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Consultant Vol 42 No 4

To help relieve the pain of a sore
throat, patients are often instructed to
gargle with warm salt water—usually
4 times a day.

To help elderly patients avoid stumbling
and falling, advise them to
“walk like a drum major” and lift their
knees high.

Meningococcal septicemia can be
deadly if not diagnosed and treated
early.

To remove impacted cerumen, have
patients pour a drop or two of baby oil
in the affected ear before going to bed
(just enough to fill the canal), then occlude
the ear with a cotton ball.

A 57-year-old man was referred for
evaluation of an enlarging, painful,
irregular ulceration on his lower abdominal
wall. The patient recalled
having a small, red, “blister-like” lesion
that had rapidly expanded to its
current size of 2.5 * 4.5 cm. He
denied specific injury to the skin;
however, he often wore jeans that
rubbed the area. The patient was
taking ibuprofen for seropositive
rheumatoid arthritis.

Q:What is the best screening test for suspected
renal artery stenosis?

Q:My patient’s family appears to be genetically predisposed to
pulmonary fibrosis. How should I follow this patient? What early
warning signs herald the condition, and what diagnostic tests are most
appropriate?

We read with great interest the “Dermclinic” case of a 44-year-old man with a
changing pigmented lesion on his trunk (CONSULTANT, March 2001, page 354).

A persistent, 2-month-old rash under both breasts has not responded to overthe-
counter antifungal creams. The 55-year-old patient now seeks medical care;
she is otherwise healthy.

An ulcer was noted on the right arm of
a 65-year-old woman with ulcerative
colitis who was being evaluated for a
partial bowel resection. Antibiotic therapy
given 2 months earlier had no impact
on the lesion; subsequent debridement
only increased the ulcer’s size.

Your patient with atrial fibrillation (AF)
is hemodynamically stable and you
have successfully established rate control.
Your next step is to weigh the
risks and benefits of attempting to restore
sinus rhythm. In up to one half of
patients, AF of recent onset converts
spontaneously to normal sinus rhythm
within 24 hours. Thus, in some cases,
the most appropriate approach may
be to control the ventricular response,
identify and treat comorbid conditions,
initiate anticoagulation, and closely
monitor the patient.

After a routine examination reveals heme-positive stool, a 56-year-old man
undergoes upper and lower endoscopy. Esophageal varices are found, as well
as internal hemorrhoids and a few gastric erosions.

A 56-year-old man who has type 2 diabetes presents with fever
of 3 to 4 days’ duration, scrotal swelling, and a feculent odor. He has no
history of trauma or serious illness; however, his glucose level has not been
well controlled during the past several weeks.

A 33-year-old man with AIDS presented to the emergency department with fever, dyspnea, cough, and pleuritic chest pain of 3 days’ duration. He had had a Pneumocystis carinii infection 3 years before recently emigrating from the Dominican Republic to the United States.

Have any specific genes been identified for type 1 or type 2 diabetes? If so, how
many genes are involved?

Numerous plaques, some with yellow crusting and central scarring, had erupted primarily on the face and neck of a 46-year-old man. A single lesion had developed on his left elbow as well. The lesions were initially diagnosed as impetigo, but they failed to resolve after 2 courses of oral cephalexin.

A 41-year-old man is admitted for evaluation of acute
chest pain, which started while he was watching
television after dinner. The retrosternal pain was sudden,
severe, pressing, and stabbing; it radiated to the neck and
was associated with dizziness and diaphoresis. The patient
rated the pain as 9 on a scale of 1 to 10 (10 being the most
severe). In the emergency department, he was given
2 sublingual nitroglycerin tablets, which promptly relieved
his pain.

Pyoderma gangrenosum is frequently
associated with systemic diseases,
such as ulcerative colitis and Crohn’s
disease (Table). The occurrence of the
skin ulcers does not necessarily correlate
with the activity of the underlying
disorder.

Infection with hepatitis C virus (HCV) was recently diagnosed
in a 45-year-old man when a positive enzyme-linked immunosorbent
assay was followed by a polymerase chain reaction assay
that showed a viral load of 835,000 copies/mL. The patient probably
acquired the infection when he was using intravenous heroin, a practice he quit 10 years
ago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfection
with HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis
(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in the
liver. The HCV genotype is 1A.

A 65-year-old woman with metastatic adenocarcinoma of the colon was undergoing chemotherapy following a colectomy and a hepatic wedge resection. The physical examination and laboratory data were unremarkable.

Atrial fibrillation (AF) is the most common
sustained cardiac arrhythmia; it
affects about 2.2 million Americans.
The prevalence of AF, which increases
with age,1 is approximately 5.9% in persons
older than 65 years2 and greater
than 10% in those older than 75 years.3

This condition is characterized by
a localized narrowing of the jejunum
without a disruption of continuity
or defect in the mesentery. At the
stenotic site, there is often a short,
narrow segment with a minute lumen
where the muscularis is irregular
and the submucosa is thickened.
The resultant intestinal obstruction
is incomplete.

