PHAR 837 IPC-Infectious Diseases 1 Medications

Case Presentations 2 Clonidine 0.2 mg/24 H transdermal patch every

week
A. Sepsis
Acetaminophen 500 mg PO Q 6 H as needed for
Chief Complaint pain/fever
The patient presents from her nursing home with
altered mental status and lethargy that has Lorazepam 0.5 mg PO Q HS
progressively worsened over the past 24 hours.
Hydralazine 50 mg PO TID
HPI
Omeprazole 20 mg PO QAM
Ruth Carter is an 80-year-old woman who resides in
a nursing home with a past medical history that Rivastigmine 4.6 mg/24 H transdermal patch Q HS
includes hypertension, advanced dementia, chronic
kidney disease, depression, and GERD. She was
Levofloxacin 500 mg PO Q 24 H for 3 days (received
discharged last week from another hospital after
5 days of inpatient therapy; completed total course
being treated for 5 days for a urinary tract infection.
2 days ago)
She did well through the first 2 days after discharge
but has become increasingly lethargic and drowsy
Allergies
in the past 24 hours. She is barely responsive at the
time of assessment. She has had no reports of NKDA
fever, nausea, vomiting, or pain.
Review of Systems
PMH
Unable to obtain due to patient’s mental status
HTN
Physical Exam
Advanced dementia
Gen
CKD, stage II Unresponsive, thin appearing woman in acute
distress
Depression
Vital Signs
GERD
BP 86/42 mm Hg, P 118–142 bpm, RR 14–35
breaths/min, T 35.6°C; SpO2: 94% on 8L NC, Ht 5′3″,
PSH
Wt 50.8 kg
Noncontributory
Skin
FH Skin is warm, dry and pink, intact with no rashes or
No HTN, DM, CAD, cancer, or vascular disease lesions

SH HEENT
Normocephalic, no scleral icterus, no sinus
Lives in a nursing home due to dementia
tenderness

No tobacco, alcohol, or illicit drug use

Neck/Lymph Nodes: Supple, nontender, no carotid
bruits, no JVD, no lymphadenopathy

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Lungs Other
Decreased air entry in the bases, otherwise clear, ECG: sinus tachycardia (HR 122), QRS 98/QT-
tachypnea QTc 358/425

CV Clinical Course
Tachycardia, regular rhythm, no murmur, gallop, or After several hours in the ED, Ms Carter’s blood
edema pressure failed to improve despite receiving 2 L of
normal saline. Her mental status did not improve,
Abdomen and her urinary output has been approximately 50
Soft, NT/ND, normal bowel sounds, no masses mL over past 3 hours (via foley catheter). She was
intubated and placed on mechanical ventilation
secondary to respiratory failure and concern for
Musculoskeletal
airway protection due to her mental status. The
Normal range of motion and strength, no intensivist is called to evaluate the patient. The
tenderness or swelling intravenous medications she received in the ED
included:
Neuro
Responsive to painful stimuli at this time, unable to • Normal saline 2 L
assess further
• Etomidate 20 mg
Labs • Succinylcholine 75 mg
• Midazolam 2 mg
• Norepinephrine 15 mcg/min continuous
Na 135 mEq/L Mg 2.2 mg/dL WBC 19.3 × Arterial blood gases
infusion begun
103/mm3
• Ceftriaxone 2 g × 1 dose

K 4.4 mEq/L Phos 3.1 mg/dL PMNs 72% pH 7.15

Assessment

Cl 105 mEq/L Alb 2.3 g/dL Bands 18% PaCO2 28 mm Hg

An 80-year-old woman is admitted to the ICU with
concerns of septic shock, respiratory failure, and
acute kidney injury secondary to a UTI.
CO2 12 mEq/L Alk Phos 55 IU/L Lymphs 5% PaO2 165 mm Hg

BUN 42 mg/dL T. bili 0.4 mg/dL Monos 5% HCO3 9.8 mEq/L

SCr 2.3 mg/dL AST 15 IU/L Hgb 12.2 g/dL Lactate 6.3 mmol/L

Glu 195 mg/dL ALT 10 IU/L Hct 38%

Ca 7.2 mg/dL Plt 205 × 103/mm3

Urinalysis
Color yellow, appearance cloudy, WBC 120/hpf,
RBC 5/hpf, leukocyte esterase (+), nitrite (+),
epithelial cells 3–5/hpf, pH 5, bacteria 15/hpf

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B. Lower Urinary Tract Infection Physical Examination

