Amebic Colitis

ID CC A 45-year-old male Peace Corps volunteer who recently spent 2 years in rural Mexico complains of a spiking fever, malaise, headache, and right upper quadrant abdominal pain. HPI He admits to having had bloody diarrhea with mucus (dyskntkry) and tenesmus that disappeared with some pills that he took several months ago. PE VS fever (S9.6 C). PE pallor slight jaundice tender 3+ hepatomegaly with no rebound tenderness pain on fist percussion of right lower ribs. Labs CBC leukocytosis with...

Info

A 9-year-old male complains of pain during swallowing (odynophagia) for 2 days, accompanied by muscle aches, headache, and fever. HPI He has otherwise been in good health. PE VS fever. PE moderate erythema of pharynx enlarged, erythematous tonsils covered with white exudate tender cervical adenopathy. Labs CBC neutrophilic leukocytosis. Streptococcus pyogenes isolated on throat swab and culture. Gross Pathology Hyperemia and swelling of upper respiratory tract mucosa cryptic enlargement of...

Co

Treatment Amoxicillin ampicillin therapy TMP-SMX, azithromycin, and clarithromycin are also excellent drugs for the treatment of clinically mild to moderate H. influenzae infections of the upper respiratory tract. Discussion Infections caused by nontypable, or unencapsulated, Haemophilus influenzae strains have been increasingly recognized in pediatric and adult populations. Nontypable H. influenzae strains are frequent respiratory tract colonizers in patients with COPD and commonly exacerbate...

Herpangina

ID CC A 25-year-old homosexual male visits a health clinic complaining of headache, low-grade fever, and a painful skin rash in the perianal area. HPI He has no history of penile ulcerations and admits to unprotected anal sex with multiple partners. PE Perianal vesicular rash in clusters on erythematous base no penile ulceration painful inguinal lymphadenopathy. Labs Multinucleated giant cells with intranuclear inclusions surrounded by clear halo on Pap-stained section or Tzanck preparation of...

Pe

A 56-year-old male professor of veterinary medicine from New Zealand experiences sudden high fever with chills, jaundice, and right upper quadrant pain while attending a conference in the United States. His past history is unremarkable. He has been healthy and has been physically active working in the Held with sheep and -z.

Salmonella Food Poisoning

ID CC A 50-year-old alcoholic white male presents with fever, abdominal pain, and rapidly progressive distention of the abdomen. HPI He was diagnosed with alcoholic cirrhosis 1 month ago, when he was admitted to the hospital with jaundice and hematemesis. PE VS fever. PE icterus on palpation, abdominal tenderness with guarding fluid thrill and shifting dullness to percussion (due to ascites) splenomegaly decreased bowel sounds. Labs CBC leukocytosis. Ascitic fluid leukocyte count > 500 cc...

Epidemic Typhus

A 4-year-old male presents with fever, hoarseness, and respiratory distress because of partial airway obstruction. The child is also unable to speak clearly and has pain while swallowing (odynopi iagia) . VS fever tachypnea. PE patient is leaning forward with neck hyperextended and chin protruding drooling marked suprasternal and infrasternal retraction of chest inspiratory stridor on auscultation. Culture of throat swab (no role in management of acute t 5 disease) reveals...

Molluscum Contagiosum

ID CC A 30-year-old black male presents with a nonpruritic skin rash on the trunk, upper arm, and neck HPI The patient is otherwise in excellent health. PE Multiple hypopigmented, scaling, confluent macules seen on trunk, upper arms, and neck no sensory loss demonstrated over areas ofhypopigmen ration Wood's lamp examination of skin macules displays a pale yellow to blue-white fluorescence. Labs Examination of KOH mounting of scales from lesions demonstrates the presence of short, thick,...

Aspiration Pneumonia With Lung Abscess

ID CC A 88-year-old HIV-positive male is admitted to the hospital with fever, rigors, night sweats, and diarrhea. HPI He reports excessive weight loss over the past few weeks. He was treated for Pneumocystis pneumonia a few weeks ago and still reports a persistent productive cough. PE VS fever. PE patient is extremely emaciated hepatosplenomegaly and lymphadenopathy noted. Labs CD44- count < 50 cc Mycobacterium avium-intraceUulare isolated on blood culture smears of tissues obtained from...

