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Environmental Medicine: Integrating a Missing Element into Medical Education
A 48-year-old handyman with progressive cystic acne and abnormal liver function
You have been treating a 48-year-old man conservatively for his facial acne vulgaris. He first sought treatment about 3 months ago, remarking that such blemishes are typical for a teenager but he never had them during adolescence. Therapy was initiated with benzoyl peroxide washes and topical antibiotics, in addition to instructions for skin hygiene. When no real improvement was noted, oral antibiotics were prescribed. Due to continued lack of efficacy, this regimen was later supplemented by Retin-A™* (tretinoin) cream.
The patient has returned for a follow-up visit and complains that the acne is worse. On examination, you agree, and tell the patient you would like to refer him to a dermatologist for Accutane™* (isotretinoin) therapy. A serum biochemical and hematologic profile are ordered to document baseline values before therapy begins.
To your surprise, the biochemical panel reveals the following abnormalities: total bilirubin 2.8 mg/dL (normal 0–1.5), direct bilirubin 0.4 mg/dL (normal 0–0.4), SGPT (ALT) 74 IU/L (normal 0–50), SGOT (AST) 88 IU/L (normal 0–50), GGPT (GGT) 190 IU/L (normal 15–85), LDH 230 IU/L (normal 50–225). Other testing, including complete blood count, alkaline phosphatase, BUN, creatinine, and urinalysis are within normal limits.
On questioning, the patient denies history of hepatitis, contact with hepatitis patients, other liver difficulties or blood transfusion. He informs you he has Gilbert’s syndrome and has had elevated bilirubin levels in the past. There is no family history of cardiovascular disease or cancer. The patient does not smoke; he drinks 2 to 3 bottles of beer each evening, and sometimes more on weekends. He is currently taking no medications other than those mentioned. Review of systems is otherwise unremarkable.
Social history reveals the patient is married with three teenaged children; his wife and children are in good health. They live in a high-rise apartment building where the patient has been handyman and part-time building manager for the last year. He spends much time in the basement area, which includes a workshop, recreation room with pool table, and laundry and heating facilities. An avid fisherman, he spends most weekends fishing in Lake Michigan with his two sons. Physical examination reveals mild, nontender hepatomegaly without jaundice. His acne, which is most prominent on the upper face lateral to the eyebrows, began about 8 months ago.
Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services.
(a) What should be included in the patient’s problem list?