Diagnosing Common Benign Skin Tumors.

Patients will experience a wide range of skin growths and changes over their lifetime. Family physicians should be able to distinguish potentially malignant from benign skin tumors. Most lesions can be diagnosed on the basis of history and clinical examination. Lesions that are suspicious for malignancy, those with changing characteristics, symptomatic lesions, and those that cause cosmetic problems may warrant medical therapy, a simple office procedure (e.g., excision, cryosurgery, laser ablation), or referral. Acrochordons are extremely common, small, and typically pedunculated benign neoplasms. Simple scissor or shave excision, electrodesiccation, or cryosurgery can be used for treatment. Sebaceous hyperplasia presents as asymptomatic, discrete, soft, pale yellow, shiny bumps on the forehead or cheeks, or near hair follicles. Except for cosmesis, they have no clinical significance. Lipomas are soft, flesh-colored nodules that are easily moveable under the overlying skin. Keratoacanthomas are rapidly growing, squamoproliferative benign tumors that resemble squamous cell carcinomas. Early simple excision is recommended. Pyogenic granuloma is a rapidly growing nodule that bleeds easily. Treatment includes laser ablation or shave excision with electrodesiccation of the base. Dermatofibromas are an idiopathic benign proliferation of fibroblasts. No treatment is required unless there is a change in size or color, bleeding, or irritation from trauma. Epidermal inclusion cysts can be treated by simple excision with removal of the cyst and cyst wall. Seborrheic keratoses and cherry angiomas generally do not require treatment.

When to worry about incidental renal and adrenal masses.

Greater use of imaging has led to a corresponding rise in the detection of renal and adrenal incidentalomas-and left many primary care physicians unsure of what to do about the masses they've found.

The 'crashing asthmatic.'.

Asthma is a common chronic disorder, with a prevalence of 8 to 10 percent in the U.S. population. From 5 to 10 percent of patients have severe disease that does not respond to typical therapeutic interventions. To prevent life-threatening sequelae, it is important to identify patients with severe asthma who will require aggressive management of exacerbations. Objective monitoring of pulmonary status using a peak flow meter is essential in patients with persistent asthma. Patients who have a history of fragmented health care, intubation, or hospitalization for asthma and those with mental illness or psychosocial stressors are at increased risk for severe asthma. Oxygen, beta2 agonists, and systemic corticosteroids are the mainstays of acute asthma therapy. Inhaled anticholinergic medications provide additional bronchodilation. In patients who deteriorate despite usual therapeutic efforts, evidence supports individualized use of parenteral beta2 agonists, magnesium sulfate, aminophylline, leukotriene inhibitors, or positive pressure mask ventilation before intubation.

Case management of asthma for family practice patients: a pilot study.

OBJECTIVE: Asthma is a chronic inflammatory disease of the airways that affects between 14 and 15 million persons in the United States. It is responsible for more than 470,000 hospitalizations annually and an estimated $6 billion in total medical cost. The Asthma Case Management Program instituted at our hospital is based on the concept of patient self-management. It involves patient education, a home treatment plan (HTP), and physician/nurse follow-up. This study was performed to determine whether an organized case management program improves outcomes and cost in family practice asthma patients. STUDY DESIGN: A prospective cohort study of 48 asthmatic patients was conducted with a retrospective review. Data were obtained from health, pharmacy, and computer records. PATIENTS AND METHODS: Forty-eight asthma patients, ages 1 year to adult, assigned to the Family Practice Department were enrolled in the Asthma Case Management Program. This cohort was offered asthma education from a provider trained in national asthma guidelines. Most of these patients received a coordinated HTP completed by their primary care provider. The asthma case manager initiated regularly scheduled nursing follow-up. Hospital admissions, emergency department and clinic visits, number of chest radiographs, and use of beta 2 agonists and anti-inflammatory drugs were recorded for a mean of 6 months before and 6 months after the intervention. Twenty-eight patients who had received the HTP as part of their intervention were compared with 12 patients who did not. A cost analysis was completed. RESULTS: All measured parameters showed favorable changes after intervention. Statistically significant decreases in clinic visits, chest radiographs ordered, beta 2 agonists, and oral anti-inflammatory drugs were obtained with the 28 patients who received the HTP. Six-month resource savings after intervention were estimated at $19,677.42 ($491.90 per patient). Ninety-three percent of these savings are attributed to those patients with the HTP. There were no statistically significant improvements and considerably fewer savings for those patients not on the HTP. CONCLUSION: A combined intervention consisting of patient education, a coordinated self-monitoring plan, and patient follow-up was associated with improved care and economic outcomes in this group. The greatest clinical improvement and resource savings are clearly seen in those patients who have received the HTP as part of their asthma case management. Every effort should be made to include the HTP as the central part of asthma case management.