PhotoclinicThe appearance of a rash on his hands and feet prompted this man to seek medical evaluation. For the past year, he had been in a monogamous relationship with a male sex partner.
Factitious dermatitisA 16-year-old boy presents with a 1-month history of an asymptomatic rash on his sacral area. There are no other rashes on his body.
Purpura<p class="p1"><img src="/sites/default/files/images/1209Con_DC_C3.jpg" alt="Bateman, actinic, purpura" title="Bateman, actinic, purpura" width="90" height="90" style="float: left; margin: 5px;"><br>The occurrence of new bruises on his arms disturbs a 69-year-old man. He reports no history of trauma or <span class="s1">use of aspirin or other anticoagulants. The patient denies</span>hemoptysis, hematuria, hematochezia, epistaxis, and other bleeding.</p>
Tinea Manuum<p><img alt="Tinea manus" src="/sites/default/files/images/1209Con_DC_C2.jpg" style="height:90px; margin:5px; width:90px; float:left" title="Tinea manus" /><br /> A 56-year-old man has had eczema only on his dominant, right hand for 30 years. He had tried topical corticosteroids, but they failed to clear the condition.</p> <div> </div>
Dermatitis<p class="p1"><span class="s1"><img src="/sites/default/files/images/1209Con_DC_C1.jpg" alt="Stasis dermatitis" title="Stasis dermatitis" width="90" height="90" style="float: left; margin: 5px;"><br>Two months of scratching her itchy lower legs have sent a 62-year-old woman to her physician. The pruritus began</span> shortly after she started taking a calcium channel blocker for hypertension.</p>
Photoclinic<p class="p1"><img src="/sites/default/files/images/1209Con_PCGeoTong.jpg" width="90" height="90" style="float: left; margin: 5px;">The smooth areas in the typical “mapping” of geographic tongue, shown here, represent flattened or denuded filiform papillae. The cause of this common condition is unknown. The case of this 5-year-old girl is unusual because the geographic mapping—usually appearing only on the dorsum of the tongue—extends to the ventral surface. According to the patient’s mother, the child’s tongue had always had this appearance. The only symptom was an occasional burning sensation when she ate ketchup.</p>
von hippel-lindau syndrome<p class="p1"><img src="/sites/default/files/images/1209Con_PCVHLSynd.jpg" alt="Von Hippel-Lindau Syndrome " title="Von Hippel-Lindau Syndrome " width="90" height="90" style="float: left; margin: 5px;"><br>For 3 days, a 43-year-old man had had a progressively worsening headache. The pain had increased in severity to the point at which he considered it unbearable and sought medical attention.</p>
Photoclinic<p><img src="/sites/default/files/images/1209Con_PCGlomus_A.jpg" alt="Glomus Tumor" title="Glomus Tumor" width="90" height="90" style="float: left; margin: 5px;"><br>A 49-year-old woman presented for evaluation of spontaneous bloody discharge from her nipple of 2 weeks’ duration. She was also able to express the discharge and had some associated breast soreness. Results of yearly screening mammograms had all been normal.</p>
Chest painPrimary care patients with chest pain comprise a sizeable cohort. Not only do some have a potentially fatal disease (an acute coronary syndrome), but those who do not (most of them, or 85% to 90% of the visits) are often admitted from the emergency department and add needless costs.
