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Consultant Vol 42 No 12

For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk and
extremities. Five days earlier, the patient was given levofloxacin for an upper
respiratory tract infection; because she is prone to yeast infections while taking
antibiotics, fluconazole also was prescribed.

A detailed drug history is essential
when treating patients with myasthenia
gravis—especially those who
report a sudden increase in symptoms.

Anticipation of the discomfort of an
intramuscular injection causes anxiety
for many patients.

Dispel patients’ unrealistic expectations
about bloodwork by explaining what
the test results will not show as well as
what they will show.

For 1 month, a 25-year-old woman had experienced discomfort in and around the left eye and diplopia. She was in good health; she reported no weight loss, excessive nervousness, heat intolerance, decreased strength, changes in the texture of hair or skin, or altered bowel habits. There was no personal or family history of goiter or other thyroid disease.

The mother of a 6-year-old child brings her to your office because
of a pruritic rash that has been present for several days. The rash did not respond
to hydrocortisone cream and has continued to spread along the patient’s
left side.

A 19-year-old athlete complains of
pain and swelling of the anterior
pretibial area of his right lower leg. He
hopes to win a football or track scholarship
to college and is concerned
because his symptoms are impairing
his performance.

For 3 days, a 30-year-old man had had bilateral flank pain that radiated to the lower abdomen; gross hematuria had accompanied the pain for 1 day.

A pruritic rash developed on the feet of a 40-year-old woman 2 days after she had worn a new pair of shoes for a few hours. The erythematous, papular, scaly eruption was more prominent on the right foot.

A 22-year-old Filipino man with fever, lethargy, weakness, and malaise of 5 days' duration was brought to the emergency department by his family. Two days earlier, oral penicillin had been prescribed for streptococcal pharyngitis. The patient was unable to walk because of profound weakness. Circular and linear ecchymotic lesions were noted on his back.

During a routine office visit, a 64-year-old woman who has had type 2 diabetes
for more than 10 years complains of increased pedal edema. The edema is minimal
on awakening and worsens throughout the day.

A 32-year-old man who was seropositive for HIV presented with a tender lesion on his right foot of about 3 months' duration. The patient's only medication was zidovudine. His CD4+ cell count was 120/µL.

Approximately 90% of cases of lung cancer are attributable to smoking—
either directly or as a result of passive exposure. Fifty percent of smokers
die of a smoking-related disease. The 4 most common causes of death—heart
attack, lung cancer, chronic obstructive pulmonary disease, and stroke—are
all associated with smoking. More lung cancer is diagnosed in former than in
current smokers.1 The risk of lung cancer decreases each year following smoking
cessation, but former heavy smokers will always have a higher risk than

More than
1.8 million
at least 600,000 percutaneous
transluminal coronary
angioplasty (PTCA)
procedures are performed
in the United States annually.
1 The use of these diagnostic
and interventional
modalities continues to
grow even as financial constraints
increase. Yet for
many patients with coronary
artery disease (CAD),
medical therapy may be an
appropriate option.

Although acute low back pain usually
resolves within 6 weeks—with or without
treatment—the pain may signal a
significant neurologic or life-threatening
disease that warrants immediate

How does amyloid in the pancreatic islets contribute to
the development and progression of type 2 diabetes?

In his article, “Anemia: A Strategy for the Workup”
(CONSULTANT, June 2002, page 869), Dr James Bergin
makes several references to a test that measures the
“serum transferrin receptor level.”

My patient is a 42-year-old woman who experienced a nonblanching, purpuric
rash and edema of the lower legs after she started taking nifedipine (Figure).

I have a 74-year-old male patient who has peeling lips and recurrent painful aphthous

ABSTRACT: A thorough history and physical examination can establish the diagnosis of tension headache; further evaluation is generally unnecessary. In contrast, the workup of cervicogenic headache includes standard radiographs, 3-dimensional CT, MRI, and possibly electromyography; nerve blocks may also be used to confirm the diagnosis. Episodic tension headache can be treated effectively by trigger avoidance, behavioral modalities, and structured use of analgesics. Reserve opioids for patients with intractable headaches. Chronic tension headache is treated primarily by prophylactic measures, such as antidepressants and anticonvulsants, and behavioral and physical therapy. Treatment options for cervicogenic headache include analgesics; invasive procedures, such as trigger point injections, greater or lesser occipital nerve blocks, facet joint blocks, segmental nerve root blocks, and diskography; spinal manipulation; and behavioral approaches.

ABSTRACT: For patients who present with ventricular fibrillation (VF) or pulseless ventricular tachycardia that is refractory to repeated countershocks, the drug of choice is amiodarone; the recommended dose for those who are receiving cardiopulmonary resuscitation is 300 mg given as an IV bolus. Vasopressin, 40 U IV, is an acceptable alternative to epinephrine in adults with VF that is resistant to electrical defibrillation. Standard heparin or low molecular weight heparin is indicated in patients who require reperfusion therapy and in those who have unstable angina or non-Q wave myocardial infarction (MI). The initial therapy for patients with acute myocardial ischemia usually includes morphine, oxygen, nitroglycerin, and aspirin, plus a ß-adrenergic blocking agent. Glycoprotein IIb/IIIa receptor inhibitors are currently recommended for patients who have non-Q wave MI or high-risk unstable angina.


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