Patient Presentation Gen

Chief Complaint Cooperative woman in no acute distress

“It burns when I urinate. I am urinating all the VS

time.”
BP 110/60, P 68, RR 16, T 36.8°C; Wt 57 kg, Ht 5′5″
HPI
Skin
A 26-year-old woman presents to a family medicine
clinic in Seattle with complaints of dysuria, urinary No skin lesions
frequency and urgency, and suprapubic tenderness
for the past 2 days. HEENT
PERRLA; EOMI; TMs intact
PMH

Patient has been previously diagnosed with three Neck/Lymph Nodes

UTIs over the past 8 months based on symptoms. Supple without lymphadenopathy
Each episode was treated with oral TMP/SMX.
Chest
FH
CTA
Mother has DM; remainder of FH is
noncontributory. CV
RRR, no MRG
SH

Denies smoking but admits to occasional marijuana Back

and social EtOH use. Patient has been sexually
No CVA tenderness
active with one partner for the past 9 months and
typically uses spermicide-coated condoms for
Abd
contraception.
Soft; (+) bowel sounds; no organomegaly or
Meds tenderness

None Pelvic

All No vaginal discharge or lesions; LMP 2 weeks ago;

mild suprapubic tenderness
No known allergies
Ext
ROS
Pulses 2+ throughout; full ROM
Patient reports urethral pain and burning with
urination, as well as mild suprapubic tenderness. Neuro
She denies systemic symptoms such as fever, chills,
A&O × 3; CN II–XII intact; reflexes 2+; sensory and
vomiting, or back pain, and does not report any
motor levels intact
urethral or vaginal discharge. Upon further
questioning, she notes that the UTIs started soon
after she met her boyfriend, and she does not
always completely empty her bladder after sexual
intercourse.

3
Labs

Urinalysis
Yellow, cloudy; pH 5.0; WBC 50 cells/hpf; RBC 1–5
cells/hpf; protein (–); trace blood; glucose (–);
leukocyte esterase (+); nitrite (+); many bacteria

Urine Culture
Not performed

Assessment

Acute uncomplicated cystitis

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C. Osteomyelitis Physical Examination

Chief Complaint Gen

“Back spasms.” The patient does not appear to be in any acute

distress.
HPI
VS
Richard Frost is a 52-year-old man with a history of
chronic back pain who presents with a 1-week BP 152/109, P 84 bpm, RR 18, T 36.4°C; 96% SpO2 on
history of back spasms localized in the thoracic room air, Ht 5′8″, Wt 90 kg
region. He was doing relatively well until 1 week
ago when he went bowling and also did some Skin
maintenance around his house, whereupon his
Open left lateral leg ulcer 4 × 2 in in size with foul-
back felt tight. There is radiation of pain to his
smelling, purulent drainage. Patient reports this
upper right leg with movement. He had a similar
ulcer to be a result of burning his leg on a
episode 3 months ago that resolved after
motorcycle approximately 1 year previously. He has
approximately 2 days with no treatment. He reports
not previously sought medical care for this
this episode to be more severe.
condition.

PMH
HEENT
Patient reports chronic back pain starting
PERRL, conjunctivae clear. Poor dentition noted.
approximately 10 years ago. He does not routinely
seek medical care and does not report any other
Neck/Lymph Nodes
chronic conditions.
No lymphadenopathy
FH
Lungs/Thorax
Noncontributory
Clear to auscultation bilaterally, no wheezing,
SH rhonchi, or rales
The patient has smoked one pack of cigarettes per
CV
day for the past 20 years. He admits to IV heroin use
for the past 3–4 years. Regular rate and rhythm; no appreciable murmurs,
gallops, or rubs
Meds
Abd
Acetaminophen and ibuprofen as needed for back
pain; the patient has increased use of these Soft, nontender, nondistended; bowel sounds
medications over the past week. present

All Genit/Rect
No known allergies Genitalia normal

ROS MS/Ext
The patient denies nausea, vomiting, fevers, chills, Decreased dorsiflexion on the left foot, which the
chest pain, shortness of breath, and bowel or patient states is chronic. He has reproducible pain
bladder incontinence. He reports decreased oral in the thoracic spine.
intake over the past week due to pain and general
malaise. Neurologic

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Cranial nerves II–XII are intact.
Assessment
Psychiatric
Oriented to person, place, and time. Mood and 1. Paravertebral abscess and osteomyelitis in
affect are appropriate.
the presence of chronic back pain; soft-
Labs tissue infection on the left lateral leg
2. Substance use disorder—heroin
Na 136 mEq/L Hgb 13.7 g/dL
3. Chronic tobacco smoker
K 4.0 mEq/L Hct 41.1%
Cl 102 mEq/L Plt 341 × 103/mm3
CO2 25 mEq/L WBC 22.7 × 103/mm3
BUN 18 mg/dL Neutros 71%
SCr 0.87 mg/dL Bands 17%
Glu 120 mg/dL Lymphs 3%
Ca 9.4 mg/dL Monos 9%
ESR 73 mm/hr
CRP 84.2 mg/L

Abdominal and Pelvic CT Scan

CT scan of abdomen and pelvis are unremarkable.
Thoracic spine shows degenerative disk disease
from T1 to T5.

