A morbidly obese 63-year-old woman with type 2 diabetes mellitus and hypertension presented with postmenopausal vaginal bleeding. A uterine biopsy revealed papillary mucinous adenocarcinoma, and biopsy of a breast mass detected during the examination also showed adenocarcinoma. The patient underwent irradiation of the pelvis and breast.
Menstrual disorders are one of the most common complaints of women seen in primary care. Abnormal uterine bleeding (AUB) is a broad term that encompasses bleeding at abnormal or unexpected times or excessive flow at times of expected menses.
A 65-year-old woman with well-controlled hypertension comes in for a routine checkup. During the past 10 years, she has gained 25 lb and lost 1.5 inches in height.
As recommended by the authors, I commonly order a fasting lipid profile and measurements of glucose and insulin levels in children at risk for type 2 diabetes. One area of management that remains confusing is the approach to take with children who have an elevated fasting insulin level but otherwise normal laboratory results.
Several popular diets, such as the South Beach Diet and Sugar Busters, are based on the glycemic index; however, many patients are confused about its significance.
Primary care physicians are usually the first to see patients with joint pain; consequently they represent the "front line" of RA care. This fact-coupled with the projection that the number of rheumatologists is expected to decline by 20% during the next 2 to 3 decades-underscores the pivotal role that primary care clinicians are now expected to play in the early diagnosis of RA.
A 38-year-old man presented to the emergency department (ED) with a 2-week history of worsening shortness of breath and dry cough. He also complained of anorexia, a 14-kg (30-lb) weight loss over 3 months, pleuritic chest pain, and night sweats.
How important is control of obesity in the treatment of hypertension?
What steps can older patients take now to improve their health and quality of life and maintain their independence?
A 45-year-old Asian man presents with a 3-week history of weight loss, poor appetite, fatigue, intermittent sweats, and a nonproductive cough. The patient, a recent immigrant, denies previous illness.
Cardiovascular disease is the chief cause of death among women. Nevertheless, in a recent survey of women, only 13% responded that their own greatest health threat was heart disease.
Now that the role of inflammation in the pathogenesis of cardiovascular disease has been recognized, biomarkers of inflammation have become the subject of intense research interest. Once considered a novel cardiovascular risk factor, the inflammatory biomarker C-reactive protein (CRP) is currently believed to improve global risk prediction in patients not previously deemed at high risk.
ABSTRACT: Education can help improve compliance with inhaled corticosteroid therapy or correct faulty metered-dose inhaler (MDI) technique. Options for patients with poor MDI technique include use of a spacer or an alternative device, such as a nebulizer or a dry powder inhaler. If therapy is ineffective, consider alternative conditions that mimic asthma, especially vocal cord dysfunction and upper airway obstruction. Treatment of comorbid conditions, such as gastroesophageal reflux disease or rhinosinusitis, may improve control. In refractory asthma, it is crucial to identify allergic triggers and reduce exposure to allergens. If another medication needs to be added to the inhaled corticosteroid, consider a long- acting b-agonist, leukotriene modifier, or the recombinant monoclonal anti-IgE antibody omalizumab.
Exercise is a safe and effective therapy for patients with osteoarthritis or rheumatoid arthritis. It can reduce pain, increase flexibility and strength, and prevent deconditioning. To help motivate patients to initiate and adhere to an exercise program, educate them about these benefits, encourage them to set specific goals, recommend that they commit to a routine for at least 6 to 8 weeks (the minimum time needed to appreciate significant results), and warn them not to be discouraged by initial soreness. An exercise program for a patient with arthritis should include stretching (to improve joint flexibility), strengthening (to prevent deconditioning of the muscles that keep the joints stable), and aerobic exercise (to enhance overall fitness). Isotonic strengthening exercise is particularly important because it can reverse muscle wasting. Recommend that patients exercise for 30 minutes a day, 5 days a week. Water exercise is especially beneficial.
A 58-year-old man with type 2 diabetes mellitus and hypertension was hospitalized with acute diarrhea characterized by several brown, liquid depositions per day. He also complained of lower abdominal pain and bloating and a 10-lb weight loss in the past 2 months. He denied fever or chills, use of corticosteroids, and travel outside the United States.
A 40-year-old man presented with a 1-year history of progressively worsening dysphagia. He reported difficulty in swallowing both solids and liquids and had experienced mild weight loss during the past few months. He had no history of gastroesophageal reflux.
