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Consultant Vol 44 No 6

For several months, a 49-year-old woman has had asymptomatic loss of pigment
on her shins. She has no history of injury to the area.
What is your clinical impression?

A 72-year-old man with a history of rheumatic heart disease presented with pulmonary congestion and syncope. Results of the cardiac examination suggested mitral stenosis and atrial fibrillation with a controlled ventricular response.

While jogging in a park, a 45-year-old man tripped and fell on his outstretched hand. As he fell, he tried to catch himself on a nearby park bench but was unsuccessful. He felt that his shoulder was out of place, and he was unable to adduct his arm from its erect position. A witness called for an ambulance, and the man was taken to the emergency department.

The father of a 28-year-old man accompanied his son to the emergency department (ED) for evaluation of a “worm infestation.” About 6 weeks earlier, the patient had diarrhea for 2 days and claimed to have seen worms in his stool.

A 70-year-old woman with no previous
medical problems had had progressive
dyspnea and generalized weakness
for the past several days. She was
hypotensive (73/31 mm Hg), tachycardic
(120 beats per minute), and
tachypneic (28 breaths per minute);
oxygen saturation (room air) via pulse
oximetry was 84%.

An obese 61-year-old man who had
chronic obstructive pulmonary disease
and sleep apnea heard a “pop”
in his stomach while lifting a heavy
weight; severe abdominal pain followed.
He was short of breath the
next morning, and his physician empirically
prescribed cephalexin.

A 33-year-old man presented with joint pain and general malaise of about 2 weeks' duration and small yellowish lesions on the pinnae of the ears of about 6 months' duration. He had no urinary symptoms or conjunctivitis and was not taking any medications. His grandfather had been treated for gout.

Over the previous 6 months, a
59-year-old man had experienced lethargy,
fatigue, poor appetite, cold intolerance,
and abdominal distention. His
vital signs were normal; physical examination
revealed periorbital and
pretibial edema, distant heart sounds,
and delayed reflexes.

The mother of a 7-year-old girl noticed the rapid progression of a lesion on her child’s right hand over 3 weeks. Within several days of its initial appearance, the very small, nontender, and nonpruritic lesion had grown in circumference and “looked like a wart,” according to the mother. Application of over-the-counter preparations failed to resolve the lesion. A week before the office visit, the lesion “started growing straight up.”

A 70-year-old man with a history of peptic ulcer disease presented with a 1-day
history of epigastric pain. Abdominal examination revealed mild epigastric
tenderness. A pneumoperitoneum was discovered on a chest film (A), and a
left decubitus chest film (B) confirmed this diagnosis.

Azole antifungals are widely
used to treat numerous
infections.1 Many
well-documented, clinically
significant drug interactions
are associated with these agents1,2

ABSTRACT: Signs and symptoms of a full-blown ocular allergic reaction include deep red vessels in the conjunctiva, itching, and swelling of the conjunctiva and eyelids. Ocular allergy can resemble nonallergic conditions, including drug-induced conjunctivitis, blepharitis, and viral or bacterial infection. A history of itching confirms a diagnosis of allergy. To distinguish allergic conjunctivitis from more serious allergic ocular diseases, inspect the lids and cornea for papillae on the upper tarsal surface, which occur in giant papillary conjunctivitis and vernal or atopic keratoconjunctivitis. Local treatment of allergic conjunctivitis consists of over-the-counter and prescription antihistamines, with or without vasoconstrictors or mast cell stabilizers. Combination mast cell stabilizer/ antihistamine topical ophthalmic agents-the newest class of medication-are considered the most effective treatment of allergic conjunctivitis. Oral antihistamines are not indicated unless a patient has an allergic condition, such as rhinitis, dermatitis, or asthma.


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