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Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.

In his “What’s Your Diagnosis?” case of an older man with a prolapsed internalhemorrhoid (CONSULTANT, October 2002, page 1487), Dr Henry Schneidermanstates that the “patient and his family preferred a conservative approach.”

An eye magnet can remove metallic objects lodged in the ear or nose, as wellas the occasional subcutaneous foreign body.

At the end of an office visit, write medication instructions, follow-up appointments,tests, diagnoses, and warning symptoms on a small note pad and givethe sheet to the patient.

Rub a small amount of warm lotionon your fingertips before you performan office breast examination(you can warm the lotion in yourhand).

Francisella tularensis is anonsporulating, nonmotile,aerobic gram-negative coccobacillusthat is usually transmittedto humans frominfected rabbits and other small animalsvia ticks, fleas, or deer flies orby direct contact

Dr Mohammed M. Basha’s “Practical Pointer” recommendationthat patients determine how much medication is leftin their inhaler by placing the canister in a glass of water(CONSULTANT, April 1, 2003, page 502) is, unfortunately,not sound.

For more than 30 years, serumdigoxin concentrations (SDCs)have been monitored toensure safe, effective therapy.1,2Although the therapeuticrange for SDCs is often listed as either0.8 to 2.0 ng/mL or 0.5 to 2.0ng/mL, the results of clinical trials inthe 1990s suggest an upper limit of1.0 ng/mL for treatment of heart failure.3-11 An upper limit for the SDC of1.0 ng/mL is also recommendedfor patients who have heart failureand atrial fibrillation with rapid ventricularresponse.

For 2 weeks, a 58-year-old woman has experienced increasingfatigue with activity. She has needed to nap duringthe day, has not been able to perform her usual activities,and has missed 3 days of work. She also complains of“muscle aches”-mainly in her back. She denies headache,dyspnea, fever, hot or cold intolerance, and alteredmentation.

As someone who has been involved in health care education for 40 years and whowas a counselor in a private mental health practice for 24 years, I appreciated DrJoseph Lieberman’s article on the role of the primary care physician (PCP) in thetreatment of mental illness (CONSULTANT supplement, April 15, 2003, page 24).

To reduce the pain of a corticosteroid/lidocaine injectioninto the heel, first mark the location with ink and then applyan ice pack for 5 to 10 minutes.

A 67-year-old woman has had an ulcer on her left heel for at least several weeks.She applied a homemade dressing and cut her shoes to try to relieve pressureon the ulcer; however, in the past week, areas around the ulcer have becomepainful. These areas, as well as the dorsum of the foot, are red and swollen.

A 72-year-old man complains that he has been losing weightfor the last 2 months. Colon cancer was diagnosed 2 yearsearlier, and the lesion was resected; he did not receive anyadditional therapy at that time. Except for hypertension,which is well controlled with propranolol, the remainder ofthe medical history is unremarkable.

Branch WT Jr (ed)OFFICE PRACTICE OF MEDICINE (ed 4)Philadelphia, WB Saunders Company, 2003, 1387 pages, $89.95 hardcover

This 40-year-old woman has had multiple lesions on her facefor several months. She also reports occasional fevers, slight weight loss, andintermittent fatigue.

A70-year-old African American man, who is a retiredelectrician, presents with increasing fatigue anddull back pain of 4 months’ duration. Although he usuallywalks about 2 miles a day, he now becomes exhaustedafter half a block. He reports exertional dyspnea but noparoxysmal nocturnal dyspnea or orthopnea. Recently, henoticed ankle edema.

Over the past 6 months, a 76-year-old African American woman has had increasingdifficulty in swallowing solid food and has lost 40 lb. She can now tolerateonly liquids and foods with a pudding-like consistency. Ingestion of moresolid food produces the sensation that it is “sticking in her chest,” and shesubsequently regurgitates it undigested. She denies heartburn, reflux, nausea,hematemesis, abdominal pain, and melena.

To immediately relieve pain from aningrown toenail, tell patients to soakthe affected foot in warm water for3 minutes to make the nail pliable.