For 4 weeks, a 23-year-old runner has had a painful burning sensation about 1 inch above andlateral to the left knee cap. Occasionally, the pain radiates to her hip and 1 inch down the lateralside of her leg.
For years, a 60-year-old obese woman with type 2 diabetes mellitus had thiswarty lesion on the outer tarsal plate in the middle of the left upper eyelid.It was asymptomatic. She also had a few asymptomatic epidermal inclusioncysts on the upper and lower eyelids.
Age-related maculardegeneration(AMD) isthe leadingcause of untreatedvision loss amongpersons 65 years andolder and accounts for 45%of all visual disability inthe United States.1 Thiscondition usually has significantadverse effects onquality of life.2 As the USpopulation continues toage, the number of Americanswith AMD is expectedto increase.3
ABSTRACT: A host of evidence supports the treatment of high levels of low-density lipoprotein (LDL) cholesterol with HMG-CoA reductase inhibitors (statins), which are effective in both primary and secondary prevention of coronary heart disease (CHD). Studies have shown that statins prevent first cardiac events in otherwise healthy persons with elevated LDL cholesterol and low high-density lipoprotein cholesterol levels. Statins are also associated with a reduction in cardiac death, stroke, hospitalization, and the need for revascularization in patients with established CHD and hyperlipidemia. Secondary prevention trials of statin therapy that included persons aged 65 to 75 years found significant risk reduction in this age group. Among the concerns associated with statin treatment are lack of proper titration, failure to achieve LDL target goals, and underuse in patients with established CHD.
Until recently, celiac diseasewas considered a rare disorder.However, new evidencesuggests that about1% of Americans are affected.As serologic tests that detect autoantigensinvolved in celiac diseasebecome more widely used, morecases will likely be identified.1
ABSTRACT: First steps in the treatment of irritable bowel syndrome (IBS) are dietary modification, smoking cessation, and other lifestyle changes. Treatment of mild symptoms includes increased soluble dietary fiber and osmotic laxatives for constipation, antispasmodics for cramping, and over-the-counter antidiarrheals. For moderate disease, serotonergic agents work primarily in the intestine to relieve the global symptoms of IBS. Alosetron decreases gut motility and visceral sensitivity in women with chronic, severe diarrhea-predominant IBS who have not responded to conventional therapies. Tegaserod relieves pain, bloating, and constipation in women with constipation-predominant IBS. Psychotherapy, hypnotherapy, biofeedback, and other nonpharmacologic modalities may also be helpful for patients with IBS. Antidepressants are reserved for refractory symptoms; they can be combined with other modalities if needed.
The current obesity epidemic in the United States has fueled interest in nutrition and physical fitness. For many, the Internet has become a key source of information on these subjects.
ABSTRACT: The principal dietary strategy to reduce low-density lipoprotein cholesterol (LDL-C) levels is to decrease the amount of saturated fat and cholesterol in the diet. Consumption of soluble fibers, plant sterol and stanol esters, nuts, and soy protein further reduces LDL-C levels. Soluble fibers, such as psyllium, lower LDL-C levels by increasing bile acid loss, interrupting enterohepatic circulation of cholesterol, and reducing hepatic cholesterol delivery. Plant stanol and sterol esters, which are added to margarine, mayonnaise, and olive oil, are effective LDL-C–lowering agents. Nuts such as almonds and walnuts reduce LDL-C levels and have been associated with a 30% to 50% reduction in coronary heart disease risk. A diet that combines the above elements, plus soy protein, reduces LDL-C levels as much as starting doses of statins.
ABSTRACT: The cardinal feature of irritable bowel syndrome (IBS) is abdominal pain or discomfort associated with altered bowel habits. Because no serologic marker or structural abnormality exists, the diagnosis is based on clinical findings. A systematic symptom-based approach, including the Rome II criteria, ensures diagnostic accuracy. Determine whether a specific event-such as gastroenteritis, antibiotic use, or a food-borne illness-precipitated the IBS symptoms. Be alert for warning signs of cancer, infection, or inflammatory bowel disease, such as fever or unexplained weight loss. Only minimal laboratory testing is required; however, further evaluation may be warranted if a patient does not respond to treatment or loses weight, if the dominant symptom changes, or if other "red flags" are identified.
