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Consultant Vol 44 No 13

High-grade fever, chills, fatigue, malaise, and anorexia developed in a 35-year-old man following subclavian catheterization because of chronic renal failure of unknown cause. The patient, who had long-standing diabetes mellitus, was admitted to the ICU with the diagnosis of possible sepsis. The next day, he was found to have a grade 2/6 systolic murmur compatible with tricuspid regurgitation. This was confirmed when a
4-chamber echocardiogram (A) revealed a large single piece of vegetation (2 arrows) lying on the tricuspid valve, flapping in and out of the right ventricle. In a 2-dimensional echocardiogram of the right atrium and right ventricle (B), 3 arrows point to the vegetation. (RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium; TV, tricuspid valve.)

A 67-year-old woman with insulin-dependent diabetes
mellitus and uncontrolled hyperglycemia complained of
fatigue and malaise. For 2 years, a draining ulcer had
been present on the bottom of her left foot.

For 3 months, a 50-year-old man had been bothered by a worsening and spreading rash on his feet and lower legs. The multiple, nodular, fungating lesions were nonpruritic. The heterosexual, unmarried patient did not use intravenous drugs and did not know his HIV status; he denied any significant medical history.

A 46-year-old man complained of “irritation” in the groin of several months’ duration. Ted Rosen, MD, of Houston noted a tender, macerated, hypopigmented plaque at the junction of the scrotum and upper inner thigh. At the periphery of the lesion was some detectable erythema and within the plaque were several small, superficial erosions.

A 53-year-old man with a 20-year history of type 2 diabetes mellitus (for which he required insulin) sought evaluation of a hot, swollen right foot that seemed to have become “flat.” He had no pain, fever, or chills.
The patient’s metatarsal bones were readily movable, consistent with Charcot joint. Further workup ruled out osteomyelitis. Plain films demonstrated extensive deformity of the tarsal and metatarsal bones with Lisfranc fracture/dislocation through the base aspects of all 5 metatarsals.

A male infant was born to a 29-year-old woman (gravida 3, para 2), following an uncomplicated pregnancy and normal vaginal delivery. At birth, a brownish 1-cm nodule was noted on the right side of the upper abdomen. The infant was otherwise healthy.

A 48-year-old man with jaundice, nausea, vomiting, and abdominal pain was hospitalized. The patient— a recovering alcoholic— was afebrile and reported abstinence from alcohol for 6 months.

Several hours after he had installed ceramic tile, a 33- year-old man experienced muscle spasms and felt pressure in his right shoulder. He denied previous injury to the area.

A 30-year-old man has had painful genital lesions for the past
several days. He recently returned from a business trip during which he
had several unprotected sexual encounters.

Until recently, practitioners focused on the timing of initiation of renal replacement therapy (dialysis) and transplantation once advanced kidney disease had developed. However, a new CKD classification system now provides an action plan for the earlier stages of the disease.

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