This condition involves the invagination of a proximal
segment of bowel (the intussusceptum) into a more distal
segment (the intussuscipiens) (A). It occurs most
frequently in infants between the ages of 5 and 12
months and is a leading cause of intestinal obstruction
in children aged 2 months to 5 years. Intrauterine intussusception
is associated with the development of intestinal
atresia. The male to female ratio is approximately
3:2. Intussusception is slightly more common in white
than in black children and is often seen in children
with cystic fibrosis.

For 3 weeks, a 14-year-old boy had been aware of an enlarging lesion on the back of his hand. He recalled no trauma to the affected area. Further questioning by Dr D. Keith Cobb of Savannah, Ga, revealed that a 4-mm verruca, or wart, had been removed from the same site 6 months earlier with cryosurgery by a different physician.

A 3-day history of intermittent fainting spells brings a 49-year-old man to your
office. His only significant medical history includes seasonal allergic rhinitis,
for which he takes terfenadine, and mild depression, which is being treated
with amitriptyline. A week ago, he began taking erythromycin, 500 mg qid,
for acute pharyngitis.

My patient, a 33-year-old man who works with his hands, presented with a growth
under his left thumb nail (Figure).

During the last few weeks of gestation
or shortly after birth, the layers
of the processus vaginalis normally
fuse together and obliterate the entrance
to the inguinal canal in the
vicinity of the internal inguinal ring.
An indirect hernia results from a failure
of fusion of the processus vaginalis;
the bowel subsequently descends
through the inguinal canal.

This obstruction is caused by a failure of intestinal peristalsis;
there is no evidence of mechanical obstruction.
Paralytic ileus is common after abdominal surgery, especially
if anticholinergic drugs are given preoperatively
and/or narcotics are used postoperatively. It usually lasts
2 to 3 days. Paralytic ileus may also be caused by peritonitis;
ischemia or surgical manipulation of the bowel; retroperitoneal
hemorrhage; spinal fracture; systemic sepsis;
shock; hypokalemia; uremia; pharmacologic agents (eg,
vincristine, loperamide, and calcium channel blockers);
diabetic ketoacidosis; and myxedema.

A 52-year-old woman was admitted to
the hospital with progressive shortness
of breath of 2 days’ duration. Bronchial
asthma had been diagnosed 6 months
earlier; inhaled corticosteroids, bronchodilators,
and leukotriene antagonists
were prescribed. Despite aggressive
treatment, the patient’s dyspnea
and wheezing worsened.

A tiny papule that arose after minor
trauma to her finger marked the
onset of this lesion, according to the
48-year-old patient. She reports that
the papule rapidly evolved into a
pustule that grew within 2 weeks into
a painful, undermined, purple-edged
ulcer. The lesion did not respond to
antibiotic therapy. The patient had rheumatoid arthritis.

The pyoderma gangrenosum on the
right anterior tibial area of a 40-yearold
man was thought to be associated
with his rheumatoid arthritis. However,
the cause of many of these ulcers
is unknown. The patient could not recall
any recent trauma. At least half of
all pyoderma gangrenosum lesions
occur in persons who do not have associated
diseases.1

Two of my patients are older men (aged 62 years and 68
years) who have benign prostatic hyperplasia; their prostates
are soft and nontender.

A 62-year-old woman was admitted to the hospital with back pain, fatigue, and
an ulcerated lesion on the anterior left foot. Clinical and laboratory findings
confirmed the diagnosis of multiple myeloma.

A 28-year-old woman complains of intermittent
right upper quadrant pain.
The patient is thin, and she is not in
acute distress.

Although the content of
the latest childhood
immunization schedule
has remained essentially
the same since January
2001 (Table),1 the format has been
redesigned to highlight:

A 59-year-old man has had chest discomfort for several months. He first
noticed the symptoms when he was doing heavy lifting and moving at work.
The discomfort starts in the midsternal region and radiates to the left shoulder
and arm. It is often accompanied by diaphoresis, but there is no dizziness or
dyspnea. The discomfort always subsides a few minutes after the patient
stops the activity that brought it on. More recently, he has experienced similar
symptoms while walking up steep hills on the golf course and dancing at a
wedding.

Delirium in older adults needs to be
recognized early and managed as a
medical emergency. Prompt detection
and treatment improve both shortand
long-term outcomes.1,2 Because
delirium represents one of the nonspecific
presentations of illness in elderly
patients, the disorder can be easily
overlooked or misdiagnosed. Misdiagnosis
may occur in up to 80% of cases,
but it is less likely with an interdisciplinary
approach that includes input
from physicians, nurses, and family
members.3

This painful, eroded plaque on the
dorsum of a 39-year-old man’s hand
had developed over a few days from a
small, painful pustule. The patient’s
history included ulcerative colitis,
which was not active when the lesion
occurred.

The Geriatric Depression Scale is the most widely
validated screening tool. The questionnaire has been
reduced to a single question that is as sensitive and as specific
as the 15-item shortened form of the original 30-item
scale. The question is: "How often do you feel sad or depressed?'
This is certainly something that is easy to ask in
the course of a general physical examination or routine office
visit.

 
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