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Consultant Vol 50 No 5

A 45-year-old man presents with a 4- to 5-year history of an intermittent, asymptomatic, red, circular rash on his trunk. Trials of antifungal creams have not been successful. The patient is otherwise healthy and takes no medications.

During a routine skin examination, a papule of several years’ duration is noted on the upper lip of a 71-yearold man. The patient states that the lesion has been slowly enlarging; it does not bleed even during shaving.

For my patients who use nasal spray, I advise them to use the right hand to spray into the left nostril and the left hand to spray into the right nostril.

Tell patients that cotton swabs dipped in water and frozen in individual plastic bags provide quick relief for a burned tongue or lip or a tooth that is almost out.

Analogies often help make explanations clearer to patients.

Poor adherence is a problem we all confront regularly.

Advise runners to write the date they start wearing a pair of running shoes on the underside of the tongue, with a permanent marker.

Many elderly patients have fragile, atrophic skin.

A 56-year-old woman seen during physician’s hospice visit. Stormy course from lupus nephritis, dialysisdependency, repeated episodes of dialysis-catheter–related peritonitis, each treated and followed by Clostridium difficile–associated disease.

A 43-year-old white man presented to the emergency department with dyspnea, abdominal bloating, fever with chills, night sweats, decreased oral intake, and myalgia of 1 week's duration. He was found to have heart failure caused by systolic dysfunction. Viral myocarditis was the presumptive diagnosis after investigation for other causes.

These lesions on the scrotum of an otherwise healthy 42-year-old man had gradually increased in size and quantity over the past 3 to 4 years. The firm, skin-colored papules and nodules ranged in size from 0.8 to 2 cm. The lesions caused occasional discomfort and itching. No inguinal rash or urethral discharge was noted. There was no sign of a hernia, and both testes were in the scrotum.

For the past 7 years, a 32-year-old African-American man had multiple nonpruritic scalp abscesses. He also reported intermittent fever and joint pain. The abscesses had been drained on many occasions, and he had received several antibiotics, although no organisms had been isolated. Collagen vascular disease, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, osteitis), discoid lupus, and cutaneous sarcoid had been ruled out. During the past 7 years, he had been treated with prednisone, methotrexate, and hydroxychloroquine without any response.

For more than a week, a 74-year-old man has had diminished vision in his left eye. He reports that the problem started acutely with a sensation of flashing lights in the affected eye, followed by the presence of dark floaters for several days.

Some women 75 and older who are in good health and have excellent functional status may benefit from mammography screening, while others who are in poor health and have short life expectancies probably do not.

Dr Rutecki makes some excellent points about the costs of diabetes care and how the reduction of complications such as myocardial infarction, heart failure, and renal disease will decrease costs and suffering. But I have difficulty with the tone of his comments that seem to shift blame for the cause of these costs.

Dr Mara Schonberg does an excellent job of presenting the pros and cons of continued breast cancer screening in elderly women and of explaining why the current guidelines are vague. My purpose here is not to take issue with anything that she presented, but to make some additional points in favor of continuing breast cancer screening into a woman's "golden" years.


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