A 74 Year Old Chronic Smoker Presents With Fatigue And Shortness Of Breath

A 74-year-old man who is a chronic smoker presents with fatigue and shortness of breath. He has not seen a physician for many years and says he has been basically healthy.
On physical examination, he is found to be pale, mildly cachectic, and his lips are cyanotic.
His breath sounds are distant, although crackles can be heard in both lung bases. His heart sounds are best heard in the epigastrium; and a third heart sound is present. He has mild peripheral edema.
His resting pulse oximetry is 74%.
The chest X-ray (CXR) shows emphysema and his echocardiogram confirms heart failure.
The X Ray is shown below:

Case Discussion:

Emphysema:

A 55 Year Old Diabetic Woman Presents With Malignant Otitis Externa

A 55 year-old woman with type 2 diabetes presents to her family  physician with a 2-day history of bilateral ear pain and discharge as well as some hearing loss. Symptoms started in the right ear and then rapidly spread to the left ear. She had a low-grade fever and felt ill.
On examination the external ear was swollen with honey-crusts. The external auditory canal (EAC) was narrowed and contained purulent discharge Ear, nose, and throat (ENT) was consulted and she was admitted to the hospital for the presumptive diagnosis of malignant otitis externa. She was started on IV ciprofloxacin and the ear culture grew out Pseudomonas aeruginosa sensitive to ciprofloxacin. The patient responded well to treatment and was able to go home on oral ciprofloxacin 5 days later.

Case Discussion:

Otitis Externa:
Otitis externa (OE) is a common condition and is defined as inflammation, often with infection, of the external auditary canal.
It occurs more commonly in adults than in children.

Head Lice Infestation In Children

A mother brings her two children, ages 7 and 4, who have been complaining of itchy scalps. So far, they have not tried any treatments.
On examination of both children, you find erythematous papules on the occiput and small white
eggs firmly attached to the hair shaft about 1 cm from the scalp.

What is the most likely cause and how to manage it?
 Head Lice Infestation ( Pediculosis Capitis)

Case Discussion:

Head Lice (Pediculosis Capitis) is a common and highly contagioug infection most commonly seen in school going children , at day care and people living under crowded and low socioeconomic conditions.

Etiology: It is caused by infestation with the human head louse : Pediculus humanus capitis. .

Pathogenesis: Lice are very small insects that feed on human blood. The female louse attaches her eggs (nits) to the base of the hair near the scalp, and the nits hatch in 7 to 10 days. lice are spread from child to child by close head to head contact and by sharing hair brushes and other infested belongings.

Clinical features: It causes discomfort and itching but typically does not constitute a serious condition. A child may be irritable from itching or may not sleep properly. Excessive itching may cause scratches and secondary skin infections.

Management: 
1. Using fine toothed comb to remove the lice and the nits.
2. Good hygiene and regular hair washing.
3. Treatment with topical agents such as permethrin cream for two applications is also effective.
4. It is important to disinfect the bedding and treat all close contacts at the same time
5.Children need regular and frequent inspection of the hair as they may get re infected.

A Young Male Presents With Multiple Moles On His Body

A young while male is seen by the dermatologist for multiple moles on his body that are progressively increasing in number , some one them have uneven color pigmentation and notched borders. The patient is concerned as few years ago his elder sister who has similar presentation was diagnosed with malignancy.

What is the most likely Diagnosis?
.
.
Dysplastic Nevi Syndrome.

A 43 Year Old Woman With Varicose Veins

A 43-year-old woman presents to her physician’s office with complaints of heaviness and fatigue in her legs.  She does not experience the symptoms in the morning but they become more noticeable as the day progresses and with prolonged standing. When she stands for many hours, she develops swelling in both of her legs. The symptoms are concentrated over her medial calf where she has
prominent tortuous veins. She first noted the veins approximately 15 years ago when she was pregnant. Initially, they did not cause her any discomfort but have progressively enlarged now and over the past 10 years have become increasingly painful. She recalls that her mother had similar veins in her legs.

This patient was diagnosed with varicose veins or Venous insufficiency.

Case Discussion
Varicose veins: Also known as Venous insufficiency is a condition that is caused by improperly functioning valves in the venous system and is most commonly seen in the legs causing abnormally thick, enlarged and twisted, engorged veins. This may lead to skin changes and even ulceration in advanced cases.

A 70 year Old Man With Hyperkalemia Secondary To Medication Side Effect

A 70 year old man with congestive cardiac failure and taking angiotensin converting enzyme inhibitor, spironolactone , digoxin and furosemide comes to the emergency department complaining of nausea and palpitations. He also mentions having not passed urine for last 24 hours. On admission an ECG was done which is shown below:

Note the tall peaked T waves.

What investigation should be performed next?

Answer: Serum potassium

Tall tented T-waves is an ECG feature of hyperkalaemia. In this case, the cause of hyperkalaemia is a combination of potassium-sparing drugs and obstructive uropathy.

Case Discussion: