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A34-year-old woman presents to the emergency department(ED) with rapidly progressive dyspnea.The patient has a history of metastatic vaginal clearcell adenocarcinoma secondary to diethylstilbestrol exposurein utero. Following her diagnosis in 1990, she wastreated with surgery, chemotherapy, and radiation. Shehad done well for years until a recurrence of the cancer tothe left lung was found last year. She completed a courseof chemotherapy with doxorubicin hydrochloride andcisplatin 1 month ago.

Patients who are told how to breatheinto a peak flow meter often try formaximum volume rather than flow.

To facilitate insertion of an anoscopeor sigmoidoscope in a tense and anxiouspatient, ask him or her to beardown, simulating defecation.

I suspect that my patient has hereditary angioedema (HAE). During her lastpregnancy 2 years earlier, she had severe preeclampsia.

A 34-year-old woman awoke with apainful, crusted ulcer on her upperarm. She has been repairing dry wallin her home but recalls no trauma.The necrotic ulcer features an erythematousborder.

An 83-year-old man complains of weakness, easy fatigability, and poor appetitethat began 4 to 6 weeks ago. He becomes short of breath on his daily walksand has lost about 20 pounds over the last 3 months. He denies nocturia,paroxysmal nocturnal dyspnea, exertional chest pain, fever, cough, melena,and hematochezia. His only GI symptom is occasional crampy abdominal painwith bowel movements.

Many of the approximately 12.4 million Americans whohave cardiovascular disease are not being treated with themost up-to-date risk-reduction therapies.1 Strong evidencefrom recent studies, such as the National Heart, Lung, andBlood Institute’s Adult Treatment Panel III report2 and theHeart Outcomes Prevention Evaluation (HOPE) trial,3demonstrate the need for more aggressive use of appropriatemedical and lifestyle therapies for these patients.

Seizures are among the most common neurologic conditionsencountered in the primary care setting. However, they havereceived scant attention in standard textbooks and in themedical literature generally-perhaps because the topic cutsacross so many specialties. Here, an international team ofexperts fills this void with a comprehensive discussion of thecauses and management of seizures associated with a widevariety of medical problems-including organ failure,organ transplantation, electrolyte imbalance, endocrine disorders,cardiorespiratory disorders, cancer, fever and systemicinfection, medication, alcohol, illicit drug use, andenvironmental toxins. Chapters cover the various types ofseizures and their pathophysiology, how to distinguishseizure from syncope, seizures in the ICU, and the use ofanticonvulsants.

You routinely order laboratory screeningpanels, including serum liver enzymemeasurements, for nearly everypatient who has a complete physicalexamination or who is seen for any ofa host of other complaints. If you findabnormal liver enzyme levels, your familiaritywith the common causes andthe settings in which they occur mayenable you to avoid costly diagnosticstudies or biopsy.

Many patients who experience anepisode of severe low back pain willhave a recurrence at some time in theirlife. Therefore, it is usually prudent toprescribe a long-term exercise programto minimize the pain and frequency ofrecurrences. Such a program should include3 types of activities:

Low back pain affects up to 80% ofAmericans at some point in their lives.1This common ailment can be mentallyand physically debilitating.

Q:What is the best and most efficient method ofevaluating pulmonary function in primary careoffice practice?

Liperoti R, Pedone C, Lapane KL, et al, UniversitaCattolica del Sacro Cuore, Rome,and other centers. Venous thromboembolismamong elderly patients treated withatypical and conventional antipsychoticagents. Arch Intern Med. Dec 12/26, 2005;165:2677-2682.

Outbreaks of Legionnaires diseasehave been traced to the inhalationof aerosolized water containing Legionellapneumophila, often originatingfrom cooling towers. A recentstudy of an outbreak in Franceindicates that the distance of airbornetransmission of L pneumophilamay be greater than previouslythought.

Abstract: Smoking cessation is still the most important intervention in patients with chronic obstructive pulmonary disease (COPD), regardless of sex. There is some evidence that nicotine replacement therapy may be less effective in women than in men. However, women may derive greater benefits from a sustained quit attempt. For example, one study found that compared with men, women who were sustained quitters had a greater initial rise and a slower age-related decline in forced expiratory volume in 1 second. Men and women do not appear to differ in their response to bupropion or to the various types of bronchodilators. A number of factors contribute to the increased risk of osteoporosis in women with COPD. Both smoking and the degree of airflow obstruction have been identified as important risk factors for osteoporosis. Women may be particularly susceptible to the effects of smoking on bone metabolism. Immobility and decreased physical activity have also been shown to accelerate bone loss. (J Respir Dis. 2006;27(3):115-122)

A 37-year-old man presented withnew-onset fever and abdominal painof several days’ duration. No respiratorysymptoms were reported.The patient had a history of multiplestab wounds to the abdomenand back, resulting in chronic backpain and a neurogenic bladder.During a previous hospital admission,he was treated for Enterobacterpyelonephritis with intravenousgentamicin for 12 days.

Chronic headache that worsened when she bent forward and episodes of usually unilateral vision loss sent a 34-year-old woman for medical consultation. The vision loss occasionally occurred in both eyes simultaneously.

Are follow-up radiographs or laboratory studies needed when lentigo maligna has been completely excised and a biopsy has been performed?