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.
Q:My patient’s family appears to be genetically predisposed topulmonary fibrosis. How should I follow this patient? What earlywarning signs herald the condition, and what diagnostic tests are mostappropriate?
A persistent, 2-month-old rash under both breasts has not responded to overthe-counter antifungal creams. The 55-year-old patient now seeks medical care;she is otherwise healthy.
Infection with hepatitis C virus (HCV) was recently diagnosedin a 45-year-old man when a positive enzyme-linked immunosorbentassay was followed by a polymerase chain reaction assaythat showed a viral load of 835,000 copies/mL. The patient probablyacquired the infection when he was using intravenous heroin, a practice he quit 10 yearsago. The patient is immune to both hepatitis A and hepatitis B viruses, and there is no coinfectionwith HIV. Liver biopsy shows moderate cellular inflammation (grade 3) and bridging fibrosis(stage 3) but no evidence of cirrhosis. Iron staining shows no abnormal iron deposition in theliver. The HCV genotype is 1A.
Meningococcal septicemia can bedeadly if not diagnosed and treatedearly.
My patient, a 33-year-old man who works with his hands, presented with a growthunder his left thumb nail (Figure).
A 56-year-old man who has type 2 diabetes presents with feverof 3 to 4 days’ duration, scrotal swelling, and a feculent odor. He has nohistory of trauma or serious illness; however, his glucose level has not beenwell controlled during the past several weeks.
The sudden onset of asymptomatic red streaks on several sites alarms a14-year-old girl. The patient is otherwise healthy; she denies any symptoms ofdepression.
This painful, eroded plaque on thedorsum of a 39-year-old man’s handhad developed over a few days from asmall, painful pustule. The patient’shistory included ulcerative colitis,which was not active when the lesionoccurred.
