Case studies.Van Etta. 4-7-10-Heather Grothe
7 y.o. Girl
 Chief Complaint
o Dysuria and urinary frequency x 2 days
o No fever, flank pain, trauma, hematuria
(gross), or emesis
 Physical Exam
o Mild suprapubic tenderness
o
T-37.0, P-71
 Dx? UTI
 Tests? UA, gram stain, culture
 UA
o 100-200 WBC/hpf
o 5-10 RBC/hpf
 Urine Gram Stain
o 15-25 gram negative rods/hpf
 Specimen sent for culture
 RX: ___1. TMP/Sulf, _or trimethoprim_
 Culture Grew
o >100,000 ml  E. coli sensitive to
amoxicillin, sulfa, cefazolin, ciprofloxacin
 Recommended- concern is an anatomic
malformation in recurrent UTI in kids. (collect
system), abuse also in mind.
o IVP
o Voiding cystogram
o Cystoscopy
27 y.o. Male Pediatric Resident
 Chief Complaint
o Cough, chest pain, fever x 2 days, headache
 History of Present Illness
o “URI” symptoms for several days
o Developed nonproductive cough and fever
o Day before admission noted right-sided
pleuritic pain and cough productive of
blood-tinged sputum
 Physical Exam
o Moderately ill
o VSS, Temp - 103ºF
o Chest - fine, moist rales RLL posteriorly
 Dx? Pneumonia,
 Tests? Sputum and CXR
Right side abnormal, infiltrate
 WBC-8,700/ul
 Legionella urinary antigen-neg- very specific and
good to do, quick way to rule these out.
 Pneumococal urinary antigen-neg
 C-reactive protein-4.5 mg/dL
 Gram Stain (sputum)
o Many PMNs
o Few (+) cocci
o Occasional (-) rod
 RX: ceftriaxone + azythromycin (atypicals) or just
flouroquinilone
 Sputum culture - grew normal flora (probably
mycoplasma b/c test are poor for this organism)
54 y.o. Female
 Chief Complaint
o Pain in right leg, chills and fever
 History of Present Illness
o Hx of phlebitis, now has chronic edema,
especially right leg
o 18 hours prior to admission noted pain in
leg that became progressively worse
o Few hours later noted redness, swelling &
blisters; then chills and fever developed
 Physical Exam
o VSS, Temp 102.6ºF
o Right leg  indurated, erythematous,
swollen, large bullae from ankle to knee

Dx? Cellulits :Staph (doesn’t move as fast) or streplooks like beta hemolytic strep, b/c she has
recurrent edema (moves faster)
 Tests? Blood culture
 WBC-14,600
 CRP-18.2
 Blood cultures x 2-results pending
 Wound culture-moderate WBC, moderate Gram +
cocci
 Rx: nafcilln, cephlasporin, clindamycin (to prevent
toxin, works at level of ribosome)
 Blood culture and culture of skin lesions grew Group
A beta hemolytic streptococci
 Patient improved with parenteral clindamycin and
warm packs
69 y.o. Male
 Chief Complaint
o Fever, cough, pain in left leg
 History of Present Illness
o 10 days PTA  fever and cough productive
of purulent sputum
o 8 days PTA  severe pain left knee
o 7 days PTA  knee swollen, very hot and
tender
 Physical Exam
o Acutely ill, dyspneic
o VSS, Temp – 103.6ºF
o Chest - rales left mid lung field, posteriorly
o Left knee - swollen, tender, erythematous,
hot


Dx? 1. Sepsis, 2. Pneumonia, 3. septic arthritis of
knee
Tests? Blood culture, sputum culture, tap the knee,
cxr
Left lower lobe pneumonia
 WBC-17.600
 CRP-25.6
 Blood cultures x 2 –results pending
 Creatinine-1.1
 Other tests?
 Arthrocentesis
o Turbid fluid
o 70,000 WBC, 95% PMNs
o Sugar - 15 mg%- low bugs eating
o Protein - 6 grams %- too high
 Gram Stain
o (+) cocci, in pairs
 RX:
Gram + diplococci
 Blood cultures and synovial fluid grew
 Streptococcus pneumoniae
 Patient was treated with ceftriaxone (3rd gen ceph)
2 gms IV q 24 hrs for 4 weeks- also add vanco due
to severe sickness and possible resistnace
56 yr old male
 Chief complaint : abdominal pain and fever
 HPI: 3 days of increasing abdominal pain, mild
diarrhea, and fever to 100.4
 P.E: T-38, BP-130/72, P-96, R-19
 Lungs-clear, CV- RR, no murmur
 Abdomen- tender with rebound diffusely, absent
bowel sounds
 Dx? Peritonitis (diffuse rebound and absent bowel
sounds). Perforation usually causes peritonitis.
(perferated ulcer or diverticulits)
 Tests? CT of abdomen, cbc
 WBC-18,600 with 92% neutrophils
 Creatinine-1.8, BUN-34
 AST-24

Other tests?
o CT abdomen/pelvis-diverticula of sigmoid
colon with inflammatory changes,
paracolonic inflammatory mass, and
peritoneal fluid.
 Rx: antiobiotics (metronidazole (anaerobes)
ceftriaxone, extended penicillin, carbipeneum, zosin,
surgery
 Blood cultures were negative
 Peritoneal cultures grew-E coli, Bacteroides species,
Fusobacterium species, Enterococcus faecalis, and
Enterobacter cloacae
 Patient recovered after surgical resection of the
sigmoid colon with formation of a colostomy and
peritoneal irrigation combined with
 Antibiotic therapy- metronidazole combined with
ciprofloxacin (enterobacter coverage) and
piperacillin/tazobactam for 10 days
28 yr old female
 Chief complaint: confusion
 HPI: lives alone, found by her friend in bed at home
this morning-confused, weak, unsteady on feet,
speaking in nonsensical sentences
 Physical exam: T-37, BP 122/63. P-73, R-16
 Lungs-clear, CV-RR, no murmur, Abd-soft, nontender
 Neuro-neck supple, expressive aphasia, DTRs-equal
and reactive, toes down-going bilaterally
 Dx? Encephilitis, brain abscess
 Tests?
 CSF- WBC 34 with 72% mononuclear, RBC 75,
glucose-64, protein-45
 CSF- gram stain – few WBC, no bacteria seen
 CT brain- normal ( CT sensitive for abscess)
 Additional tests?- MRI of brain to better show
herpes encephilits- won’t show up on CT
 MRI brain- enhancement of the temporal region on
the left
 Rx:
 CSF PCR was positive for herpes simplex
 Patient recovered with intravenous acyclovir-10
mg/kg IV q 8 hrs for 21 days