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Consultant Vol 44 No 2

For 1 week, a 35-year-old woman’s left ear has been very painful, erythematous,
and swollen. There is no history of insect bite or trauma. Her condition
improved only slightly after the physician she initially consulted prescribed
methylprednisolone and cephalexin.

Instead of using a catheter to document
patent nares on a newborn, first
evaluate the quality of the neonate’s
suck with a clean, bare finger and
then place the wet finger under the
nose to feel exhalation.

I usually collect a urine sample as
part of a complete physical examination.

Place domestic violence pamphlets in
the women’s restroom.

When you examine a young child’s
ear, have him or her sit sideways on
the parent’s lap.

A 13-year-old girl of African American descent is brought to the pediatrician’s office because
of a lesion on her neck. The girl’s mother had telephoned the office before the visit, stating
that the lesion resembled a blister at first, but now looked like a burn.

For about 4 months, a very dry, diffuse,
fine scaly, asymptomatic eruption
covered the palms of a 28-yearold
man; several fingernails were
dystrophic bilaterally as well. Before
the onset of this condition, bilateral
onychomycosis of the toenails had
been diagnosed. The toenails had not
been treated and were still affected
at the time of presentation. Branching
hyphae were seen on a potassium
hydroxide preparation of a fingernail
cutting. The patient had tinea manuum
and tinea unguium

An eruption on the face of a 49-year-old woman had been misdiagnosed as a
staphylococcal infection; the rash failed to respond to oral and topical antibiotics.
A mid-potency topical corticosteroid also had been tried, but the eruption
worsened.

A30-year-old man complains of chest pain, dyspnea, fever, and nonproductive
cough that began earlier in the day. The pain is constant and does not
diminish with rest; it worsens somewhat with deep inspiration and has localized
to the left chest. The patient has had no nausea, vomiting, or abdominal pain.
He has been immobile for several years secondary to spinal cord disease but
has no history of cardiopulmonary disease.

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.

A 56-year-old man had an asymmetric,
maculopapular, sharply demarcated,
pruritic, excoriated dermatitis on his
upper thighs. The eruption had been
present for 2 to 3 weeks

A 24-year-old man presented for evaluation of pruritic vesicles on both feet.
Ten days earlier, dyshidrotic eczema had been diagnosed by another physician
who prescribed triamcinolone ointment. The patient reported that the foot
eruption worsened after the topical medication was applied.

A healthy 11-year-old boy complains of a “bump below his kneecap” that hurts to touch and when
he jumps. He first felt slight pain a month earlier. Since then, he has occasionally complained of
pain and a bump on the right knee.

A 70-year-old man first noticed this
skin condition when he returned from
the South Pacific at the end of World
War II. Over the years, the rash has
itched only occasionally; however,
during a recent spate of hot weather,
the eruption became highly pruritic.
Applications of an over-the-counter
1% hydrocortisone ointment exacerbated
the condition

A new lesion recently arose on the right flexor forearm of
a 67-year-old man. The 1-cm, pruritic, pink, circular, slightly
raised lesion was perfectly homogeneous with no central
clearing.

The parents of a 3-year-old girl sought evaluation of their daughter’s hair loss.
During the past several months, a large patch of alopecia with scaling had developed.
The differential diagnosis included seborrhea, trichotillomania, and
tinea capitis.

A 49-year-old man was concerned about a right flexor forearm
lesion that had been increasing in size for 6 weeks.
The light pink, well-demarcated, 5-cm, circular lesion featured
slight peripheral elevation with ulceration, crusting,
and a relatively clear central area. A culture of material
from the lesion was negative for fungi. A potassium hydroxide
evaluation was not performed.

Treatment of fibromyalgia syndrome (FMS) is a challenge. However, most patients benefit from appropriate management. Essential to treatment are a physician's positive and empathetic attitude, continuous psychological support, patient education, patience, and a willingness to guide patients to do their part in management. Other important aspects involve addressing aggravating factors (eg, poor sleep, physical deconditioning, emotional distress) and employing various nonpharmacologic modalities (eg, regular physical exercise) and pharmacologic therapies. Drug treatment includes use of tricyclic medications alone or in combination with a selective serotonin reuptake inhibitor, and other centrally acting medications. Tender point injection is useful. It is important to individualize treatment. Management of FMS is both a science and an art.

 
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