Approach To A Patient With Fever And Lymphadenopathy

A 57 year old woman comes to her family physician with the complaints of fever and lymphadenopathy in her neck.

How will you approach this case?

Clinical Approach:
There are a wide variety of causes of lymphadenopthy. Knowing theses causes helps in making a structured diagnosis. Majority of the causes for enlarged or swollen lymph nodes are benign and secondary to self limiting infectious causes. The probability for malignancy increases with age and should always be ruled out an any patient with lymphadenopathy.

Causes Of Lymphadenopathy: The important causes for lymphadenopathy include:

1. Infectious causes: 

Toxic Shock Syndrome In A Young Female

A 20 year old female university student presents to the emergency department with a 12 hour history of fever, chills and generalized body aches and pains. On arrival she is noted to be confused, breathless and hypotensive with a sinus tachycardia.

Palmar desquamation seen in the above patient.

What is the differential diagnosis?

Approach To A Patient With Chronic Diarrhoea

A 24 year old married man presents to his general physician with a history of watery diarrhea which has sometimes blood mixed in with the stools. He has lost some weight and also complains of arthralgia.. How would you approach this case ?

Clinical Approach:
The patient in this case is most likely suffering from idiopathic inflammatory bowel disease, but it is important to exclude chronic infection and to consider other causes of chronic diarrhea. Always make sure that the patient is actually having diarrhea that is increased daily stool volume.

History of Presenting Problem:

1. Character of the stool  knowing the character of the stool is very important for the appropriate diagnosis. The questions to be asked in history include:

• Frequency of passing the motion.
• Whether there is any urgency
• Any pain on defecation

2. Rectal Bleeding: If there is any rectal bleeding or blood in stool following should be clarified:

• is the blood passed freely per rectum without any stool?
• Is it mixed with stool
• is it only present on the toilet paper when the anus is wiped.

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.