James S. Studdiford

The Reliability of Patient Self-Reported Blood Pressures

Self‐monitoring of blood pressure actively involves patients in hypertension management. However, the usefulness of self‐monitoring of blood pressure may be limited by inaccurate patient reporting. The study objective was to assess reliability of patient blood pressure reporting over 6 months. Forty‐nine subjects with Joint National Committee stage 1 or 2 hypertension were enrolled. Unaware that the monitors electronically store readings, the subjects were asked to check and record outpatient blood pressures twice weekly. Stored and written readings were compared. On average, patient‐recorded blood pressures were equivalent to stored monitor values 80% or more of the time. Reliability of patient self‐reporting was sustained over the 6‐month study period. Notably, patients did not selectively report lower blood pressure readings. The overall mean self‐reported and stored monitor blood pressures were nearly identical: blood pressure (±SD) 134±16.8/78±11.6 mm Hg and 135±19.6/80±13.3 mm Hg, respectively. The reliability of self‐reporting of blood pressures for many patients supports the potential usefulness of self‐monitoring of blood pressure in hypertension management.

THE TELEPHONE IN PRIMARY CARE

The telephone, a ubiquitous instrument in the practice of medicine, continues to have new applications for clinical practice. The goals of the ever-increasing managed care environment appear to fit nicely with these applications. Heightened attention toward telephone education, protocol development, and documentation are needed. This article reviews characteristics of telephone encounters, the telephone in managed care, trends in telemedicine, telephone education, and medicolegal aspects of telephone care.

Eczema Herpeticum: Making the diagnosis in the Emergency Department

Eczema herpeticum (EH), a form of Kaposis varicelliform eruption, is the dissemination of herpes simplex virus in the setting of preexisting eczema. We discuss the case of an 18-year-old woman with underlying atopic dermatitis (AD) who presented to an Emergency Department complaining of malaise, fever, and a spreading, burning, vesiculopapular facial rash. She was treated for both presumed impetigo and a flare of her underlying AD with cephalexin, bacitracin ointment, topical steroids, and diphenhydramine. Her condition worsened, and she was seen 3 days later by her primary care physician, who recognized the superimposition of a herpetic infection on her underlying AD and revised the diagnosis to EH. An oral regimen of acyclovir led to prompt resolution of the patients rash and symptoms. Recognition of EH in the acute care setting is essential for the provision of timely and specific treatment and to avoid the serious sequelae of this condition.

Development of unilateral cervical and supraclavicular lymphadenopathy after human papilloma virus vaccination.

A 26‐year‐old woman developed significant unilateral anterior cervical and supraclavicular lymphadenopathy 3 days after receiving her first dose (of a total of three doses) of human papilloma virus (HPV) vaccine. She had no history of lymphadenopathy after other previous immunizations, and had received no vaccines other than HPV at that time. The left‐sided lymphadenopathy developed after she was vaccinated in the left deltoid muscle. The spatial and temporal relationships between the appearance of the lymphadenopathy and receipt of the vaccine in the absence of other causal agents strongly suggest that the HPV vaccine was the causal agent. Use of the Naranjo adverse drug reaction probability scale indicated that the HPV vaccine was a probable (score of 6) cause of the patients adverse reaction. The patient received her second dose of the HPV vaccine 2 months later without further lymphadenopathy. To prevent unnecessary lymph node biopsies and patient concern, clinicians should be aware that lymphadenopathy may occur after HPV vaccination.

Erythema Multiforme After Meningitis Vaccine: Patient Safety Concerns with Repeat Immunization

A 20‐year‐old college student developed an immunologic hypersensitivity reaction, erythema multiforme minor, 1–2 weeks after receiving a meningococcal conjugate vaccine. He had no history of erythema multiforme, nor had he received any other vaccine or drug therapy. The temporal relationship between the development of erythema multiforme and the vaccination suggests that the meningitis vaccine probably was the causal agent. The occurrence of this distinct cutaneous reaction, with the potential for a serious complication such as erythema multiforme major or Stevens‐Johnson syndrome on rechallenge, should serve as a warning against repeated booster vaccinations in patients who develop reactions such as this one.

Academic Men's Health – Case StudiesAndrogenic Alopecia

Androgenic alopecia (AGA), or male pattern hair loss, is the most common form of hair loss and affects up to 50% of all men by the age of 50. This article looks at the pathophysiology, diagnosis and treatment (both medical and surgical) of AGA.

Diagnosing Cancer in the Symptomatic Patient

Finding cancer at its earliest, most treatable stage gives patients the greatest chance of survival. For a number of cancers, screening tests allow for early detection and treatment, and thereby, reduce cancer-related mortality. However, many cancers are discovered by symptomatic presentation rather than screening. This article addresses several symptoms commonly reported in the primary care setting, including rectal bleeding, a breast lump, cough, lymphadenopathy, and weight loss, and offers an evidence-based approach to the consideration and possibly the diagnosis of cancer.

The management of keloids: hands-on versus hands-off.

Keloids are benign fibrous growths that appear in scar tissue. The lesions can be severely disfiguring and early recognition of genetic lesions is crucial. This case report outlines and reviews the important management strategies for these lesions and the requirement for extensive counseling for the patient and their family. Many potential medical and surgical interventions exist. Unfortunately, these lesions tend to recur and overall outcomes remain poor. Given patient susceptibility to disfiguring results, surgical intervention should be used with extreme caution.

Angioedema After Local Trauma in a Patient on Angiotensin-Converting Enzyme Inhibitor Therapy

Angioedema is a side effect that is often associated with the use of angiotensin-converting enzyme (ACE) inhibitor medications. These medications result in increased levels of circulating bradykinins. This case illustrates the result of a local traumatic event to the upper lip, presumably causing marked bradykinin release in a patient who was taking an ACE inhibitor. The local release of bradykinin from trauma, in addition to decreased bradykinin catabolism secondary to ACE inhibitor therapy, resulted in angioedema predominantly in the upper lip. The angioedema resolved with discontinuation of the ACE inhibitor.

Late Diagnosis of Early Disseminated Lyme Disease: Perplexing Symptoms in a Gardener

The timely diagnosis of early disseminated Lyme disease presenting as multiple secondary erythema migrans lesions is sometimes delayed because this stage is infrequently encountered in a general practice. We report a case of a 60-year-old woman whose initial complaints of an erythematous, “burning” rash and flu-like symptoms led to several laboratory tests with no specific diagnosis. The correct diagnosis was only made after sorting through other possibilities in the differential diagnosis. By reproducing the medical images and reviewing the medical literature, we underscore the importance of including Lyme disease in the list of diagnoses pertaining to diffuse skin rashes in the febrile patient.