A patient presents to his primary care physician for medical clearance prior to cataract surgery. His laboratory work reveals the following:
Past laboratory values reveal an elevated ANCA and anti-glucose-6- phosphate. Physical examination reveals splenomegaly.
Which additional findings are likely to be found on further evaluation?
Swan-neck deformities. This patient has Felty syndrome, characterized by neutropenia, splenomegaly, and rheumatoid arthritis. (A, D) Malar rash and nephritis are associated with systemic lupus erythematosus (SLE), which can also occasionally be associated with neutropenia, splenomegaly, ANCA, and anti-glucose-6-phosphate. However, this combination of findings is more likely to be found in Felty syndrome. (B) Oral thrush and axillary lymphadenopathy are findings associated with HIV infection, which is not associated with autoantibodies. (E) Night sweats and dyspnea are associated with TB, which is also not associated with autoantibodies.
A 32-year-old woman with a history of bipolar disorder presents with excessive urination and thirst for the last week. Desmopressin is administered and the urine osmolality does not change.
Which of the following is the treatment for this patient’s condition?
Hydrochlorothiazide. This patient is suffering from nephrogenic diabetes insipidus, likely secondary to long-term lithium use for bipolar disorder. Nephrogenic diabetes insipidus is characterized by a defective renal response to antidiuretic hormone (ADH, also known as vasopressin), in contrast to central diabetes insipidus in which there are insufficient levels of ADH. The first-line treatment is hydrochlorothiazide, which causes increased excretion of sodium and water, thereby reducing the serum osmolality and eliminating volume excess.
A 37-year-old man presents with skin changes and abdominal pain. The abdominal pain is not affected by meals, and he has noticed painful red lesions on his hands and feet. He reports that he recently went on a backpacking trip, where he was bit by many mosquitoes and a few ticks. On examination, the patient is febrile. There is an early diastolic murmur auscultated at the left upper sternal border, and there is significant tenderness to palpation in the patient’s right upper quadrant of the abdomen. The following laboratory values were obtained.
An echocardiogram shows the following figure:
Which of the following organisms is likely responsible?
Coxiella burnetii. This bacterial species is responsible for Q fever, a zoonotic infection that can be asymptomatic or cause pneumonia, hepatitis, and/or endocarditis. This patient has hepatitis and endocarditis, the latter of which should raise suspicion for Q fever given his history of recent tick exposure. Treatment is with doxycycline. Borrelia, Ehrlichia, Francisella, Babesia, and Rickettsia are all associated with ticks; however, they are less likely to be associated with hepatitis and endocarditis.
A 54-year-old man presents to his physician complaining of difficulty with urination. He says that it requires increased efforts to urinate despite feeling the urge to void. He tells his physician that he would like to be screened for prostate cancer. He explains that his father was diagnosed with prostate cancer at age 68 and passed away at the age of 70 due to widespread metastatic disease. He wants to know if there is anything that can be done to see if he too has prostate cancer.
Which of the following is the most appropriate next action?
Perform a digital rectal examination. This patient is presenting with difficulty voiding most likely secondary to benign prostatic hyperplasia (BPH). While his father’s history is concerning for prostate cancer, BPH is a much more common cause of the symptoms he is describing. A full history and physical examination should first be performed, including a digital rectal examination to evaluate for signs of prostate enlargement. (A, B, C) At this time the American College of Physicians and American Cancer Society support informed decision making in deciding whether to perform PSA testing. PSA levels should not be ordered prior to a full discussion of the risks and benefits of screening with the patient. However, a digital rectal examination is the best answer for the next step in management since it addresses the likely cause of his chief complaint. (D) While it may be true that his risk of dying from prostate cancer is low, this is an uncertain and inappropriate comment at this time.
A 65-year-old woman with a known history of Turner syndrome, GERD, and hypertension presents with acute onset of hemiparalysis of her right side. Her daughter explains that the symptoms began while they were having lunch and her mother was having difficulty holding her utensils. She has no prior history of stroke or transient ischemic attacks. The daughter notes that her mother had surgery for a tooth abscess 1 month prior, and for the past 2 weeks has had intermittent fevers for which she took acetaminophen. Physical examination reveals a crescendo–decrescendo murmur best appreciated at the left upper sternal border and painful red lesions on her hands.
What could have prevented the development of the patient’s current neurologic symptoms?
IV antibiotic administration. This woman presents with an acute stroke likely secondary to a septic embolus from infective endocarditis. Infective endocarditis occurs more commonly in individuals with predisposing valvular conditions such as a bicuspid aortic valve in Turner syndrome. Her dental procedure might have provided the source of infection; however, it is important to know that prophylactic antibiotics would not be recommended for a congenital bicuspid valve. In this case, treatment of the infective endocarditis with 4 to 6 weeks of IV antibiotic therapy based on culture specimens would have prevented her stroke.
(A) The cause of this patient’s stroke was from a septic embolus, not vascular disease as a result of hypertension. (C) There is no history to suggest that she had an indication for valve replacement, and in addition prosthetic valves cause an increased risk of endocarditis. (D) While anticoagulation is indicated in those with mechanical heart valves or atrial fibrillation, this would not have prevented the endocarditis. (E) Rapid plasma reagin testing (RPR) is a screening test for syphilis. Though she has lesions on her palms, her history of a heart murmur and current stroke suggest that these lesions are most likely Osler nodes from infective endocarditis.
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