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July 9, 2014

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Mammary Paget disease (PD) is a less common form of breast cancer which involves the nipple-areola complex and occurs almost exclusively in females. Erythema, skin thickening, pruritus, burning sensation, inversion of the nipple, ulceration, serosanguineous nipple discharge are common clinical symptoms. Approximately 1-4% of female breast carcinoma are associated with PD of the nipple-areola complex. A biopsy including the dermal and subcutaneous tissue should be performed on all suspicious lesions of the nipple-areola complex for accurate diagnosis. The first line treatment of mammary PD is mastectomy (radical or modified) and lymph node clearance for patients with a palpable mass and underlying invasive breast carcinoma. The prognosis of mammary PD is determined by the disease stage and is similar to that of other types of breast cancer.
Key Words: Mammary Paget disease, breast cancer, nipple-areola complex, metastasis.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

April 15, 2014

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Herpes simplex viruses (HSVs) are DNA viruses that present as vesicles in clusters on an erythematous base. Infection occurs when close contact between an individual without antibodies against the virus and a person shedding the virus takes place. Most HSV infections are self-limited. Lesions tend to reappear at or near the same location of the initial site of infection. Systemic symptoms such as fever, malaise and acute toxicity may appear, especially in primary infection. A viral culture from the skin vesicles can identify up to 80 to 90% of untreated infection early in the course. Antiviral treatments aim at shortening the disease course and preventing viral dissemination and transmission. Treatments are most effective when they are administered at the first sign of symptom onset.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

March 31, 2014

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Tinea incognito is a superficial dermatophyte infection in which the clinical appearance of the symptoms has been altered by inappropriate treatments, such as topical corticosteroids.
Dermatophyte infection may result from contact with infected humans, animals, or inanimate objects. An erythematous, pruritic, annular and scaly plaque is characteristic of a symptomatic infection. A potassium hydroxide (KOH) examination of skin scrapings is usually diagnostic. If topical corticosteroids have been applied recently, the amount of surface scales may be reduced and may lead to false negative results. Topical therapy is the first line treatment for localized infections. Systemic antifungals should be used in extensive condition, immunosuppression, resistance to topical antifungal therapy.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

November 24, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Hairy tongue, or known as lingua villosa, is a result of hypertrophy, elongation, and defective desquamation of the filiform papillae of the tongue. This condition may present in a variety of colors depending on the specific etiology. Etiologies of hairy tongue include poor oral hygiene, lack of mechanical stimulation and debridement of the tongue, the use of medications (especially broad-spectrum antibiotics), and therapeutic radiation of the head and the neck. This condition is also commonly seen in people having high consumption in coffee and tea, heavy use of tobacco, individuals addicted to drugs, patients who are HIV positive, and intravenous drug users. In most cases, non-pharmacologic interventions are used for the management of hairy tongue. Treatment involves brushing the tongue with a toothbrush or using a commercially available tongue scraper to retard the growth or to remove elongated filiform papillae. If Candida albicans is present, topical antifungal medications are used for patients who are symptomatic.
Key Words:
Hairy tongue, Lingua villosa, Glossopyrosis, Halitosis.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

September 27, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Green nail syndrome is a paronychia caused by Pseudomonas aeruginosa. The affected toenail may show discoloration that ranges from greenish-yellow, greenish-brown, and greenish-black. Differential diagnosis includes other conditions causing nail plate discolouration such as subungual hematoma, malignant melanoma or infections by other pathogens including Aspergillus, Candida, and Proteus. Gram stain and culture of the subungual scrapings confirm the diagnosis of suspected pseudomonas aeruginoa infection. Topical antibiotics, such as bacitracin, silver sulfadiazine, or gentamicin, applied 2 to 4 times daily will treat most patients within 1 to 4 months. Oral ciprofloxacin for 2 to 3 weeks has been successful in treating patents who fail topical therapies.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

August 22, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Erythema ab igne (EAI) is a localized hypermelanosis with erythema in a reticulated pattern. It is triggered from repeated exposure to heat and infrared radiation. Actinic keratosis, squamous cell carcinoma, and Merkel cell carcinoma have been reported in patients after chronic exposure to infrared radiation. EAI is diagnosed based on clinical symptoms. If the diagnosis is uncertain, a skin biopsy may be performed. Early in the disease process, elimination of the heat source may lead to complete resolution of the symptoms.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

