![]() On neurologic examination, the patient was oriented, with intact memory and cognition. The splenic tip was palpable no peripheral edema was found. The lungs and heart were normal on auscultation. A few shotty cervical lymph nodes were palpated. There was patchy, brownish pigmentation, with depressed, hyperpigmented areas, 2 to 5 mm in diameter, over both shins and ankles. On examination, the patient was thin and appeared older than his chronologic age. The temperature was 36.1☌, the pulse was 96, and the respirations were 20. He recalled having had headaches, visual changes, sweats, intermittent fevers, and back pain, all of uncertain duration, but he had not had any back injury, hematochezia, or melena. ![]() He smoked half a pack of cigarettes daily. He had abused alcohol but stopped drinking excessively 15 years before admission. He reported having had a positive test for infection with the human immunodeficiency virus (HIV) eight years earlier a subsequent test was negative. Three days after his discharge from the second hospital, he was admitted to this hospital. He promptly began to have numbness and “shooting pains” in the left foot and ankle, with dysesthesias in the foot he also had local motor weakness, without low back pain or sciatic pain. On the fifth hospital day, the patient was discharged while taking phenytoin, labetalol, clonidine, trazodone, bupropion, omeprazole, and potassium chloride, and a follow-up visit at this hospital was scheduled. Labetalol, clonidine, fluid, and electrolytes were given, and the hypertension diminished. A cranial magnetic resonance imaging (MRI) study was believed to suggest the presence of a low-grade occipital neoplasm. A computed tomographic (CT) scan of the brain was reported to show no evidence of intracranial hemorrhage. A lumbar puncture yielded acellular cerebrospinal fluid that was sterile on culture the glucose level was 59 mg per milliliter (3.3 mmol per liter), and the protein level was 71 mg per deciliter. An electrocardiogram revealed sinus tachycardia with diffuse, nonspecific ST- and T-wave abnormalities. Laboratory tests were performed ( Table 1 and Table 2). The initial blood pressure was 240/130 mm Hg. He was taken to a second hospital, where another seizure was controlled with phenytoin sodium and a benzodiazepine. One week later, shaking occurred in the patient's left leg and spread to his left arm he lost consciousness and had a witnessed generalized tonic–clonic seizure. Supportive care included parenteral nutrition. The results of tests for hepatitis B virus and hepatitis C virus were reported to be positive. Five weeks before admission, he was admitted to another hospital, where hypertension was diagnosed. He noted erythematous lumps over the shins and ankles the lumps waxed and waned for a month before healing. Three months before admission, tingling developed in the left toes and progressed to numbness in the foot these symptoms were accompanied by recurrent vomiting, night sweats, intermittent diarrhea, abdominal pain, subjective fever, and a weight loss of 16 kg. One year before admission, he discontinued his use of illicit drugs and began to feel vaguely unwell. The patient had an 18-year history of intravenous drug abuse, including abuse of heroin and cocaine with needle sharing. ![]() The most trusted, influential source of new medical knowledge and clinical best practices in the world.Ī 36-year-old, right-handed man was admitted to the hospital because of seizures and severe hypertension. Information and tools for librarians about site license offerings. Valuable tools for building a rewarding career in health care. The authorized source of trusted medical research and education for the Chinese-language medical community. The most advanced way to teach, practice, and assess clinical reasoning skills. Information, resources, and support needed to approach rotations - and life as a resident. The most effective and engaging way for clinicians to learn, improve their practice, and prepare for board exams. NEW! Peer-reviewed journal featuring in-depth articles to accelerate the transformation of health care delivery.Ĭoncise summaries and expert physician commentary that busy clinicians need to enhance patient care. NEW! A digital journal for innovative original research and fresh, bold ideas in clinical trial design and clinical decision-making.
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