HIV AIDS

An asymptomatic 42-year-old woman who has HIV/AIDS presents for aroutine check-up. She denies abdominal pain, nausea, vomiting, diarrhea,paresthesias, and muscle weakness.

A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

Drug interactions and adverse drug reactions result in thehospitalization (or extended hospitalization) of more than100,000 Americans each year. Here an international teamof experts from such fields as pharmacology, toxicology, medicine,and nutrition discuss drug-drug interactions as wellas interactions that occur between drugs and certain foods,alcohol, nicotine, or performance-enhancing agents. Amongthe drug classes covered are benzodiazepines, anticonvulsants,opioids and opiates, monoamine oxidase inhibitors,tricyclic antidepressants, selective serotonin reuptake inhibitors,antipsychotic agents, cardiovascular drugs, antimicrobials,HIV/AIDS medications, and NSAIDs. The authorsreview the pharmacology, pharmacodynamics, pharmacokinetics,chemistry, and metabolism of each class. Also includedis an overview of the theories of liability used in recentdrug interaction litigation and a discussion of the role ofpsychotropic medications in criminal defenses. A detailedindex is provided.

A 48-year-old African Americanwoman with HIV infection who hadbeen hospitalized several days earlierfor presumed Pneumocystis cariniipneumonia (PCP) is readmittedbecause of worsening dyspnea and atemperature of 38.8oC (102oF).She also complains of painful swellingand erythema on her right arm.Her symptoms have worseneddespite treatment with trimethoprimsulfamethoxazole.

A24-year-old man who worked ina warehouse is brought tothe emergency department following2 days of high fever with rigors, generalizedweakness, and a purplishrash on both lower legs that had progressedrapidly during the past24 hours. He had become ill about5 days previously, with a worseningsore throat and achiness that did notrespond to over-the-counter lozengesand ibuprofen.

Good nutritional care can improve the short-and longtermcourses of many illnesses that are common in olderadults. The experts who have contributed to this handbookdiscuss the disorders that can seriously affect andbe affected by nutrition, and they present specific recommendationsfor secondary prevention and management.

A46-year-old white man is hospitalized with increasing dyspnea of 3weeks’ duration. He has a history of stable chronic obstructive pulmonarydisease secondary to heavy smoking (2 packs of cigarettes a day for 27years, discontinued 6 years previously) and uses inhaled bronchodilators.

For 3 days, a 42-year-old man has had episodic dullchest pain. The anterior precordial and retrosternalpain intensifies with inspiration and movement. He has nohistory of recent viral infection, hypertension, coronaryartery disease, cardiac surgery, diabetes mellitus, or hyperlipidemia.There is no family history of cardiovasculardisease.

For nearly 3 years, my patient has had frequent recurrences (now, almost monthly)of erythematous, slightly pruritic lesions on the lower back, inguinal area, orbuttocks-but never on the genitalia.

An 84-year-old man complains of worsening angina pectoris that started3 months earlier. The patient has had aortic stenosis for about 10 years. Healso has diabetes, which is controlled with oral agents.

Two winters ago, the members of CONSULTANT’sEditorial Board met for 3 days with the journal’seditorial staff to brainstorm ways in whichCONSULTANT might best address the educationalneeds of primary care clinicians. One idea in particulargenerated unanimous enthusiasm: an entire issuedevoted to the health care problemsand needs of African Americans.

Q:What is the most common radiographicpresentation of pulmonary tuberculosis (TB)among persons with HIV infection?

For several weeks, a 29-year-old woman has had worsening left lower backpain that is aggravated by sitting and walking. The pain is most severe aboveher left buttock; it radiates into the buttock and very slightly into the leg. Overthe-counter analgesics have been ineffective. Assuming a supine position providessome relief, but the pain still occasionally awakens her at night. She deniesweakness, other neurologic symptoms, and any symptoms of bowel orbladder dysfunction.

A 62-year-old man has had nightsweats and worsening fever andcough for the last 4 days; 2 days agohe had an episode of hemoptysis. Hedenies trauma or travel to a foreigncountry but has a 30-pack-year smokinghistory. The medical history isotherwise noncontributory.