July 15, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Kaposi varicelliform eruption (KVE) is an infection of a dermatosis by pathogens such as herpes simplex virus (HSV) type 1, HSV-2, coxsackievirus A16, or vaccinia virus. KVE begins as a sudden eruption of painful and crusted or hemorrhagic vesicles, pustules, or erosions in areas of a preexisting dermatosis. Transmission occurs through contact with an infected individual or by dissemination of primary or recurrent herpes. Viral cultures of fresh vesicular fluid or direct observation of infected cells scraped from ulcerated lesions by direct fluorescent antibody staining are the most reliable diagnostic tests for KVE. Antivirals, such as acyclovir and valacyclovir, are used in the treatment of KVE.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

June 11, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Basal cell carcinoma (BCC) is a type of non-melanoma skin cancer that arises from basal cells found in the lower layer of the epidermis. It is the most common type of skin cancer in humans, but they rarely metastasize. If BCC is left untreated and progresses, it may lead to significant morbidity and cosmetic disgurement. In nearly all cases, the recommended treatment modality for BCC is surgery. Small and superficial BCC may respond to local immune-modulating therapies. For tumors that are more difficult to treat or those in which tissue preservation is essential, Mohs micrographic surgery should be considered. Radiation therapy can be used for advanced and extended BCC and in those patients for whom surgery is contraindicated. Photodynamic therapy is usually used as an adjunct in BCCs with poorly defined border, in cases which oculoplastic surgery will be extensive or difficult, or in recurrent BCCs with tissue atrophy or scar formation. Oral vismodegib has been approved for the treatment of adult patients with locally advanced basal cell carcinoma who are not candidates for surgery or radiation and for those with metastatic disease. The prognosis for BCC is generally great with 100% survival rate for localized cases.
Keywords: Basal cell carcinoma, Nonmelanoma skin cancer, Hedgehog intracellular signalling pathway, Imiquimod 5% cream, 5-Fluorouracil 5% cream.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

January 31, 2013

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Impetigo is a gram-positive bacterial infection of the superficial layers of the epidermis. There are two forms of impetigo: bullous and nonbullous. Diagnosis of impetigo is usually based solely on the history and clinical presentation. Culture and sensitivity results can help the physician choose appropriate antibiotic therapy. Treatment of impetigo typically involves local wound care, along with antibiotic therapy, either topical alone or in conjunction with systemic therapy. For mild or localized cases, topical mupirocin or topical fusidic acid applied 2 to 3 times daily for 7 to 10 days are adequate treatment. Systemic antibiotics are indicated for widespread, complicated, or severe cases associated with systemic manifestations of impetigo. Beta-lactam antibiotics remain an appropriate initial empiric choice, with coverage against both Staphylococcus aureus and Streptococcus pyogenes. For patients with recurrent impetigo or Staphylococcus aureus nasal carriers, topical mupirocin cream or ointment can be applied inside the nostrils 3 times daily for 5 days each month to reduce colonization in the nose.
Keywords: Impetigo, Staphylococcus aureus, Group A beta hemolytic streptococci Bullous impetigo, Nonbullous impetigo.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

November 20, 2012

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Periorificial dermatitis is a common eczematous eruption on the face. Clusters of follicular papules, vesicles, and pustules on an erythematous base are usually found in a perioral distribution. Other common locations include the nasolabial folds and periocular area. An underlying cause may not be found in all cases, but the use of topical corticosteroids on the face may precede onset of symptoms. Periorificial dermatitis is diagnosed clinically and no specific investigation is required. Topical anti-inflammatory therapies (such as metronidazole and erythromycin) are appropriate in mild cases. In severe cases, systemic treatments such as tetracycline or one of its derivatives are beneficial. Patients should be warned that symptoms might worsen before improvement is apparent. This complication is more commonly seen when topical corticosteroids are withdrawn.
Keywords: periorificial dermatitis, perioral dermatitis, facial rash, steroid-induced.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