Hpi

A 28-year-old male from India complains of gradual-onset, intermittent, crampy abdominal pain with one to four foul-smelling, frothy loose stools daily. His stools sometimes contain blood and mucus. He also complains of flatulence, tenesmus, and, at times, alternating diarrhea and constipation. Slight tenderness during palpation of cecum and ascending colon no hepatomegaly. CBC mild leukocytosis no eosinophilia. Fresh stool examination reveals presence of Entamoeba histolytica cysts and motile...

Pi Pe

Intrauterine growth retardation was prenatally diagnosed on ultrasound. The child's mother had a flulike episode during the first trimester of her pregnancy. Small for gestational age generalized hypotonia with sluggish neonatal reflexes extensive pinpoint petechial skin rash (mulberry muffin rash) microcephaly chorioretinitis mild icterus hepatosplenomegaly sensorineural hearing loss in right En CBC PBS mild thrombocytopenia atypical lymphocytosis. Moderately elevated direct serum bilirubin...

Preface To The 3rd Edition

We were very pleased with the overwhelmingly positive student feedback for the 2nd edition of our Underground Clinical Vignettes series. Well over 100,000 copies of the UCV books are in print and have been used by students all over the world. Over the last two years we have accumulated and incorporated over a thousand updates and improvements suggested by you, our readers, including many additions of specific boards and wards testable content deletions of redundant and overlapping cases...

Cellulitis

ID CC A 16-vear-old teenager presents to the outpatient clinic with a painful facial rash and fever HPI One week ago, the patient went on a camping trip and scratched his face on some low-lying tree branches. There is no medical historv of diabetes, cancer, or other chronic conditions. PE VS fever (39.0 C) tachycardia (HR 110) BP normal. PE erythematous, warm, plaque-like rash extending across cheeks and face bilaterally with sharp, distinct borders and facial swelling. Labs CBC leukocytosis...

Vignettes

Study with the student-to-student publisher you can trust Blackwell's Underground Clinical Vignettes Microbiology Volume I, 3rd Edition is your primary source for clinically relevant, case-based material essential for Step 1 review. Each clinical vignette book presents approximately 100 cases with over 1000 classic buzzwords in Hx, PE, lab, imaging, pathology and treatment. High-yield updates to nearly every case Links to Basic Science and Clinical Science Color Atlas New Cases on commonly...

Cmv Pneumonitis

ID CC A 30-year-old homosexual white male presents to his family physician with a rapidly progressive diminution of vision. H PI He is known to be HIV positive and periodically comes in for checkups. PE Cotton-wool exudates, necrotizing retinitis, and perivascular hemorrhages on funduscopic exam. Treatment Ganciclovir foscarnet (CMV is resistant to acyclovir). Discussion CMV retinitis is an important treatable cause of blindness that occurs in 20 of AIDS patients 50 to 60 of patients develop...

Lo

Gross Pathology Encapsulated, nodular area (chagoma) or Romana's sign may be seen at point of entry, commonly the face. Micro Pathology Intense neutrophilic infiltrate with abundant macrophages at site of entry myocardial necrosis with mononuclear cell infiltration pseudocysts in infected tissues contain parasites that multiply within cells denervation of myenteric gut plexus. Treatment Nifurtimox for acute disease. Discussion Ghagas' disease is a parasitic disease that is restricted to the...

Ehrlichiosis

ID CC A 30-year-old male from Texas presents with fever and a skin rash that began about 2 weeks ago. HPI The onset was gradual, with prodromal symptoms of headache, malaise, backache, and chills. These symptoms were followed by shaking chills, fever, and a more severe headache accompanied by nausea and vomiting. A remittent pattern of fever accompanied by tachycardia continued for 10 to 12 days, with the rash appearing around the fifth day of fever. The patient worked at a rat-infested...

