Pain Management

To what do you attribute symptoms of rash and fever in: a man with type 2 diabetes; a woman with systemic lupus erythematosus; a previously healthy girl.

Three case studies of patients with fever and rash challenge you to distinguish infectious from other causes and serious from non-threatening.

A staff nurse calls the physician to see "something really bizarre-we have no idea what this is": the plastic of a urine collection bag of an 81-year-old woman has turned purple, although the urine within is more orange-brown and distinctly less odd looking. Patient has had an indwelling urethral catheter for 7 months, and this discoloration had not been noted before. Current history includes marked constipation, atrial fibrillation, and symptomatic osteoarthrosis of the hips and knees.

A 17-year-old boy hashad severe pharyngitis, fever, anddysphagia for the past 2 days. Althoughhe took an NSAID and triedgargling with hydrogen peroxide, heobtained no relief.

Early diagnosis enables patients to derive maximum benefit from highly active antiretroviral therapy (HAART). Primary care practitioners can play a key role in the timely identification of HIV infection.

Which of the rashes pictured here is cellulitis?

Match each picture with the phrase below that best describes it. The organisms in these pictures might be microscopicor macroscopic, and they can be recovered from skin lesions or clothing by the patient and/or clinician.Answers and discussion appear on the following page.

Some sexually transmitteddiseases (STDs), such assyphilis and gonorrhea, arecenturies-old scourges; othershave attained clinicalsignificance only in recent years.Despite the availability of effectivetherapy for many of these diseases,they remain an important publichealth problem.

A staff nurse calls the physician to see "something really bizarre-we have no idea what this is": the plastic of a urine collection bag of an 81-year-old woman has turned purple, although the urine within is more orange-brown and distinctly less odd looking.

A 66-year-old woman confined to a wheelchair was evaluated for leg pain and an indurated rash on the upper thighs of 2 weeks' duration. Her medical history was significant for end-stage renal disease and renal transplantation with subsequent renal graft failure. She is currently receiving hemodialysis.

Man With Worsening Cough and Dyspnea

The mumps outbreak in midwestern states appears to be slowing, but as college students return home and engage in summer travel, it's possible that mumps will spread. Are you prepared?

This patient has a febrile illness that began shortly after he returned from foreign travel. The differential diagnosis is intriguing--malaria, yellow fever, typhoid fever, and dengue.

A 1-year-old woman comes to theemergency department (ED) 3hours after a male friend punched herin the left lower back. The blowknocked her to the floor and madeher feel faint. She also noticed bloodin her urine when she voided athome after the injury.

A 79-year-old woman with a 37-year history of type 2 diabetes mellitus complains of head pain that began more thana month ago and is localized to the left frontotemporal region. She characterizes the pain as constant and burning, with minimalfluctuations in intensity. The pain does not increase with any particular activity but is quite disabling; it has causedemotional lability and insomnia. She denies nausea, visual disturbances, weakness of the extremities, dizziness, or tinnitus.Her appetite is depressed; she has experienced some weight loss.

A 35-year-old veterinary technician who lived in south central Texas presented with a raised, warm, tender 2- to 3-cm papule on her lower leg of more than 2 weeks' duration. Topical mupirocin and oral trimethoprim/ sulfamethoxazole were prescribed, but the papule continued to enlarge and became increasingly erythematous and painful.

Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith 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 theliver. The HCV genotype is 1A.

The patient presented with left-sided, throbbing headaches that had gradually increased in severity and frequency. These headaches, which occurred once or twice a month, were associated with photophobia, phonophobia, and nausea, and usually lasted 8 to 12 hours. The headaches affected the patient's job performance and attendance, and she complained of fatigue, lack of sleep, and difficulty in concentrating.

The most common chronic blood-borne infection in the United States is caused by hepatitis C virus (HCV), an RNA virus transmitted through blood-to-blood contact. In this article, we identify risk factors for HCV infection and discuss which patients should be tested and treated.

A 36-year-old man with a 15-year history of episodic migraine presents to the emergency department (ED) at 5 AM witha right-sided throbbing headache of 4 hours' duration. The headache awakened him, which is typical of his more severemigraine attacks. Unfortunately, the patient forgot to refill his prescription for pain medication and did not "catch" thisheadache in time. He took an over-the-counter combination of aspirin and caffeine, which seemed to help for about 60minutes, but the headache has returned full force. He has vomited twice-another characteristic typical of his migraineattacks

A 47-year-old woman who wasseropositive for HIV-1 presented tothe emergency department with severemaculopapular, erythematouseruptions. Her antiviral regimen hadrecently been changed from zidovudine,300 mg bid; lamivudine, 150 mgbid; and saquinavir, 600 mg tid, tolamivudine, 150 mg bid; stavudine, 40mg bid; and nevirapine, 200 mg/d.

I suspect that my patient has hereditary angioedema (HAE). During her lastpregnancy 2 years earlier, she had severe preeclampsia.

Monday morning your nurse hands you charts for 4 new patients. Each patient is a woman with widespread body pain, stiffness, and fatigue. All have already been evaluated by another physician and were advised that they should reduce stress and practice distraction techniques. They are in your office today seeking a second opinion.

What are the current recommendations for hormonal contraception (eg, oralcontraceptives, medroxyprogesterone injections) in patients with migraine?

As many as 300,000 sportsrelatedconcussions arediagnosed each year inthe United States.1 Thisfigure underestimatesthe true incidence, however, becausemany concussive injuries are notrecognized by the injured persons,trainers, or physicians. A recentstudy found that 4 of 5 professionalfootball players with concussionwere unaware that they had sufferedthis injury.2

A neurologic deficit caused by a transient ischemic attack should last less than 24 hours. This woman presented with signs of paresis that had persisted for 36 hours, thus ruling out transient ischemic attack.

A 71-year-old man presented with a 6-week history of decreased vision in his right eye. The patient, who had hypertension and migraine headaches, had successfully recovered from a stroke that occurred 1 year earlier. His medications included aspirin, 81 mg/d, clopidogrel, atenolol, and furosemide. He also took gabapentin, 300 mg hs, for his migraine headaches. He had a remote history of cigarette smoking.

What are the current recommendations for the use of corticosteroids in the treatment of migraine? Is this a therapy primary care clinicians might consider?

No double-blind, randomized controlled studies of the effectiveness of vertebroplasty have been performed. However, this reflects less the effectiveness or safety of the procedure than it does the difficulty involved in conducting randomized controlled trials of any treatment for a pain disorder.

Low back pain is a widespread and costly complaint that affects virtually all Americans at some point in their lives. After the common cold, it is the second most frequent cause of work absence in the United States.