The mother of a 7-year-old girl noticed the rapid progression of a lesion on her child’s right hand over 3 weeks. Within several days of its initial appearance, the very small, nontender, and nonpruritic lesion had grown in circumference and “looked like a wart,” according to the mother. Application of over-the-counter preparations failed to resolve the lesion. A week before the office visit, the lesion “started growing straight up.”
The father of a 28-year-old man accompanied his son to the emergency department (ED) for evaluation of a “worm infestation.” About 6 weeks earlier, the patient had diarrhea for 2 days and claimed to have seen worms in his stool.
While jogging in a park, a 45-year-old man tripped and fell on his outstretched hand. As he fell, he tried to catch himself on a nearby park bench but was unsuccessful. He felt that his shoulder was out of place, and he was unable to adduct his arm from its erect position. A witness called for an ambulance, and the man was taken to the emergency department.
A 33-year-old man presented with joint pain and general malaise of about 2 weeks' duration and small yellowish lesions on the pinnae of the ears of about 6 months' duration. He had no urinary symptoms or conjunctivitis and was not taking any medications. His grandfather had been treated for gout.
ABSTRACT: The presence of blood in the urine is a significant finding that calls for prompt evaluation. Gross hematuria usually indicates a serious problem; its correlation with malignancy-typically a transitional cell carcinoma-is fairly high. Microscopically detectable blood is less likely to signal a major underlying condition; a finding of 0 to 3 red cells per high-power field is probably innocent. The workup for gross and microscopic hematuria focuses on disturbances of urinary tract function and includes a history and physical examination, urinalysis, radiologic imaging, urine cytology, and cystoscopy. The presence of hematuria, proteinuria, and renal insufficiency warrants referral to a nephrologist. A search for the cause of microscopic hematuria is much less likely than a workup for gross hematuria to uncover a life-threatening condition. If the hematuria persists, repeat the urinalysis and cytology every 6 months until the problem resolves or 3 years have passed.
ABSTRACT: Most hypertensive patients require lifestyle modification and multiple-drug therapy to achieve current blood pressure (BP) goals of less than 140/90 mm Hg and less than 130/80 mm Hg for those with diabetes mellitus or renal disease. For patients older than 65 years, the recommended initial antihypertensive is a thiazide diuretic. If a diuretic does not adequately control BP or is contraindicated, base the selection of an antihypertensive medication on comorbid conditions. For example, a ß-blocker may benefit a patient with coronary artery disease, while an angiotensin-converting enzyme inhibitor may help forestall renal disease in a patient with type 2 diabetes mellitus. The adage "start low and go slow" is appropriate to help avoid side effects and ensure compliance; however, most elderly patients eventually require standard dosages of medications to adequately control BP.
A 40-year-old womanwith HIV infection has had an occasionallypruritic facial rash for severalmonths. The rash is not associatedwith any systemic symptoms.
A 52-year-old man complains of nausea, fever, and malaise following a 2-day diarrhealillness that developed at the end of a family vacation in New England.Two family members suffered a similar illness, characterized by watery diarrhea.Symptoms developed in all who were affected within 24 hours of eatinghamburgers at a local restaurant.
Painful blue toes developed in a 72-year-old woman with coronary artery andperipheral vascular disease after she underwent angiography.
A 32-year-old African American man presented with an asymptomatic rash of 10 years’ duration.The patient reported that eruption abated during the winter.
A 34-year-old white woman presentswith a 4-month history of diarrhea,with bulky, foul-smelling stools; flatulence;diffuse abdominal discomfort;and episodic nausea and vomiting. Shehas lost 13.5 kg (30 lb) during this period.The patient has had no fever, andher medical, family, and travel historyare unremarkable.
For several months, a 70-year-old woman had had dysphagia,mild dyspnea on exertion, and the Raynaud phenomenon.Her skin was waxy and edematous; 2- to 10-mm pinkishspots had appeared on her fingers, palms, and oral mucousmembrane over the past 2 weeks. These disappearedcompletely with pressure. Subcutaneous calcific depositswere present on the extensor surfaces of the forearms.
