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When a patient with a history of severe anaphylactic reactions needs an epinephrine auto-injector, prescribe two rather than just one. An injector at home does a patient no good if he or she is at the office or out backpacking when a reaction occurs.

THECASE:An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema. Congestive heart failure is diagnosed, and the patient is admitted to the care of a hospitalist. A standard therapeutic regimen, including diuretics, angiotensin-converting enzyme inhibitors, and oxygen, is instituted, in addition to the patient's home regimen of isosorbide mononitrate, glipizide, and amlodipine. The hospitalsubstitutes pravastatin for the patient's atorvastatin. A Foley catheter is inserted by a urologist because of the patient's benign prostatic hypertrophy. The patient complains of insomnia and is given diphenhydramine. His hospital course is otherwise uneventful.

After shooting himself in the finger during target practice in his backyard, a 37-year-old man presented with a traumatic injury to the left second digit. The patient said he was looking through the scope at the target when he released the trigger. However, he failed to realize that his finger was still at the base of the barrel of his 22-caliber pistol. He reported no significant medical history, routine medication use, or drug allergies, and denied smoking. The patient, a social drinker, admitted to having 2 to 3 beers that day.

Inflamed hemorrhoids are traditionally treated with hemorrhoidal pads impregnated with witch hazel. I have found that ordinary baby wipes work just as well and in addition are readily available, less expensive, and less painful to use. Be sure to remind patients to purchase flushable wipes so that they don't later present you with a bill from the plumber!

ABSTRACT: Risk factors for oral cancer include tobacco use and alcohol intake (especially in conjunction with tobacco use). Many benign conditions may be confused with squamous cell carcinoma, the most common type of intraoral neoplasm. Any red and/or white lesion that has surface corrugation, stippling, or induration is considered dysplastic or neoplastic until proved otherwise. Even without these clinical signs, white plaques of any size that persist for several months may represent dysplasia. These lesions should be assessed by biopsy. Risk factors for lichen planus include stress, exposure to certain foods and medications, and systemic illness. Erosive lichen planus may cause significant pain and oral dysfunction.

To simplify knee aspiration (after a standard knee prep), use a regular vacuum tube with an adapter and a 21-gauge needle supplied by your laboratory. By switching tubes, you can remove as much fluid or blood as needed as well as a sample for cell count, culture, or crystal analysis if these are called for. Not having to change the syringe minimizes patient discomfort.

ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.

A trip to the supermarket or a meal in a restaurant can be a challenge for patients who have celiac disease. Treatment of the disease consists of strict adherence to a gluten-free diet. This regimen can be difficult to follow because gluten is found not only in such obvious sources as wheat-based cereals and pasta but also in many processed foods (eg, salad dressings and gravies).

An 84-year-old man with a history of stable angina, type 2 diabetes, hyperlipidemia, and hypertension presents to the emergency department with worsening dyspnea and peripheral edema.

ABSTRACT: Only a small number of patients with celiac disease exhibit the textbook symptoms of malabsorptive diarrhea with steatorrhea, weight loss, and nutritional deficiencies. Others may present with a subclinical enteropathy, GI complaints without constitutional symptoms, persistent travelers' diarrhea, or extraintestinal manifestations alone. Be alert for suggestive signs, such as weight loss, skin lesions, oral aphthae, muscle atrophy, de-enamelization of the teeth, and vague GI symptoms, such as bloating. Helpful serologic tests include IgG and IgA antigliadin antibodies, enzyme tissue transglutaminase antibodies, antiendomysial antibodies, and total IgA. Typical endoscopic findings are mucosal atrophy, fissuring, and scalloping. In addition to a gluten-free diet, management encompasses repletion of vitamins and minerals, including iron, folate, calcium, and vitamin D; screening for thyroid disease and diabetes mellitus; bone densitometry and age-appropriate cancer screening; and pneumococcal vaccination.

When a patient with a history of severe anaphylactic reactions needs an epinephrine auto-injector, prescribe two rather than just one. An injector at home does a patient no good if he or she is at the office or out backpacking when a reaction occurs.

Inflamed hemorrhoids are traditionally treated with hemorrhoidal pads impregnated with witch hazel. I have found that ordinary baby wipes work just as well and in addition are readily available, less expensive, and less painful to use.

To simplify knee aspiration (after a standard knee prep), use a regular vacuum tube with an adapter and a 21-gauge needle supplied by your laboratory.

After shooting himself in the finger during target practice in his backyard, a 37-year-old man presented with a traumatic injury to the left second digit. The patient said he was looking through the scope at the target when he released the trigger. However, he failed to realize that his finger was still at the base of the barrel of his 22-caliber pistol. He reported no significant medical history, routine medication use, or drug allergies, and denied smoking. The patient, a social drinker, admitted to having 2 to 3 beers that day.

BOSTON -- The brain of babies who die of sudden infant death syndrome (SIDS) have multiple serotonin system defects, and this appears to pin down an underlying fatal susceptibility in these children, according to researchers here.

LAS VEGAS -- Pill-sized cameras, self-navigating endoscopes, and other high-tech gadgetry may one day supplant or augment colonoscopy for colon cancer detection, according to a technology review presented here.

LAS VEGAS -- For treating patients with chronic constipation, a recently approved chloride channel activator compares well with other medications in efficacy and tolerability, according to a review of published data presented here.

LAS VEGAS -- Drugs that activate cannabinoid receptors in the colon might help treat lower GI conditions such as diarrhea or certain types of fecal incontinence, according to a proof-of-concept study presented here.