Infectious Disease

Two weeks after undergoing a laparoscopic partial nephrectomy for renal adenocarcinoma, a 78-year-old man with myelodysplastic syndrome was hospitalized with nonhealing abdominal wounds. The patient had started a course of oral cephalexin 4 days before admission to treat erythematous areas at 2 of the trocar port sites.

Abstract: A number of factors can complicate the diagnosis of asthma in elderly patients. For example, the elderly are more likely to have diseases such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) that--like asthma--can cause cough, dyspnea, and wheezing. Spirometry can help distinguish asthma from COPD, and chest radiography and measurement of brain natriuretic peptide levels can help identify CHF. Important considerations in the management of asthma include drug side effects, drug interactions, and difficulty in using metered-dose inhalers. When discussing the goals of therapy with the patient, remember that quality-of-life issues, such as the ability to live independently and to participate in leisure activities, can be stronger motivators than objective measures of pulmonary function. (J Respir Dis. 2006;27(6):238-247)

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.

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.

ANN ARBOR, Mich. - Even if there were a foolproof vaccine against avian flu, but with a small risk or mortality from the vaccine itself, many people would take their chances with the virus.

ROCKVILLE, Md. - The FDA approved a shingles vaccine, and Merck said it is ready to accept physician orders, with rapid shipment promised.

Since gout can precipitate olecranon bursitis, should I routinely order a crystalanalysis for patients who present with this bursitis?

A young child is brought to your office with a several-dayhistory of earache, sore throat, and low-grade fever. The nurse is concernedabout lesions she noticed on the child’s tongue while attempting to take histemperature.

A 52-year-old man complains of right knee pain that hasbeen increasing steadily for several weeks. Two years earlierhe underwent a total arthroplasty of the same knee to treatsevere osteoarthritis secondary to a meniscal injury. He hasno history of recent trauma or increased activity.

Green discoloration of the fingernailsdeveloped 6 weeks after a 29-year-oldwoman had artificial nails placed duringa manicure. The patient was a doctorof pharmacy degree candidate whowas married and had 2 children.

For the past few weeks, pruriticpatches have been erupting on a38-year-old man’s extremities. He recallsthat similar lesions occurredduring the last 2 winters. The patienthas a history of seasonal allergies;he owns a cat and 2 dogs.

A 6-year-old girl presents witha several-month history ofgenital discomfort that includesitching, irritation, andoccasional bleeding. Themother reports that there isblood on the toilet paper afterthe child wipes herself. Therehas also been some spottingin the child’s underwear. Thepatient seems to be grabbingat her crotch frequently.

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.

To reduce the incidence of candidalinfections in patients with dermatologicproblems, instruct them to drythe affected area with a blow-dryeron a cool or warm setting before theyapply topical medications.

The patient was a 41-year-old manwith a history of HIV infection diagnosed10 years before admission.He had been noncompliant withtreatment, and therapy with tenofovir,efavirenz, and lamivudinehad not been started until 2 monthsbefore admission, when he presentedto another hospital. At thetime, his CD4+ cell count was156/µL and his viral load was45,743 copies/mL. He also had ahistory of incarceration; had usedinjection drugs, cocaine, alcohol,and marijuana; and had a 20-packyeartobacco history.

Four cases to test your diagnostic skills: bizarre circular ecchymoses, abdominal ecchymosis, myriad nodules, and cavernous dilated blood vessel in a patient’s arm.

Young Man With Painless Penile Ulcer

Is prophylactic oophorectomy recommended for healthy postmenopausal women with a strong family history of cancer?

Which test--antistreptolysin O titers, coronary angiography, enzyme-linked immunosorbent assay (ELISA), Western blot testing for Borrelia burgdorferi, or genetic testing for long QT syndrome--would help you diagnose a young man with worsening chest pain, frontal headache, and diffuse muscle and joint pain?

A patient who is allergic to penicillin was bitten on his wrist by a dog. What is the first test you order?

Initiation of early aggressive therapy is critical to averting fatal outcomes in exacerbations of acute life-threatening asthma.

A 24-year-old woman presents tothe emergency department withincreasing left lower quadrant pain,nausea, and persistent retching andvomiting of 48 hours’ duration. Thepain ranges from dull and aching tocramping; it has become generalized,and there is no specific relieving factor.During the last 12 hours, she hasalso had fever and chills. She has nourinary symptoms, hematemesis,melena, diarrhea, constipation, or abdominaldistention.

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.

We live in a world of toxins and potential toxins, and thus we are often just a misstep away from a toxic exposure and its consequences. Even that which is meant to cure can kill. All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy; exposure to the wrong dose of a medication (whether accidental or not) remains a common form of toxic exposure.

Are there any generally accepted guidelines for performing arthrocentesis in patients who are receiving anticoagulants?

The line on the gums of this 30-year-old man indicates lead poisoning. The patient had been employed for 8 months at a lead smelting plant in which no occupational safety precautions had been enforced. He was admitted to the hospital with the classic symptoms and signs of lead poisoning--pain in the nape of the neck that radiated down the spine, posterior thighs, and calves to the plantar aspect of the feet; colicky panabdominal pain; anorexia; weight loss; nausea; vomiting; constipation; bone and muscle tenderness; hyperesthesia of all extremities; insomnia; irritability; generalized weakness; malaise; and dizziness.

For 2 months, a 35-year-old woman has been troubled by a bilateral pruritic eruption on her neck. The condition did not respond to a 3-week course of oral terbinafine. The patient has a history of childhood asthma; her only current medication is an oral contraceptive. She has had a cat for the past 2 years. She has not used any new shampoos or conditioners.

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.