Student case

[EMEDPA]

16 hours ago, thinkertdm said:

Just a side point: this is a patient that could show up anywhere, uc, fp, Ed, etc.  While I certainly understand studying is important, but when you get to the real world, this will be the eleventh patient of the day, you haven't eaten because you charted during lunch, and the previous ten patients included COPD exacerbations with diabetes, chfer who gained six pounds over night, a fellow on warfarin with a "UTI" who fell last night...

You are not going to be called when you are at your best, but you will be expected to act like you are.  

true story. Saw a significant post-tonsilectomy bleed last night at o'dark 30 at a facilty without ENT on call. Was maintaining an airway ok. gave TXA and transferred within 30 min of arrival to facility with ent 45 min away. Didn't want to mess with any clot that they had established by mucking around in the airway, just wanted them out. play hero or live to play another day....they did fine, but seeing them 2 min after being sound asleep was certainly a wake up call.

[Joelseff]

Good on the labs.  I ordered all of those, plus a TSH and an A1c because those were done 2 months ago and problematic, and I wanted to see how they had changed since.  I also ordered blood cultures, just in case, but in retrospect that was probably overly cautious. I agree that IV antibiotics are indicated in this case, but my gut made the call that I wasn't going to be able to get her to go and get admitted that night, and I don't have IV support.

Based on the Sanford guide, (p. 17, 2018 edition) I went with Augmentin and Doxycycline.  I seem to recall she was Sulfa-allergic, but don't have the chart in front of me. We DO have Rocephin (Ceftriaxone) available so I had her given 1 gm IM before she left.  Keflex is one of the other options, and would have been reasonable given no history of MRSA.  I went with Augmentin in part because of the less frequent dosing--bid for Augmentin, qid for Keflex.  When in doubt, go with the easier med for patient compliance.

OK, that pretty much wraps up what I wanted students to comment on.  Practicing PAs, feel free to pick it apart.

 

 

Even if she were not sulfa allergic, Bactrim, which one of the students suggested, though a good anti MRSA agent can be nephrotoxic esp in someone with uncontrolled DM, renal status is a consideration (I didnt see gfrs in the thread apologies if already addressed). Augmentin (if not MRSA suspect but again I almost always assume MRSA) or Doxycycline would be my choice. In my area we assume MRSA given its ubiquity here.

 

Ok carry on lol.

 

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[rev ronin]

Just now, Joelseff said:

(I didnt see gfrs in the thread apologies if already addressed).

I didn't post them, but I did look at her previous labs--significant proteinuria with preserved eGFR as of two months ago, probably Stage 2 CKD.

[Joelseff]

I didn't post them, but I did look at her previous labs--significant proteinuria with preserved eGFR as of two months ago, probably Stage 2 CKD.

Yeah I wouldn't use Bactrim then.

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[JD2012]

Always up for another case!

[rev ronin]

I saw this patient again today, essentially four months later after a confirmed osteomyelitis diagnosis and some intensive effort to save the foot.  She's been seeing podiatry weekly, and this is the result.  Guess where I'll be referring future diabetic foot problems...