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Consultant Vol 42 No 7

For 1 week, a 2-year-old boy has had
asymmetric erythematous patches
on the anterior trunk. There is no
family or personal history of eczema.
His mother has not used new soaps
or detergents recently; there are no
pets in the household.

With proper guidance, a parent can
assist in the difficult task of examining
a young child’s throat.

Plumbing analogies can help asymptomatic
patients comprehend the seriousness
of elevated lipid and blood
pressure levels.

Campers and hikers often suffer superficial
lacerations far from a source
of medical care or supplies.

A broken nose can result in a great
deal of swelling and discomfort—and
often bleeding as well.

In his Photo Essay, “Hazards of Immobilizing Musculoskeletal Injuries” (CONSULTANT,
January 2002, page 72), Dr John Connolly points out problems caused
when ankle injuries are splinted incorrectly in equinus, resulting in excessive

Patients with psychiatric disorders
often present a diagnostic challenge—
even for psychiatrists. Their demeanor
may not readily reveal the nature or
severity of the problem. Nevertheless,
there are clues that can help you sort
through the differential and arrive at
the correct diagnosis.

A 22-year-old woman presents with fever and malaise of
1 month’s duration. About 3 weeks earlier she went to the
emergency department. Erythromycin was prescribed,
and the patient was told to seek medical attention if her
condition did not improve. Since that time, her health
has worsened, the fever has continued, and she has lost
weight. She says she has had painful areas on her hands
and feet but no rash.

A 77-year-old woman who had had
anorexia and weakness for 3 months
was seen after a syncopal episode. She
appeared pale but alert. Heart rate was
110 beats per minute; respiration rate,
22 breaths per minute; and blood pressure,
170/70 mm Hg. Her hematologic
indices were: hemoglobin level, 4.3 g/dL;
mean corpuscular volume (MCV), 60
fL; mean corpuscular hemoglobin concentration
(MCHC), 29 g/dL; red blood
cell count, 1.6 million/μL; white blood
cell count, 7500/μL; and platelet count,

I have read that the concurrent use of an NSAID and an angiotensin-converting
enzyme (ACE) inhibitor may impair the antihypertensive effect of the ACE
inhibitor. What is the mechanism of this interaction?

A 25-year-old man reports that he has had a swollen eye for the
past several days. He noticed a small amount of yellow discharge the previous
evening. He denies systemic complaints, including fever, chills, nausea, vomiting,
and recent trauma. He also tells you that he has a drip in my private area.

A 43-year-old woman presents to the emergency department
with fatigue, dyspnea, and intermittent chest pain
of 3 days’ duration. Her symptoms have worsened since
she arose, and 2 hours ago palpitations developed. She describes
the chest pain as a heavy pressure under her sternum
that does not radiate; she denies fever, nausea, vomiting,
and diaphoresis.

Match each picture with the phrase below that best describes it. The organisms in these pictures might be microscopic
or macroscopic, and they can be recovered from skin lesions or clothing by the patient and/or clinician.
Answers and discussion appear on the following page.

Anemia is usually detected as an incidental
finding on a screening complete
blood cell (CBC) count. Occasionally,
a patient presents with symptoms and
signs that strongly suggest anemia,
and a CBC count is ordered. In either
setting, the next step is to determine
the cause of the anemia.

Some sexually transmitted
diseases (STDs), such as
syphilis and gonorrhea, are
centuries-old scourges; others
have attained clinical
significance only in recent years.
Despite the availability of effective
therapy for many of these diseases,
they remain an important public
health problem.

My patient is taking a statin for hypercholesterolemia, and his liver enzyme levels
are markedly elevated. How should I proceed?

In addition to the extensive body of literature
that supports medical therapies
for osteoporosis and for prevention
of postmenopausal fractures, numerous
studies have explored the
benefits of exercise in both premenopausal
and postmenopausal women.1
The results of these studies indicate
that weight-bearing exercise and resistance
training may play a role in preventing
bone loss and increasing bone

Highly pruritic, 2- to 4-mm, papular lesions with central ulceration erupted on the back of a 66-year-old woman. She had had 2 similar outbreaks in the past. The patient was taking conjugated estrogens, alprazolam, and alendronate.

