Oral corticosteroids arecommonly used inambulatory patientsas short- or long-termtherapy for a numberof diseases. For example, patientswith acute exacerbations of asthmaor chronic obstructive pulmonary diseaseare routinely given 1- to 2-weekcourses of prednisone, methylprednisolone,or another oral corticosteroid.In addition, oral corticosteroidsare used as maintenance therapy inpatients with such conditions assystemic lupus erythematosus, sarcoidosis,and post-organ transplantcomplications.
An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.
The scientific literatureon screeningmammography can be confounding.This poses a continuingdilemma for bothpatients and clinicians. Nevertheless,objective analysisof the available data canprovide reasonable guidelinesfor the primary careclinician who must decidewhether screening mammographyhas benefit foran individual patient.
A 52-year-old man presented to theemergency department (ED) with a12-hour history of cramping abdominalpain, nausea, vomiting, andwatery, brown diarrhea. Mid upperquadrantpain had begun suddenlythe night before, 1 hour after the patienthad lifted heavy bags of rocks.The GI symptoms persisted with varyingintensity throughout the night.
If you are a long-time reader of this journal, you may rememberthe photographs of authors that once gracedthe cover of every issue of Consultant. The May 1979issue of Consultant featured the picture of Donald Vidtyou see here; for that issue, Dr Vidt wrote “FiveMajor Vasodilators: How They Work” and advised readersabout the cardiovascular and renal hemodynamics ofhydralazine, prazosin, diazoxide, nitroprusside, and (atthat time the investigational agent) minoxidil. A quarter of a century later,Dr Vidt is still writing on the treatment of hypertension for readers of thisjournal-and it is with real pleasure that we introduce him here as a memberof our editorial board.
When a peak flow meter is not immediately available, testfor obstructive lung disease by asking the patient to fill hisor her lungs completely and then rapidly expel the air.
Although mammographyis still generallythought to be advantageous,a number of problemswith this screeningtool have recently beenbrought to light. Some ofthe latest studies suggestthat mammography maynot be as effective as washoped at decreasing mortalityfrom breast cancer.Moreover, the quality ofmammography itself hasbeen questioned-both theprocessing of films andtheir interpretation by radiologists.1 Errors can occuras a result of inadequateexposure or insufficientpenetration of the film. Radiologistswho have lesstraining in mammographyor who read a lower volumeof mammograms maymake more errors in interpretation.There are clearvariations between mammographycenters in ratesof false-positive and falsenegativeresults. While theanxiety and costs associatedwith false-positives areimportant, higher rates offalse-negatives are of mostconcern.
A 12-year-old black girl is hospitalized because of increasinglysevere dyspnea and sore throat. The sorethroat started about a week earlier and was accompaniedby fever and chills. The patient was evaluated at an urgentcare center when her symptoms worsened, where she wasgiven ampicillin for a presumptive “strep throat.” A generalizedmaculopapular erythematous rash developed within24 hours of the start of therapy, and the ampicillin waspromptly withdrawn. The rash cleared gradually thereafter.Now the patient’s sore throat has worsened to the pointthat she has difficulty with drinking and eating. She hasbecome increasingly dyspneic during the past 24 hours.
A 40-year-old man has had discomfort at the distal end of thefingers of both hands for several weeks. He has also noticed nail pitting andonycholysis. He denies any trauma or inciting event and has been otherwisehealthy. He has no family history of inflammatory bowel disease, althoughhe believes that some family members have had rashes.
In her response to a reader’s question about clot prevention in a patient with systemiclupus erythematosus (SLE) and anticardiolipin antibody syndrome,Dr Bonnie Bermas recommends warfarin (CONSULTANT, September 15, 2003,page 1329).
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.
Mammography is auseful tool. However,it has limitations. Until recently,it had been viewedas the ultimate diagnostictest, capable of detecting allbreast cancers in their earliest,treatable stages. Thissimply is not true. Evenwhen performed by themost capable institutionsand radiologists, mammographyhas a sensitivity of80% to 85% for the detectionof breast cancer. This hasbeen established by numerousstudies.1,2
A 21-year-old man presents to the emergency department with abdominal painof 6 hours’ duration. When the pain began, it was diffuse and periumbilical; now,it is worse and localized to the right lower quadrant. It has been accompanied byanorexia but not by diarrhea or emesis. Lying down, consuming liquids, andshowering have not provided relief.
Q:How frequently does hypertension occur in association withobstructive sleep apnea (OSA), and how is OSA best treated?
Heart failure statistics are daunting:550,000 new cases each year, a 1-yearmortality rate of nearly 20%, and annualdirect and indirect costs that total $24.3billion.1 The diverse etiology of heartfailure and the complex, progressivecourse of the disease can make treatmentdecisions daunting as well.
Breast cancer causesmore deaths than anycancer except lung cancer inwomen of all ages. In womenbetween the ages of 40and 59 years, it is the leadingcause of cancer death.1
The US Preventive Services Task Force (USPSTF) recentlydetermined that there is insufficient evidence (Table) toeither recommend or discourage the use of vitamin supplementsto prevent cancer or cardiovascular disease.1 The useof supplements for other purposes was not included in theanalysis.
A 56-year-old African American woman complains of malaise, nausea, and vomitingof several weeks’ duration. In addition, urinary output is reduced, and shehas mild dyspnea. She denies abdominal pain, diarrhea, constipation, and bonepain; however, she has had a mild but persistent backache for several months.
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 38-year-old woman presents with a pruritic, tender rash on the trunk and extremitiesthat has not changed over the past few days. She has taken fluvastatinand sertraline for 1 year and a popular, over-the-counter weight-loss product for1 or 2 weeks. The patient denies using any other medications. She has had norecent illnesses.
