In his article, “The Primary Care Physician’s Role in Treating Mental Illness”(CONSULTANT supplement, April 15, 2003, page 24), Dr Joseph Lieberman correctlyasserts that “more and more primary care physicians are prescribing psychotropicmedications.”
An 81-year-old man presents with severe Alzheimer dementia. Hishistory includes benign prostatic hypertrophy with 2 transurethralresections. He has a remote history of tobacco use and has not used alcohol excessively. He isotherwise in good health. At the time of his original diagnosis, a cholinesterase inhibitor was notprescribed.
A 74-year-old man comes to your office because his wife and childrenhave noticed that his memory has become mildly impaired. He continuesto work part time in the family business. Recently, however, his daughter has found thathe is making significant errors with clients. For example, he has failed to show up for appointmentsthat he had scheduled, and has set up appointments with clients whom he has already served.Because of errors he has made in client billing, he has turned over the company’s bookkeepingresponsibilities to his daughter.
My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.
A 43-year-old woman presents with a 1-week history of fatigue and weakness.She has also experienced vague abdominal discomfort and constipation for thepast month. She has no history of cardiac disorders.Which of the following metabolic disturbances does the ECG implicateas the most likely cause of the patient's symptoms?
Duloxetine (Cymbalta), from EliLilly and Company, has beenapproved by the FDA for the treatmentof both the emotional and thephysical symptoms of major depressivedisorders. This drug inhibitsreuptake of both serotonin andnorepinephrine.
What is bovine spongiform encephalopathy(BSE), or “mad cow disease,” and how is itthought to infect cattle?
A 51-year-old man presents with aseverely infected leg and 1- to 2-cmlesions on all of his extremities andtrunk; the bases of the lesions aredepressed, atrophic, and scarred.According to the patient, the lesionstypically appear as tender nodulesor pustules, which spontaneouslyburst, drain purulent material, andeventually heal as pictured.
Many of my patients with chronic pain are women who are depressed and whohave experienced a tragedy of some sort in their past.
For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.
A 72-year-old farmer is brought by his daughter for a comprehensivegeriatric assessment. His previous history is unremarkable. The patientreports that he has had vivid visual hallucinations, which he calls "visitors." He becomes frightenedand hostile when these incidents occur; on several occasions, he has exhibited violent behavioras persons around him tried to calm him. Although the patient was able to recall each episode indetail, he felt as if he had watched it from a distance and had not been an active participant.
A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.
Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.
Highlights:Unique features of depression in the elderly.Keys to picking up the diagnosis.Pharmacologic treatment.When to recommend referral.
A 45-year-old woman is admitted for evaluation of intermittentmidsternal chest pain that began 48 hours earlier.The pain is intense and radiates down both arms to theelbows; it has been accompanied by several episodes ofnausea and diaphoresis. She denies classic angina pectorisbut reports that she has experienced episodes of chestdiscomfort that is similar to her current pain-but muchless severe and without radiation-for about 3 months.She has no history of dyspnea on exertion, orthopnea, orparoxysmal nocturnal dyspnea.
A 69-year-old woman is broughtto the emergency department(ED) after a head-on collision in whichshe sustained injury to the right sideof the chest and the left ankle in additionto a laceration on her left forearm.She possibly had a transient loss ofconsciousness, but in the ED she canrecall all the events of the car accident.She complains of pain in the chestand ankle.
Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.
Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.
Q:Recent research has defined mild cognitiveimpairment as a transitional state between thecognitive changes of normal aging and Alzheimerdisease (AD) and other dementing illnesses. Whatcriteria are used to differentiate mild cognitiveimpairment from more innocuous syndromes, such asbenign senescent forgetfulness? Are patients with mildcognitive impairment considered to have incipientclinical AD?
A 54-year-old man with a history of type 2 diabetes, hypertension, and coronaryartery disease with angina presents to the physician’s office withchest pain. The pain began 3 hours earlier and is associated with diaphoresisand dyspnea. Examination results are unremarkable, except for diaphoresis.A 12-lead ECG reveals normal sinus rhythm with large R waves and horizontalST-segment depression in leads V1 through V3. The patient is given nitroglycerin,aspirin, heparin, morphine, and a β-blocker for noninfarction acutecardiac ischemia and transferred to the local emergency department (ED).
A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.
A 54-year-old Hispanic housewife presents to the emergencydepartment with a 3-week history of moderatelysevere, progressive, generalized, pulsating headache.The headache, which is partially relieved by propoxyphenenapsylate, is associated with weakness, vomiting of recentonset, and intermittent bilateral blurred vision. The symptomsbegan after an incident in which the patient’s sonwas stabbed.
A 40-year-old woman reports increasingly frequent and severe headaches during the past few months. She has had boutsof severe headaches since college, and episodic migraine was diagnosed a decade ago. She uses over-the-counter products(ibuprofen, ketoprofen, or aspirin) at the onset of an attack; if these fail to relieve symptoms, she takes hydrocodone/acetaminophen. During her worst attacks, she is typically forced to halt her activities, is unable to eat or drink, and mayvomit. For unresponsive or persistent (more than 24-hour) attacks, her husband drives her to the urgent care centerfor intravenous hydration, intramuscular promethazine, and additional doses of hydrocodone/acetaminophen. Accordingto the patient, a visit to the urgent care center “completely ruins our day.”
Q:Which patients with chronic respiratory disorders are good candidatesfor pulmonary rehabilitation? When is it a better option than surgery?
An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.
