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Presentation on theme: "?... See how the font is RED when you type your answers after the "prompt" (the red "?")... Every "?" means that you have to answer a question in the text."— Presentation transcript:

1 ?... See how the font is RED when you type your answers after the "prompt" (the red "?")... Every "?" means that you have to answer a question in the text box that is provided, which will expand to fit the material that is added... This to facilitate corrections by the course instructor, who will make comments to you in BLUE font. YOUR NAME: Dr. ? YOUR ADDRESS: ? NAME OF YOUR CASE: A Day at the Fair

2 CASE: A Day at the Fair LEVEL 1 Mr. Burgas is acutely ill – He is a 75-year-old male who presented in the ER of Flamingham General Hospital with fever, nausea, and acute abdominal pain that had persisted for 5 days. Along with the abdominal discomfort, the patient complained of watery diarrhea for the last 2 days with a slight appearance of blood in the stools. The patient was awake but lethargic. He mentioned that he had been to a country fair in their town 6 days ago. Their son-in-law, who had accompanied him, is also exhibiting similar symptoms, while his wife is fine. Hospital Admission - On admission, your initial examination of Mr. Burgas revealed the following: T 39.1 o C, Pulse 110/min, BP 80/40 mm Hg, and Respirations 22/min. An examination of the head and neck revealed pale mucosae. There was moderate diffuse abdominal tenderness without masses or rebound tenderness.

3 This PowerPoint is a tutorial demonstrating the basics of an ID case study … The complete example is available as the MSWord document “06_EXAMPLE CASE STUDY_FAIRGROUND” LEVEL 1 QUESTIONS Questions must be answered completely – Demonstrate that you have mastered the readings and understand the infectious process occurring in your patient and the physiological responses of the patient – Define "uncommon" medical terms, give examples, etc.! 1A. After the preliminary examination of the patient and the possibly incomplete history of the illness, you must make an ANATOMICAL DIAGNOSIS and a DIFFERENTIAL DIAGNOSIS …

4 The following questions entail the ANATOMICAL DIAGNOSIS; to do so, you must first look up the following vocabulary: Define the term “Symptom” and give an example of a typical symptom - Provide an answer that explains this! Define the term “Sign” and give an example of a typical sign - Provide an answer that explains this! Define the term “Syndrome” - Provide an answer that explains this!

5 1B. What is the general, clinical name for the Illness or Syndrome … Include a brief description … What are the typical SIGNS and SYMPTOMS …

6 Syndrome – Brief description List of SIGNS and SYMPTOMS (define each) ? SYNDROME: GASTROENTERITIS Gastroenteritis is the GENERAL syndrome …It’s your job to find the description SIGNS & SYMPTOMS: Fever and chills: is a frequent medical symptom that describes an increase in internal body temperature to levels that are above normal (the common oral measurement of normal human body temperature is 36.8±0.7 °C or 98.2±1.3 °F). Fever is most accurately characterized as a temporary elevation in the body’s thermoregulatory set- point, usually by about 1-2°C. Headache: A headache is pain or discomfort in the head, scalp, or neck. Diarrhea: (may be bloody) Diarrhea is loose, watery, and frequent stool. Diarrhea is considered chronic (long-term) when you have had loose or frequent stools for more than 4 weeks. SYNDROME: Based on the oral history taken as well as the signs and symptoms, it appears that the patient is suffering from FOOD POISONING. …It’s your job to find the description SIGNS & SYMPTOMS: The symptoms from the most common types of food poisoning generally start within 2 to 6 hours of eating the food responsible. That time may be longer (even a number of days) or shorter, depending on the toxin or organism responsible for the food poisoning. The “delayed” onset of the symptoms indicates that the food poisoning is due to food infection versus food infection. The possible symptoms include: …

7 1C. Begin to consider the EPIDEMIOLOGICAL DIAGNOSIS. List any "environmental" or host factors that may have “PREDISPOSED” the patient … Patient's recent visit to a county fair is suspicious … the timing is “right” for something at the fair being involved in his illness … his son-in-law’s similar symptoms reinforce the connection … His age (75 years) might also be of importance (why?) … (I-A: 1[1] of 30[35] pts)

8 2. What is the DIFFERENTIAL DIAGNOSIS (“The List of the Usual Suspects”)?  So for now, list the usual microbes that typically can cause this illness or syndrome … … Spend the time to carefully research the microbes that are frequently associated with your patient's syndrome(s)

9  Very, VERY briefly describe the possible involvement of each microbe with the patient’s anatomical diagnosis: - Use this EXACT format: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). - Genus species* (or Genus species*): Brief mention of the syndromes caused by the microbe and the situations in which the typically occur. * Use the proper taxonomic style (binomial nomenclature) for writing the species name.

