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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.

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.

Hyperpigmentation is seen on the cheeks and eyelids of a 36-year-old woman.She became hyperthyroid at age 19 years, with accompanying exophthalmosand hyperpigmentation, following the birth of her first child. Thyroidectomywas carried out at that time, and the patient has been receiving thyroid replacementtherapy ever since. The hyperpigmentation, an uncommon accompanimentof hyperthyroidism, has persisted.

Macrolides are commonlyused to treat avariety of infections.Erythromycin haslong been recognizedas having numerous highly importantdrug interactions.1 Althoughclarithromycin generally has somewhatless of an effect on the clearanceof other drugs, it also has severalclinically relevant interactions.1-3

Because bariatric surgery has traditionally been associated with a high incidence of complications, it has been used primarily for superobese patients. A large body of evidence suggests that laparoscopic adjustable gastric banding is a much safer procedure that is also very effective. This procedure offers an additional option to patients who might benefit from bariatric surgery when diet, exercise, and pharmacologic approaches have failed. Here we address questions primary care physicians often ask about the procedure.