Roseola Infantum

ID CC A 2-month-oId female infant presents with extensive bullae and large areas of denuded skin. HPI Her mother had suffered from staphylococcal mastitis 1 week ago. PE VS fever. PE large areas of red, painful, denuded skin on periorbital and peribuccal areas flaccid bullae with easy dislodgment of epidermis under pressure (Nikoi.sky's sign) mucosal surfaces largely uninvolved. Labs Vesicle fluid sterile Staphylococcus aureus on blood culture. Treatment IV penicillinase-resistant penicillin...

Go

Imaging XR, hips joint effusion and soft tissue swelling without destruction. MR, spine evidence of spondylitis. Gross Pathology Lymphadenopathy and splenomegaly hepatomegaly rare. Micro Pathology Granulomatous foci in spleen, liver, and lymph nodes, with proliferation of macrophages epithelioid and giant cells may be seen. Treatment Combination therapy with doxycycline or TMP-SMX and rifampin or streptomycin. Discussion Also called Malta fever, a microbial disease of animals, brucellosis is...

Prosthetic Valve Endocarditis

ID CC A 25-vear-old female complains of low-grade fever and myalgia of 3 weeks' duration. HPI She has a history of rheumatic heart disease (RHD). One month ago, she underwent a dental extraction and did not take the antibiotics that were prescribed for her. PE VS fever. PE pallor small peripheral hemorrhages with slight nodular character ( Janewaylesions) small, tender nodules on finger and toe pads (Oslf.r's nodes) subungual linear streaks (splinter hemorrhages) petechial hemorrhages on...

Granuloma Inguinale

A 60-year-old male presents with cough productive of mucopurulent sputum together with mild fever and worsening breathlessness. HPI He is a chronic smoker who has been diagnosed with COPD. PE VS fever. PK in moderate respiratory distress emphysematous chest with obliterated cardiac and liver dullness wheezing and crackles heard over both lung fields. Labs Haemophilus influenzae organisms seen as small, pleomorphic gram-negative bacilli on Gram stain of sputum nontypable H. influenzae isolated...

Erysipelas

ID CC A 30-year-old slaughterhouse worker presents with a painful red swelling of the index finger of his right hand. HPI The swelling developed 4 days after he was injured with a knife while slaughtering a pig. PE Well-defined, exquisitely tender, slightly elevated violaceous lesion seen on right index finger no suppuration noted right epitrochlear and right axillary lymphadenopathy noted. Labs Biopsy from edge of lesion yields Erysipelothrix rhusiopathiae, a thin, pleomorphic, nonsporulating,...

Amebic Meningoencephalitis

ID CC A 30-year-old male goes to the emergency room because of dyspnea, cyanosis, hemoptysis, and chest pain. HPI He has had a high fever, malaise, and a nonproductive cough for 1 week. The patient is a sheep farmer who remembers having been treated for dark black skin lesions in the past. PE VS fever. PE dyspnea cyanosis bilateral rales heard over lungs. Labs CBC normal. Negative blood and sputum cultures diagnosis of anthrax confirmed by fourfold increase in indirect m ic roh e maggl u tin a...

African Trypanosomiasis

ID CC A 28-year-old male homosexual complains of continuous low-grade fever, weight loss, and diarrhea of 1 month's duration. HPI He also complains of an extensive skin rash, mucous membrane eruptions, recurrent herpes zoster infection, and oral ulcerations. He reports practicing receptive anal intercourse. PE VS low-grade fever. PS cachectic generalized lymphadenopathy maculopapular rash severe seborrheic dermatitis aphthous ulcers white confluent patch with corrugated surface (orai. hairy...

Microbiology Vol I 3e

University of California, San Francisc o, Class of 1991 Series Editor, Diagnostic Radiologist Government Medical College, Chandigarh, India, Class of 1996 Series Editor, U. of Texas, Galveston, Resident in Internal Medicine 8c Preventive Medicine University of California, San Francisco, Class of 1996 Northwestern University, Class of 2001

Atypical Mycobacterial Infection

ID CC A 20-year-old male from India presents to the ER with severe nausea and vomiting. HPI Careful history reveals that 2 hours ago he ate some unrefrigerated fried rice that his wife had cooked the night before. He does not complain of any fever or diarrhea (may or may not be present). PE VS no fever. PE mild dehydration diffuse mild abdominal tenderness. Labs Fecal staining reveals no RBCs, WBCs, or parasites Bacillus cereus, a gram-positive rod, isolated from vomitus and stool and shown to...

