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Consultant Vol 42 No 10

A 37-year-old woman complains of “itchy bumps” that erupted just above her
waist 2 or 3 days earlier. She denies having had this condition in the past.
The patient is otherwise healthy and takes no medications. An avid gardener,
she claims to be able to identify and avoid poisonous plants.

Antihistamines, corticosteroids, and
epinephrine can take time to relieve
angioedema of the uvula.

Children often resist examinations for
otitis externa because of pain and tenderness.

To detect wheezing during forced
expiration in patients with dyspnea,
asthma, or reactive airway disease,
ask the patient to take a big breath
and exhale as if he or she were blowing
out the candles on a birthday

To facilitate removal of a subdermal
foreign body from a patient’s hand,
turn on an otoscope and lay it on
a work surface, turn off the lights in
the room, and hold the hand against
the otoscope.

After 5 weeks of undulating fever, weight loss, and night sweats, a 22-year-old man presented to the emergency department. He reported no significant medical history. The patient had recently completed a course of tetracycline followed by another of azithromycin for a presumed upper respiratory tract infection.

A 58-year-old man recently underwent coronary artery bypass graft (CABG)
surgery after emergent cardiac catheterization for a myocardial infarction revealed
diffuse 3-vessel disease.

The parents of a 3-year-old boy were
concerned about their son's "droopy"
right eyelid; the abnormality had
been present since birth. All other aspects
of the child's eyes and his general
development had been normal.

Some degree of hyperpigmentation
develops in most pregnant
women. This coloration is more pronounced
in dark-skinned women; on
naturally pigmented areas, such as the
areolae, perineum, and umbilicus; and
on the axillae, inner thighs, and other
regions that are prone to friction.

Many of my older women patients think they
are at much higher risk for breast cancer than
coronary heart disease (CHD). How can we raise women's
awareness about their risks of CHD and thereby
encourage them to take measures to prevent it?

Heart failure
(HF), the most
common Medicare
has a significant and growing
impact on health care
resources. The incidence
of HF has tripled during the
last decade. Almost 5 million
Americans have HF, and an
estimated 500,000 new cases
are diagnosed yearly. The
lifetime risk of HF is about
20%.1 Drug therapy has improved
considerably in recent
years, but the magnitude
and severity of the
problem has created a need
for newer therapies--particularly
since HF is associated
with an increased risk of
sudden death and a diminished
quality of life.2

A 35-year-old woman noticed that her
right upper eyelid started to droop as
the day progressed. She denied other
ocular problems, including decreased
visual acuity, pain, or diplopia. The patient
had no generalized fatigue, difficulty
in swallowing, or weakness of
her arms or legs.

A 65-year-old woman with a long history of hypertension treated with metoprolol and felodipine complained of dizziness, headache, nausea, and vomiting of acute onset. Her blood pressure was 220/110 mm Hg. She was drowsy and unable to stand or walk.

A bright, active 10-year-old boy has been experiencing recurrent bouts of
abdominal pain with nausea and occasional vomiting for 3 years. Although he
has had 1 or 2 attacks at school, the pain usually occurs at home—frequently
on weekends. His mother has been unable to correlate these episodes with particular
foods or activities. She notes that her son has experienced motion sickness
during long auto trips and during a family holiday in the mountains of

A 24-year-old woman's first
pregnancy was uneventful until the
sixth month when mild malaise and a
highly pruritic abdominal rash occurred
(Figure 1). A biopsy and direct
immunofluorescence confirmed
the suspected diagnosis of herpes

The most appropriate choice is B. The history and
physical findings suggest that the patient may have a
fracture or contusion of the foot from trauma. There are
no systemic signs that suggest an underlying infectious,
chronic inflammatory, or oncologic process. A plain x-ray
film of the foot is necessary to see
whether a fracture is present and
whether immobilization will be necessary.
In the absence of fever and local
erythema, infection appears unlikely,
and a CBC count is unwarranted.

The mother of this 5-month-old boy was concerned about the large birthmark in the infant's diaper area.

This 40-year-old man was punched in
the left eye the night before his evaluation.
Traumatic ptosis of the left upper
eyelid with accompanying edema and
periorbital ecchymosis (A) were found.
When the ptotic eyelid was lifted and
held in place with tape, conjunctival
injection and traumatic mydriasis were
seen (B). The patient had no complaints
of diplopia; the remainder of the
eye examination was unremarkable.

A swollen, painful eyelid prompted a 39-year-old man to seek medical attention.
The patient had noticed swelling, redness, and irritation in his left lateral eyebrow
area 2 days earlier. Upon awakening on the morning of his appointment,
the left upper eyelid also felt full and tender and was drooping. A pointed draining
area of purulent material had formed in the lateral brow region (not visible
here). The patient was afebrile and denied any recent periorbital trauma. He
was otherwise healthy; his only medication was a daily multivitamin.

A 12-year-old boy with a history of atopy complained of pruritus and severe dryness of the hands. Over-the-counter moisturizers failed to resolve the condition. The patient did not wash his hands frequently and had no hobbies that exposed him to environmental irritants or allergens.

A 13-year-old boy presents with swelling of the left eyelids
that started 12 hours earlier; the eyelashes are matted
with yellow discharge. He does not wear contact lenses or
eyeglasses and denies ocular trauma or foreign bodies. He
has been nauseated and has vomited once; his mother
attributes these symptoms to an antibiotic that was prescribed
5 days earlier for a sinus infection. Medical history
is noncontributory; there is no family history of ocular

Approximately 2 weeks earlier, a pruritic,
papular eruption had developed over
the abdomen of a 33-year-old woman
who was 34 weeks' pregnant. The
rash was confined mainly to the striae
distensae (Figure 3). Because the
site was severely pruritic, the patient
was unable to sleep. Based on the
clinical presentation, pruritic urticarial
papules and plaques of pregnancy
(PUPPP) was diagnosed.

My patient reports that erythema
nodosum occurred when she took an
oral contraceptive (OC) in the

In their article, “Dyslipidemia in Patients With CAD: How to Make Best Use
of Drug Therapy” (CONSULTANT, October 2000, page 2097), Drs Harry Yu,
Richard Pasternak, and Geoffrey Ginsberg discuss the adverse effects associated
with statin therapy, including myositis.

In his “What’s Your Diagnosis?” column, Dr Henry Schneiderman discussed the
case of a young man with periorbital swelling caused by nephrotic syndrome
(CONSULTANT, June 2001, page 1017) (Figure 1).

I read with interest Dr Virenda Parikh’s case of a young woman with extensive
anal condylomata acuminata (CONSULTANT, April 15, 2001, page 737).

My patient is a 48-year-old woman who has no significant medical history and
takes no medications or supplements.


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