Infection

My 60-year-old male patient complains of urgency and frequency of urination.

A4-year-old boy has a 4-day historyof fever; a persistent dry,irritating cough; coryza; and anonpruritic rash. The rash startedaround the ears and then spread overthe trunk and limbs.

Acute gastroenteritisremains amajor cause ofmorbidity andhospitalizationamong infants and childrenin this country. Every yearin the United States, acutediarrheal illness accountsfor more than 1.5 millionpediatric outpatient visits,200,000 hospitalizations-and approximately 300deaths.

For patients who have repeated culture-positive episodes of streptococcalpharyngitis, current recommendations include treatment with amoxicillin/clavulanate or clindamycin.

A 45-year-old womanpresents with redness in the righteye, which she noticed that morning.She has not sustained trauma to theeye and reports no discomfort or lossof visual acuity. Recently, the patienthad a bout of bronchitis with a numberof severe coughing episodes. Herhistory is significant for asthma andcigarette smoking.

A 27-year-old woman is hospitalized after laboratory studies revealed extremelyelevated liver enzyme levels. The studies were ordered after the patient soughtmedical attention for severe headaches that began 3 weeks earlier and for thepast several days had been accompanied by malaise, nausea, and vomiting.

A healthy 21-year-old man presented with a rapidly growing, filiform, ringshapedwart on his great toe (Figure).

My patient is a 70-year-old man who has had several episodesof cellulitis in his right thigh; he does not have diabetes.After the third episode, a 1-cm subcutaneous mass was excisedabove the area of recurrent cellulitis.

A 66-year-old woman presents tothe emergency department(ED) with exertional dyspnea, generalizedweakness, and orthostaticdizziness; the symptoms startedabout 1 week earlier and have progressedinsidiously. The patient alsoreports diaphoresis and nausea withoutvomiting. She has no chest pain,palpitations, cough, or hemoptysis;she has not had a recent respiratorytract infection. While she is waitingto be admitted, she has an episode ofsyncope.

A 13-year-old girl reportsthat her right eye has beendraining and uncomfortable for thepast several days. She is also concernedabout several "bumps" on theupper lid of her left eye. She has hadthese bumps in the past, but theyhave always resolved spontaneously.

The FDA has approved Ketek (telithromycin) fromAventis Pharmaceuticals to treat acute exacerbationof chronic bronchitis, acute bacterial sinusitis, and mild tomoderate community-acquired pneumonia. This is thefirst agent in a new class of antibiotics known as ketolides.Ketek has already been released in European, Latin American,and Asian markets.

During a routine physical examinationof a 21-year-old man, a 1-cm cysticlesion is detected on the posterior wallof the lower nasopharynx.

When you examine the oral cavityof a patient who has an upper respiratorytract infection, use a tonguedepressor that has been rinsed inwarm water and lightly flavored withlemon juice.

For 15 years, a 33-year-old man hashad scale on the soles of his feet;the condition has failed to respondto various topical antifungal agents.He has no other rashes. He ishealthy except for a history of seasonalallergies controlled by overthe-counter medications.

Instead of nail removal, another option for treating a subungualabscess is to scrub the digit and drill a hole in thenail plate with a hot wire loop.

I have been caring for a child, now 18 months old, duringa series of visits over 71⁄2 weeks. The child was originallybrought to our community health clinic by her mother, whoreported that the toddler had diarrhea.

My patient is a 78-year-old woman with heart failure and type 2 diabetes, bothof which are well controlled.

A 36-year-old man presents with a 10-day history of progressive dyspnea anddiscomfort on the left side of his chest.Three weeks earlier, he was dischargedfrom the hospital after a 2-week stayfor acute pancreatitis. He has a historyof long-term alcohol abuse and recurrentpancreatitis.

A 59-year-old woman complainsof progressively worsening bloatingand right upper quadrant pain thatbegan 1 day earlier. She denies feverand trauma. Her medical history includescholecystectomy for cholelithiasisand several emergency departmentvisits for treatment of woundssustained in falls. She has a history ofalcohol abuse, for which she now receivescounseling. However, she admitsthat she occasionally has boutsof heavy drinking.

Increase compliance with testing forasymptomatic chlamydial infectionby letting patients know that they arenot being “singled out”; screening isrecommended for all sexually activewomen aged 25 years and younger.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

A 59-year-old woman presents with generalized facialswelling and dyspnea that has progressed graduallyover the past month. The patient also reports a sensationof pressure in her neck and ears and swelling of the lowereyelids, neck, upper chest, and upper limbs. The bloodvessels on her upper chest are prominent. A dry, irritatingcough has worsened.

My patient has a test-proven Candida allergy. Because hepatitis B virus (HBV)vaccine contains yeast, another physician would not give it to him. I administereda diluted dose and then a full-strength dose of the HBV vaccine, and the patienthad no adverse reaction.

When you treat a patient for tineacruris (jock itch), always check hisfeet as well.

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.

ABSTRACT: The key factor in reducing morbidityand mortality in patients with chronicobstructive pulmonary disease (COPD)continues to be smoking cessation. Newerformulations of nicotine replacementtherapy-a nasal spray and an inhaler-provide rapid delivery of nicotine and maybe appropriate for highly dependent smokers.Bupropion has been shown to improvesmoking cessation rates, either when usedalone or with a nicotine patch. Both theinfluenza and pneumococcal vaccines arerecommended to reduce the morbidity andmortality associated with respiratory infectionsin patients with COPD.

What is bovine spongiform encephalopathy(BSE), or “mad cow disease,” and how is itthought to infect cattle?

A 55-year-old constructionworker who spends a gooddeal of time outdoors has had occasionalblurred vision and an irritatedeyelid for several days. He has wellcontrolleddiabetes and hypertension.Which of these conditions doyou suspect?

Plague is caused by Yersiniapestis, a gram-negative, nonmotile,nonsporulating bacillus.It is a zoonotic disease, and rodentsare the primary reservoir.Plague can present as bubonic,pneumonic, or primary septicemic disease.Y pestis is usually transmitted tohumans via the bites of infected fleas,causing the bubonic form of the disease.Primary septicemic and secondarypneumonic disease are muchless common. Primary pneumonicdisease results from aerosol exposureto an infected animal or human withplague pneumonia; however, it too hasbecome uncommon as a natural event.Nonetheless, primary pneumonicplague, or a similar illness, is the mostlikely manifestation following a bioterroristattack.1,2 Despite the substantialinvestment by the former Soviet Unionin this agent as a potential weapon,there is little experience from whichto predict the clinical consequencesof intentional aerosolization of thisorganism.

A 51-year-old man presents with aseverely infected leg and 1- to 2-cmlesions on all of his extremities andtrunk; the bases of the lesions aredepressed, atrophic, and scarred.According to the patient, the lesionstypically appear as tender nodulesor pustules, which spontaneouslyburst, drain purulent material, andeventually heal as pictured.