Australian Doctor Australian Doctor 7th July 2017 | Page 16

Grand Rounds PART 1 A very personal drought THE AUTHOR RHEUMATOLOGY A patient’s recurrent facial pain leads to an unexpected diagnosis. Dr David Bossingham is a retired rheumatologist and associate professor at James Cook University College of Medicine and Dentistry, Queensland. HAVE AN INTERESTING CLINICAL CASE? Email the editor at [email protected]. We pay $400 for each case and photos are encouraged. H ANNAH, 40, is single parent who is well known to you. She presented feeling mis- erable and in considerable pain from a swelling on the left side of her face. She had experienced rigors overnight and had been vom- iting. Swallowing had become impossible. Examination Hannah was septic with a temperature of 39°C, pulse of 120bpm and BP of 100/50mmHg. Oxygen satura- tion are 94% on room air, urinalysis revealed ketones and blood sugar was 6.3mmol/L. Her breath was faeculent and dental hygiene poor, with widespread tartar deposits. She was dehydrated. On inspecting her mouth, you noted pus under the tongue. There was swelling in the left parotid gland, which, along with the submandibular lymph glands, was exquisitely tender. She also had labial herpes with crusting. You referred her to the local hospital where she was admitted for rehydration and IV antibiotics. A week later, she returned to see you after her hospital discharge to collect a further prescription for antibi- otics; she was then well and as chipper as ever. Six months later, she attended again with pain and swelling in the right side of her face and a modest fever. This time, she acted early and requested anti- biotics. Suspecting infective parotitis again, you prescribed a