Examined III

Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M49_F1.jpg"}},{"insert":"\n\n\u0022Feels better on the other side, doesn\u0027t it?\u0022 Ann, your former teacher (and current colleague) asks.\n\n\u201cDefinitely!\u201d you reply with a smile.\n\n\u201cRemember\u2014being an examiner can be tricky too,\u201d she says and continues, \u0022so, shall we meet our first candidate then?\u0022\n\nYou look at the list in your hands and ask for Wendy, the first candidate, to be ushered in.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M49_F4.jpg"}},{"insert":"\n\n\u201cHello Wendy, how are you?\u201d Ann asks as the student sits down in front of you.\n\nShe responds with a somewhat timid, \u201cI\u0027m doing good, thank you doctor.\u201d\n\nConjuring up a gentle smile, you ask Wendy to tell you about her patient.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M49_F5.jpg"}},{"insert":"\n\nHector, a 26-year-old photographer, presented with fever and generalized weakness for one week, in a background of anorexia, night sweats, and easy fatigability for three weeks; and a 5-kg weight loss during the same time period. There was no history of cardiac, respiratory, gastrointestinal, or urinary symptoms.\n\nHector mistrusts \u201callopathic\u201d medicine and relies on homeopathy. His homeopathic practitioner prescribed a one-week course of chamomile drops at the start of his illness. Hector\u0027s symptoms continued to persist; and finally, his brother persuaded him to visit your hospital.\n\nHector\u0027s medical, surgical, and family histories are unremarkable. His allergic history is significant for allergy to penicillin. His social history is significant for intravenous (IV) drug abuse for 3 years, predominantly heroin and cocaine. He claims to have been drug free for the past 6 months after the pastor of his church helped him \u201cfind his true path\u201d.\n\nHector has a single stable female sexual partner. He has had a total of 4 different partners over the years. He was persuaded to undergo HIV testing 3 months ago, which was negative. He has a 10-pack-year smoking history. He has also consumed alcohol regularly since the age of 21, with an estimated consumption of 3 to 4 units per week, on average.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M49_F10.jpg"}},{"insert":"\n\nAt admission, Hector\u0027s temperature was 100.94\u02daF (38.8\u02daC); pulse was 96\/min; blood pressure was 100\/60 mmHg; and respiratory rate was 18\/min. General examination was significant for multiple old needle marks on both arms and thighs; grade 2 clubbing of all fingers and toes; darkened linear streaks running from the tip to the nail bed of the right second finger and left second and third fingers; and multiple small painless erythematous lesions on the soles of both feet. \n\nCardiovascular examination revealed a grade 3\/6 holosystolic murmur that was loudest over the left lower sternal border. Abdominal, respiratory, and central nervous system examinations were normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M49_F13.jpg"}},{"insert":"\n\n\u201cHector\u0027s investigations showed ...\u201d Wendy continues\u2014but she is cut short by Ann.\n\n\u201cWell done. Before we move on, what\u0027s your provisional diagnosis?\u201d she asks.\n\nHow do you expect Wendy to respond?\n"}]}
1. “Left-sided infective endocarditis”
2. “Right-sided infective endocarditis”