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57-year-old woman is hospitalized because of a 3-week history of persistent left-sided dull flank pain that worsens with movement and is associated with intermittent high fever.

Although proton pump inhibitors (PPIs) are highly effective, clinical failure in patients with gastroesophageal reflux disease (GERD) is seen regularly--not only in GI clinics but also in primary care offices. In fact, the prevalence of failure with PPIs has increased in proportion to the expanding indications for their use.

A 55-year-old man complains of fatigue. Although he sleeps 8 hours every night, he has to push himself to perform his usual daily activities. He has also experienced loss of libido and episodic impotence, which he ascribes to the fatigue.

We were taught in medical school to wait 3 minutes after a posture change to check orthostatic vital signs. Many patients with orthostatic hypotension experience symptoms immediately on standing.

Some patients are allergic to ester-type anesthetics, such as procaine.

To foster equal stimulation and drainage of both breasts, advise lactating mothers to alternate the breast they begin nursing with at each feeding.

How many bottles of nitroglycerin should your cardiac patients have?

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

An 82-year-old woman complains that for the past 6 months, she has "not felt like herself." Previously, she was very active and energetic; in fact, 9 months earlier, she had vacationed in Hawaii. It now takes all of her energy just to get out of bed.

Is it prudent to prescribe an oral bisphosphonate for an elderly woman with osteoporosis who has had acute hemorrhaging from a lower colonic diverticulum, for which a transfusion of 3 units of packed red blood cells was required?

While spending a month in Cuba, my travel companion experienced seabather's eruption, which was described by Drs Mary Sy and Gary Williams in their Photo Essay "The Dermatologic Perils of Swimming"

The incidence of malignant melanoma has been rising at an alarming rate. There is still no cure for metastatic melanoma; thus, early diagnosis followed by prompt excision is essential for a good prognosis.

A 69-year-old woman presents with inflammation near the antecubital fossa of her right elbow that first appeared 4 days earlier. She has a cat but does not recall being scratched or bitten, and she does not recall injuring the area.

A 68-year-old white man complained of a painful "raw" lip that had gradually developed over several years. Multiple, discrete, small erosions were noted on the lower lip, some of which were covered with an adherent yellow scale/crust. Removal of the scale/crust led to bleeding. None of the involved areas were indurated; regional lymph nodes were normal.

An 84-year-old woman presents with progressive ptosis of her right upper eyelid and blurred vision in the right eye . The eyelid started to droop 1 month earlier. She denies recent ocular injury or diplopia. Her history includes bilateral pseudophakia and a trabeculectomy.

A single papule with surrounding erythema followed by bullae, gray discoloration, and pain was thought to be a reaction to the bite of a brown recluse spider, commonly known as the fiddleback or violin spider. These spiders prefer dark, dry, and undisturbed locations and are most common in the south central US.

The parents of a 16-year-old girl report that during the past several months, she has exhibited behavioral changes, irritability, increased anger, depression, and anxiety. The girl had previously been healthy, and there has been no recent illness or trauma.

Tar on the feet and legs can be an unwelcome consequence of summer trips to the beach.