Leukemia, tonsillitis<p>Many patients with hematologic malignancies are initially seen in the primary care setting. Here we demonstrate such a case in a young woman who presented with a sore throat. She was referred to a tertiary care center because of abnormal blood cell counts and was then rapidly treated with resolution of symptoms.</p>
Complete Heart Block, sinus hypersensitivity<p>An 85-year-old man presents to the emergency department (ED) with fatigue and dizziness of several weeks’ duration; these symptoms have worsened during the past 2 hours. He has not had any frank syncope, chest pain, or palpitations. He is normally active and plays singles tennis every day but has not had sufficient energy to play for the past 2 weeks. He denies any fever or headache. He denies any modifying factors; he has not noticed any orthostatic relationship to his symptoms or any change with head motion. He has limited cervical spine mobility as a result of a vertebral fusion he underwent 20 years ago for degenerative disc disease. His medical history is notable for a myocardial infarction 20 years earlier, for which he was treated with streptokinase while visiting Belgium; hypertension; prostate cancer (in remission); hypothyroidism; gastroesophageal reflux disease; and osteoarthritis.</p>
Pitfalls In Prescribing<p>The benefits of <em>cardioselective </em>beta-blocker therapy outweigh the associated risks in patients with nonsevere asthma after myocardial infarction (MI) or for the long-term treatment of heart failure. We have recently observed both medical residents and attending physicians prescribing noncardioselective beta-blockers to patients with asthma. Consequently, we believe this summary will be a timely reminder to healthcare professionals to be careful to administer cardioselective beta-blockers for appropriate indications in asthma patients and clearly avoid noncardioselective agents.</p>
Scabies<p>Twin 16-month-old boys were referred by a pediatric endocrinologist to the pediatric dermatology clinic for assessment of generalized itchy lesions of 7 months’ duration. The lesions had been treated as eczema with a topical corticosteroid, which provided no relief. The twins were born prematurely at 33 weeks’ gestation and had been receiving thyroxine for congenital hypothyroidism. There was no personal or family history of atopy.</p>
What’s Your Diagnosis?®<p>A 46-year-old man with a history of asthma and hyperlipidemia presents with migrating polyarthralgia, swelling of the extremities, and a worsening purpuric, raised rash of 1 week’s duration.</p>
malignancy<p><u>Images of Malignancy</u></p> <p>-Chondrosarcoma <br /> -Renal cell carcinoma metastases to the lung <br /> -T-cell acute lymphoblastic leukemia and mediastinal mass <br /> -Cutaneous T-cell lymphoma <br /> -Glioblastoma multiforme</p> <div> </div>
Elderly Patients, fallsElderly Patients, fallsYour 75-year-old patient recently fell on the stairs in her home and sustained multiple contusions but no fractures. She had been living independently and was active in the community; however, she now has become fearful of falling again. What effective preventive measures can you offer her?
epigastric pain, melena<p>A 67-year-old man is admitted to the hospital after he experienced 4 or 5 episodes of melena in the past 24 hours. He has had no emesis, but complains of moderate epigastric pain.</p>
prolactinomas<p>Amenorrhea, infertility, osteopenia, decreased libido, and impotence are common primary care complaints. Typical evaluations effectively address potential problems—estrogen excess or depression as examples—leading to these abnormalities. One organ that may be overlooked in the work-up is the pituitary gland. Forty percent of pituitary tumors produce prolactin. This hormone may be the culprit for all the symptoms and signs mentioned in the opening sentence. A “Top Paper” provides a comprehensive, but clear review of this important pathology.<sup>1,2</sup></p> <div> </div>
Wounds<p>We enjoyed reading Dr Keith Harding’s article on the value of moist dressings for chronic wounds (CONSULTANT, March 2012, page 214), but we feel that some of his comments do not give the full spectrum of challenges one may encounter with a wound of this type. His article implies that chronic wounds are known for their copious exudate production. To manage these wounds, Dr Harding states that there needs to be a fine balance between controlling the amount of exudates produced from the chronic wound while ensuring a moist environment is maintained over the wound base. This is needed to promote collagen synthesis and granulation tissue.</p> <div> </div>
Primary Care<p><img alt="Imhotep" height="90" src="/sites/default/files/images/1209Con_GCColgan_OpenerPic.jpg" style="float:left" title="Imhotep" width="90" /><br /> We must look at many historical figures in order to better understand what it means to be a healer and how to best practice the art of caring. Sir William Osler recommended that we “must come to the land of the Nile for the origin of many of man’s most distinctive and highly cherished beliefs.” Osler urges us to pay attention to the contributions of Imhotep—and so I am.</p>