What’s Your Diagnosis?®A 24-year-old woman presents to your office complaining of “pus” on her right tonsil. She noticed this while brushing her teeth 2 days earlier.
urticarial reaction<p class="p1"><img src="/sites/default/files/images/1207Con_DC_C4.jpg" alt="urticarial reaction" title="urticarial reaction" width="90" height="90" style="float: left; margin: 5px;">A 63-year-old woman believes that her hives of 1 day’s duration were brought on by something she ate.</p><p class="p2">Which specific food(s) do you query the patient about?</p>
Neurofibromatosis<p class="p1"><img src="/sites/default/files/images/1207Con_DC_C3Ans.jpg" alt="Neurofibromatosis" title="Neurofibromatosis" width="90" height="90" style="float: left; margin: 5px;">Axillary freckles are noted on a 28-year-old woman during a skin examination.</p><p class="p2">Which of the following signs do you need to look for when this freckling is found?</p>
Dermclinic<p class="p1"><img src="/sites/default/files/images/1207Con_DC_C2.jpg" alt="Melanoma" title="Melanoma" width="90" height="90" style="float: left; margin: 5px;">During a skin examination, a lesion is noted on the thigh of a 32-year-old woman. The patient says she has had the “spot” all of her life, and its appearance has not changed.</p><p class="p2">What is your next step?</p>
DermclinicIncreased pigmentation on her lower back is noted by a 38-year-old woman who has used a heating pad for several months for low back pain. What condition are you looking at here?
PhotoclinicOne hour after sustaining a puncture wound to the left ankle, a 2-year-old boy was brought the emergency department. The father, a commercial fisherman, was attempting to free a catfish from a crab trap when it fell and its dorsal spine punctured the child’s ankle.
colloid milium<p><img src="/sites/default/files/images/1207Con_PCColloidMilium.jpg" width="90" height="90" style="float: left; margin: 5px;">For 6 years, slightly pruritic “bumps” had been present on the ears of a 52-year-old man. He had worked at an oil refinery for 30 years and had an extensive history of unprotected sun exposure.</p>
omental cake<p class="p1"><img src="/sites/default/files/images/1207Con_PCOmentalCake.jpg" width="90" height="90" style="float: left; margin: 5px;">Abdominal bloating and pain of 3 months’ duration prompted a 70-year-old woman to seek medical evaluation. She also reported minimal weight loss and fatigue, but she denied any bowel symptoms.</p>
bronchocele<p class="p1"><img src="/sites/default/files/images/1207Con_PCBronchocele_0.jpg" width="90" height="90" style="float: left; margin: 5px;">Left-sided chest pain of less than 24 hours’ duration caused a 39-year-old man to present to the emergency department. </p><p class="p4">He described the pain as non-radiating, sharp, and intermittent, lasting less than 1 minute. The patient had associated shortness of breath with shallow and deep inspirations. He denied any other constitutional symptoms, such as nausea, dizziness, or diaphoresis.</p>
Vasculopathy<p><img alt="" height="90" src="/sites/default/files/images/1207Con_CPSanchez_Fg2.jpg" style="float:left" width="90" />A 16-year-old girl presented with a rash of 4 months’ duration. Initially, the rash consisted of pruritic, erythematous macules with excoriations, but no pustules or drainage, located on the right shin. </p>
food poisonAlthough widespread outbreaks of food poisoning attract public attention, the latest data from the CDC show that incidences of foodborne disease are decreasing.
haemophilus endocarditis<p>For 5 days, a 30-year-old man has had fever, rigors, and diaphoresis. He admits to intravenous (IV) cocaine use. His temperature is 38.6°C (101.4°F); pulse, 108 beats per minute (regular); respiration rate, 18 breaths per minute (unlabored); and blood pressure, 120/70 mm Hg. There are no peripheral signs of endocarditis (petechiae, conjunctival hemorrhages, Janeway’s or Osler’s lesions, or splinter hemorrhages or Roth’s spots on funduscopic examination). He has good dentition, no oral lesions, and a normal tongue that is not pierced; no nasopharyngeal abnormalities are noted.</p>
Enema<p><strong><em>How safe is the use of sodium phosphate enemas and laxatives in elderly persons?</em></strong></p> <p>In an age of polypharmacy, a variety of medications may result in constipation. One group particularly prone is the elderly, especially those in extended-care facilities. A durable remedy has been sodium phosphate, both as enemas and as oral purgatives. A number of adverse outcomes with these agents suggest that the medical community exercise caution in the future.</p>
Photo Essay<p>This article features several cases of skin lesions caused by leisure activities, such as swimming, beach-going, and sports. It features curaneous larva migrans, swimmer's itch, second-degree sunburn, seabather's eruption, and more.</p>
Deep vein thrombosis<p>A 44-year-old woman is hospitalized for evaluation and management of an excessively elevated international normalized ratio (INR). She takes warfarin for a thromboembolic diathesis of 10 years’ duration. Her first episode of deep vein thrombosis (DVT) was in 1999 and was idiopathic. Evaluation at that time revealed factor V Leiden heterozygosity. She has had multiple episodes of DVT and a pulmonary embolism in the intervening years. A vena cava filter was placed 5 years ago.</p>
Diabetes Q&A<p>When insulin secretion by the pancreatic ß-cell is not sufficient to maintain normal blood glucose levels, diabetes develops. Although the exact cause of defective insulin secretion is not well-defined in type 2 diabetes, it is generally accepted that there is progressive ß-cell failure. The ß-cell produces proinsulin, which is then processed into C-peptide and insulin. C-peptide and insulin are released in equal concentrations in the blood. Therefore, C-peptide and insulin levels should be a marker for ß-cell function.</p>
Doctor’s Stories<p>All doctors are writers. We write about providing medical care and about our patients over and over, every day, in the form of history and physicals, progress notes, and consultant’s letters. These writings, for the most part, tell other health care providers what is “wrong” with the patient, and what it is we plan to do about it.</p> <div> </div>
Commentary<p><img alt="" height="90" src="/sites/default/files/images/Screen%20shot%202012-07-06%20at%2011.02.40%20AM.png" style="float:left" width="90" /><br /> It is with great pleasure that we welcome Dr Brunton to the Editorial Board of CONSULTANT. His 30 years of experience in the development of education for primary care clinicians make him well qualified to serve as one of our key advisors.</p>