Obesity Medicine

ABSTRACT: Topical agents can provide temporary relief from osteoarthritis symptoms with little or no risk. Acetaminophen is first-line oral therapy. Be alert for risk factors for NSAID-induced GI toxicity, such as concurrent use of prescription and OTC agents. Tramadol, narcotic analgesics, muscle relaxants, and antidepressants are options when NSAIDs are ineffective or contraindicated. Intra-articular injections of corticosteroids or hyaluronan are appropriate for patients who have a single joint exacerbation. Total knee and total hip arthroplasty are considered the most effective surgical interventions.

Cardiac stress imaging has become increasingly sophisticated; nevertheless, standard exercise electrocardiography can provide valuable clinical information, such as time to onset of angina or ST-segment depression, maximal heart rate and blood pressure response, and total exercise duration. Pharmacologic stress agents may be substituted for patients who cannot exercise on a treadmill; however, these agents must be used in conjunction with echocardiography or nuclear scintigraphy to obtain adequate diagnostic information.

A 42-year-old woman complains of anxiety, unexplained weight loss, and palpitationsthat started about 3 weeks earlier. She denies fever, trauma, and newstress. She has a history of several urinary tract infections for which imagingfailed to reveal any predisposing factors; all were successfully treated withmedication. The remainder of the history is unremarkable.

In the United States, osteoporosis affects 12% to 28% of women over age 65 years. Among women who live to be 85, 50% will sustain an osteoporosis-related fracture. Hip fractures occur in 15% of these women, and vertebral deformities develop in 25%

ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.

ABSTRACT: A key objective in the follow-up of women with a history of breast cancer is the detection of local and distant disease at a curable stage. Regular clinical examination and yearly mammography are the standard of care. No consistent evidence supports annual chest radiography, bone scans, or tests of serum tumor markers. Order laboratory or diagnostic tests only if indicated by clinical findings. Advise women to report new symptoms promptly rather than waiting for the next scheduled examination. Some evidence supports the use of venlafaxine for tamoxifen-associated hot flashes. Despite the increased incidence of endometrial carcinoma in women taking tamoxifen, routine endometrial biopsies are not recommended. Most experts advise that women with a history of breast cancer who wish to have a child wait 2 to 3 years before becoming pregnant.

ABSTRACT: Age-related anatomic and physiologic alterations in the thyroid gland have a variety of clinically important effects. Hypothyroidism, which is common in older persons, raises cholesterol and triglyceride levels; hyperthyroidism may be masked by the severity of the cardiac problems it causes. In younger persons, depression may accompany hypothyroidism but not hyperthyroidism; however, in the elderly, it may be a feature of either condition. Papillary carcinoma-the most common type of thyroid cancer-is more aggressive in older persons. All these factors necessitate a cautious and deliberate approach to the management of thyroid disorders in elderly patients.

During a routine office visit, a 64-year-old woman who has had type 2 diabetesfor more than 10 years complains of increased pedal edema. The edema is minimalon awakening and worsens throughout the day.

For 1 month, a 25-year-old woman had experienced discomfort in and around the left eye and diplopia. She was in good health; she reported no weight loss, excessive nervousness, heat intolerance, decreased strength, changes in the texture of hair or skin, or altered bowel habits. There was no personal or family history of goiter or other thyroid disease.

Although acute low back pain usuallyresolves within 6 weeks-with or withouttreatment-the pain may signal asignificant neurologic or life-threateningdisease that warrants immediateintervention.

More than1.8 millioncardiaccatheterizationsandat least 600,000 percutaneoustransluminal coronaryangioplasty (PTCA)procedures are performedin the United States annually.1 The use of these diagnosticand interventionalmodalities continues togrow even as financial constraintsincrease. Yet formany patients with coronaryartery disease (CAD),medical therapy may be anappropriate option.

A 22-year-old Filipino man with fever, lethargy, weakness, and malaise of 5 days' duration was brought to the emergency department by his family. Two days earlier, oral penicillin had been prescribed for streptococcal pharyngitis. The patient was unable to walk because of profound weakness. Circular and linear ecchymotic lesions were noted on his back.