10 - Reason to Consider: Brief explanation regarding why the microbe that is a likely cause of the illness, i.e. for which infectious agents should the patient specimen(s) be tested. Think of the illnesses or syndromes that you suspect; explain why you decided to continue the microbe in the prioritized list of "Likely Suspects?" - or Reason to Disregard: Brief explanation regarding the microbe is an unlikely cause of the illness. Explain why you initially considered this microbe and why you decided to exclude it from your prioritized list of "Likely Suspects?"

11 NOTE: In certain cases, the following might be an acceptable answer: “There are no microbes (Bacteria, Fungi, Parasites, and/or Viruses) that are typically associated with the symptoms that were observed in the patient.” Do not use this answer to avoid properly researching all the potential pathogens associated with the patient’s syndrome! …Below are just a few examples of the microbes that can cause invasive gastroenteritis

12 Gram-Positive Bacteria: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? Listeria monocytogenes: Although an uncommon cause of illness in the general population, is an important pathogen affecting pregnant patients, neonates, elderly individuals, and immunocompromised individuals. It typically is a food-borne organism. Listeria also is a common veterinary pathogen, being associated with abortion and encephalitis in sheep and cattle. It can also be isolated from soil, water, and decaying vegetation. Reason to disregard: … Why? Other Gram-Positive Bacteria associated with food poisoning were considered but quickly disregarded given the vastly different symptoms … Perhaps discuss those that are suspicious …

13 Gram-Negative Bacteria: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? Escherichia coli O157:H7: one of many species of bacteria living in the lower intestines of mammals, known as gut flora. When located in the large intestine, it assists with waste processing, vitamin K production, and food absorption. Known to cause food poisoning. Strain O157:H7 was first recognized as a cause of illness in 1982 during an outbreak of severe bloody diarrhea; the outbreak was traced to contaminated hamburgers. The bacteria can also contaminate raw fruits, particularly melons, and vegetables, such as lettuce, sprouts, tomatoes, spinach and green onions. Prepackaged vegetables and salad mixes may present a particular risk. Symptoms are usually characterized by severe abdominal pain, cramps, nausea, vomiting, diarrhea and occasionally fever. The onset period for E. coli O157:H7 infection is generally 1 – 6 days. An incubation period of less than 24 hours is, however, very unlikely. Reason to consider: The illness that O157:H7 causes is often a severe and bloody diarrhea and painful abdominal cramps, without much fever. Patient is showing signs of food poisoning for 4 days, including bloody diarrhea.

14 Gram-Negative Bacteria: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). Campylobacter jejuni: Campylobacteriosis is an infectious disease caused by bacteria of the genus Campylobacter. The common routes of transmission are fecal-oral, person- to-person sexual contact, ingestion of contaminated food or water. It produces an inflammatory, sometimes bloody, diarrhea, periodontitis or dysentery syndrome, mostly including cramps, fever and pain. The infection is usually self-limiting and in most cases, symptomatic treatment by reposition of liquid and electrolyte replacement is enough in human infections. The use of antibiotics, on the other hand, is controversial. The onset period for Campylobacter is generally 2 – 5 days but can vary between 1 and 10 days. Symptoms usually last between 2 days and 1 week. Reason to consider: Most people who become ill with campylobacteriosis get diarrhea, cramping, abdominal pain, and fever within 2 to 5 days after exposure to the organism. The diarrhea may be bloody and can be accompanied by nausea and vomiting. The illness typically lasts 1 week.

15 Gram-Negative Bacteria: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). In cases if gastroenteritis there are numerous other Gram-negative bacteria that can cause disease … They should be discussed if there is an outside chance that they are the causative agent … The Reason to disregard option should be addressed, e.g. The following bacteria were reviewed as possible causes of the patients symptoms, but were disregarded due to …..

