ABSTRACT: High-sensitivity C-reactive protein (hs-CRP), a marker of low-grade vascular inflammation, reflects baseline inflammatory predilection-a key factor in the genesis and rupture of atheromatous plaque. Measurement of hs-CRP is recommended in persons who have an intermediate (10% to 20%) 10-year risk of coronary artery disease; a level above 3 mg/dL indicates higher cardiovascular risk. Although dietary therapy and statins may lower hs-CRP levels, such reductions have not been shown to prevent cardiovascular events or death. Elevated homocysteine levels have been associated with an increased risk of cardiovascular disease. Consider screening in patients with a personal or family history of cardiovascular disease who do not have well- established risk factors. Supplementation with folic acid and vitamin B12 reduces homocysteine levels by about 30%. Elevated fibrinogen levels have been associated with ischemic heart disease and stroke; however, fibrinogen-lowering therapy has not led to better outcomes than standard treatment regimens.

ABSTRACT: The prevalence of erectile dysfunction (ED) is higher among men with hypertension than among normotensive men. Sexual dysfunction is a common side effect of many antihypertensive medications and can lead to noncompliance. Treatment-related ED is more often associated with diuretics and ß-blockers and is less common with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. If ED complicates therapy, consider switching to an antihypertensive agent with fewer sexual side effects. However, if compelling reasons exist for the use of a particular antihypertensive agent (eg, a ß-blocker in a patient with previous myocardial infarction), several options for the treatment of ED are available. Phosphodiesterase-5 inhibitors have been shown to be safe and effective in men who are receiving antihypertensive therapy.

A symptomatic brown macules developed on the face of a 32-year-old woman 1 year ago. She had been taking oral contraceptives for the past 5 years. Her medical history was unremarkable, and the results of a physical examination were normal.

A left-handed 84-year-old retired attorney is seen for a routine scheduled visit 5 months after a stroke. The nondominant hemisphere was affected by an embolism that arose in the newly fibrillating left atrium.

ABSTRACT: During the history taking, pay particular attention to pharmacologic and toxic exposures; among the medications and substances associated with tremor are ß-adrenergic agonists, stimulants, psychotropic agents, anticonvulsants, dopamine agonists, methylxanthine, and heavy metals. During the examination, observe the amplitude, frequency, and rhythm of the tremor. In contrast to physiologic tremors, which have low amplitude and high frequency, pathologic tremors typically have a higher amplitude and lower frequency. Tremors can be classified as resting, postural, or action. Resting tremor is almost always associated with other features of Parkinson disease, while postural and action tremors are prominent features of essential tremor. When essential tremor interferes with normal daily functioning, treatment is indicated. ß-Adrenergic antagonists, anticonvulsants, benzodiazepines, primidone, and nimodipine have been used in this setting. If these medications are ineffective, consider botulinum toxin A or surgery.

When vesicles developed on a 35-year-old man’s right sole, he thought he washaving a recurrence of "athlete’s foot." However, pain and tenderness in thearea suggested herpes zoster. Indeed, the vesicles and erosions shown aremainly in the S1 dermatome.

For 3 years, numerous skin-colored papules had been present on the face of a 59-year-old man. The lesions developed several months after renal transplantation and the start of immunosuppressive therapy.

35-year-old Hispanic man presented with nonproductive cough; dyspnea; fever; and a painful, ulcerated, 1.5-cm, red-brown plaque on the left flank. He had had the lesion for 3 months and the symptoms for 1 week. The patient had grown up in Arizona, and he traveled there 4 months before the lesion arose.

We have recently had an upsurge in children with type 1 diabetes at our gastroenterologyclinic for celiac screening.

