1. Christopher Manacci, MSN, ACNP Director, ACNP Flight Nursing Program France Payne Bolton School of Nursing Case Western Reserve University Acute Care Nurse Practitioner Critical Care Transport Cleveland Clinic

2. Subjective  Fever x 24 hrs  Chills  Scant Dry Cough  Very Weak Feeling  Sore Throat / Ear Pain  Stiff Neck, Rash  Nasal Congestion  CP / SOB  Weight Loss  Exertional Dyspnea  ABD Pain, N / V Positive Negative

3. History History  Tx 2 wks prior for GC  One dose injection of PCN  IV heroin, cocaine use x 5 years. Last use 3 days ago  Unemployed  No Living Family  Vague Historian  Smoker “a lot, I always have…”  Negative HIV from 4 months ago.

4. Physical Examination  Unkempt, disheveled  Appears older than age  Lying down on stretcher  Shivering  110/70, P 96, R 24, T 37  HEENT: ◦ fundi benign ◦ TM normal ◦ pharynx slightly red ◦ dry oral mucosa ◦ no excudate ◦ poor dentition ◦ supple neck ◦ no thyromegaly

5. Physical Examination  Cardiac ◦ S1 normal ◦ Split S2 ◦ +Loud P2 ◦ No murmur or Rub ◦ 3/6 R carotid bruit ◦ cool peripherally ◦ warm centrally ◦ pale nailbeds  Lungs- clear bilat  ABD- unremarkable  No lymphadenopathy  No peripheral edema  Tracks w/o phlebitis  Neuro- unremarkable  Muscskel- no joint swelling, pain

6. Chemistry Profile  Na 132 -  Cl 102  K 3.0 -  Bun 29  Cr 2.7 +  Glu 120 +  Pro 5.6 -  Alub 2.8 -  Ca 11.0 -  Mg 1.8 -  Phos 5.2 +  LDH 201  CK 68  Uric 6.0 -  Chol 98 -  Triglys 70 -

7. Hematologic Profile  Hct32 -  Hgb8.8 -  WBC12.0 +  RBC4.1 -  Plts188 -  Seg65 +  Bands17 +  Lymph10 +  Mono3+  Eos1+  MVC74 -  MHC22-  MHHC28 -  RDW10 -

8. Enzymatic Profile  Alk phos99 -  AST27 -  ALT32 -  GGT42 -  Bili Total1.0  Bili Direct.3 -  TSH.2

9. Questions and Answers  Why Ceftriaxone and Erythromycin ? ◦ Penicillin, ampicillin and tetracycline are not reliable agents. Third generation cephalosporins highly effective. ◦ Ceftriaxone 1-2gms q 12 hrs. x 14 d (bactericidal; inhibits cell wall mucopeptide synthesis) ◦ Erythromycin 1 gm q 6 hrs. x 14 d (binds to P site of 505 ribosomal subunit interfering with protein synthesis)

10. Problem List  Hypoxia *  Weakness  Azotemia  Dehydration  Hypoproteinemia  Anemia  Drug abuse  Infection *

11. Differential Diagnosis  Gonococcal Endocarditis  Bacteremia  Sepsis  Mitral Regurgitation  Chromosonal Deficiencies  Dehydration

12. Necessary Diagnostic Studies  Sed Rate  VDRL  Blood Cx  Chlamydia Cx  C- Reactive Protein  Complement C  CXR  EKG  TTE  TEE  Duplex Doppler

14. Normal Thermic  Subacute Bacterial Infection