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An 83-year-old man with a history of hypertension and coronary artery disease presented with a 4-day history of mental status changes, slurred speech, and difficulty ambulating. He reported a lack of appetite and weakness of several days.

Metastatic Melanoma in an 83-year-old Man 


These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite.

These 2 patients presented with a swollen hand and rapidly proximally progressive edema secondary to a bite. What creature did the biting?

Swollen Hands-What’s Biting?

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma.

A 67-year-old woman noted the appearance of several non-tender, rock-hard, purple-colored nodules on her legs. Her medical history was significant for distant non-Hodgkin lymphoma. The violaceous color and configuration of the skin lesions suggests which of the following? 

Clinical Topics

Hard Purple Nodules: Your Dx?

These are the hands of a 60-year-old black woman who, besides a chronic palmar discoloration, has a history of joint pain, muscle weakness, and Raynaud phenomenon. Physical examination showed proximal muscle weakness and mild synovitis in her metacarpophalangeal joints. She was mildly anemic, but renal function and urinalysis results were normal. Her creatine phosphokinase level was elevated at 3435 U/L. Her chest x-ray showed mild interstitial changes at the lung bases.

The 60-year-old black woman has a history of joint pain, muscle weakness, and Raynaud phenomenon. Why the “dirty hands”?

Dirty Hands

A 5-year-old boy with a history of atopic dermatitis since 6 weeks of age, presents with a rash around his mouth that has been present for approximately 1 year. The patient’s mother reports that desonide topical cream was applied to the affected area for about 5 days, which initially resulted in improvement, however the rash returned after this medication was discontinued. The rash also recently improved after the patient took amoxicillin for an infection. She also notes that the patient has been licking his lips more frequently.

On examination there is an erythematous papulopustular eruption restricted to the perioral region, with sparing of the vermillion border. Mild hyperpigmentation is noted on the patient’s neck. There is no active involvement of other areas of the body.

The eruption has been present for 1 year and is restricted to the perioral region. What is included in your differential? 

Rash Around the Mouth of a 5-year-old Child

 with office blood pressure readings not at goal and and home blood pressure monitoring readings suggestive of a significant white coat effect, it may be useful to confirm the latter with ambulatory blood pressure monitoring.

This is one of 7 recommendations on the detection and management of white coat and masked hypertension made in the landmark 

 for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. 

In this brief slide show for primary care practitioners, we summarize all 7 recommendations as well as the evidence in support of each. 

White coat and masked hypertension can be elusive and dangerous. Click through a topline look at recommendations from the 2017 ACC/AHA hypertension guidelines.

White Coat & Masked Hypertension: A Primary Care Guideline Topline

A 32-year-old man presents with dysphagia to solid foods. His symptoms have increased in frequency during the past 6 months. He has taken to eating much more slowly and needs water to help swallow food. His history is remarkable for seasonal allergies, for which nasal fluticasone is prescribed. He undergoes an upper endoscopy, which demonstrates diffuse rings, longitudinal furrows, and white plaques. Esophageal biopsies reveal dense eosinophilia throughout.

A. Start swallowed topical corticosteroids

B. Refer to allergist for skin prick testing

C. Begin treatment with an acid suppressant

These endoscopic findings help explain worsening dysphagia in a 32-year-old man. Esophageal biopsies prove positive for eosinophilia. How would you proceed? 

Esophageal Rings, Furrows, and Plaques: What Next?

Abdul M. Swied, MD

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