16 "Non-Gram-Stainable" Bacteria: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? IF YOUR EXTENSIVE SURVEY OF THE PATIENTS SYNDROME(S) DOES NOT TURN UP ANY MICROBES, THIS IS THE APPROPRIATE ANSWER: There are no Non-Gram-Stainable Bacteria that are typically associated with the symptoms that were observed in the patient Fungi: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? You got the idea of how to answer this question … Mushrooms were reviewed as a possible cause of the patient’s symptoms, but were disregarded due to the unlikelihood that …

17 Parasites: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? You got the idea of how to answer this question … The following parasites were reviewed as possible causes of the patients symptoms, but were disregarded due to the intoxication nature of the food poisoning: Giradia and Cryptosporidium Viruses: Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to Disregard: Brief explanation). ? You got the idea of how to answer this question … The following viruses were reviewed as possible causes of the patients symptoms, but were disregarded due to the intoxication nature of the food poisoning: Calicivirus, Rotavirus, Astrovirus, Adenovirus

18 3. Begin to consider the ETIOLOGICAL DIAGNOSIS by first determining which specimen(s) should be collected and analyzed. Use the request form (below) to order the specimen(s) that you wish to request "TODAY.“  Remember that hospitals and insurance companies “frown upon unnecessary testing” - So, “thoughtfully” request samples and tests that will “economically” permit you to deal with your patient’s situation, but do not make your patient a victim of “downsizing!”

19  Therefore, only order the tests that are “logical.” There will be other opportunities (in other LEVELS of this case study) to order additional tests, i.e. “TOMORROW” when the preliminary lab results from "TODAY" become available.

20 3A. So firstly, what specimen(s) should be obtained from your patient? Request the specimen(s) using the “ - Specimen Request Form” (below) - In this example, let’s suppose that you are going to request a specimen of BLOOD and a GI STOOL

21 Specimen Request Form X Blood  CSF  Catheter Tip  Bone Marrow  Dialysis Fluid  Miscellaneous Specimen (e.g. Aspirate, Abscess, Fluid, Tissue, Wound, Ulcer, etc.) * * Specify source of sample EENT - Upper Respiratory  Eye  Ear  Nose, Nasopharnyx  Throat Genital – Urinary Tract  Ulcer Swab  Vaginal Swab  Cervical Swab  Midstream Urine  Catheter Urine  Urethral Swab Lower Respiratory Tract  Sputum  Alveolar/Bronchial *  Aspirate* Gastro – Intestinal Tract X GI Stool  Vomitis

22 3B. Explain the value of each specimen that you requested as part of your ETIOLOGICAL DIAGNOSIS. For each specimen that was requested, correlate the “logic” behind the request with the DIFFERENTIAL DIAGNOSIS (question 2). Demonstrate how these specimens will be “sufficient” to allow you to diagnose your patient’s syndrome. ? Blood - The infection may have spread from a localized one to a systemic one, it may be possible to isolate bacteria from the bloodstream. However, it is also possible that the patient's own immune reaction is the cause of the systemic effects, not circulating bacteria. Stool – A stool culture is done to identify bacteria, viruses, fungi, or parasites that may be causing an infection. This test will assist in isolating and identifying the microorganism causing the gastrointestinal distress of this patient.

23 3C. Describe EXACTLY IN DETAIL how each specimen should be taken. Include in the discussion any special measures ("quality control") necessary to ensure that each specimen(s) is appropriate, including quantity and quality of the specimen, transport to the lab, etc. SPECIMEN: ? SAMPLING METHOD (i.e. HOW SPECIMEN IS OBTAINED): ? MINIMAL QUANTITY (IF CRITICAL): ? SPECIMEN QUALITY (e.g. CONTAMINATION WITH MISCELLANEOUS MATERIAL, OF SPECIMEN): ? TRANSPORT & STORAGE (e.g. SPECIAL MEDIA, TEMPERATURES, etc.): ?

24 4A. In detail, describe and discuss the concept of “Normal Flora” (i.e. “Microbiota”). ? Provide a detailed answer that explains this! 4B. The presence of microbiota, in or around the site(s) of infection (or in specimens that you requested) may complicate efforts to determine the causative agent of an illness. Are microbiota normally found in specimens that you requested? If so, name some of the relevant species that may be present in each specimen that might complicate the determination of causes of the patient’s illness. ? Normal flora are not usually found in the blood. So, from the blood sample, normal flora will not complicate my efforts to find the pathogen. Stool is not normally sterile; there are lots of normal bacteria, and the pathogens may be rare among them. Therefore, it is essential to use selective media, atmosphere, and temperature to try to isolate the pathogens.