A 72-year-old woman presented for her annual physical examination. She had been treated for tuberculosis 20 years earlier. The patient did not smoke cigarettes; she denied fever, chills, and rigors.

For 2 months, a 31-year-old woman had had dyspnea and
dull, continuous retrosternal pain. She was admitted to the
hospital, and a helical CT scan of the thorax identified a
saddle pulmonary embolism. An ultrasonogram revealed
deep venous thrombosis (DVT) in the left leg. Intravenous
heparin was given; the patient was discharged,
and warfarin was prescribed.

A 1 X 0.5-cm hemorrhagic, polypoid lesion that had been present for 2 months
on a 13-year-old boy’s left anterior chest was excised. Pathologic examination
confirmed the diagnosis of pyogenic granuloma.

The extent of mucosal or transmural
intestinal necrosis varies. Pneumatosis
progresses from the submucosa
through the muscular layer to the subserosa.
The distal ileum and proximal
colon are most frequently involved.

Inspissated, sticky, immobile meconium
causes this transient form of distal
colonic or rectal obstruction in newborns.
The incidence has been estimated
at 1 in 500 to 1000 live births.
The condition is thought to result
from dehydration of the meconium.

Tortuous, dilated varicosities; multiple smaller caliber
abnormal perforating vessels; and chronic brawny
edema of chronic venous insufficiency (CVI) were seen
on a 70-year-old man’s left leg (A). He reported that the
edema and discoloration had worsened over the last
15 years. The brawny edema stopped just above the
ankle, indicating that compression by the patient’s sock
controlled the signs and symptoms of CVI.

A 76-year-old woman had a 40-year history of rheumatoid arthritis (RA). She had repeatedly refused treatment with disease-modifying drugs, including methotrexate. Nodules began to develop 15 years after the initial diagnosis; they recurred after surgical removal.

Affected infants present shortly after
birth with a large bowel obstruction
secondary to transient dysmotility in
the descending colon. Although the
cause is unknown, immaturity of the
colonic myenteric plexuses has been
demonstrated in some cases. More
than 50% of affected infants are born
to mothers with diabetes. Other predisposing
factors include hypoglycemia
and sepsis.

This condition, which accounts for
about 30% of cases of intestinal obstruction
among neonates, is characterized
by the inspissation of thick,
tenacious meconium in the bowel.
The most common cause is cystic fibrosis;
approximately 6% to 20% of infants
with cystic fibrosis have meconium
ileus. Hyperviscous mucus secreted
by abnormal intestinal glands,
an abnormal concentrating process
in the proximal small intestine, and a
deficiency of pancreatic enzymes
have been implicated in the pathogenesis.
The histologic hallmark is distention of the goblet
cells in the intestinal mucosa.

A 58-year-old black woman sought evaluation of areas of increased pigmentation on her cheeks that had been present for many years. Bleaching agents did not lighten the area; new, non–nickel-containing eyeglass frames had no effect. A 3-week course of halobetasol cream failed to fade the hyperpigmentation.

Also known as congenital aganglionic megacolon (A), this condition is characterized by a congenital absence of ganglion
cells in the submucosal (Meissner) plexus and the
myenteric (Auerbach) plexus in one or more segments of
the colon. This is attributable to a failure of migration of
nerve cell elements from the neural crest in a cephalocaudal
direction along the GI tract. The absence of parasympathetic
innervation causes failure of relaxation of the internal
anal sphincter. An aganglionic colon does not permit
normal peristalsis to occur and thus results in a
functional obstruction.

Cutaneous manifestations develop in
approximately 30% of persons with
diabetes. Premature atherosclerosis
is a common complication of the
disease and can cause peripheral infarction,
ulceration, and necrosis.


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