Infection

abstract: The keystone of influenza prevention is still vaccination. The 2 available types of influenza vaccine--the inactivated vaccine, which is administered intramuscularly, and the attenuated vaccine, which is delivered via nasal spray--have efficacy rates of 70% to 80%. Unfortunately, only about 65% of persons who should receive the influenza vaccine are, in fact, vaccinated. The neuraminidase inhibitors oseltamivir and zanamivir are 70% to 90% effective in preventing influenza. These antivirals also are effective in reducing the severity of influenza symptoms and the duration of illness when administered within 48 hours of the onset of clinical disease. Some patients have difficulty in self-administering zanamivir because the inhalation process is fairly complicated. Because of the resistance pattern observed in 2005, amantadine and rimantadine are not currently recommended for prophylaxis or therapy. (J Respir Dis. 2007;28(1):21-29)

My patient-an 84-year-old woman with hypertension-presented with itchingand blistering of 3 days’ duration on her right foot (Figure).

What Are Trigger Points?Tender areas, swellings, or knots under the skin are referred to as“trigger points.” Injection of these trigger points with medication mayalleviate discomfort. At times you may feel pain in an area distant fromthe trigger point. Your doctor will feel the various muscle groups tolocate the trigger points and the most tender areas.

Frequent hand washing is extremelyimportant to help prevent nosocomialinfections; however, compliance can bea problem.

Every year thousands of physicians must take-andpass-an examination to become board certifiedin internal or family medicine. Thousands moremust pass a board recertification examination tomaintain their license to practice medicine-andsimilar exams are required of physician assistants andnurse practitioners. To pass a certification or recertificationexamination requires up-to-date and in-depth knowledgein at least a dozen areas of clinical medicine.

An area of pigment loss in the skinand surrounding hair is noted on thehead of a 10-year-old boy. Examinationof the vertex of the scalp revealsa nevus encircled by depigmentation.

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 35-year-old woman has a lifelong history of recurrent blisters on the handsand feet that heal without scarring. No other family members have this condition,and she has no children. She is visiting your office for the first time toseek new treatment options.

Apreviously healthy 22-year-oldHawaiian man presents to theemergency department (ED) of a hospitalin California with a 3-day historyof fever and chills. He has also had aprogressively worsening, persistent,dull aching pain in the right upperquadrant of the abdomen for the pastweek. The pain is localized-with noaggravating or relieving factors-andis not related to meals. The patienthas had no nausea, vomiting, loss ofappetite, jaundice, abdominal distension,cough, chest pain, dyspnea,weight loss, or lymphadenopathy.

A 22-year-old man hashad a swollen tongue for the past2 days. The swelling is not associatedwith trauma, recent illness, or medicationuse. The patient denies dysphagia,drooling, and shortness ofbreath but does have some difficultyin speaking because of the swelling.

A 32-year-old man recently noticed a dark lesion behind his right knee. The patientdenies trauma and fever and has no other medical problems. Since he started workingfor the parks and recreation department of the state of Florida 18 months ago, hehas spent an increased amount of time outdoors.

I work part-time at a drug and alcohol detoxification unit.

A 12-month-old previously healthy boypresented to the pediatric emergencydepartment (ED) with a 10-day historyof fever, irritability, and anorexia.The patient’s mother had originallynoted the development of 3 erythematouspapules on the patient’s back, leftaxilla, and chest; these were followedby the onset of daily fevers, with temperaturesranging from 38.8°C to41.1°C (102°F to 106°F). The lesionsgrew progressively larger and erythematous,and became ulceratedwith central eschars.

I have heard that a trial of prednisone is effective in some patients with recurrent rhinosinusitis.

For several weeks, a 68-year-old man has had painful blisterson his hands that crusted as they healed. The patienthas diabetes mellitus, hypertension, and chronic renalfailure, for which he is undergoing hemodialysis. His longtermmedications include a hypoglycemic agent and adiuretic.

A 62-year-old woman was found on thefloor of her bathroom at home with herwheelchair partially on top of her.She was unresponsive except to painfulstimulus.

Case 1: A 42-year-old woman presents for anevaluation of an acute pruritic eruptionthat began 2 days earlier on herface, trunk, and extremities. The lesionsresolve and recur at differentsites from one day to the next. Theoutbreak began after the patient ateChinese food the night before; shealso had a recent sinus infection. Shetakes vitamins and hormone replacementtherapy.

It struck me when reading Dr Thomas Petty’s “PulmonaryQ&A” on when to treat latent tuberculosis (TB) infections(CONSULTANT, January 2003, page 48) that it is importantto remind clinicians how misleading tuberculin testingin the elderly can be if the 2-step testing procedure is notfollowed.

A 62-year-old woman presents with severe, sharp pain in her right mid chestthat worsens when she breathes. The pain began the previous night, shortlyafter she had been awakened by a shaking chill, followed by the sensationof fever. She also has a relatively nonproductive cough of recent onset.

In our practice, we see many adolescents who are in residentialtreatment facilities or in group foster homes.

A 9-year-old boy, who has no significantmedical history, presents with a generalizedpruritic eruption of 2 weeks’ duration.One week earlier, another practitionerruled out scabies and treatedhim presumptively for varicella.

To palpate the abdomen in a ticklishpatient, begin by placing the patient’shand on the abdomen in a pain-freearea.

A 49-year-old man complains of sharp pain in the medial left ankle that begansuddenly 3 nights earlier, waking him up. That night he also felt feverish anddiaphoretic, but those symptoms have subsided. The pain is present whenhe moves the ankle or when a shoe compresses the area. No other joints areinvolved. He denies trauma to the ankle or foot.

Until they can see a physician,patients can try using cold milk compresses(whole milk, low-fat, or skim)for temporary relief from the itchingof poison ivy or simple eczema.

When sterile saline is needed for repeatedhome use (eg, for daily cleansingof a foot ulcer), suggest thatthe patient buy an over-the-counter,

A 23-year-old man presents to the emergency department with fever, headache,and photophobia. His illness began 5 days earlier with malaise, followed byfever, prostration, nausea, and vomiting. After 3 days, a severe headache developed,accompanied by photophobia; the headache did not respond to over-thecounteranalgesics.

An 81-year-old man presents with severe Alzheimer dementia. Hishistory includes benign prostatic hypertrophy with 2 transurethralresections. He has a remote history of tobacco use and has not used alcohol excessively. He isotherwise in good health. At the time of his original diagnosis, a cholinesterase inhibitor was notprescribed.

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.

A 16-year-old Somali girl presents witha 3-day history of bilateral arm swellingand painful vesicular eruptions; hersymptoms are worsening. She reportsthat 5 days earlier, she and her friendshad used henna and black hair dyeto “tattoo” their skin. The others havenot experienced similar signs or symptoms.This patient has used henna(which is dark red) since childhoodfor decorative purposes. However, outliningan intricate design with hairdye is new for her.

A preoperative evaluation performed shortly before a 66-year-old man is scheduledto undergo coronary artery bypass graft (CABG) surgery reveals a peripheralblood leukocyte count of 23,500/μL with 28% neutrophils, 70% lymphocytes,and 2% monocytes. The patient’s hemoglobin level is 14.5 g/dL; plateletcount is 265,000/μL.