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Consultant Vol 42 No 3

Painful erosions developed on the sole of a 14-year-old girl's foot several weeks
earlier. Within the last few days, the condition has spread to the other sole.
The patient is otherwise healthy and takes no medications. She enjoys playing
soccer and has no history of trauma.

Patients with diabetes who find repeated pricking of the fingertips
painful can obtain glucose readings by pricking their earlobe.

Patients who are told how to breathe
into a peak flow meter often try for
maximum volume rather than flow.

To facilitate insertion of an anoscope
or sigmoidoscope in a tense and anxious
patient, ask him or her to bear
down, simulating defecation.

When children are repeatedly asked
to take deep breaths during auscultation
of the lungs, they often get discouraged
after the second request.

Adhesions (A) can form within the
peritoneal cavity after abdominal
surgery, especially if there is an underlying
inflammatory condition such
as appendicitis (B) or inflammatory
bowel disease. The incidence of adhesive
intestinal obstruction following a
laparotomy is approximately 2%. Most
adhesive obstructions occur within 3
months of the laparotomy, and 80%
occur within 2 years. Adhesive obstructions
tend to be more common
in children than in adults.

A34-year-old woman presents to the emergency department
(ED) with rapidly progressive dyspnea.
The patient has a history of metastatic vaginal clear
cell adenocarcinoma secondary to diethylstilbestrol exposure
in utero. Following her diagnosis in 1990, she was
treated with surgery, chemotherapy, and radiation. She
had done well for years until a recurrence of the cancer to
the left lung was found last year. She completed a course
of chemotherapy with doxorubicin hydrochloride and
cisplatin 1 month ago.

The mother of an 8-year-old girl sought medical care for her daughter who had complained of intermittent chest pain for 3 days. The patient denied nausea, vomiting, and diarrhea. There was no shortness of breath, chills, fever, or diaphoresis.

A 54-year-old woman presents with severe, throbbing
pain in her right shoulder that began 3 days
earlier. She has no history of trauma or of problems with
this shoulder. She denies shortness of breath, fever,
chills, and rash.

For the past 3 years, comedones, papules, pustules, and nodules had been erupting on the face of a 16-year-old boy. Acne vulgaris had been diagnosed. Topical tetracycline cream and oral tetracycline were used without success.

A 44-year-old homeless man complains of a “sore” on
his penis. The ulcer developed from a macular lesion
on the glans penis about 5 days earlier. The painless ulcer
has not responded to a topical antibiotic ointment he received
at another clinic.

A 59-year-old woman comes to your office for evaluation of her heart murmur.
During the last several months, she has tired more easily and has had less energy.
Recreational activities, such as lap swimming, have become difficult because
she is easily winded. She denies chest pain, foot swelling, and nocturnal dyspnea.

A 36-year-old man with a 15-year history of episodic migraine presents to the emergency department (ED) at 5 AM with
a right-sided throbbing headache of 4 hours' duration. The headache awakened him, which is typical of his more severe
migraine attacks. Unfortunately, the patient forgot to refill his prescription for pain medication and did not "catch" this
headache in time. He took an over-the-counter combination of aspirin and caffeine, which seemed to help for about 60
minutes, but the headache has returned full force. He has vomited twice-another characteristic typical of his migraine

This obstruction results from hypertrophy
of the circular and longitudinal
muscularis of the pylorus and the distal
antrum of the stomach. It occurs
in approximately 3 of every 1000 live
births and is 4 times more common
in boys. Pyloric stenosis (PS) is relatively
uncommon in African American
and Asian infants. The observation
that it occurs primarily in first-born
infants has been disputed.

A 34-year-old woman awoke with a
painful, crusted ulcer on her upper
arm. She has been repairing dry wall
in her home but recalls no trauma.
The necrotic ulcer features an erythematous

I enjoyed the Photo Essay by Drs Alexander K. C. Leung and C. Pion Kao on infectious
diseases in children (CONSULTANT, March 2001, page 459).

Rheumatoid arthritis (RA) affects 1% of
adults during their most productive
years and can result in significant disability.
The goals of therapy are to reduce
pain, limit joint destruction, and
preserve function.

The patient might have
been exhibiting a phenomenon sometimes seen in methamphetamine users that is
referred to as "crank bug bites." Patients claim to see and/or feel bugs on their
body and attempt to remove them or pick at them until they create open wounds
and scabs.

Seizures are among the most common neurologic conditions
encountered in the primary care setting. However, they have
received scant attention in standard textbooks and in the
medical literature generally—perhaps because the topic cuts
across so many specialties. Here, an international team of
experts fills this void with a comprehensive discussion of the
causes and management of seizures associated with a wide
variety of medical problems—including organ failure,
organ transplantation, electrolyte imbalance, endocrine disorders,
cardiorespiratory disorders, cancer, fever and systemic
infection, medication, alcohol, illicit drug use, and
environmental toxins. Chapters cover the various types of
seizures and their pathophysiology, how to distinguish
seizure from syncope, seizures in the ICU, and the use of

I suspect that my patient has hereditary angioedema (HAE). During her last
pregnancy 2 years earlier, she had severe preeclampsia.

