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Chills, Thrills and Neutrophils

Chills, Thrills and Neutrophils. 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. Subjective. Negative. Positive.

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Chills, Thrills and Neutrophils

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  1. Chills, Thrills and Neutrophils 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 Negative Positive 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

  3. 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 Hct 32 - Hgb 8.8 - WBC 12.0 + RBC 4.1 - Plts 188 - Seg 65 + Bands 17 + Lymph 10 + Mono 3+ Eos 1+ MVC 74 - MHC 22- MHHC 28 - RDW 10 -

  8. Enzymatic Profile Alk phos 99 - AST 27 - ALT 32 - GGT 42 - Bili Total 1.0 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

  13. Normal Thermic Subacute Bacterial Infection

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