October 31, 2012

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Juvenile spring eruption is a photodermatosis that is considered a localized variant of polymorphic light eruption. This condition appears on the light exposed areas of the ears and is primarily found in boys and young males in early spring or summer. The exact pathogenesis of juvenile spring eruption is not clear. The symptoms usually clear within 2 weeks, but recurrences are common under similar climatic conditions. The diagnosis of juvenile spring eruption is made clinically and investigations are not required. Treatments include avoidance of sun exposure, emollients, potent topical corticosteroids, and antihistamines.
Keywords: juvenile spring eruption, photodermatosis, polymorphic light eruption, spring, ears.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

August 28, 2012

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Cutaneous larva migrans is a parasitic infection caused by percutaneous penetration and subsequent migration of the larvae of hookworm. The tracks are commonly raised, erythematous, serpiginous, and pruritic. Cutaneous larva migrans is diagnosed based on its clinical characteristics. It is a self-limiting condition because larvae eventually die in humans without being able to infest new hosts. Treatment is used to shorten the disease course, control the intense pruritus, and prevent the risk of secondary infection. Topical thiabendazole is the treatment of choice for mild and localized condition. Systemic treatment such as albendazole, mebendazole, and ivermectin are used in widespread cases or cases recalcitrant to topical treatment.
Keywords: cutaneous larva migrans, parasitic infection, hookworm, Ancylostoma braziliense, thiabendazole.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

July 19, 2012

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

Abstract
Granuloma annulare (GA) is a benign and usually self-limited cutaneous condition that classically presents as arciform to annular plaques in a symmetrical and acral distribution. The exact etiology of GA is unknown. Two-thirds of patients with GA are less than 30 years old. GA is recognized based on its characteristic appearance and no specific investigation is necessary. Reassurance and clinical observation may be the treatment of choice for localized and asymptomatic disease. Spontaneous resolution occurs within 2 years in 50% of cases. Persistent lesions may be treated with very potent topical corticosteroids, intralesional corticosteroid injections, or cryotherapy. Use of more toxic treatments are controversial in recalcitrant cases.
Keywords: Granuloma annulare, Overview, Paraneoplastic, Self-limiting, Treatment.

Francesca Cheung, MD CCFP, is a family physician with a special interest in dermatology. She received the Diploma in Practical Dermatology from the Department of Dermatology at Cardiff University in Wales, UK. She is practising at the Lynde Centre for Dermatology in Markham, Ontario and works closely with Dr. Charles Lynde, MD FRCPC, an experienced dermatologist. In addition to providing direct patient care, she acts as a sub-investigator in multiple clinical studies involving psoriasis, onychomycosis, and acne.

January 23, 2012

Keywords: Syphilis; Treponema pallidum; HIV.

A 27-year-old MSM, presented to care with a rash. The rash appeared several weeks prior to presentation and involved the face, chest and back, arms and legs and was not accompanied by pruritus. He denied fever, chills, but complained of fatigue. No respiratory, gastrointestinal or urinary symptoms were present. He disclosed a diagnosis of HIV infection a year earlier, but has not kept his follow up appointments and was not receiving anti-retroviral medications or opportunistic infection prophylaxis. His most recent CD4 count was 109/mm3. He admitted sexual encounters with several male partners with inconsistent condom usage, and recalled a penile lesion that was present several weeks before the rash had appeared. The lesion has healed without specific therapy.

On physical examination: in no apparent distress, vital signs were within normal limits.

Notable finding on the examination included multiple small and non-tender anterior cervical, posterior cervical, axillary and inguinal lymph nodes. Genital examination revealed a healed lesion on the glans penis. A macular skin rash was widely distributed over face, trunk and extremities with several lesions on palms and soles (figure 1. and 2.)


1. What is your diagnosis?
2. Would you obtain a lumbar puncture?

Keywords: Syphilis; Treponema pallidum; HIV.

May 1, 2008

Amira Rana, MD, Medical Resident, Department Of Medicine, University of Toronto, ON.
Anselmo Mendez, BSc, BScN, Medical Student, Jagiellonian University, Medical College, Kraków, Poland.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Staff Physician, Department of Medicine, University Health Network; Assistant Professor, Departments of Medicine & Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.

Key words: myasthenia gravis, dysphagia, pyridostigmine, dysarthria, ptosis.