As the world of sport has embraced the participation of women and girls, the incidence of health problems that pertain specifically to premenopausal female athletes has increased significantly. One of these is the female athlete triad, which consists of 3 interrelated medical conditions associated with athletic training

ABSTRACT: Exercise can be an effective way to stabilize or slow the degenerative process of osteoarthritis-provided convenient, safe, and enjoyable activities are selected and achievable goals are set. Implement an osteoarthritis exercise plan in phases, and progress gradually from one phase to the next; this will help both you and your patient anticipate difficulties and gauge progress. The first phase-the initial evaluation-includes gathering baseline data, targeting an area of the body to focus on first, and identifying potential contraindications to activities. Subsequent phases include range of motion exercises (stretching), isometric and isotonic strengthening exercises, and recreational or functional activities. Encourage patients to continue stretching exercises throughout the program.

After 5 weeks of undulating fever, weight loss, and night sweats, a 22-year-old man presented to the emergency department. He reported no significant medical history. The patient had recently completed a course of tetracycline followed by another of azithromycin for a presumed upper respiratory tract infection.

Many of my older women patients think theyare at much higher risk for breast cancer thancoronary heart disease (CHD). How can we raise women'sawareness about their risks of CHD and therebyencourage them to take measures to prevent it?

ABSTRACT: A focused history taking and physical examination directed toward uncovering signs that suggest a serious underlying cause of low back pain are crucial. "Red flags" include pain that lasts more than 6 weeks; pain in persons younger than 18 years or older than 50 years; pain that radiates below the knee; a history of major trauma; poor rectal tone; constitutional symptoms; atypical pain (eg, that which occurs at night or that is unrelenting); the presence of a severe or rapidly progressive neurologic deficit; and a history of malignancy. These markers provide a cost-effective means of guiding your selection of laboratory and diagnostic imaging studies.

A 72-year-old man slipped and fell backward in the bathroom, hitting hishead on the toilet seat; he suffered only minimal discomfort. The followingday, he presented with mild back pain and extensive bruising.

About 1 month ago, a 58-year-old man experienced malaiseand fatigue accompanied by mild diffuse swelling in his neck.After 3 days, the malaise and fatigue began to abate. They resolvedafter a week; however, minimal swelling on the left sideof the neck remains. The patient has no other symptoms.

Q:Many of my patients appear to have white-coathypertension: their pressure is elevated whenmeasured in my office-but normal when measured athome. Am I ignoring significant hypertension if I do nottreat these patients? Or am I overtreating if I do treat?

Over the past 20 years, obesity has reached epidemic proportions in the United States and throughout the world. The need for effective prevention and treatment is thus more urgent than ever.

For 2 months, a 31-year-old woman had had dyspnea anddull, continuous retrosternal pain. She was admitted to thehospital, and a helical CT scan of the thorax identified asaddle pulmonary embolism. An ultrasonogram revealeddeep venous thrombosis (DVT) in the left leg. Intravenousheparin was given; the patient was discharged,and warfarin was prescribed.

A 72-year-old man presented after several months of dyspepsia and 1 day of hematemesis. He was not taking NSAIDs.

The past several years have witnessedimportant advances in the evaluationand management of chronic heart failure(HF). Drugs such as β-blockersand spironolactone have been shownto reduce morbidity and mortality, andstrategies that employ new devices,such as pacing and defibrillator therapy,are evolving. This has promptedthe American College of Cardiology(ACC)/American Heart Association(AHA) to update guidelines first publishedin 1995.1 The guidelines highlightthe importance of early and accuraterecognition of the clinical syndromeof chronic HF and offer anoutline for evidence-based therapeuticdecision making.

Although the cardiovascular death ratehas declined in the United States, thenumber of hospitalizations for cardiacdisease has not. The improvement incare has been offset by an increase inthe number of older Americans. By2050, more than 100 million Americanswill be 60 years of age or older,and about 30 million will be older than80 years.