25 5. Next, to determine the possible microbial cause of your patient's disease, request a series of tests (inoculation on growth media, serology, etc.) to be performed on each specimen that you requested as part of your ETIOLOGICAL DIAGNOSIS. - Additional tests will often be needed and may by ordered (questions 5 and 6) from the following laboratories: bacteriology, mycology, parasitology, virology, hematology, and chemistry; specific serological and molecular tests are performed in each of those laboratories.

26 BACTERIOLOGY 5A. What is meant by Bacteriology? ? Provide an answer that explains this! What is the function of the Clinical Bacteriology Laboratory, i.e. what information does the Bacteriology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? ? Provide an answer that explains this! Once the microbes grow on media, they will be routinely subjected to additional tests to identify them to the level of genus and species; the physician does not need to request those tests. Exactly, yet generally, how does the laboratory normally identify a bacterium to the level of genus and species? ? Provide an answer that explains this!

27 SEROLOGY 5B. Each of the various clinical labs participates in the diagnosis of an infectious disease via microscopic observations and cultures of specimens; additionally, immunological methods are often part of the diagnostic process. What is meant by Serology? ? Provide an answer that explains this! What is the function of the Clinical Serology Laboratory, i.e. what information does the Serology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? ? Provide an answer that explains this!

28 This is what’s gonna “automatically” happen to each of the specimens that are sent to the bacteriology laboratory … Flamingham General Hospital INOCULATION PROTOCOLS FOR THE ISOLATION OF BACTERIAL PATHOGENS Note: These are the protocols for bacteria only (there are other laboratories that deal with other microbes, i.e. virology, mycology, and parasitology (question 6, below ) This series of inoculation protocols was designed to ensure that the typical bacterial pathogens, which might infect a particular body site, are provided with the appropriate nutritional and environmental conditions for growth. The Director of the Microbiology Laboratory chose those tests and media because they will allow the most efficient detection and/or isolation of the typical bacterial pathogens that are usually associated with each type of clinical specimen. …

29 The routine inoculation protocols followed in FGH are below; these protocols are a list of the media that according to your hospital’s protocols MUST be used to isolate BACTERIAL pathogens from EACH SPECIMEN that has been ordered. EACH SPECIMEN MUST BE INOCULATED ONTO EACH OF THE MEDIA AS “ASSIGNED” TO THAT TYPE OF SPECIMEN IN THE TABLES, below. Abbreviations of the Names of TESTS and GROWTH MEDIA BROTH – Brain Heart Infusion Broth BLOOD – Agar Containing 5% (vol/vol) Sheep RBCs (Red Blood Cells) CAMPY - Campylobacter Agar MAC - MacConkey Agar MTM - Modified Thayer Martin Agar PEA - PhenylEthylene Alcohol Blood Agar … etc. Note: Certain specimens [e.g. Blood, CSF, etc] should also be sent to the Chemistry and Serology laboratories for additional, NECESSARY testing!

30 BLOOD * * An Automated (Anaerobic and Aerobic) Blood Sample System, e.g. “BACTEC” will be used in addition to these media NO SMEAR – This Specimen is NOT Routinely Gram Stained BLOOD CHOC MAC ANA Note: The Serology, Hematology, and Clinical Chemistry Laboratories, and perhaps others should also analyze this specimen. STOOL VOMITIS N O SMEAR – This Specimen is NOT Routinely Gram Stained Upon Special Request - EXAMINATION FOR LYMPHOCYTES BLOOD MAC HE SS CAMPY - Incubate at 42 o C SELENITE - Place Remaining Specimen on Swab in Selenite Broth Flamingham General Hospital INOCULATION PROTOCOLS FOR THE ISOLATION OF BACTERIAL PATHOGENS SOURCE/TYPE OF SPECIMEN MEDIUM and SPECIAL INSTRUCTIONS

31 5C. Bacteria typically considered to be pathogens (not normal flora or environmental contaminants) that are isolated on any of the media above will be identified to genus and species (when possible/practical) using - BIOCHEMICAL and/OR ENZYMATIC TESTS - usually via the Microscan  Combo Panel - If appropriate, the antibiotic sensitivities (MICs) will also be determined - Those tests do not have to be ordered; they will be performed automatically by the lab  Use the form below to request any additional tests that would not be routinely performed in the Bacteriology Laboratory

