Download Module #10 - UNM Hospitalist Wiki

Learner Version
Module #10
Created by Dr. Wendy Gerstein
9/2013
Objectives:
See facilitator version
References:
See facilitator version
CASE
Patient is a 79 yo male with past medical history notable for diabetes, hypertension, and
moderate aortic stenosis presents with 2-3 day history dizziness, fever to 101 F,
weakness, and associated cough with sputum (unknown color). Patient denied chest pain
or tightness, denied sob, no GI or GU symptoms. He had no sick contacts, no recent
travel or procedures. In ED was febrile 101.5, bp 101/40, p 95, 93% RA; exam notable
for poor dentition, lungs with few crackles left base, CV with 2-3/6 sem radiating up to R
carotid, skin exam unremarkable except small abrasion on shin with minimal surrounding
erythema.
What is your initial assessment?
What are possible sources of infection?
What is your initial management step?
What is your initial treatment plan?.
Based on history and exam what would you choose for empiric antibiotics?
Initial labs/studies:
UA completely negative except trace blood and 6 rbc/hpf
BUN/creatinine 48/1.8 (baseline 1.0)
Sodium 133, K 4.4, Cl 97, CO2 22
Transaminases and lfts wnl
Wbc 12.7, 94.9% neutrophils
Hct 43, platelets 151
Lactate 1.0
CXR: relatively clear, hazy small patchy opacity LLL c/w atelectasis vs. small infiltrate.
The following day you are called by the lab because blood cultures are positive for GPC
in chains.
What organisms are possible?
Possible sources of the bacteremia?
How does this information change your management plan?
What are the vascular (embolic and immunologic) phenomena of endocarditis?
What would be the findings on the physical exam?
The following day the organism is identified as alpha-hemolytic strep in 4/4 blood culture
bottles. TTE obtained on the 4th day shows small vegetation (<1cm) on the aortic valve
with associated mild AR and stable moderate AS.
What risk factor(s) did this patient have for endocarditis?
What other evaluation would be done if organism was S. bovis?
What would be your final management plan?
.
When should ID be consulted in patients with endocarditis? What workup should
be complete prior to consultation?
What would you do differently if organism was S. aureus?
What are other clinical scenarios in endocarditis that CT Surgery should be
consulted?
Associated Infectious Diseases MKSAP 16 questions for this module:
A)
B)
C)
D)
Question 10 –
Question 46 –
Question 66 –
Question 78 -
Post Module Evaluation
Please place completed evaluation in an interdepartmental mail envelope and address to
Dr. Wendy Gerstein, Department of Medicine, VAMC (111), or give to Dr. Patrick
Rendon, UNM Hospital.
1) Topic of module:__________________________
2) On a scale of 1-5, how effective was this module for learning this topic? _________
(1= not effective at all, 5 = extremely effective)
3) Were there any obvious errors, confusing data, or omissions? Please list/comment
below:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
4) Was the attending involved in the teaching of this module? Yes/no (please circle).
5) Please provide any further comments/feedback about this module, or the inpatient
curriculum in general:
6) Please circle one:
Attending
Resident (R2/R3)
Intern
Medical student