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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.

These tips can make pills easier to swallow for childrenor adults.

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.

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.

For several months, a 26-year-old man has had persistent bumps on his scalpand the back of his neck. Some hair loss has also occurred at the site.

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.

A chest film obtained as part of a routine insurance evaluation reveals a nodulein the right lower lobe of a 67-year-old man.

Here is a guide to common fractures that can be evaluated and treated in theoffice as well as uncommon fractures that warrant referral to a specialist. Morethan 300 radiographs, photographs, and drawings are included. New to this secondedition are chapters on facial and skull fractures and rib fractures; sectionson fractures in children and recommendations for when the patient can resumenormal activities; and expanded coverage of joint dislocations, including reductiontechniques, and stress fractures of the pelvis, rib, ulna, and calcaneus. Eachchapter provides detailed coverage of anatomic considerations, clinical signs andsymptoms, radiographic findings, potential complications, indications for orthopedicreferral, and treatment strategies. Included are tables that summarize keyaspects of management.

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.

At Consultant, our goal is to provide the practical, authoritative information youneed to best serve your patients. That is why we “pre-test” article ideas (beforewe invite articles on those topics) to be sure they are of high interest to you andyour colleagues. It is also why we take great care in checking facts, creating usefultables and figures, and choosing illustrations and photographs to enhanceteaching messages.

Smallpox, which is caused byinfection with poxvirus variola,may follow variouscourses. An erythematouseruption can precede theappearance of tense, deep-seatedpapules that rapidly transform intovesicles. The lesions may be sparseor so numerous that they becomeconfluent.