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For 3 weeks, a 52-year-old woman has had right-sided, intermittent, dullabdominal pain and jaundice; these symptoms have worsened in the past fewdays. The pain radiates to the back, worsens with movement, is somewhatrelieved in certain positions, and is unrelated to eating or defecation. Duringthe past 3 weeks, she has also noticed darkening of her urine, a profound decreasein appetite, and an increase in fatigue; she has lost considerable weightbut is unsure of the exact amount. She has had no nausea, vomiting, or melenaor other change in her bowel movements.

The parents of a 3-year-old girl seekmedical evaluation of the nodules ontheir daughter’s back. The lesionshave been present since birth andhave grown with the child.

A 58-year-old man complains ofintermittent headaches that beganabout 2 months earlier and have recentlyincreased in severity. Theheadaches occur at various times ofthe day and improve slightly whenhe sits. He denies trauma, fever, photophobia,and other neurologicsymptoms. He has 1 alcoholic drinka day and has smoked 1 pack of cigarettesa day for the past 20 years.Medical history is noncontributory.

A 24-year-old African American man presents for a routine eye examination. Theocular findings are unremarkable; however, well-circumscribed areas of whitenedskin are noted on his forehead and hands (A and B). The patient reportsthat the patchy loss of pigment has been progressing over a number of years.

Child abuse is common. Each year in thiscountry, nearly 3 million children are reportedto Child Protective Services. Approximately50% of reports are for neglect, 30% forphysical abuse, and 20% for sexual abuse.Retrospective studies suggest that 1 in 4 girls and 1 in 8boys are sexually abused before age 18.1

A 47-year-old woman is bothered by the numerous small, smooth, darkbrown papules that have developed on her face and neck during the pastdecade. She asks if the asymptomatic lesions can be removed.

For more than a decade,screeningmammography hasbeen the subject ofintense public scrutinyand debate. Probably atno time has this debatebeen more heated thanduring the last 3 years,which saw the publicationof the now-famous “Danishstudy” as well as a majorexposé of poor quality controland radiologic interpretationerrors in the mammographyindustry (Box).

When a colleague heard last month thata book of my poems and drawingshad just been published,1 he askedwhat, if anything, these pursuits hadto do with physical diagnosis. Surprisedat his response, I set about trying to articulate whyI see the arts as essential spiritual nourishment for all ofus in medicine.

Laser in situ keratomileusis, orLASIK, was first described in 1990 1;since then, it has surpassed cataractsurgery as the most common eye operationperformed in the world. 2 Asmany as 1.5 million corneal refractivelaser surgeries are done annually inthe United States. 3,4

A 54-year-old Hispanic housewife presents to the emergencydepartment with a 3-week history of moderatelysevere, progressive, generalized, pulsating headache.The headache, which is partially relieved by propoxyphenenapsylate, is associated with weakness, vomiting of recentonset, and intermittent bilateral blurred vision. The symptomsbegan after an incident in which the patient’s sonwas stabbed.

Prolonged exposure to coldtemperatures can have a profoundeffect on the skin.When tissues are exposed toabove-freezing temperatures,localized vasoconstriction and increasedblood viscosity reduce bloodflow and decrease the amount ofoxygen available to tissues. Whentissues are exposed to freezing temperatures,water within those tissueschanges into ice crystals; this resultsin either intracellular or extracellulardamage and tissue necrosis.

A 73-year-old man is admittedto the hospital with pulmonary tuberculosis.A 3-drug fixed combination-isoniazid, rifampicin, and pyrazinamide-and ethambutol are given.Within an hour, a global urticarialrash erupts (A and B).

Rifampin is associated with numerousclinically significantdrug interactions.1-4 New interactionswith rifampin-aswell as rifabutin-continue tobe reported in studies and clinical observations.Here we present highlightsof our recent update on the interactionsthat are most relevant toprimary care practice.5

A 25-year-old man complainsof right hip pain that began earlierin the day when he fell and landedon his hip while playing basketball.He has no other symptoms, and hishistory is noncontributory.

A 60-year-old woman reportsthat she has felt intermittent“fullness” in her face for the past day.This sensation is present when sheis supine on the examination table.She denies shortness of breath, dysphagia,and chest discomfort. Thepatient has a 25 pack-year history ofcigarette smoking.

Allopurinol has been usedto treat gout for well over3 decades. In addition,this drug is prescribed toprevent urate nephropathyin patients who are receiving cancerchemotherapy.

A 67-year-old man with poorly controlled type 2 diabetes mellitus presents withleg pain and swelling that began 3 days earlier. Multiple ulcers are noted at thelateral malleolus. His temperature is 38.9°C (102.1°F). Right lower extremitycellulitis is diagnosed, blood samples are taken for culture, and the patient ishospitalized.

An 84-year-old woman with hypertension and type 2 diabetes mellitus isbrought to the emergency department (ED) after an episode of nearsyncope.When emergency medical service personnel initially assessed her,blood pressure was 96/60 mm Hg and heart rate was “slow”; however, shehad no symptoms.