A 0.5-cm mass with overlying erythema on the forehead of a 5-monthold girl was first noticed after she had been hit on the head with a rattle. Excision of the mass was deferred because it was considered to be a hemangioma.

Many patients who experience an
episode of severe low back pain will
have a recurrence at some time in their
life. Therefore, it is usually prudent to
prescribe a long-term exercise program
to minimize the pain and frequency of
recurrences. Such a program should include
3 types of activities:

Sir William Osler once called pneumococcal
pneumonia “the captain of the
men of death.”1 Pneumonia is the sixth
leading cause of death in the United
States and the fourth leading cause
among Americans 80 years of age and

This disorder occurs in fetal development,
when the midgut supplied by
the superior mesenteric artery grows
too rapidly to be accommodated in
the abdominal cavity. Prolapse into
the umbilical cord occurs around the
sixth week of gestation. Between the
tenth and eleventh weeks, the midgut
retracts from its location at the exocelomic
umbilical stalk back into the
abdominal cavity. During this return,
the midgut undergoes a 270-degree
counterclockwise rotation about the
axis of the superior mesenteric artery,
followed by fixation to the posterior
abdominal wall. Malrotation
results from failure of the midgut to
properly rotate and affix itself to this
wall. This disorder occurs approximately
once in 500 live births.

What is your opinion of using intramuscular (IM) injections of corticosteroids,
such as triamcinolone acetonide, for seasonal allergies?

A 58-year-old man with a history of a seizure disorder was hospitalized with acute-onset shortness of breath immediately following a tonic-clonic seizure. He was afebrile; in respiratory distress; and hypoxic, with an oxygen saturation of 84% on room air. Auscultation revealed bibasilar crackles and an S3 gallop. The patient was given noninvasive mechanical ventilatory support, oxygen, and diuretics.

Alimentary tract duplications are uncommon. Gastric duplication accounts for only 3.8% of these duplications. The cause is not known, but faulty separation of the endoderm and notochord early in embryonal development is thought to be responsible. The anomaly occurs in twice as many female as male infants.

Persistent bloating, epigastric discomfort, and increased gastric acidity prompted a 47-year-old woman to seek medical care. Gastroesophageal reflux disease was diagnosed; antacids and H2-blockers were prescribed but provided no relief.

Numerous factors, including
other drugs, diseases,
and diet, affect
the response to warfarin.
Some of these factors
decrease the response and may
lead to therapeutic failure; others
enhance the response and may result
in life-threatening bleeding.

Q:What is the best and most efficient method of
evaluating pulmonary function in primary care
office practice?

Recent headlines in the nation’s newspapers have
riveted public attention on medication errors—a
problem that has long plagued the medical community.
1 Prescribing mistakes are common, and
they exact a costly toll: the US Institute of Medicine
estimates that 98,000 Americans die each year because
of a failure in the drug treatment process.2 Estimates
suggest up to 5% of all inpatients will experience
some type of medication error.3,4

A 3-year Australian study found that when patients who underwent bypass surgery
were given coenzyme Q10 for a week or more before the operation, their heart
muscle tolerated stress better, recovered more quickly, and had better pumping
ability after surgery than did the heart muscle in patients given placebo.1

An 83-year-old man complains of weakness, easy fatigability, and poor appetite
that began 4 to 6 weeks ago. He becomes short of breath on his daily walks
and has lost about 20 pounds over the last 3 months. He denies nocturia,
paroxysmal nocturnal dyspnea, exertional chest pain, fever, cough, melena,
and hematochezia. His only GI symptom is occasional crampy abdominal pain
with bowel movements.

Low back pain affects up to 80% of
Americans at some point in their lives.1
This common ailment can be mentally
and physically debilitating.

Concerned about a lesion between her eyes, a 91-year-old woman sought medical evaluation. She had not seen a physician for 23 years. The patient was strong-willed and alert, with no evidence of Alzheimer disease. A huge goiter was evident.

In 1978, a ricin-filled pellet—which was injected with a
spring-loaded device disguised in an umbrella—was
used to assassinate Bulgarian defector Georgi Markov.
A similar device was employed unsuccessfully against a
second defector in the same year.1

Many of the approximately 12.4 million Americans who
have cardiovascular disease are not being treated with the
most up-to-date risk-reduction therapies.1 Strong evidence
from recent studies, such as the National Heart, Lung, and
Blood Institute’s Adult Treatment Panel III report2 and the
Heart Outcomes Prevention Evaluation (HOPE) trial,3
demonstrate the need for more aggressive use of appropriate
medical and lifestyle therapies for these patients.

You routinely order laboratory screening
panels, including serum liver enzyme
measurements, for nearly every
patient who has a complete physical
examination or who is seen for any of
a host of other complaints. If you find
abnormal liver enzyme levels, your familiarity
with the common causes and
the settings in which they occur may
enable you to avoid costly diagnostic
studies or biopsy.

A 35-year-old woman has been losing weight and has had
worsening abdominal pain and fullness for the past 2 months.
She denies nausea, vomiting, and fever. Medical history is
significant only for asthma.


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