For 2 years, a 79-year-old man had postprandial fullness and epigastric discomfort. He also experienced regurgitation and substernal pain after eating that was relieved by belching. He had a history of hypertension and gout. The patient’s vital signs were normal.
A 34-year-old man experienced feverand arthralgia several days afterappearance of the rash shown here(A). He did not recall being bittenby a tick, as is often the case withpersons who contract Lyme disease.
ABSTRACT: To determine the stability of the injury, examine phalangeal and metacarpal fractures for intra-articular involvement. Suspect carpal bone fracture in any patient with wrist pain and tenderness; proper splinting is essential to prevent avascular necrosis of the bone, arthritis, and chronic disability. After successful reduction of a distal or proximal interphalangeal joint dislocation, order follow-up x-ray films. Apply stress testing of the joint space to all injured joints to ensure ligamentous integrity. Carpal and carpometacarpal dislocations require immediate consultation with a hand specialist. Therapy for bite wounds includes copious irrigation, debridement (in the operating room if necessary), and antibiotic prophylaxis. A patient with an infected bite wound requires hospitalization and intravenous antibiotics.
In their article, “Diabetes: How Early-and Aggressively-to Intervene?”(CONSULTANT, November 2005, page 1416), Drs Thomas Clark and John R.Holman discussed the results of the lifestyle intervention and metformin armsof the Diabetes Prevention Program (DPP) study. However, the authors neglectedto include data from the troglitazone arm of the DPP study.
Exercise is a safe and effective therapy for patients with osteoarthritis or rheumatoid arthritis. It can reduce pain, increase flexibility and strength, and prevent deconditioning. To help motivate patients to initiate and adhere to an exercise program, educate them about these benefits, encourage them to set specific goals, recommend that they commit to a routine for at least 6 to 8 weeks (the minimum time needed to appreciate significant results), and warn them not to be discouraged by initial soreness. An exercise program for a patient with arthritis should include stretching (to improve joint flexibility), strengthening (to prevent deconditioning of the muscles that keep the joints stable), and aerobic exercise (to enhance overall fitness). Isotonic strengthening exercise is particularly important because it can reverse muscle wasting. Recommend that patients exercise for 30 minutes a day, 5 days a week. Water exercise is especially beneficial.
A massive amount of blood in the inferior medial quadrantof the conjunctiva and ecchymosis of the lowereyelid of the right eye prompted a 60-year-old woman toseek medical attention. She had first noted blood in theeye 5 days earlier. There was no history of trauma.
A 14-year-old boy presented with a 3-day history ofrunny nose, cough, and fever. His temperature was37.7°C (100ºF); heart rate, 78 beats per minute; and respirationrate, 26 breaths per minute. Several symmetric,circular ecchymotic lesions that measured 4 cm in diameterwere noted on the upper chest. There was no evidenceof external injury to other parts of the body. Thechild reported that the bruises resulted from cupping,performed by a Chinese practitioner in an attempt torelieve the fever.
A 7-year-old Chinese boy presented with fever, cough,and sore throat of 2 days’ duration. His temperature was38.3°C (101°F); heart rate, 85 beats per minute; andrespiration rate, 26 breaths per minute. The throat waserythematous but without any exudate. There weresmall cervical lymph nodes bilaterally. The chest wasclear.
This 9-year-old girl had a slightlypruritic perioral rash for 6 months.The skin around her mouth wasred, scaly, thickened, and hyperpigmented.She also had eczematouslesions in the antecubital andpopliteal fossae.
A 16-year-old girl of normal weight for height (body mass index, 21) was evaluated for a 6-month history of binge-purge cycles and amenorrhea. She met the diagnostic criteria for bulimia nervosa and began treatment that involved a multidisciplinary team. During the second month of therapy, the patient presented to the emergency department after she accidentally swallowed a toothbrush while trying to induce vomiting with the brush’s handle.
A 14-year-old girl was concerned about this 1-cm, red, nodulocystic lesion on her left posterior shoulder that had been present for several months. The lesion had developed over the site at which a 0.5-cm pilomatrixoma had been excised a year before. Four years earlier, another 1.9-cm pilomatrixoma had been excised from the girl’s right outer upper arm. There was no family history of the lesion.
A 58-year-old man with type 2 diabetes mellitus and hypertension was hospitalized with acute diarrhea characterized by several brown, liquid depositions per day. He also complained of lower abdominal pain and bloating and a 10-lb weight loss in the past 2 months. He denied fever or chills, use of corticosteroids, and travel outside the United States.
ABSTRACT: Glenohumeral joint osteoarthritis may result from trauma, concomitant shoulder pathology, or crystal deposition disease, or it may have no discernible cause. The physical examination reveals muscular atrophy, abnormalities during palpation, and limited range of motion, particularly in external rotation and flexion. Treatment includes both nonpharmacologic and pharmacologic interventions. Nonpharmacologic strategies include patient education, activity modification, and structured rehabilitation followed by transition to a long-term home exercise program. Pharmacologic treatment may involve progressively potent oral analgesics and perhaps corticosteroid injections. Surgical procedures, such as shoulder arthroplasty and arthroscopic debridement, are indicated for intractable pain and loss of function.
For 2 years, a 66-year-old woman had a winglike structure on the nasal sideof her right eye. She had normal vision. A diagnosis of pterygium was made.
A 36-year-old woman was concerned about the diffuseyellow pigment at the temporal aspect of the conjunctivaof her right eye.
The irides of a legally blind 19-year-old woman had been absent since birth.When she was 6 weeks of age, her parents noted that she was not focusingon objects the way her siblings had. They consulted an ophthalmologistwho diagnosed aniridia. The woman is able to read book print close up andcan ambulate independently, although she has difficulty at times, such aswhen stepping off a curb in unfamiliar surroundings.
Brown pigmentation of the medial 60% of the left iris was noted in a 40-yearoldwoman. The remainder of the iris was blue, as was the entire right iris.She stated that she had a “spot” of brown in the left iris at birth. The pigmentedarea had gradually enlarged until puberty and had not changedsince then. Her vision was normal.
For a year, a 35-year-old man had an asymptomatic, slowly growing, semifirm nodule on the lateral aspect of his hand. He was concerned that it was malignant.
A 37-year-old man is referred after a routine employment physical reveals anabnormal blood cell count. He has felt well and noticed no obvious symptomsexcept for mild fatigue, which he attributes to excessive work. He denies fever,unusual or frequent infections, and abnormal bleeding.
Until recently, celiac diseasewas considered a rare disorder.However, new evidencesuggests that about1% of Americans are affected.As serologic tests that detect autoantigensinvolved in celiac diseasebecome more widely used, morecases will likely be identified.1