Spontaneous Bacterial Peritonitis

A 25-year-old male U.S. citizen on vacation in Mexico presents with abrupt-onset explosive watery diarrhea, abdominal cramps, and a low-grade fever and chills. HPI The patient does not complain of tenesmus or passage of blood or mucus in his stools, but he does complain of a feeling of urgency to defecate. PE VS low-grade fever. PE unremarkable. Labs No erythrocytes, WBCs, or parasites seen in stained stool bioassays for enterotoxigenic Escherichia coli (ETEC) reveal presence of the labile...

Epiglottitis

ID CC A 30-year-old soldier who had been admitted for a gunshot wound in the right thigh presents with severe pain and swelling at the site of his injury. HPI The patient's right lower limb had become discolored, and several bullae had appeared on the skin. He has passed very little urine over the past day, and the urine he has passed has been dark (cola-colored). PE VS low-grade fever marked tachycardia. PE diaphoresis skin of right thigh discolored (bronze to purple red) site of injury...

Influenzae In A Copd Patient

ID CC A 25-year-old male presented with sudden-onset breatlilessness, cough, cyanosis, and high-grade fever. HPI The patient failed to improve on 100 oxygen, became hypotensive, and died of type 2 respiratory failure a few hours after admission. He had been in perfect health and had been hiking in several rodent-infested areas before falling ill. PE On admission he was found to have fever, tachycardia, cyanosis, hypotension, and rales on auscultation over both lung fields 110 meningeal signs or...

Subacute Bacterial Endocarditis

ID CC A 54-year-old female who underwent a left mastectomy with axillary lymph node dissection a year ago presents with pain together with rapidly spreading redness and swelling of the left arm HPI One year ago, she was diagnosed and operated on for stage 1 carcinoma of the left breast. PE Left forearm swollen, indurated, pink, and markedly tender overlying temperature raised margins and borders of skin lesion ill defined and not elevated (vs. erysipelas). Labs Needle aspiration from advancing...

Chlamydia Pneumonia

ID CC An 8-year-old male who recently emigrated from India presents with bilateral eye irritation and photophobia. HPI He reports recurrent episodes of similar eye irritation and redness in the past. PE Conjunctival congestion multiple (> 5) follicles, each at least 0.5 mm in diameter, seen in upper tarsal conjunctiva inflammatory thickening of tarsal conjunctiva new vessels (pANNtJs) seen in cornea at superior limbus punctate keratitis. Labs Diagnosis confirmed by demonstration of...

Herpes Zoster Ophthalmicus

ID CC An 18-vear-old male complains of severe irritation in the left eye, blurred vision, excessive lacrimation, and photophobia. HPI Me reports that he has had similar episodes in the past that were treated with an antiviral drug. His records indicate that he suffered the first attack at the age of 7, at which time his condition was diagnosed and treated as a severe follicular keratoconjunctivitis his records also indicate a history of recurrent episodes of herpes labialis. PE Examination of...

Anthrax

ID CC A 38-year-old male receiving cytotoxic chemotherapy (immunosuppressed) for acute leukemia presents with pleuritic chest pain, hemoptysis, fever, and chills. HPI He also complains of dyspnea, tachypnea, and a productive cough. PE VS fever. PE severe respiratory distress bilateral rales heard over lungs. Labs CBC severe neutropenia. Negative blood and sputum culture for bacteria. Imaging CXR necrotizing bronchopneumonia. Gross Pathology Necrotizing bronchopneumonia abscesses. Micro...

Otitis Externa

ID CC An 18-month-old white female presents with irritability together with a bilateral, profuse, and foul-smelling ear discharge of 2 months' duration. HPI The patient had recurrent URls last year, but her mother did not administer the complete course of antibiotics. The patient's mother has a history of feeding her child while lying down. PE Bilateral greenish-white ear discharge perforated tympanic membranes in anteroinferior quadrant of both ears diminished mobility of tympanic membrane on...

