Infection

ABSTRACT: Unless the cause of back pain is obvious, order anteroposterior and lateral radiographs of the spine, a complete blood cell count, erythrocyte sedimentation rate, and urinalysis. If you suspect infection, tumor, or bony abnormalities, obtain an MRI or CT scan. MRI has surpassed bone scanning as the gold standard for diagnosing spinal infections, because it confirms a specific anatomic diagnosis. Spondylolysis and spondylolisthesis are 2 of the most common causes of back pain in adolescents; the diagnosis is made with plain radiographs, which show slippage on the later-al view in patients with spondylolisthesis and fracture through the pars interarticularis on the oblique views in those with spondylolysis.

The most common blood-borne infection in the United States, hepatitis C is also one of the leading causes of chronic liver disease in this country. About 35,000 new hepatitis C virus (HCV) infections are diagnosed each year; by 2015, the number of persons with documented HCV infection is expected to have increased 4-fold from what it was in 1990.

ABSTRACT: Patients can greatly reduce the risk of traveler's diarrhea by drinking only bottled water and eating only hot foods prepared in sanitary conditions or peelable fruits and vegetables. Antibiotic prophylaxis for traveler's diarrhea is no longer routinely recommended; reserve it for patients who may have to consume food and beverages of questionable safety, those with reduced immunity, and those likely to experience serious consequences of illness. Adequate hydration is the first step in treating traveler's diarrhea. Drug therapy-loperamide or fluoroquinolones in adults and bismuth subsalicylate or azithromycin in children-can ameliorate symptoms and speed recovery. Recommend that patients who are prone to motion sickness take an antiemetic/antivertigo agent before symptoms begin. Acetazolamide can be used both to prevent and to treat altitude sickness. Contraindications to air travel include a resting oxygen saturation of less than 90%, pregnancy of more than 36 weeks' duration, pneumothorax, recent myocardial infarction or chest or abdominal surgery, active infectious diseases, and poorly controlled seizures or sickle cell anemia.

A 78-year-old man presented to theemergency department with a 3-weekhistory of progressive shortness of breathand cough with blood-streaked, yellowishsputum. The patient had dyspnea onexertion limited to 2 blocks, 2-pilloworthopnea, paroxysmal nocturnal dyspnea,and nocturia. Neither fever norchills were present. He had lost 7.2 kg(16 lb) during the last year.

Smoking-related diseases have reached epidemic levelsamong women in the United States. Since 1980, neoplastic,cardiovascular, respiratory, and pediatric diseases attributableto smoking-as well as cigarette burns-havebeen responsible for the premature deaths of 3 millionAmerican women and girls. Lung cancer is now the leadingcause of cancer-related deaths among US women; itsurpassed breast cancer in 1987.1

A 77-year-old man is brought to the emergency department after severaldays of illness that began with fever, nausea, emesis, and headache. Muscleweakness and associated myalgia developed; the weakness became so severethat the patient needed help to get out of bed and walk to the bathroom.The day before he came to the hospital, he slept much of the time and wasdifficult to arouse.

A 44-year-old man with type 2 diabetes was recently hospitalized for an acuteexacerbation of pancreatitis. This was his seventh admission for the conditionwithin the past several years. Although imaging studies revealed no calcifications,the hospitalist suspected that acute relapsing pancreatitis was evolvinginto chronic pancreatitis.

A 48-year-old woman was admitted to the hospital with deep venous thrombosis of the right leg. She had a history of non-Hodgkin lymphoma, which was in remission. The patient had been a heavy smoker for many years.

Fourteen months of intermittent, foul-smelling, perianal discharge prompted a 45-year-old man to seek medical evaluation. He also complained of occasional bright red rectal bleeding and soreness of the perianal region; he denied fever.

A 7-year-old black girl comes toyour office with a 10-week historyof scaling and scalp redness,and hair loss. About 3 weeks beforethe visit, the child’s motherfirst noticed a boggy, drainingyellow plaque on her daughter’sparietal scalp. A different physicianprescribed ketoconazoleshampoo. At 1-week follow-up,the symptoms had not abated;the clinician then prescribed oralcephalexin as well as a topical mixture of the antifungal agent, clotrimazole, and the high-potency topicalcorticosteroid, betamethasone. After 2 weeks of therapy, the symptoms were no better.

A 69-year-old retired accountant presents with a 2-month history of daily headaches. The pain is moderate, constant,global, pressure-like, and occasionally pulsating; it is sometimes exacerbated when the patient lies down. He denies nauseaor vomiting, ocular symptoms, weakness, or sensitivity to light. His wife reports that years ago he experienced throbbingheadaches regularly.