A 65-year-old woman, who was confined to a wheelchairbecause of severe rheumatoid arthritis, was concernedabout nodules that had erupted on her fingers and handsduring the previous 3 weeks (A). Her medical historyincluded colon cancer, chronic renal insufficiency, anemia,and hypertension. The nonpruritic nodules were painfulwhen they began to form under the skin; however, oncethey erupted, the pain disappeared.
Ten weeks before presentation, this55-year-old woman noticed decreasedsensation in her feet and a bluish discolorationof her toes. These symptomsprogressed rapidly, and pain andcoldness in both feet increased in intensity.Her feet subsequently becamegangrenous. Her seropositive arthritishad been diagnosed about 6 yearsearlier. The disease had been wellcontrolled until about 10 weeks beforethis photograph was taken.
Bilateral swelling and pain in the distal interphalangeal (DIP) joints for severalmonths brought this 65-year-old woman to her physician. She complained alsoof stiffness in the region of the DIP joints when she arose in the morning andafter short periods (less than 15 minutes) of inactivity. A history such as this,in conjunction with the appearance of the patient’s hand, is typical of Heberdennodes, which are a manifestation of osteoarthritis (OA).
Extreme synovial inflammation resulted in the articular degradation seen in the hands of this 40-year-old woman who has Still disease, or juvenile rheumatoid arthritis (JRA).
ABSTRACT: The auscultatory features of heart murmurs-intensity, frequency, quality, configuration, timing, duration, and radiation-can help identify a variety of cardiac disorders. Systolic ejection murmurs have a crescendo-decrescendo configuration. These include innocent murmurs and those associated with aortic stenosis and hypertrophic cardiomyopathy. Systolic murmurs associated with retrograde flow from a high-pressure chamber to a low-pressure chamber usually have a holosystolic configuration. Examples of holosystolic murmurs include mitral regurgitation, tricuspid regurgitation, and the murmur associated with a ventricular septal defect. Diastolic murmurs include regurgitant murmurs, such as the decrescendo murmur of aortic regurgitation, and filling murmurs, such as the presystolic rumble of mitral stenosis, which is preceded by an opening snap. The murmur associated with patent ductus arteriosus is continuous.
Numerous factors put elderly patients at risk for adverse drug events. On average, they take at least 6 medications a day, which increases the likelihood of drug-drug interactions. In addition, many drugs that are safe and effective in younger patients are inappropriate for older persons because of age-related changes and comorbid conditions that affect absorption, distribution, metabolism, and elimination. First-pass metabolism decreases with age, which may increase systemic absorption of some oral nitrates, ß-blockers, estrogens, and calcium channel blockers. The age-related rise in body fat increases the volume of distribution of lipid-soluble compounds, such as diazepam, and prolongs clearance. About two thirds of elderly persons have impaired kidney function; in these patients, the dosage of renally excreted drugs-such as digoxin-needs to be reduced. Other strategies for avoiding adverse drug events are detailed here.
ABSTRACT: The basic screening studies for rheumatic diseases are a complete blood cell count, a determination of the erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) level, a rheumatoid factor assay, an antinuclear antibody (ANA) test, a measurement of serum uric acid level, and a urinalysis. Test results must be interpreted within a clinical context; for example, a positive ANA assay suggests the possibility of a rheumatic disorder, but it is not specific for any diagnosis. Tests that reveal the nature and extent of target-organ involvement, such as renal function studies in patients with systemic lupus erythematosus, can help guide the selection of therapy. Laboratory results also reflect disease activity; the ESR and CRP level are useful gauges of the activity of most inflammatory rheumatic disorders. Finally, laboratory monitoring can help you minimize the significant toxicity associated with many of the drugs used to manage rheumatic diseases.
A52-year-old white man presented with a pruritic eruption on the neck of 3 months’ duration. The rash had not responded to a potent topical corticosteroid prescribed by another practitioner for the presumed diagnosis of eczema. The patient reported no current health problems. His history included a pubic louse infestation and several episodes of uncomplicated urethral gonorrhea. He readily admitted to having unprotected sexual intercourse with prostitutes.