been relieved by acetaminophen.

HIV AIDS

An 84-year-old Ethiopian woman presented with tender, violaceous, nonblanching nodules that had coalesced into plaques on the soles of both of her feet over the past 3 months. Similar discrete nodules were found on the dorsal aspect of her right wrist.

HIV AIDS

A 46-year-old man with AIDS (CD4+ cell count, 150/μL) presented with a painful nodular lesion on the plantar surface of his right foot. The lesion had appeared 1 month earlier as a painless, 1-cm, raised, reddish purple nodule and had progressively enlarged to 5 cm. Six months earlier, the patient had cryosurgery to remove a similar, larger lesion on the posterior aspect of his right midcalf.

HIV AIDS

Depression

A 49-year-old man presented to the emergency department (ED) with substernal chest pain that had started an hour earlier. The pain radiated to the left arm, was constant, and was associated with diaphoresis, nausea, and dyspnea. A similar episode 4 days earlier had spontaneously resolved. He denied fever or chills, pleuritic chest pain, vomiting, and diarrhea.

Depression

For many patients with diabetic peripheral neuropathy, severe pain can be controlled to a degree sufficient to improve their quality of life. Here: effective management strategies, including topical agents, oral medications, and nonpharmacological therapies (eg, acupuncture and transcutaneous nerve stimulation).

Depression

A 74-year-old man who had Parkinson disease dementia presented with constipation and bloating associated with abdominal pain.

Kaposi sarcoma was diagnosed in a 54-year-old woman who had had a renal transplant. These multiple purple patches, plaques, and nodules abruptly appeared on the patient’s abdomen when she was taking prednisone and azathioprine.

Prostate Cancer

To screen or not to screen? The answer is not straightforward when it comes to prostate cancer. Recently updated guidelines from the US Preventive Services Task Force (USPSTF) recommend against prostate- specific antigen (PSA) screening in men who are 75 years and older and state that there is insufficient evidence to confirm whether screening is beneficial—or harmful —to men younger than 75 years.1,2 The recommendations are summarized in the Table.

Prostate Cancer

Obesity

Open biopsy or fine-needle aspiration of a supraclavicular
lymph node—especially the node on the left side of the
neck where the thoracic duct exits—is a relatively easy
way to diagnose malignancies.

Obesity

Levothyroxine is one of the most commonly prescribed medications for the treatment of hypothyroidism as well as the suppression of thyroid neoplasms.1 Most patients with hypothyroidism require lifelong therapy with levothyroxine; therefore, the likelihood of drug interactions is high.

Obesity

For 10 years, a 32-year-old woman has had an asymptomatic rash on both sides of her neck. She is otherwise healthy.
Do you recognize this rash?

Obesity

COPD

For 1 month, a 66-year-old man had had an asymptomatic lesion on the dorsum of his left hand. The flesh-colored, dome-shaped, maroon-crusted lesion measured 0.7 cm and was located over the fourth knuckle. The patient had chronic obstructive pulmonary disease but was otherwise in good health. He was seronegative for HIV.

COPD

Infection

Several readers wrote in response to Dr Andres Pinto’s “Consultations & Comments” answer to a question about treatment options for a patient with severe aphthous ulcers (CONSULTANT, May 2008, page 411). The additional treatments suggested by these readers appear below, along with Dr Pinto’s comments.

Infection

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