Amira Rana, MD, Medical Resident, Department Of Medicine, University of Toronto, ON.
Anselmo Mendez, BSc, BScN, Medical Student, Jagiellonian University, Medical College, Kraków, Poland.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Staff Physician, Department of Medicine, University Health Network; Assistant Professor, Departments of Medicine & Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON.

October 1, 2007

David Wan, School of Medicine, University of Toronto, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Staff Physician, Department of Medicine, University Health Network, Toronto, ON; Assistant Professor, Departments of Medicine & Health Policy, Management, and Evaluation, University of Toronto.

Case Presentation
Mr. L was a 75-year-old man who presented in April 2007 with a one-month history of multiple discrete ulcerative lesions on his extremities, his trunk, and in his mouth. He had progressive weakness and severely restricted oral intake over the past two weeks due to pain from his oral ulcers...

David Wan, School of Medicine, University of Toronto, Toronto, ON.
Shabbir M.H. Alibhai, MD, MSc, FRCPC, Staff Physician, Department of Medicine, University Health Network, Toronto, ON; Assistant Professor, Departments of Medicine & Health Policy, Management, and Evaluation, University of Toronto.

March 1, 2007

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician in Geriatric Medicine, Department of Geriatric Medicine, Blacktown-Mt-Druitt Health, Blacktown, NSW, AUS.

A 73-year-old woman was seen in hospital troubled with visual hallucinations for over a year. They had increased in both frequency and intensity in the past few months, necessitating hospitalization. To her annoyance, the visual images took the form of people watching her through the glass windows. She less frequently saw animals. The hallucinations occurred both during the day and night but were worse as evening approached.

Nages Nagaratnam, MD, FRCP, FRACP, FRCPA, FACC, Consultant Physician in Geriatric Medicine, Department of Geriatric Medicine, Blacktown-Mt-Druitt Health, Blacktown, NSW, AUS.

May 1, 2006


From the Department of Medicine, Cardiology and Geriatrics Divisions, New York Medical College, Valhalla, NY, USA.
Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine;
Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY, USA; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

A 73-year-old woman saw a physician because of a three-month history of pain on walking after two blocks, which was relieved by rest. She had no other symptoms and was not on any medications.


From the Department of Medicine, Cardiology and Geriatrics Divisions, New York Medical College, Valhalla, NY, USA.
Wilbert S. Aronow, MD, CMD, Clinical Professor of Medicine, Divisions of Cardiology, Geriatrics, and Pulmonary/Critical Care Medicine;
Chief, Cardiology Clinic; Senior Associate Program Director and Research Mentor, Fellowship Programs, Department of Medicine, New York Medical College, Valhalla, NY, USA; Adjunct Professor of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York City, NY, USA.

April 1, 2006


Sanjeev Rastogi, MD, CAc, Consulting Physician and Lecturer, Government Ayurvedic College and Hospital, Handia, Allahabad, India.
Rajieev Rastogi, MBSc, BNYS, Assistant Director (Naturopathy), Central Council for Research in Yoga and Naturopathy, New Delhi, India.

Acute low back pain (ALBP) is a common condition that results in huge economic losses in the form of treatment and absenteeism (direct monitary loss for incurring the treatment and indirect monitary loss resulting from absence). It responds well to conservative therapy, but it often takes a period of between one and three months before improvement is seen. Acupuncture has its effect in pain reduction in various musculoskeletal conditions including ALBP. As is observed in the present case, this technique can reduce the recovery period in these patients and, thus, can improve the net outcome.
Key words: acute low back pain, acupuncture, conservative management, recovery period, analgesia.


Sanjeev Rastogi, MD, CAc, Consulting Physician and Lecturer, Government Ayurvedic College and Hospital, Handia, Allahabad, India.
Rajieev Rastogi, MBSc, BNYS, Assistant Director (Naturopathy), Central Council for Research in Yoga and Naturopathy, New Delhi, India.

October 1, 2005

Please read "A Case of Iron Deficiency Anemia: Commentary" below

Anna Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD, USA.

