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Consultant Vol 42 No 14

A 50-year-old man
presents to your office with severe
discomfort in the great toe that began
24 hours earlier. He denies any trauma
but says that he may have had
similar symptoms many years before.
He has no recent history of fever
or illness. You aspirate fluid from the
first metatarsophalangeal joint for

How critical—and cost-effective—is in-office
pulmonary function equipment for the primary
care practitioner?

A 41-year-old woman has had a 2-week bout of nausea, vomiting, and diarrhea.
Her history includes chronic hepatitis C and alcohol abuse. She also has orthostatic
hypotension. A baseline ECG is obtained.

After exposure to the sun, an erythematous, edematous, pruritic allergic
reaction developed at the site of a 22-year-old man’s new tattoo. In addition
to photoallergy—as seen in this patient—direct allergy to the dyes in the
tattoo can produce an adverse reaction.

A 23-year-old woman presented with medial and lateral
pruritic keloids on her right earlobe, which had been
pierced several years earlier. These lesions began to develop
during the patient’s pregnancy 2 years earlier.
Keloids also were noted on the presternal region. The
patient reported that these had begun as pimples that
spontaneously enlarged.

A 52-year-old man presented to the
emergency department (ED) with a
12-hour history of cramping abdominal
pain, nausea, vomiting, and
watery, brown diarrhea. Mid upperquadrant
pain had begun suddenly
the night before, 1 hour after the patient
had lifted heavy bags of rocks.
The GI symptoms persisted with varying
intensity throughout the night.

Postoperative inflammation occurred shortly after this
25-year-old woman’s earlobes were pierced. Within a few
months, bilateral keloids developed at the sites. The
keloid on the left ear is shown here.

Three carbon dioxide laser treatments were used to remove a 35-year-old
woman’s tattoo (A). Four months after the procedures, significant scarring
was noted at the site (B).

Laser in situ keratomileusis, or
LASIK, was first described in 1990 1;
since then, it has surpassed cataract
surgery as the most common eye operation
performed in the world. 2 As
many as 1.5 million corneal refractive
laser surgeries are done annually in
the United States. 3,4

Primary care providers are seeing
an increasing number of
patients who have snakes or
barbwire coiling around their
arms or gold rings dangling
from their eyebrows and navels. Tattooing
and body piercing are particularly
popular among adolescents and
young adults—many of whom may not
be aware of the possible medical complications
of these ancient practices.

A 53-year-old man has had
malaise, intermittent cough, and occasional
fever and night sweats for 2
weeks. He has also lost some weight
during this time but denies hemoptysis
and sputum production; he has
not traveled abroad recently. His only
significant medical condition is hypertension,
which is well controlled with

A 42-year-old woman complains of anxiety, unexplained weight loss, and palpitations
that started about 3 weeks earlier. She denies fever, trauma, and new
stress. She has a history of several urinary tract infections for which imaging
failed to reveal any predisposing factors; all were successfully treated with
medication. The remainder of the history is unremarkable.

ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.

In the United States, osteoporosis affects 12% to 28% of women over age 65 years. Among women who live to be 85, 50% will sustain an osteoporosis-related fracture. Hip fractures occur in 15% of these women, and vertebral deformities develop in 25%

The most common blood-borne infection in the United States, hepatitis C is also one of the leading causes of chronic liver disease in this country. About 35,000 new hepatitis C virus (HCV) infections are diagnosed each year; by 2015, the number of persons with documented HCV infection is expected to have increased 4-fold from what it was in 1990.

ABSTRACT: Unless the cause of back pain is obvious, order anteroposterior and lateral radiographs of the spine, a complete blood cell count, erythrocyte sedimentation rate, and urinalysis. If you suspect infection, tumor, or bony abnormalities, obtain an MRI or CT scan. MRI has surpassed bone scanning as the gold standard for diagnosing spinal infections, because it confirms a specific anatomic diagnosis. Spondylolysis and spondylolisthesis are 2 of the most common causes of back pain in adolescents; the diagnosis is made with plain radiographs, which show slippage on the later-al view in patients with spondylolisthesis and fracture through the pars interarticularis on the oblique views in those with spondylolysis.

ABSTRACT: The main therapeutic goals for patients who have an acute coronary syndrome are to reestablish normal epicardial flow and to increase distal myocardial perfusion. Fibrinolytic treatment with tissue plasminogen activator within 70 minutes of the onset of symptoms dramatically reduces the mortality rate from myocardial infarction. Other fibrinolytic agents include reteplase, which is given as a double bolus, and tenecteplase, which is given as a single bolus. In most hospitals, fibrinolytic therapy is more readily available than percutaneous transluminal coronary angioplasty (PTCA); however, PTCA may be the preferred approach if it is available within an hour and a half. Antiplatelet drugs, such as glycoprotein IIb/IIIa receptor antagonists, are used to improve distal myocardial perfusion. If follow-up coronary angiography is not available to assess whether epicardial blood flow and distal myocardial perfusion have been restored, a 12-lead ECG can provide valuable information. The resolution of ST-segment abnormalities is a marker for improved perfusion.


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