Louise de Ham
Portrait of an Old Woman
A 69 y/o, Caucasian, female, sought medical care for lower back
pain about six months ago. She said that she was moving boxes around
in the attic, it was late in the day, and she went to a local quick care
clinic because it was after normal office hours. Her insurance would not
cover the emergency room. The doc poked, prodded, and wrote a script for
metaxalone 800 mg PO tid. The physician told her to use a warm, not hot, water bottle to the area as needed. If the symptoms do not resolve in a week, follow up with her primary care physician.
Harriet, being the tough old “gal” she was, finished off the medication
and put up with the more than occasional aches and pains in her back, saying to herself “it’s just old age, and I am a spring chicken, so let’s get on with life”. She did not pay any attention to the occasional fevers she had been having but the fullness in her left side made her wonder.
Then four days ago, she was showering to get ready for her date, with Mr. Right
and noticed a couple lumps in the area of her right groin. At last she thinks,
I must have a low-grade infection, so the next day (after an exhausting night)
she makes an appointment to see you, her primary care physician.
You perform a complete history and physical examination.
Your findings are positive for the following: A vague history of
fever, but no weight loss or night sweats. Never a smoker, no alcohol, no breast masses,
no occupational exposures,
no pets, no foreign travel, no outdoor adventures, no weird diet,
never any needle drugs.
Mr. Right is clean-living so far as she knows. Physical exam findings include an
enlarged spleen, palpable bi-lateral inguinal and left axillary adenopathy.
At this point, which of the following are you considering?