ABSTRACT: To assess a child for overweight, begin by calculating his or her body mass index (BMI). Note that BMI is used differently in children than it is in adults. A child's BMI is plotted on a growth curve that reflects that child's age and gender. This yields a value-BMI-for-age-that provides a consistent measure across age groups. Children whose BMI-for-age is between 85% and 95% are at risk for becoming overweight. Any child whose BMI-for-age is 95% or more is considered overweight. The 2 main factors associated with overweight in children are poor eating habits and decreased physical activity. Recommend that children have at least 5 servings of fruits and vegetables a day. Children should engage in moderate physical activity for at least 60 minutes on most days of the week, and TV viewing and computer activities should be limited to no more than 2 hours a day.

Four hours before he arrived at the emergency department, a 33-year-old man had been struck in the face by a rock. A laceration and periorbital hematoma were noted on the left side of the patient’s face. He complained of pain in this area. There was no history of intraocular disease. The left globe was intact, and no neurologic deficit was found.

Scrotal enlargement and pain of rapid onset prompted a 28-year-old man to seek medical attention.The testicle was displaced posterior and inferior in the engorged scrotum and wasdifficult to palpate.

A 30-year-old man presentedwith severe left flankpain radiating to his abdomenand gross hematuriaof 5 to 10 days’ duration.He also reported a 4- to 6-monthhistory of nausea with intermittentvomiting, anorexia, and progressiveweight loss. He took no medicationsand had no allergies.

ABSTRACT: Restriction of fluid and salt intake is essential in patients with edema. Bed rest and supportive stockings are also helpful. However, diuretics are usually the mainstay of therapy. The effect of thiazide diuretics is relatively mild; they may be adequate in patients with cirrhosis but are ineffective in those with congestive heart failure (CHF) or nephrotic syndrome. Loop-acting diuretics can induce massive natriuresis and diuresis. Intravenous loop diuretics are preferred to oral agents for the relief of pulmonary edema. Acetazolamide, a carbonic anhydrase inhibitor, is commonly used in patients with glaucoma and is also recommended for those with CHF accompanied by metabolic alkalosis. Combination therapy is recommended for patients with refractory edema and normal or somewhat impaired renal function. The adverse effects of thiazide and loop-acting diuretics include renal insufficiency, hyponatremia, hypochloremia, hypokalemia, hypomagnesemia, metabolic alkalosis, hyperglycemia, and hyperlipidemia. These effects are typically reversed when the dosage is reduced or therapy is discontinued. Potassium sparing diuretics can cause life-threatening hyperkalemia.

For 24 hours, a 62-year-old woman had had severe weakness, abdominal pain, and watery diarrhea that had become bloody in the past 12 hours.She had no significant medical history.

For 3 days, a 47-year-old woman had a painful red swelling on her finger.The patient--a cellist--had tried to lance the lesion at home, but itprogressively worsened and was now “throbbing.” She denied fever andnail biting.

A 32-year-old woman presents with weight loss of 6.4 kg (14 lb) during the past 8 months and diarrhea of recentonset. Menstruation had ceased 10 weeks earlier. She appears anxious, with pressured speech. Physical examination detectsbaseline sinus tachycardia, sweaty palms, and a diffusely enlarged thyroid gland. Laboratory tests reveal a thyroid-stimulatinghormone (TSH) level of 0.00 µU/mL (normal, 0.45 to 4.5 µU/mL), a free thyroxine (FT4) level of 4.8 ng/dL (normal,0.61 to 1.76 ng/dL), and a positive thyroid-stimulating immunoglobulin (TSI) level with high titer.

Swelling of the lower legs broughtthis 57-year-old woman to a familypractice clinic. She had a history ofhyperthyroidism with weight loss,tachycardia, and anxiety. This conditionwas confirmed with blood testsand radioactive iodine uptake testing.

This 17-year-old presented with a 1-month history of weight loss, increased appetite, mild insomnia, hand tremor, palpitations, sweating, heat intolerance, and quick loss of temper. The number of daily bowel movements had increased from 1 to 2. There was no family history of thyroid disorders.

A mildly painful, nonpruritic rash on the forearms and legs prompted a 42-year-old man to go to the emergency department. The patient noted the rashwhen he awoke that morning. He had had joint pain and fever for the past7 days and generalized malaise with chills that began about 3 days earlier.He had no significant medical history.