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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Discuss the possible etiology of bacterial disease following a viral illness such as influenza.

  • Discuss the use of rapid diagnostic testing methods that help differentiate coagulase-negative staphylococci from Staphylococcus aureus.

  • Design a therapeutic plan to treat a bloodstream infection due to Staphylococcus aureus based on laboratory-based information.

  • Evaluate culture and sensitivity results, and determine the clinical significance of the MIC for S. aureus.

  • Recommend a plan for monitoring efficacy and adverse effects of antimicrobial therapy.

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PATIENT PRESENTATION

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Chief Complaint

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Patient’s wife states of her husband, “Lately he has not been acting like himself. He has been very dizzy, tired and has not been eating or drinking well.”

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HPI

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David Covey is a 72-year-old man who came to the ED via ambulance. The patient’s history is obtained from his wife. She describes a change in mental status, lethargy, and shortness of breath, along with a significant decrease in activity and nutritional intake. The symptoms started 3 days ago and have progressively worsened. Over the past 24 hours he has become very nauseated and developed a fever (39°C). She states that Mr Covey has not eaten anything over this time period. He was recently hospitalized (last week) for 4 days due to influenza A pneumonia confirmed by PCR.

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PMH

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  • Diabetes mellitus

  • Resistant hypertension

  • Depression

  • Influenza pneumonia

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FH

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Both parents are deceased (mother, aged 88, of PE; father, aged 71, of stroke). He is married without any children.

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SH

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Retired steel mill worker and union chief, distant history of tobacco and alcohol use with no current use

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Meds

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  • Metformin 1000 mg PO BID

  • Glyburide 5 mg PO daily

  • Spironolactone 25 mg PO daily

  • Lisinopril 40 mg PO Q HS

  • Amlodipine 10 mg PO daily

  • Paroxetine 10 mg PO daily

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All

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  • Penicillin: hives when he was a child

  • Morphine: itching

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ROS

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Patient’s primary complaint is of nausea and dizziness but due to current status unable to review further

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Physical Examination

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Gen
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The patient is frail, disheveled, appearing in respiratory distress

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VS
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BP 108/58, P 108, RR 36, T 39°C; Wt 64.2 kg, Ht 68 in

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Skin
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Warm and diaphoretic

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HEENT
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PERRLA; EOM intact; dry mucous membranes, teeth clean and intact, pharynx negative

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Neck/Lymph Nodes
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No nodules, negative lymphadenopathy

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Chest
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Respiratory distress with marked effort and ...

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