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 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.
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.
A 74-year-old man with a history ofatrial fibrillation presents to hisprimary care physician with dyspneaof 4 days’ duration. The dyspnea developedwhile he was walking as partof his recovery from back surgery forspinal stenosis 1 month earlier. Hebecame progressively short of breathand was unable to carry out his exerciseprogram.
A 56-year-old woman complainsof right hip pain that has been presentfor several weeks but has recentlyworsened. She denies recent trauma,fever, and increased physicalactivity. She has no history of arthritis,but she does have systemiclupus erythematosus, which a dailyregimen of prednisone, 20 mg PO,has kept in remission. Her medicalhistory is otherwise unremarkable.
An 84-year-old woman presents with a 3-year history of slowly progressivememory impairment accompanied by functional decline. Thepatient lives alone but has been receiving an increasing amount of support from her 2 daughters,who accompany her to the appointment. The daughters first noticed that their mother was havingtrouble driving. About a year ago, she started forgetting family recipes. She also left food cookingon the stove unattended and burned several pans. Currently, the daughters are providing mealsand transportation, assisting with housework, and doing their mother’s laundry. They have becomeincreasingly alarmed because she takes her medications only sporadically, despite the factthat they fill her pillboxes and call her regularly with reminders. Their chief concern is whether itis safe for their mother to continue to live alone.
