3. A 17-year-old boy presents with pain in his wrists, elbows, and knees bilaterally. He has felt fatigued, and he has been unable to work his summer job as a cashier and bagger in his family's community grocery store for the past 2 weeks. He also reports intermittent fevers and a large rash on his back in the area of his right shoulder; the rash is depicted in the image. All of these symptoms have emerged in the last 4 weeks, after a weeklong backpacking trip in upper state New York. He has no significant past medical history. His only medication is acetaminophen daily for joint pain. He does not smoke tobacco; he does not drink alcohol or use illicit drugs. He has no known allergies.
Physical examination reveals a thin male adolescent in no acute distress.
Temp 99.1°F, P 100 bpm, RR 14, BP 120/70 mm Hg.
Small, nontender, mobile lymph nodes are palpable in the neck and axilla bilaterally. There is a large, warm, erythematous patch with central clearing at the patient's posterior right shoulder region; it extends across the arm and axilla and measures approximately 25 cm in diameter. There is limited range of motion in his right wrist and left elbow. There were no gross focal neurologic deficits.
What is the most likely cause of these symptoms?
6. A 16-year-old girl was admitted to the hospital 2 days ago with the diagnosis of fever, the cause of which is not known. She has a 1-week history of fever, chills, headache, anorexia, nausea, vomiting, and myalgia. She developed a rash yesterday. She denies abdominal pain or diarrhea. She has had no previous medical problems, hospitalizations, or surgeries. The week prior to the onset of symptoms, the patient went camping in Texas with her church youth group. No one else from the group is ill. Upon admission to the hospital, her initial laboratory results revealed leukopenia, anemia, and elevated liver enzymes. While performing a physical exam, you unexpectedly discover a tick embedded in the girl's scalp.
After sending the appropriate diagnostic studies to the laboratory, what medication should be started empirically?
6. 18-year-old previously healthy woman presents with low-grade fever, chest pain, dry cough, wheezing, and intermittent abdominal pain; symptoms started 1 week ago during her visit to the relatives in the rural Alabama. Aspirin has not helped. Today, her vitals are a BP of 110/65mmHg, a pulse of 80 beats/min, a RR of 15 breaths/min, and a temperature of 37.3 C. Auscultation reveals bilateral diffuse crackles, and the rest of the examination is normal. Her CBC showed a significant increase in eosinophils and IgE. Metabolic panel and liver function tests are within normal limits. The chest X-ray shows bilateral patchy shadows in her upper lung fields. Immunological studies, including ANA, ANCA, and rheumatoid factors are all negative; stool cultures for eggs, cysts, and parasites are negative. Serology for viruses (CMV, EBV, HSV, influenza, adenovirus, echovirus, and Coxsackie virus) is also negative. Based on the likely causative agent, what treatment should you consider? 2. A 4-year-old boy presents to your office with his mother. She states that he has been coughing, occasionally wheezing, and has had a fever for the past two days. She has not noticed any skin abrasions, rashes or inflammation, and the child does not seem to have any SOB or dyspnea. The mother is a stay-at-home mom, so the child does not attend preschool or daycare. The patient is an only child, and he spends a lot of time playing with their 6-month-old puppy outside.
Physical exam reveals a fever of 100.2, swollen cervical lymph nodes, and hepatomegaly. Pt does not appear to be in any distress, and the rest of the exam is WNL. PMH is positive for pica, but the mother states that she tries to watch him carefully, and has not witnessed him eating dirt recently.
CBC with differential reveals eosinophilia, and a blood test looking for antibodies is pending. What is this patient's most likely disease?
A 23-year-old Hispanic man presents with a 2-week history of upper abdominal pain, occasional right lower chest pain, and low grade fever with malaise and appetite loss. He has been in USA for 2 years, and he recently went to Mexico about 3 months ago to visit his family. He denies nausea or vomiting. He does remember having a short, self-limiting period of diarrhea right after returning from Mexico. He has no past medical history and takes no medications. He does not smoke or drink. On examination, his temperature is 101.2 F, pulse 90/minute, BP 120/76 mm Hg, and respiratory rate 16/minute. There is no icterus, cyanosis, or pallor. Chest exam reveals decreased breath sounds in the base of the right lung and normal heart sounds. Abdominal examination shows tenderness in the right upper quadrant and an enlarged liver about 2 inches below the subcostal margin. Bowel sounds are normal, there is no ascites or splenomegaly, and rectal exam is unremarkable. Labs show WBC of 18,000/uL, Hb 12%, platelets 320,000/uL, ALT 76 U/L, AST 62 U/L, and AP 85 U/L. Gamma GT is normal. CXR reveals small right-sided pleural effusion, and EKG is normal. Stool culture and blood cultures are pending. Ultrasound of the liver shows a single abscess 3 inches by 2 inches in the right lobe of the liver.
1. What is the most likely etiological agent responsible for the patient's illness?