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Consultant Vol 42 No 8

For 3 days, a 36-year-old woman has had a painful rash on the dominant left
hand. She had noticed a tingling sensation before the lesions erupted. The
patient is otherwise healthy and takes no medications. She is a teacher.

A 79-year-old man has an elevated prostate-specific antigen (PSA) level
(11.3 ng/mL). About 1 month earlier, when he was hospitalized for a serious
urinary tract infection (UTI), his PSA level was 13.3 ng/mL. The more recent
level was obtained after he received antibiotic therapy for the UTI.

A 39-year-old man sought evaluation of
newly erupted skin lesions on his arms.
Ten days earlier he had fallen on his
forearms, but no bruises appeared at
that time.

Q:Many of my patients appear to have white-coat
hypertension: their pressure is elevated when
measured in my office—but normal when measured at
home. Am I ignoring significant hypertension if I do not
treat these patients? Or am I overtreating if I do treat?

An 82-year-old woman who had recently
arrived from Japan presented to the
emergency department with a 3-day
history of abdominal pain that began
immediately after she swallowed several
pills with a small amount of water.
The severe, intermittent pain radiated
to the patient’s back and worsened with
meals. The patient denied chills, nausea,
vomiting, coughing, diarrhea, and
constipation. She had well-controlled
type 2 diabetes mellitus and hypercholesterolemia,
and had undergone an
appendectomy 50 years earlier.

What is the next step when a patient’s urine culture shows -hemolytic streptococci?

Because of the potential harm they pose to patients, prescribing errors continue to be a focus of attention in the medical literature.1-4 Indeed, the primary impetus for the creation of this column was to help prevent these errors.

A 56-year-old man presented to
the emergency department with a
history of constipation, abdominal
pain, and blood-stained mucus
drainage from the rectum. The patient
had no fever; vital signs were
stable. A vague fullness was felt in the
lower abdomen. Rectal examination
revealed anal warts; a patulous anal
sphincter; and a smooth, mobile, firm
mass above the dentate line.

An otherwise healthy 18-month-old boy presented with palpable purpura over the legs, arms, and buttocks; his face, neck, and trunk were spared. The patient was otherwise asymptomatic, alert, and playful. His mother reported that the child had a “stuffy nose and cough” 1 month earlier.

For 2 days, a 79-year-old man with a history of congestive heart failure experienced abdominal pain, diarrhea, and dark red rectal bleeding. The pain was localized to the left lower quadrant.

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

A middle-aged woman reports that for several days she has had
a facial rash, some mild facial discomfort, and a low-grade fever. She denies
previous illness, recent contacts with infected persons, or history of a similar

A 37-year-old woman presents to the emergency department
with a diffuse, sharp, pounding headache,
which started 2 hours earlier. She rates her discomfort as
4 on a scale of 1 to 10. Neck muscle soreness is also present,
but the pain does not radiate.

Is there a meaningful percentage of patients who contract Lyme disease but have
none of the early symptoms—neither the rash nor the flu-like symptoms (eg, fever,
myalgia, headache, and stiff neck)—and in whom the disease only becomes clinically
evident in a later stage when it is much harder to treat?

Q:Should I avoid angiotensin-converting enzyme (ACE) inhibitors in my
patients with progressive renal insufficiency?

A 65-year-old man had had an asymptomatic lesion on his left lateral lower leg for several weeks. The dark maroon, almost black, 3- to 4-mm, circular, elevated lesion had a convoluted surface of dilated vessels. Dr Robert P. Blereau of Morgan City, La, excised the papule via a punch biopsy; pathologic examination identified an angiokeratoma.

What are the consequences—if any—of not treating tinea

Three strategies have commonly been used for episodic migraine. In step care across attacks, the least expensive medications are tried for several episodes. If these fail, treatment is "stepped up" to specific agents.

Over the past 20 years, obesity has reached epidemic proportions in the United States and throughout the world. The need for effective prevention and treatment is thus more urgent than ever.

Recently the CDC updated its guidelines for treating sexually transmitted diseases (STDs). This article focuses on genital herpes simplex virus (HSV) infection and human papillomavirus (HPV) infection.


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