MRI
MRI shows T2–T3 osteomyelitis and paravertebral
abscess.

Cultures
• CT guided paravertebral abscess
aspiration culture: S. aureus
• Wound culture of leg: S. aureus
• Blood Culture: (2/2) S. aureus
Staphylococcus aureus from all sources

Cefazolin Susceptible

Clindamycin Susceptible

Oxacillin Susceptible

Trimethoprim/sulfamethoxazole Susceptible

Vancomycin Susceptible, MIC =

0.5 mg/L

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D. Clostridioides difficile Infection Medications

Patient Presentation Metoprolol XL 100 mg PO once daily

Chief Complaint
Lisinopril 10 mg PO once daily
“I have been having to go to the bathroom a lot
more frequently, and my stomach hurts a lot.” Atorvastatin 10 mg PO once daily

HPI Pantoprazole 40 mg PO once daily

Bernice Cooper, a 68-year-old woman, is
transferred to your medical team from the MICU All
after being admitted for sepsis secondary to a NKDA
urinary tract infection and hypotension requiring
pressor support. Over the past 2 days, she has been Physical Examination
complaining of frequent foul-smelling stools. One
week prior to being transferred to your team, she Gen
was admitted to the hospital complaining of
Patient is overweight and complains of abdominal
urinary frequency and urgency for 3 days, nausea,
discomfort.
vomiting, and left-sided flank pain, as well as light-
headedness and dizziness. In the ED, the patient
VS
was hypotensive (BP 92/63 mm Hg) and tachycardic
(HR 112–124 bpm), with an elevated lactate level BP 149/85, P 98, RR 20, T 38.8°C; Ht 5′8″, Wt 87.2 kg
and leukocytosis. She was transferred to the MICU
for pressor support and started on an empiric Skin
regimen of cefepime and vancomycin 1 g IV Q 12 H
for suspected urosepsis. Urine (×2) and blood (×3) Warm and moist secondary to diaphoresis, no
cultures were subsequently found to be lesions
growing Escherichia coli and enteric gram-negative
rods, respectively, and antibiotic coverage was HEENT
narrowed to ceftriaxone 2 g IV daily on day 5. The PERRLA; EOMI; TMs intact; clear oropharynx, moist
patient’s blood pressure was stabilized, no ileus oral mucosa
was detected, and she was transferred to the
internal medicine service on day 7 of Neck/Lymph Nodes
hospitalization. She is now complaining of new-
onset diarrhea and abdominal pain. Neck is supple and without adenopathy; no JVD.

PMH Lungs/Thorax

CDI 2 months ago (Treated with vancomycin 125 CTA

mg PO QID x 10 days)
CV
Hyperlipidemia RRR; normal S1, S2; no murmurs

HTN Abd
Abdomen is soft and nondistended, diffusely tender
s/p MI 2003
to palpation. Slight rebound and guarding. Positive
bowel sounds.
SH

Lives at home alone, lifetime smoker (half pack per Genit/Rect

day for 54 years), drinks alcohol socially

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 Not performed Assessment

A 68-year-old woman presents with frequent, foul-

MS/Ext
smelling stools for 2 days with recent history of
Muscle strength and tone 5/5 in upper and lower; receiving broad-spectrum antibiotics and currently
no C/C/E receiving ceftriaxone for pyelonephritis and a
bloodstream infection (day
Neuro 9); C. difficile antigen/toxin positive.
A&O × 3; CN II–XII intact

Labs

Na 138 mEq/L Hgb 16.1 g/dL WBC 16.9 × T. chol 205

103/mm3 mg/dL

K 3.5 mEq/L Hct 49.8% Neutros 50% LDL 137 mg/dL

Cl 102 mEq/L Plt 375 × Bands 9% HDL 29 mg/dL

103/mm3

CO2 22 mEq/L A1C 7.9% Eos 0% Trig 197 mg/dL

BUN 36 mg/dL Lymphs 34%

SCr 1.8 mg/dL Monos 7%

(baseline 0.9

mg/dL)

Glu 101 mg/dL

Alb 1.9 mg/dL

CXR

Clear

ECG

NSR, unchanged from previous

Clostridioides difficile GDH/toxin EIA test

GDH antigen and A/B toxin assay both positive