2nd article Flashcards
A 45-year-old man was admitted to this hospital because of a
new rash.
The patient had been well until 2 p.m. on the day before admission, when nausea, epigastric pain, and vomiting developed.
The next morning, he was seen at another hospital, where he reported increasing asthma and right-sided back pain, which he rated at 10 on a scale of 0 to 10 (with 10 indicating the most severe pain).
On examination, he was in moderate distress. The temperature was 36.5°C, the blood pressure 112/69 mm Hg, the pulse 125 beats per minute, the respiratory rate 35 breaths per minute, and the oxygen saturation 94% while he was breathing ambient air. The mucous membranes were dry, and he had scattered inspiratory wheezes, pallor and decreased skin turgor, and puncture wounds on his arms and hands.
Laboratory-test results are shown in Table 1. Urinalysis was normal. Ipratropium and albuterol were given by inhalation, and famotidine, ondansetron, normal saline, metoclopramide, and methylprednisolone were administered intravenously; hydromorphone was then administered because of increasing pain.
Dr. Connie Y. Chang: Computed tomography (CT) of the abdomen and pelvis, performed at the other hospital after the oral (but not intravenous) administration of contrast material, did not reveal any findings of acute disease (e.g., bowel distention or bowel-wall thickening) to explain the patient’s severe pain and vomiting.
The spleen appeared small, measuring 8 cm in the maximal craniocaudal dimension (normal range for adults, 12 to 14 cm), with at least two granulomas. There was also mild enlargement of the caudate lobe of the liver.
Dr. Micalizzi: Shortly after CT was performed, skin mottling and livedo developed, and additional history was obtained. Three days before presentation, the patient was bitten on his hands and forearms while bathing his dog; later that day, his wife washed the wounds with hydrogen peroxide. Levofloxacin, piperacillin, and tazobactam were administered at the other hospital. He was transferred to this hospital, arriving approximately 23 hours after the onset of symptoms.
On presentation, the patient reported malaise, shaking chills, a burning pinsand-needles sensation in his limbs, and diffuse body pain that he rated at 10 out of 10. He had had head trauma caused by a rusty nail a few days before presentation and dental extractions 1 to 2 weeks before presentation. He also had a history of asthma, mild chronic obstructive pulmonary disease, anxiety, depression, chronic back pain, and alcohol abuse (with recent consumption of up to 18 beers daily); he had stopped drinking 3 days before admission. His medications were citalopram and omeprazole daily, alprazolam as needed for anxiety, and albuterol and a combination of budesonide and formoterol, which were administered by inhalation as needed for asthma. He was allergic to codeine, and tramadol had caused auditory hallucinations. He smoked one pack of cigarettes daily (and had done so for 30 years), and he had used illicit drugs in the past. He reported no recent tick bites or exposures to other animals, sick persons, raw oysters, fresh water, or saltwater.