Mr. WH is a 72-year-old-man who presented in April 2004 with a hematocrit of 21%. His previous hematocrit was 34% in February 2004. He complained of bright red blood per rectum and rectal pain secondary to external hemorrhoids. Mr. H was admitted with a presumed gastrointestinal bleed.
Mr. H’s past medical history is significant for bovine aortic valve prosthesis in 1997 secondary to aortic stenosis, Addison’s disease, hypocalcemia, seizure disorder, B12 deficiency, colon cancer with partial colon resection, and small bowel obstruction due to adhesions. Mr. H had chronic diarrhea secondary to bowel surgeries. His last colonoscopy was in 1997 and it revealed hemorrhoids. An esophagogastroduodenoscopy done at the time showed duodenitis.
The patient’s medications on hospital admission were as follows: calcium carbonate 500mg three times a day, vitamin B12 1000mcg I.M. monthly, divalproex sodium 750mg twice a day, hydrocortisone 25mg every 12 hours, vitamin D 100,000 IU every three months, phenobarbital 30mg every 12 hours, lasix 20mg by mouth daily, and potassium chloride 20m.e.q. daily. He has no known drug allergies.

Please read "A Case of Iron Deficiency Anemia: Commentary" below

Anna Monias, MD, Erickson Retirement Communities, Oak Crest Village, Parkville, MD, USA.

April 1, 2002

Derick M Todd MB, ChB, Clinical Fellow, Arrhythmia Service,
University of Western Ontario, London, ON.
Andrew D Krahn MD, Associate Professor, Cardiology, Department of Medicine,
University of Western Ontario, London, ON.

Introduction
A prompt and accurate diagnosis of syncope in the elderly is important in reducing morbidity1 and mortality, and for maintaining independence.2,3 The risk of a serious cardiac arrhythmia as the underlying cause for syncope is increased in the elderly, especially in those with an abnormal resting electrocardiogram and/or impairment of left ventricular function.4 The key to the diagnosis most often lies in the history from the patient and an eyewitness account. Detecting underlying heart disease by history, clinical examination and a resting 12-lead ECG are crucial in directing further investigation and treatment.5 Patients considered likely to have a cardiovascular cause for syncope have a significantly increased mortality rate compared to patients with a non-cardiovascular cause or who remain undiagnosed.6 The following case report is intended to illustrate some of these issues.

Derick M Todd MB, ChB, Clinical Fellow, Arrhythmia Service,
University of Western Ontario, London, ON.
Andrew D Krahn MD, Associate Professor, Cardiology, Department of Medicine,
University of Western Ontario, London, ON.

Introduction
A prompt and accurate diagnosis of syncope in the elderly is important in reducing morbidity1 and mortality, and for maintaining independence.2,3 The risk of a serious cardiac arrhythmia as the underlying cause for

February 1, 2002

Chui Kin Yuen, MD, FRCSC, FACOG, FSOGC, MBA, Chairman, Manitoba Clinic, Winnipeg, MB.

Current History
Mrs. Brittle Bone presents to your office because of low back pain of insidious onset in the past three weeks. Mrs. Brittle is a healthy 68 year old female and is an active gardener. Following the death of her husband one year ago, she continued to live in her house and has done many of the household chores, including gardening. Her pain began three weeks ago and, since then, she has found it difficult to do her household work. She is not able to rest peacefully at night because of the discomfort.

Family History
She has no family history of osteoporosis. However, her mother was diagnosed with breast cancer at 55 years old.

Lifestyle Habits & Medications
Mrs. Brittle Bone is a healthy non-smoker with adequate nutrition and regular exercise. She drinks occasionally. She takes calcium and vitamin D supplements every day. She is not on any medications and has never been on Hormone Replacement Therapy.

Physical Examination
Physical examination of the spine demonstrates that she has mild kyphosis. Her range of motion is limited and the pain is exacerbated with extension and rotation. Percussion of the spine reveals point tenderness at L2.

Chui Kin Yuen, MD, FRCSC, FACOG, FSOGC, MBA, Chairman, Manitoba Clinic, Winnipeg, MB.

Current History
Mrs. Brittle Bone presents to your office because of low back pain of insidious onset in the past three weeks. Mrs. Brittle is a healthy 68 year old female and is an active gardener. Following the death of her husband one year ago, she continued to live in her house and has done many of the household chores, including gardening.