Question

A 45 y/o Anglo male comes into the ER. He says he is a retired Special Forces veteran (since 2006) who has been teaching Chemistry at a high school since 2009. He complains of fever, malaise, anorexia for three weeks. He states he has had that rash for several days. He denies having diabetes, kidney problems, stiff neck or headaches. He had a flu shot about three weeks ago.

1.What is your differential diagnosis? 4 pts.

You weigh patient and find his weight to be 186 lb (86.3 kg). Patient responds that his weight last month was 205 lb (93.2 kg). He says food does not taste and smell the same. On physical exam, you note patient has temperature of 38oC, presents with petechiae on his left shoulder, nodules on his left and right fingers which are sensitive to touch, and macules on his palms and soles. His eyes are clear. Auscultation of lungs is unremarkable, but heart indicates some murmurs—a grade 3/6 diastolic murmur.

2. What questions should you ask the patient about his medical history? 5 pts

3. Given patient’s signs:

a. what might the patient have, and what is your rationale? 4 pts.

b. What general treatments and tests should be performed next? 3 pts

c. What organisms should be suspected--name at least six? 3 pts.

The patient admits that he recently started using his kitchen and bathroom water to prepare intravenous drugs, and he was making methamphetamine. A flu PCR was negative. Antibody tests and PCR for Covid-19 were both negative. Several blood cultures were performed, and five of the seven were positive for Gram-negative bacilli, and were oxidase positive; oxidized fructose and mannitol. The patient was later placed on an antibiotic regimen.

4. What antibiotics were most likely used to treat the patient? 3 pts.

5. What was the final diagnosis of the patient? 3 pts

6. Extra credit (up to 5 pts)—Bacteria were tested by Kirby–Bauer antimicrobial susceptibility testing; organisms were resistant to aminoglycosides, colistin (Polymixin E) and polymixin B. The organism is aerobic, grows on MacConkey agar, motile with polar or amphitrichous flagella, reduces nitrate but not nitrite, and is urease negative.

Answer 1

ANSWER

1.What is your differential diagnosis? 4 pts.

-Infections of blood or urine.

-Covid -19

-Acute gastroenteritis

-Any bites of bugs or other insects

--Any clotting disorders

-Respiratory tract infections

-Rare chance of Extra pulmonary tuberculosis and any malignancies ( because of weight loss)

2. What questions should you ask the patient about his medical history? 5 pts
-Is there any co morbidities like BP ,DM ?

-Any history of travel of attending functions?

-Foods had last day ?

-Symptoms experience since how many days ?

-History regarding hygiene?

3. Given patient’s signs:

a. what might the patient have, and what is your rationale? 4 pts

patient is having some infection which is clear from his symproms symptoms of fever.So mostly the infection can be of any blood or urine infection .Patient can even be suspected for extra pulmonary tuberculosis due to weight loss and must be ruled out by further history and laboratory findings.

b. What general treatments and tests should be performed next? 3 pts
Treatment must be initiated with IV antibotics

-Injection magnex forte 1.5 gm IV BD(antibiotics)

-Injection doxy 200 mg iv OD(antibiotics)

-Injection PCM 1gm IV TID ( for fever )

-Injection Pan 40 mg iv OD( protan pump inihibitors to prevent acidity)

-Syrup Aristozyme 10 ml TID ( to increase intestinal motility and increases hunger)

INVESTIGATIONS

-CBP

-CRP

-Blood culture and sensitivity

-Urine culture and sensitivity

-Chest xray

-ESR

-LFT and RFT

-2D echo

-Usg abdomen

c. What organisms should be suspected--name at least six? 3 pts

-Ecoli

-Streptococcus aureus

-vibrio cholerae

-Clostridium botulinum

-Campylobacter jejuni

-mycobacterium marinum

-Salmonella

-Shigella

-Enterobacteriaceae

4. What antibiotics were most likely used to treat the patient? 3 pts.

These antibiotics include

-cephalosporins (ceftriaxone-cefotaxime, ceftazidime, and others)

-fluoroquinolones (ciprofloxacin, levofloxacin)

aminoglycosides (gentamicin, amikacin)

imipenem, -( meropenem)

broad-spectrum penicillins with or without β-lactamase inhibitors (amoxicillin-clavulanic acid, piperacillin-tazobactam)

5. What was the final diagnosis of the patient? 3 pts
Enteric fever ( Typhoid )

6. Extra credit (up to 5 pts)—Bacteria were tested by Kirby–Bauer antimicrobial susceptibility testing; organisms were resistant to aminoglycosides, colistin (Polymixin E) and polymixin B. The organism is aerobic, grows on MacConkey agar, motile with polar or amphitrichous flagella, reduces nitrate but not nitrite, and is urease negative.?

Enterobacteriaceae is a family of Gram-negative, they can stay in both aerobic and anaerobic environment, non-spore-forming rods. These causes enteric diseases most likely. Can be grown in MacConkey agar.
Characteristics of this family include being motile, catalase positive, and oxidase negative; reduction of nitrate to nitrite; and acid production from glucose fermentation.