Question

Part I – The PA

It had nally arrived! e day Margo had been waiting for—retirement day. And given that the temperature had hovered around 40 degrees the last week of March in Ohio, retirement along with the move to the warm south couldn’t come soon enough. Most of Margo’s belongings had been boxed up and sent on to Florida the previous week, but a few remaining items, including her wide screen TV, would be transported in the car.

Week of April 7th

The drive to Bradenton, Florida, went smoothly. After spending three days on the road, Margo arrived at the condo retirement community. It had all the luxuries one could imagine, including a spa-like pool area, a nail salon providing manis and pedis, a beauty shop, yoga studio, nutritionist, and therapeutic massage service. But before any of those amenities could be enjoyed, final moving efforts had to be undertaken. Although family had o ered to help with the move, Margo wanted to do this solo, and felt there was nothing she couldn’t lift or move herself—so she spent the rest of the afternoon rearranging and positioning the furniture, rugs, stereo, and computer equipment.

Week of April 14th

As she surveyed her new place the following week, Margo felt satisfied that her decision to move to Florida had been the right one and that her new condo suited her perfectly. One final move of the television away from the window and closer to her replace would be her last task. Unfortunately, while positioning the large at screen, she caught her right index finger on the plastic trim, resulting in a painful cut that bled a little more than expected. But after washing the wound with soap and water, things seemed to be under control and the warm sun and balmy 80 degree temperatures made her think it was time for a swim. After the swim, a nice massage would prevent any aches and pains that might result from overdoing the furniture moving, and a manicure to repair the damage the manual labor had done to her nails would be the perfect end to the day.

Week of April 28th

Margo had been enjoying Florida-living for two weeks now. The only down side was the fact that the area where she had cut her ngertip was painful, swollen, appeared red, and felt warm to the touch. If the pain didn’t go away soon, Margo was going to have to have her finger looked at by a physician. Then, in the middle of the next night, the throb- bing became unbearable and she knew it was time to head to the doctor. Unfortunately, she hadn’t had the time to

find a personal physician in the area and so her only option was to go to the urgent care facility not far from her condo.

May 3rd

At the urgent care center, a physician’s assistant (PA) asked Margo a variety of personal health questions and carried out his clinical assessment, noting the following details:

Age: 65

BP 134/80

Weight 120 lbs., Height 5 ́5 ̋

HR 59

Respiration rate 18

O2 sat. 99

Type 2 diabetes (diagnosed 3 years prior)

Following careful cleaning and examination of Margo’s wound, the PA prescribed an antibiotic called Bactrim DS (trimethoprim/sulfamethoxazole-double strength) in a tablet form to be taken by mouth two times a day for 10 days. The patient information sheet that Margo received from the clinic identified her diagnosis as cellulitis, which was curious because the person who had examined her had not mentioned that particular word. Margo dutifully followed prescribing instructions, taking her medication as suggested, but after five days the wound continued to swell, her pain had increased, and moving her finger had become dificult.

Part II – The ARNP

May 8th

The next day, Margo went to another urgent care facility where she hoped she would nd some relief. John, an Advanced Registered Nurse Practitioner (ARNP), took her history and performed his clinical assessment, noting a normal body temperature and normal-size lymph nodes. While examining the injured finger, he observed significant

swelling, mild erythemia, and a small wound with minimal clear exudate. Other than the index finger, the rest of Margo’s hand appeared normal. Upon completing his examination, John cleaned the wound, numbed the area, and injected a medication called Depo-Medrol into Margo’s finger. Afterwards, he talked to Margo about wound infections, including the redness and swelling she had been dealing with. John told Margo to clean her wound three times a day with soap and water and then to dry it thoroughly. He gave her a prescription for the antibiotic Keflex to be taken two times a day for 10 days. He also gave her a visit summary/discharge instruction paper that identified the clinical impression/diagnosis as “cellulitis/foreign body/fungi.” John further instructed Margo to return in 72 hours if her symptoms did not improve.

Once home, Margo closely read the written information she had been given and noted that the document mentioned she had been taking the drug Septra since May 3rd without improvement. Also, her medical services/charge sheet noted “foreign body removal” as a procedure carried out, yet she had no memory of such a procedure. Although at the end

of her clinical visit Margo had signed the paper acknowledging her treatment, she was now more confused than ever regarding the cause of her wound and the course of her treatment.

Questions

1. What is the function of Depo-Medrol? Speculate on the reasoning/consequences of its use in this particular case. 2. What pathogens are targeted by Ke ex (the newest prescription)?

3. What types (genus/species) of fungal pathogens typically cause wound infections?

4. If a fungal pathogen was implicated, would Ke ex eliminate that particular infectious agent?

5. Why did Margo’s recent documents mention she was taking Septra rather than Bactrim as her earliest (May 3rd) documents listed?

Answer 1

1) Depo-Medrol is anti-inflammatory glucocorticoid for intramuscular drug given in form injection when oral dose in not feasible. This drug prevent the inflammation and swelling of wound and second visit of Margi the nurse parctioner observed swelling of wound and reduce inflammation Depo-Medrol was given.

2)Keflex is cephalosporins class of drugs used to treat bacterial infections and slows the growth of bacteria as Margo wound was seen with clear white discharge citing bacterial infection Keflex was recommended. The main bacteria which are targeted by keflex us forming bacteria which includes Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, E. coli and several others

3) Nonalbicans Candida and candida is some common agent which might cause fungal infections.

4) Use of Ke ex would not be useful in fungal treatment as it works as bactericidal affecting only bacterial antifungal agents will be helpful for fungal infections

5) The drug septra contains the same composition of bactrim just the brand name differs but both drugs contain same combination of sulfamethoxazole and trimethoprim and has the same mode of action on variety of bacterial infections.