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Consultant Vol 42 No 6

For the past few weeks, pruritic
patches have been erupting on a
38-year-old man’s extremities. He recalls
that similar lesions occurred
during the last 2 winters. The patient
has a history of seasonal allergies;
he owns a cat and 2 dogs.

Patients with ear problems often pinch
their nose and blow in an attempt to
open up and clear their ears.

Standard first aid for insect bites
and stings involves cleansing the skin
with soap and water followed by
application of an antiseptic and topical

When you need to obtain an in-office
stool sample to test for occult blood,
a cotton swab is easy to use and comfortable
for the patient.

To reduce the incidence of candidal
infections in patients with dermatologic
problems, instruct them to dry
the affected area with a blow-dryer
on a cool or warm setting before they
apply topical medications.

My patient has lung cancer with liver metastasis.

Diabetes is epidemic! The numbers
are truly alarming. In 1997, official data
showed that 16 million people in the
United States had diabetes. Approximately
1 million had type 1 disease,
and 10.4 million had type 2 disease; the
remainder had undiagnosed diabetes.1
If these numbers are projected out
against an annual increase in disease
prevalence of about 3.5%, it means that
by the year 2028, 50 million people will
have diabetes. However, the actual rate
is closer to 7% each year. As such, approximately
100 million Americans—
roughly 1 of every 4—will have diabetes
by 2028.

A 6-year-old girl presents with
a several-month history of
genital discomfort that includes
itching, irritation, and
occasional bleeding. The
mother reports that there is
blood on the toilet paper after
the child wipes herself. There
has also been some spotting
in the child’s underwear. The
patient seems to be grabbing
at her crotch frequently.

Green discoloration of the fingernails
developed 6 weeks after a 29-year-old
woman had artificial nails placed during
a manicure. The patient was a doctor
of pharmacy degree candidate who
was married and had 2 children.

Since gout can precipitate olecranon bursitis, should I routinely order a crystal
analysis for patients who present with this bursitis?

In Dr David Kaplan’s Dermclinic case of a teenager with aphthous stomatitis
(CONSULTANT, April 15, 2001, page 665), the patient wears braces in the photograph

A 48-year old man presents to the emergency department
with constant, dull epigastric pain and right upper
quadrant pain. The pain has been present for 2 to 3
months; does not radiate; has not changed its pattern; and
is not associated with fever, nausea, vomiting, diarrhea, or
changes in urine or stool color. There are no alleviating or
precipitating factors.

A young child is brought to your office with a several-day
history of earache, sore throat, and low-grade fever. The nurse is concerned
about lesions she noticed on the child’s tongue while attempting to take his

A 52-year-old man complains of right knee pain that has
been increasing steadily for several weeks. Two years earlier
he underwent a total arthroplasty of the same knee to treat
severe osteoarthritis secondary to a meniscal injury. He has
no history of recent trauma or increased activity.

My 46-year-old patient had a fasting plasma glucose level of 115 mg/dL; a followup
fasting plasma glucose level was 116 mg/dL.

A 1-year-old woman comes to the
emergency department (ED) 3
hours after a male friend punched her
in the left lower back. The blow
knocked her to the floor and made
her feel faint. She also noticed blood
in her urine when she voided at
home after the injury.

The parents of a 2-year-old boy with a 3-day history of fever took him to the emergency department. The child’s temperature fluctuated between 38°C (100.4°F) and 39°C (102.2°F).

A 72-year-old man presented after several months of dyspepsia and 1 day of hematemesis. He was not taking NSAIDs.

The atrophic patches on the lower legs of this 47-year-old woman who has had
diabetes mellitus for over 20 years are those of necrobiosis lipoidica diabeticorum.
These areas involve degeneration of collagen and elastic fibers in the
lower dermis and changes in blood vessel walls. The lesions usually begin as
single or multiple elevated reddish nodules, most commonly in the pretibial
area. Over time, they expand and coalesce into distinctive brownish yellow
patches. These areas may be somewhat tender, but as they spread, they
frequently become painless—unless they ulcerate. Because the involved skin
is fragile, ulcers can form after any minor trauma.

This patient with long-standing insulin-dependent diabetes has difficulty
closing his hand because of “tight skin.” Diabetes is the cause: this finding
occurs more often in persons with microvascular complications, such as
retinopathy and nephropathy. The condition may occur even in patients with
well-controlled diabetes.

Syndrome The mother of a 7-year-old boy with cardiofaciocutaneous syndrome sought treatment for the cutaneous aspects of her son’s disease. Dry skin and keratosis pilaris of the upper outer arms were noted. Cardiofaciocutaneous syndrome— a rare autosomal dominant genetic disorder—had been diagnosed when the child was 3 years old.

Numerous brown spots on the leg of a man with longstanding
diabetes are diabetic dermopathy. This is a
microangiopathy of the small arterioles of the legs, which
results in atrophic brown papules.

Migraine is an episodic, often debilitating
condition that affects women more
often than men. Twenty-eight million
Americans suffer from migraine
headaches—and nearly 75% of these
are women.1 Unlike other chronic pain
conditions, migraine has its peak
prevalence during the years of greatest
productivity, when most women are
juggling family responsibilities and
careers.2 Many women are particularly
susceptible to migraine attacks just
before and during menses.

The past several years have witnessed
important advances in the evaluation
and management of chronic heart failure
(HF). Drugs such as β-blockers
and spironolactone have been shown
to reduce morbidity and mortality, and
strategies that employ new devices,
such as pacing and defibrillator therapy,
are evolving. This has prompted
the American College of Cardiology
(ACC)/American Heart Association
(AHA) to update guidelines first published
in 1995.1 The guidelines highlight
the importance of early and accurate
recognition of the clinical syndrome
of chronic HF and offer an
outline for evidence-based therapeutic
decision making.

This huge blister developed spontaneously on the foot of a woman with
diabetes mellitus. There was no area of redness around the blister, which
normally occurs with burns and inflamed lesions. Spontaneous blisters and
other skin manifestations are common in persons with diabetes.

An 83-year-old man with
a history of hypertension
and coronary artery
disease presented with a
4-day history of mental
status changes, slurred speech, and
difficulty ambulating. He reported a
lack of appetite and weakness of several

Diabetic retinopathy is the most common cause of legal blindness in persons
between the ages of 20 and 65 years. In this 56-year-old man with a 20-year
history of type 2 diabetes, multiple, scattered intraretinal (dot-blot) hemorrhages
and superficial nerve fiber layer (splinter) hemorrhages can be seen.
An occasional Roth spot—an intraretinal hemorrhage with a white center that
represents a fibrin thrombus which occludes a ruptured blood vessel—is also
evident. Numerous yellow, waxy, hard exudates are seen between the inner
plexiform and inner nuclear layers of the retina. Cotton-wool spots are also
present, although no neovascularization is present.

A 42-year-old woman presented with a papular eruption that first appeared during childhood. Severe pruritus, which worsened during the summer, accompanied the lesions. The patient reported that family members, including her mother and brother, had a similar skin problem. A biopsy of a characteristic lesion on the patient’s chest revealed diffuse acantholytic dyskeratosis, which confirmed the clinical diagnosis of Darier’s disease.

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