32  Note that the requests for several specimens and tests require specific additional information. - The laboratory technologists must know exactly which tests are to be performed on which specimens; their question is, “What (exactly) do you want us to look for?” - For the specimens and tests indicated by either “*” or “**” in the Request Form, you must specify the exact version of the test to be performed. - Do not fail to provide the appropriate information; without it, the specimen(s) will not be processed.  All tests are performed in the lab using commercially- available/ FDA-approved kits (THE TEST MUST BE COMMERCIALLY AVAILABLE AND FDA-APPROVED; A TEST THAT DOES NOT EXIST CANNOT BE ORDERED! )

33 ADDITIONAL BACTERIOLOGY TEST REQUEST FORM (Tests in addition to those specified in the “INOCULATION PROTOCOLS FOR THE ISOLATION OF BACTERIAL PATHOGENS”) Bacteriology:  Acid-Fast Stain  Special Microscopy**  Anaerobic Culture  Special Culture**  Molecular Probe**  PCR** ** Specify the specific tests to be performed and/or pathogens being sought Serology - Antibody Detection:  Syphilis Serology Screen  Borillia Serology Screen  Other** Serology - Antigen Detection:  Mycobacterial Detection  Chlamydia Detection  Legeionella Detection  Francisella Detection  Toxin Assay**  Other **  No Tests Are Required At This Time Explanations – Justify (according to your differential diagnosis) if you are (or are not) requesting additional testing. Indicate which patient specimen(s) is to be tested. Explain the value of any of any of these tests that you want to request!

34 6. Aside from the bacteriology laboratory, there are several other clinical labs that can potentially provide information that will be useful in the diagnosis of your patient’s illness In the next step of the ETIOLOGICAL DIAGNOSIS, request any additional tests (e.g. mycology, parasitology, virology, hematology, clinical chemistry) that should be ordered "TODAY" using the Test Request Forms (below)

35 MYCOLOGY 6A. What is meant by Mycology? ? Provide an answer that explains this! What is the function of the Clinical Mycology Laboratory, i.e. what information does the Mycology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? ? Provide an answer that explains this!

36 Flamingham General Hospital MYCOLOGY LABORATORY TEST REQUEST FORM Mycology:  Direct Exam - Stain  Culture ** Specify the specific tests to be performed and/or pathogens being sought Serology - Antibody Detection:  Antibody Detection** Serology - Antigen Detection:  Cryptococcus Antigen Detection  Other **  No Tests Are Required At This Time Explanations – Justify (according to your differential diagnosis) if you are (or are not) requesting additional testing. Indicate which patient specimen(s) is to be tested. Explain the value of any of any of these tests that you want to request!

37 PARASITOLOGY 6B. What is meant by Parasitology? ? Provide an answer that explains this! What is meant by “Parasitology,” particularly, medical (or veterinary) parasitology as performed on a clinical Parasitology Laboratory; what types of organisms are studied in Parasitology Laboratory? ? Provide an answer that explains this! What is the function of the Clinical Parasitology Laboratory, i.e. what information does the Clinical Parasitology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? ? Provide an answer that explains this!

38 Flamingham General Hospital PARASITOLOGY LABORATORY TEST REQUEST FORM Parasitology:  Direct Examination**  Direct Exam – Stain**  Culture**  Pneumocystis Detection  Molecular Probe** Serology - Antigen Detection:  Antigen Detection ** ** Specify the specific tests to be performed and/or pathogens being sought  No Tests Are Required At This Time Explanations – Justify (according to your differential diagnosis) if you are (or are not) requesting additional testing. Indicate which patient specimen(s) is to be tested. Explain the value of any of any of these tests that you want to request!

39 VIROLOGY 6C. What is meant by Virology? ? Provide an answer that explains this! What is the function of the Clinical Virology Laboratory, i.e. what information does the Virology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? ? Provide an answer that explains this!

