A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.
To improve compliance in patientswith diabetes mellitus who measureglucose levels 4 times a day (beforeeach meal and at bedtime), offerthis alternating, twice-daily option.
An 87-year-old man had recently been hospitalized for5 days for treatment of hypernatremia and dehydration.His condition improved following hydration and cautiouscorrection of the hypernatremia, and he was discharged.However, within 48 hours the patient's caregiver notedthat he was obtunded and less responsive; she broughthim to the emergency department.
Highlights:Unique features of depression in the elderly.Keys to picking up the diagnosis.Pharmacologic treatment.When to recommend referral.
An 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.
A 23-year-old woman has had 2 episodesof syncope during the past month.Her mother witnessed 1 episode inwhich the patient collapsed and lostconsciousness for a few minutes. Sheexperienced tonic-clonic seizure activitybut no subsequent confusion.
In his article “High-Risk Hypertensive Patients: How to Optimize Therapy UsingACE Inhibitors and ARBs” (CONSULTANT, October 2003, page 1390), Dr JanBasile recommends angiotensin-converting enzyme (ACE) inhibitors for patientswith type 1 diabetes with or without hypertension, whether or not nephropathyis present.
An 84-year-old man with back and abdominal pain ofrecent onset arrives at the emergency department(ED) of a small community hospital at 5 AM. Sudden,severe back pain awakened him from sleep 2 hours earlier.The patient has had back pain for 12 hours and intermittentcolicky pain in the suprapubic region for the past2 hours.
A 45-year-old woman is admitted for evaluation of intermittentmidsternal chest pain that began 48 hours earlier.The pain is intense and radiates down both arms to theelbows; it has been accompanied by several episodes ofnausea and diaphoresis. She denies classic angina pectorisbut reports that she has experienced episodes of chestdiscomfort that is similar to her current pain-but muchless severe and without radiation-for about 3 months.She has no history of dyspnea on exertion, orthopnea, orparoxysmal nocturnal dyspnea.
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.
