Question: The Rest Part 1 – The PA It Had Finally Arrived! The 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 Che Previous Week, …

the rest Part 1 – The PA It had finally arrived! The 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 che previous week, but a few remaining items, including her wide screen TV, would be transported in the car. Week of April 7 The drive to Bradenton, Horida, 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 providin 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 offered 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 of the afternoon rearranging and positioning the furniture, rugx, stereo, and computer equipment. Week of April 14 As she surveyed her new place the following week, Margo felt satisfied that her decision to move to Horida had been the right one and that her new condo suited her perfectly. One final move of the television away from the window and doser to her fireplace would be her last rask. Unfortunately, while positioning the large flat screen, she caught her right index finger on the plastic trim, resulting in a painful cut that blod 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 28 Margo had been enjoying Horida-living for two weeks now. The only down side was the fact that the arca where she had cut ber fingertip was painful, swollen, appeared sed, and felt warm to the touch. If the pain didn’t go away soon, Marco was poing to have to have her finger looked at by a physician. Then, in the middle of the next night, the throb- hing 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 het only option was to go to the urgent care facility not far from her condo. May 3 At the urgeat 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’s HR 59 Respiration rate 18 O, 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 difficult. Questions 1. List the various activitics Margo engaged in from which she may have encountered a bacterial pathogen. 2. What is cellulitis? Name some infectious agents that are often implicated in the development of cellulitis. 3. list the variety of pathogens which Bactrim is typically used to treat. 4. Given Margo’s vital signs and history, are there any factors that might result in a complicated recovery? Group Discussion / Assignment In paragraph form, identify the most likely microbe causing infoction as well as the source of the microbe and expected treatment outcome. Justify your choices with explanations and cite details from the case study. Complete your assignment by providing a list of three to five reliable references you used to gather your supporting information. Part II – The ARNP May 80 “The next day, Margo went to another urgent care facility where she hoped she would find some relief. John, an Advanced Registered Nurse Practitioner (ARNP), took her history and performed his dinical assessment, noting a normal body temperature and normal-sine lymph nodes. While examining the injured finger, be 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 deaned 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 dean her wound three times a day with soup 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 dosely read the written information she had been given and noted that the document mentioned she had been taking the drug Septra since May 314 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 Keflex (the newest prescription)? 3. What types (genus/species) of fungal pathogens typically cause wound infections? 4. If a fungal pathogen was implicated, would KeHex eliminate that particular infectious agent? 5. Why did Margo’s recent documents mention she was taking Septra rather than Bactrim as her carliest (May 3rd) documents listed? Part III – The Physician June 5 Three weeks had passed. The swelling was still present and it had become even more difficult for Margo to move her finger. In addition, the amount of fluid oozing from the wound had increased, suggesting that the medication hadn’t worked. It was now time to visit a local physician. Following the advice of a neighbor, Margo set up an office appointment with Dr. Chan, an internist. After the usual battery of questions, Dr. Chan sent in the nurse to collect a specimen from Margo’s finger. Dr. Chan mentioned to Margo that the specimen would be sent off to the regional hospital laboratory for analysis and that he would provide her with another prescription for Keflex, which she should continue to take until test results came back. June 15″ . “The test results arrived in Dr. Chan’s office on June 15 and were as follows: No yeast or fungal elements were noted Gram-stain reaction: no organisms seen Culture of anaerobes and acrobes @ 48 hours yielded no growth Enrichment culture results: moderate growth on day 5 of an acid-Fast bacterium (AFB). • Growth identified as Mycobacterium fortuitum by the Horida State Laboratory Armed with a microbial identification. Dr. Chan prescribed Doxycycline and Bactrim to be taken for four months. Dr. Chan also mentioned that the solated organism was known to be found in tap water. Consequently, Margo planned to ask her condo community why an organism that could cause so much pain would be living in the water that was coming out of her faucets. And although she was annoyed to learn of the source of the organism, at least she could take some comfort in the fact that she finally had an accurate diagnosis and that by taking her medicine she could fully recover from her injury and start to enjoy her new home. Questions 1. Compare and contrast acrobes and anacrobes. Why were no microbes noted upon aerobic and anaerobic culture? 2. Investigate the properties and characteristics of M. fortuitum. Where is this organism typically found (reservoirs)? 3. Why must the acid fast stain be performed to identify organisms of the genus Mycobacterium? 4. Why did Dt. Chan prescribe two antibiotics rather than only one? 5. How does doxycycline kill bacteria (cellular target)? 6. Why were the antibiotics prescribed for an extended period (4 months)? 7. No organisms were noted upon Gram staining, yer the enrichment culture yielded M. fortitum after several days. Provide an explanation. Group Discussion/Assignment Having completed all three parts of the case, you are now ready to re-address the question posed in Part 1 of the case and retrospectively evaluate why it took almost two months to correctly identify the implicated etiological agent and treat the infection appropriately The Assignment In narrative form, identify and discuss the most likely microbial etiology as well as the source of the microbe and expected treatment outcome. Justify your choices with explanations as well as citations of details from the entire case study Discuw any different conclusions you have now come to compared to the first time you had this discussion). What details, if any, forced you to rethink your diagnosis/explanation! If you were acting as a care-giver, how would you have approached this problem differently to provide a more timely diagnosis and resolution to the problem? Complete your assignment by liating three to five reliable seferences that provided information to allow you to arrive at your condusions Condusion Margo’s infection eventually deared after two months of treatment, although she continued to take her medication for the full four months as prescribed. Ultimately, her finger required physical therapy in order to again become fully functional because the infectious agent had caused some soft tissue destruction. When she inquired about the contaminant (M. fortuitum) being in the tap water, ber condo Homeowners Association (HOA) referred her to the officials at the Public Water System. Although the water department issued a report of elevated (yet within acceptable limits) xylenes in one monthly sample, they failed to acknowledge the presence of M. fortuitum and stated that they only screen the water supply for coliforms-and no other organisms Lesson learned: For the time being. Margo was careful to limit her use of the tap water in het condo to only certain activities such as those that required boiling water (cooking and the use of large amounts of soap or detergent (bathing and laundry). In addition, the installation of a whole house ultraviolet water purification system was her immediate renovation priority. After that installation, Margo could hopefully achieve some peace of mind and begin to fully enjoy her tropical paradise.