Erythema Infectiosum

ID CC A 5-vear-old white male presents with golden-yellow, crusted lesions around his mouth and behind his ears. HPI 1 le has a history of intermittent low-grade fever, frequent nose picking, and purulent discharge from his lesions. He has 110 history of hematuria (due to increased risk of poststreptococcal glomerulonephritis). PE Characteristic honey-colored crusted lesions seen at angle of mouth, around nasal orifices, and behind ears. Labs Gram-positive cocci in chains (strknococci) in...

Acute Conjunctivitis

ID CC A 35-year-old woman complains of fever and pain in the face and upper teeth (maxillary sinus), especially while leaning forward. HPI She has had a chronic cough, nasal congestion, and discharge for the past few months. PE VS fever. PE halitosis greenish-yellow postnasal discharge bilateral boggy nasal mucosa bilateral percussion tenderness and erythema over zygomatic arch clouding of sinuses by transillumination dental and cranial nerve exams normal. Labs Nasal cultures reveal...

Acute Bacterial Endocarditis

ID CC A 25-year-old male complains of increasing shortness of breath and ankle edema that have progressively worsened over the past 2 weeks. HPI He also complains of fatigue, palpitations, and low-grade fever. His symptoms followed a severe URI. He denies any history of joint pain or skin rash (vs. rheumatic fever). PE J VP elevated pitting pedal edema line inspiratory crepitations heard at both lung bases mild hepatosplenomegaly. Labs ASO titers not elevated. CBC lymphocytosis. EGG...

Herpes Genitalis

ID CC A 45-year-old HIV-positive male is seen by his family doctor following the appearance of a painful, burning skin rash on the left side of his chest that is accompanied by a headache and low-grade fever. HPI The patient had chickenpox as a child. He had been well until 1 year ago, when he was diagnosed with non-Hodgkin's lymphoma, for which he is currently undergoing chemotherapy. PE Vesicular rash on erythematous base in dermatomal distribution (left T6-T8) exquisitely tender to touch....

Pityriasis Versicolor

ID CC An 18-month-old male is brought to the pediatrician following the appearance of an extensive skin rash. H PI Four days ago he suddenly developed a very high fever (40 C) with no other symptoms or signs. The fever continued for 4 day until the day of his admission, when it abruptly disappeared, coinciding with the onset of the rash. PE Child looks well in no acute distress generalized rash apparent discrete 2- to 5-mm rose-pink macules and papules on trunk, neck, and extremities (face is...

Urticaria

ID CC A 7-year-old male is brought to his family physician complaining of a thick yellowish discharge in his eyes that prevents him from opening his eyes in the morning for the past few clays, his eyes have been blood-red, painful, and watery. His eye pain is exacerbated by exposure 10 light (photophobia). HPI Three of his classmates and a neighbor had a similar episode about 7 days ago (suggesting a local epidemic of such cases). PE VS no fever. PE normal visual acuity erythematous palpebral...

How To Use This Book

This series was originally developed to address the increasing number of clinical vignette questions on medical examinations, including the USMLE Step 1 and Step 2. It is also designed to supplement and complement the popular First Aid for the USMLE Step 1 (Appleton 8c Lange McGraw Hill) and First Aid for the USMLE Step 2 (Appleton & Lange McGraw Hill). Each UCV 1 book uses a series of approximately 100 supra-prototypical cases as a way to condense testable facts and associations. The...

Hepatitis A

ID CC A 25-year-old male medical student presents with jaundice and dark yellow urine. HPI He admits to having experienced an accidental needle stick 2 months ago, which he did not report. He also complains of nausea, low-grade fever, and loss of appetite. PE Icterus tender, firm hepatomegaly no evidence of ascites or splenomegaly. Labs Direct hyperbilirubinemia elevated serum transaminases (ALT > AST) mildly elevated alkaline phosphatase HRsAg positive IgM anti-HBc positive (present during...