The emphasis in this clinically focused text is on syndromesand patient care rather than on pathogens. Among the topicscovered are antimicrobial pharmacokinetics and pharmacodynamics;head and neck infections; upper respiratory tractinfections; bronchitis and pneumonia; endocarditis; pericarditisand myocarditis; peritonitis, liver abscess, and biliary tractinfections; viral hepatitis; CNS infections; skin and soft tissueinfections; animal and human bites; osteomyelitis and infectiousarthritis; foot infections in patients with diabetes; scarletfever and toxic shock syndromes; fever of unknown origin;bacterial, viral, and protozoal diarrhea; obstetric-gynecologicinfections; urinary tract infections; sexually transmitted diseases;infectious complications of HIV infection; tuberculosis;tropical diseases; zoonoses; bioterrorism; and fungal infections.Color and black-and-white photographs, photomicrographs,CT scans, radiographs, drawings, tables, and flowchartshighlight seminal points in the text.

A 52-year-old woman is hospitalized because she has had jaundice, anorexia,and occasional nausea and vomiting for about 2 weeks. She has also had moderatepain in the epigastrium and right upper quadrant, but it has not been severeenough to require analgesics. She denies hematemesis and hematochezia.

An 18-year-old college studentpresents with a 4-day history ofincreasing throat pain, low-gradefever, and extreme exhaustion. Previously,she had been healthy and participatedactively in sports, includingmarathon running. Her appetiteand intake have been poor. No historyof cough, chest pain, shortness ofbreath, nausea, vomiting, diarrhea,or abdominal distention. She has noallergies, takes no medications, anddoes not smoke or drink alcohol.She is sexually active with a single partner.

Your patients who want to stop smoking need all the helpthey can get. Where can they turn for support?

Over the past 8 years, fragile vesicles,painful ruptured bullae, and erosionshave developed on the sun-exposed skinof a 57-year-old man. Some of the vesicleserupt at sites of minor trauma; othersarise spontaneously. A corticosteroidcream prescribed by another practitionerfor presumed atopic dermatitisfailed to clear the lesions.

A 53-year-old man complains ofdyspnea and a cough that has progressivelyworsened over the pastweek. He denies recent trauma.

For 2 days, a 45-year-old woman has had a painful rash on her left upper chest,upper back, neck, shoulder, and upper arm; she has also had pain around herleft ear. She describes the pain as burning, needlelike, and so severe that it hasprevented sleep; it is unrelieved by topical emollients. The rash was precededby 24 hours of a similar burning pain in the same area. No neurologic deficitsare associated with the rash. She has no history of rashes; no pain or rashesoccur elsewhere on her body.

For about 3 to 4 months, a 53-year-old man has had gradually worsening footdiscomfort. He describes the discomfort as a burning sensation accompaniedby numbness and tingling. Initially, these symptoms were present only in hisfeet, but for several weeks they have involved both ankles as well. Althoughthe discomfort is always present, it is occasionally aggravated by the bed coversor by heavy woollen socks. The patient has no skin lesions, motor symptoms,or other abnormalities of his legs or feet.

The patient is a 4-year-old boy who hasbeen coughing persistently for the past 2months. The mother reports that aboutthe time the coughing began, the childhad a “cold” with nasal congestion andfever. These symptoms resolved, but acough ensued. The mother tried usingover-the-counter medications, includingcough suppressants, but the cough hasnot abated. It occurs during the day andat night. It is disrupting the child’s sleep,and the teachers at his day-care centerare concerned that he may be infectingother children.

A 55-year-old woman has had a lump under her right jaw for thepast 24 hours. She has difficulty in swallowing because of neck discomfort, andher voice is raspy. Both of these symptoms have progressed rapidly during thepast 12 hours. The patient has no difficulty in breathing, sore throat, or historyof recent illness. Her temperature is 38.5°C (101.5°F).

A 64-year-old woman presentsto the emergency department withworsening crampy abdominal painthat began the night before. Afterthe pain started, she had a bowelmovement containing a significantamount of blood; since then she hashad episodes of diarrhea. She hadbeen previously healthy, denies traumaand fever, and knows no one withsimilar symptoms. She reports norecent enema, endoscopy, or otherabdominal procedure.