40 Flamingham General Hospital VIROLOGY LABORATORY TEST REQUEST Virology:  Electron Microscopy  Culture**  Molecular Probe**  ** ** Specify the specific tests to be performed and/or pathogens being sought Serology - Antibody Detection:  Antibody Screen  Respiratory Antibody Screen  Hepatitis Screen  Mono Spot/Epstein-Barr  HIV Serology Screen  Viral Exanthems Antibody Screen  Other** Serology - Antigen Detection:  Antigen Detection**  No Tests Are Required At This Time Explanations – Justify (according to your differential diagnosis) if you are (or are not) requesting additional testing. Indicate which patient specimen(s) is to be tested. Explain the value of any of any of these tests that you want to request!

41 6D. Other clinical laboratories often provide information that is helpful or essential in the diagnosis of infectious diseases. HEMATOLOGY What is meant by Hematology and what is the function of the Clinical Hematology Laboratory? ? Provide an answer that explains this! Name and briefly discuss several tests performed by the Hematology Laboratory that might be useful in the diagnosis and management of infectious diseases? (Via the request form below, you will order appropriate tests that may shed light of your patient’s illness.) ? Provide an answer that explains this!

42 CLINICAL CHEMISTRY What is meant by Clinical Chemistry and what is the function of the Clinical Chemistry Laboratory? ? Provide an answer that explains this! Name and briefly discuss several tests performed by the Chemistry Laboratory that might be useful in the diagnosis and management of infectious diseases? (Via the request form below, you will order appropriate tests that may shed light of your patient’s illness.) ? Provide an answer that explains this!

43 RADIOLOGY What is meant by Radiology and what is the function of the Clinical Radiology Laboratory? ? Provide an answer that explains this! What information might the Radiology Laboratory provide that might be useful in the diagnosis and management of infectious diseases? (Via the request form below, you will order appropriate tests that may shed light of your patient’s illness.) ? Provide an answer that explains this!

44 HEMATOLOGY, CLINICAL CHEMISTRY, & RADIOLOGY TEST REQUEST Hematology:  Cell Count* * Specify source of sample ** Specify the specific tests to be performed Clinical Chemistry:  Clinical Chemistry*/**  Other*/** Radiology:  X-Ray**  Other**  No Tests Are Required At This Time Explanations – Justify (according to your differential diagnosis) if you are (or are not) requesting additional testing. Indicate which patient specimen(s) is to be tested. Explain the value of any of any of these tests that you want to request! … But remember, very often you will want to order a “Cell Count” from Hematology!

45 Upon receipt of the “Level 1” answers by the instructor, you will be sent “Levels 2 and 3” of this case.

46 YOUR NAME: Dr. ? YOUR ADDRESS: ? CASE: A Day at the Fair LEVEL 2 - Here’s the 1 st set of results of some of the lab tests that you (should have) ordered …  After admitting Mr. Burgas to the ICU, you immediately ordered that he be given intravenous fluids and the antibiotic ceftriaxone as a preventative measure. You requested standard analysis of the following samples: - For bacteriology - STOOL and BLOOD - For serology and hematology - BLOOD - For chemistry - URINE  No urinalysis could be performed since he was unable to provide a sample at time of admission. Later that day, Mr. Burgas continued to display symptoms such as lethargy, pale skin, very low urine output, vomiting, and continual bloody diarrhea.

47 - You’ll also be given more info about your patient and asked to explain the results of some of the lab tests …  Since you were also the bacteriology stat lab tech that night and it was not busy, you decided to amuse yourself by Gram-staining the stool specimen. You observed many Gram-positive bacilli, many Gram-negative bacilli, and moderate Gram-positive cocci. However, the microscopic examination of the feces was remarkable for the presence of WBCs (fecal leukocytes). EXPLAIN WHY THE "FGH PROTOCOLS" DO NOT ROUTINELY INCLUDE GRAM-STAINING OF SPECIMENS SUCH AS THROAT, MIDSTREAM URINE, STOOL, etc. EXPLAIN THE SIGNIFICANCE OF THE GRAM STAIN OF THE STOOL SPECIMEN. WHAT MIGHT IT BE TELLING YOU ABOUT WHAT’S GOING ON WITH YOUR PATIENT?

48 - You’ll be given more info and asked to explain your current thoughts on the case…  By the end of your shift, the BLOOD culture showed “no growth.” The results of the STOOL specimen are still pending. BASED ON YOUR INITIAL DIFFERENTIAL DIAGNOSIS AND ALL THE RESULTS AVAILABLE TO DATE, WHO IS THE "MOST LIKELY SUSPECT?" DISCUSS IN DETAIL HOW AND WHY YOU HAVE REACHED THIS DECISION.

