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A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

When you need to obtain a specimenfor throat culture, ask the patient toexhale while you swab the pharynx.

A 76-year-old woman complains of gradually worsening back pain thatbegan 6 weeks earlier, after she fell off a ladder rung 3 feet from the ground(she landed on her feet). She is otherwise in good health and denies fever andloss of sensation or control in the lower extremities.

It is difficult to visualize the pharynxof patients who gag whenever youuse a tongue blade, but you can frequentlydispense with its use.

Rapid, accurate diagnosisof acute myocardialinfarction(MI) in patientswith chest pain isa formidable challenge.

In his “What’s Your Diagnosis?” case of an older man with a prolapsed internalhemorrhoid (CONSULTANT, October 2002, page 1487), Dr Henry Schneidermanstates that the “patient and his family preferred a conservative approach.”

An eye magnet can remove metallic objects lodged in the ear or nose, as wellas the occasional subcutaneous foreign body.

At the end of an office visit, write medication instructions, follow-up appointments,tests, diagnoses, and warning symptoms on a small note pad and givethe sheet to the patient.

Rub a small amount of warm lotionon your fingertips before you performan office breast examination(you can warm the lotion in yourhand).

Dr Mohammed M. Basha’s “Practical Pointer” recommendationthat patients determine how much medication is leftin their inhaler by placing the canister in a glass of water(CONSULTANT, April 1, 2003, page 502) is, unfortunately,not sound.

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