ABSTRACT: A key objective in the follow-up of women with a history of breast cancer is the detection of local and distant disease at a curable stage. Regular clinical examination and yearly mammography are the standard of care. No consistent evidence supports annual chest radiography, bone scans, or tests of serum tumor markers. Order laboratory or diagnostic tests only if indicated by clinical findings. Advise women to report new symptoms promptly rather than waiting for the next scheduled examination. Some evidence supports the use of venlafaxine for tamoxifen-associated hot flashes. Despite the increased incidence of endometrial carcinoma in women taking tamoxifen, routine endometrial biopsies are not recommended. Most experts advise that women with a history of breast cancer who wish to have a child wait 2 to 3 years before becoming pregnant.

According to the CDC, last year's influenza season in the United States was mild to moderate.1Influenza activity increased in mid January and peaked during mid to late February. The percentage of deaths associated with pneumonia and influenza exceeded the epidemic threshold for 5 consecutive weeks. Influenza A (H3N2) viruses predominated, although toward the end of the season, influenza B viruses were identified more often than influenza A viruses.

During a routine office visit, a 64-year-old woman who has had type 2 diabetesfor more than 10 years complains of increased pedal edema. The edema is minimalon awakening and worsens throughout the day.

The mother of a 6-year-old child brings her to your office becauseof a pruritic rash that has been present for several days. The rash did not respondto hydrocortisone cream and has continued to spread along the patient’sleft side.

I have a 74-year-old male patient who has peeling lips and recurrent painful aphthousulcers.

A 32-year-old man who was seropositive for HIV presented with a tender lesion on his right foot of about 3 months' duration. The patient's only medication was zidovudine. His CD4+ cell count was 120/µL.

For 1 month, a 25-year-old woman had experienced discomfort in and around the left eye and diplopia. She was in good health; she reported no weight loss, excessive nervousness, heat intolerance, decreased strength, changes in the texture of hair or skin, or altered bowel habits. There was no personal or family history of goiter or other thyroid disease.

A pruritic rash developed on the feet of a 40-year-old woman 2 days after she had worn a new pair of shoes for a few hours. The erythematous, papular, scaly eruption was more prominent on the right foot.

Although acute low back pain usuallyresolves within 6 weeks-with or withouttreatment-the pain may signal asignificant neurologic or life-threateningdisease that warrants immediateintervention.

A 22-year-old Filipino man with fever, lethargy, weakness, and malaise of 5 days' duration was brought to the emergency department by his family. Two days earlier, oral penicillin had been prescribed for streptococcal pharyngitis. The patient was unable to walk because of profound weakness. Circular and linear ecchymotic lesions were noted on his back.

For 2 days, a 43-year-old woman has had a slightly tender rash on her trunk andextremities. Five days earlier, the patient was given levofloxacin for an upperrespiratory tract infection; because she is prone to yeast infections while takingantibiotics, fluconazole also was prescribed.

Even though highly active antiretroviral therapies and effective chemoprophylaxis are available, the exposure of HIV-infected patients to opportunistic pathogens remains a concern.

ABSTRACT: Most patients with nonspecific low back pain recover spontaneously within 4 to 6 weeks. Patients who resume their normal activities as soon as possible generally recover faster than those who stay in bed; analgesics speed recovery. Sciatica is usually caused by a herniated disk. However, if the patient has a demonstrable neurologic deficit, obtain plain radiographs to rule out tumor, spondylolisthesis, fracture, and infection. Administer high-dose intravenous corticosteroids immediately to patients with suspected epidural compression syndrome. Back pain in a patient with a history of cancer may indicate metastasis to the spine. If a cancer patient has new or aggravated symptoms, start corticosteroid therapy and order plain radiographs and MRI scans.

A previously healthy elderly woman reports that she has hadunilateral facial pain and crusting skin lesions for several days. She decides toseek medical care because of concomitant impaired visual acuity.

Several of my female patients have chronic itchy, burningvulvitis.

For 2 days, a 68-year-old woman had watery, yellowish diarrhea with mucus and left lower quadrant pain. Her medical history included hypertension, diabetes mellitus, and congestive heart failure (CHF); she had left the hospital 5 days earlier following treatment of an exacerbation of CHF with intravenous furosemide and sodium and fluid restriction. The patient was taking furosemide, lisinopril, and glipizide; she denied any recent antibiotic therapy.

A 63-year-old woman seeks evaluation of a persistent, rough, red area onthe dorsum of her left index finger. The lesion has been present for severalmonths. The patient’s manicurist is convinced it is a wart.

A 13-year-old boy presents with swelling of the left eyelidsthat started 12 hours earlier; the eyelashes are mattedwith yellow discharge. He does not wear contact lenses oreyeglasses and denies ocular trauma or foreign bodies. Hehas been nauseated and has vomited once; his motherattributes these symptoms to an antibiotic that was prescribed5 days earlier for a sinus infection. Medical historyis noncontributory; there is no family history of ocularproblems.

To facilitate removal of a subdermalforeign body from a patient’s hand,turn on an otoscope and lay it ona work surface, turn off the lights inthe room, and hold the hand againstthe otoscope.