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Consultant Vol 43 No 1

Frequently, I have seen cerumen removal with water picks and syringes
result in trauma, including significant tympanic membrane perforation,
and infection; thus, I no longer use these devices.

In their case report, “Sudden Headache in a Woman With Hypertension” (CONSULTANT,
July 2002, page 1049), Drs Gary Quick and Maggie Law describe a
patient with uncharacteristically severe headache and very high blood pressure.

Asymptomatic, enlarging growths had been present on the bottom of a 56-year-old woman’s feet for 3 years. The nodules initially arose—first on the left foot, then on the right—at the sites of blisters on the insteps after the patient had taken a long hike in uncomfortable boots.

A 25-year-old man sought evaluation of a painless, palpable, left testicular mass that had been present for more than 1 year. There was no personal or family history of cryptorchidism or malignancy. A circumscribed mass was palpated within the anterior superior pole of the left testis.

Patients as young as 20 years need to be evaluated for
cardiovascular risk factors, according to recently updated
recommendations from the American Heart Association
(AHA).1 In addition, the risk of heart disease should be
assessed every 5 years in persons aged 40 or older and
those with multiple risk factors.

A Young Boy With High Fever and Lethargy

A 5-year-old boy is brought to the emergency department
(ED) by his parents. They report that, for the
past week, the child has had a high fever (temperature
up to 40oC [104oF]), generalized weakness, lethargy, and
lack of appetite. The boy’s eyes are bloodshot and he has
refused food and drink. The child has no history of
cough, shortness of breath, hematemesis, melena, headaches,
vision problems, or seizures. He has not been in
contact with sick persons, has not traveled abroad, does
not have a pet, and is not taking any medications. His immunizations
are up-to-date.

Q:Should I prescribe isoniazid prophylaxis for an elderly patient with
multiple health problems who recently converted from negative to
positive tuberculin status?

Patients with ankylosing spondylitis are
at increased risk for fractures (particularly
extension fractures of the cervical
and thoracolumbar spine) and spinal
cord injury. Fractures in these patients
are extremely unstable; in fact, they are
among the most complication-prone of
all cervical spine injuries likely to be
seen in the primary care setting.

For 10 years, a 22-year-old woman had had an erythematous, translucent patch of grouped blisters on her left thigh. A recent increase in the size of the patch prompted the patient to seek treatment. There was no burning or tingling at the site. The patient reported that the erythema occasionally cleared; however, the blisters always remained. She denied fever, weight loss, and other constitutional symptoms.

Satellite lesions are usually associated with Candida
infections but not with Bowen disease.

A 76-year-old woman is admitted to the hospital for increasing fatigue and weakness
that began about 3 weeks earlier. Her symptoms have worsened during
the past week to the point of profound weakness and both dyspnea and nearsyncope
with minimal exertion.

In my view, "very low calorie diet" is a more appropriate term for the type of diet you describe.

A 56-year-old man, who was involved in an automobile accident, was brought to the emergency department by ambulance. He was awake, intoxicated with alcohol, and complained particularly of pain in his left shoulder. The patient was unable to recall any details of the accident; he believed that he had been hospitalized for a back spasm.

For the past 3 months, a 72-year-old man has had progressively
worsening dyspnea on exertion and constant
vague discomfort in the left chest that appears to have a
pleuritic component. He denies paroxysmal nocturnal
dyspnea and has no history of chest trauma. However, he
has a chronic cough that sometimes produces purulent
sputum—although it is not associated with hemoptysis.
His feet swell occasionally, and he has mild anorexia and
has lost 20 lb in 6 months.

An 87-year-old woman sought treatment of what she described as a “bite” of 1 month’s duration. The pink, nodular lesion on the dorsum of the left hand had central superficial ulceration with yellow crusting at the web space between the thumb and index finger.

For the past several weeks, a 54-year-old man has had progressively
worsening abdominal pain and general achiness.
He has no nausea, vomiting, diarrhea, or fever and no history
of trauma.

Cardiac stress imaging has become increasingly sophisticated; nevertheless, standard exercise electrocardiography can provide valuable clinical information, such as time to onset of angina or ST-segment depression, maximal heart rate and blood pressure response, and total exercise duration. Pharmacologic stress agents may be substituted for patients who cannot exercise on a treadmill; however, these agents must be used in conjunction with echocardiography or nuclear scintigraphy to obtain adequate diagnostic information.

Back pain is second only to upper respiratory tract infection as the most frequently reported illness in the United States; up to 20% of Americans experience back pain each year.

The diagnosis of osteoarthritis (OA) is primarily clinical. Key historical clues to idiopathic OA include patient age greater than 45 years, joint pain that increases with activity and is relieved with rest, morning stiffness of 30 minutes duration or less, and involvement of one or more of the following: hips, knees, cervical or lumbar spine, basilar thumb joints, interphalangeal joints of the hands, midfoot joints, and first metatarsophalangeal joints.


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