49 YOUR NAME: Dr. ? YOUR ADDRESS: ? CASE: A Day at the Fair. LEVEL 3 At the same time that you get the Level 2, you’ll also get the results of the WBC count of the patient …  The hematology lab reported that the hematocrit and platelet count were "normal," and the following: a total WBC count of 15,500/mm 3, consisting of 58% “segs” (segmented neutrophils), 27% “bands,” 1% basophils, 1% eosinophils, 10% lymphocytes, and 3% monocytes. … And you’ll be expected to completely discuss each cell type in the WBC count 

50 USING THE TABLES BELOW, COMPLETELY EXPLAIN THE NATURE IMPORTANCE OF EACH WBC TYPE THAT’S FOUND IN HUMAN BLOOD. INCLUDE IN YOUR DESCRIPTION: WBC Type (Normal Values) Immunological Functions - DETAILED DISCUSSION OF GENERAL FUNCTION(S) OF EACH TYPE IN THE MAINTENANCE OF NORMAL HEALTH IN THE PREVENTION OF/RECOVERY FROM INFECTIOUS DISEASES. BE CERTAIN TO ADDRESS: - THEIR TYPICAL TARGET(S), (i.e. WHAT TYPES OF MOLECULES, PATHOGENS, CELLS, etc. DO THEY TYPICALLY RECOGNIZE - THEIR MECHANISM(S) OF ACTION, i.e. EXACTLY THEY FUNCTION TO ELIMINATE FOREIGN MATERIALS FROM THE HOST (WHAT IMMUNE-MEDIATOR COMPOUNDS DO THEY PRODUCE; WHAT PHYSIOLOGICAL PROCESS DO THEY PERFORM?) Disorders Associated With Deviations – (Which Illnesses Or Disorders Are Associated With Deviations From The Normal Range?) - IN GENERAL, UNDER WHICH SITUATIONS WOULD THE NUMBER OF CELLS OF EACH TYPE BE LESS/GREATER THAN THE NORMAL RANGE - i.e. WHAT WOULD DEVIATIONS FROM THE NORM INDICATE ABOUT WHAT IS GOING ON IN PATIENTS IN GENERAL? Your Patient’s Status - WHAT DOES THE SURVEY OF THE POPULATIONS OF WBCS IN YOUR PATIENT INDICATE REGARDING THE POTENTIAL INFECTIOUS PROCESS THAT IS/MIGHT BE OCCURRING? (Enter Patient’s Value For Each Cell Type and Discuss Its Importance)

51 The final question regarding your patient’s WBC count … IN SUMMARY, WHAT DO THE WBC COUNTS (ABOVE) INDICATE ABOUT WHAT IS GOING ON IN YOUR PATIENT? (REMEMBER THAT YOUR PATIENT IS SICK! EVEN IF THE COUNTS “NORMAL,” WHAT DOES THIS TELL YOU ABOUT YOUR PATIENT’S ILLNESS?) ?

52 Upon receipt of these answers by the instructor, you will be sent the next level(s) of this case.

53 YOUR NAME: Dr. ? YOUR ADDRESS: ? CASE: A Day at the Fair LEVEL 4 - You’ll be asked to explain your patient’s condition and the decisions you’ve made about his/her treatment, etc. … e.g.  You decided to admit your patient for further diagnostic testing, and begin a regimen of antibiotic therapy! WAS THAT THE CORRECT MANAGEMENT OF THE CASE? IS IT NECESSARY TO ADMINISTER ANTIBIOTICS TO YOUR PATIENT? EXPLAIN WHY. IF NO, EXPLAIN WHY NOT. CITE THE SOURCE(S) OF YOUR INFORMATION.

54 - You’ll get a 2 nd set of results of lab tests that you (should have) ordered and will learn more about your patient’s illness …  By the next morning, his urine became dark and “smoky” and he voided only twice in the last twenty-four hours. You decided to have him placed on peritoneal dialysis.  The causative agent that was recovered from the FECES (STOOL SAMPLE). The Gram-stained colonies consisted of Gram-negative bacilli. BASED ON YOUR INITIAL DIFFERENTIAL DIAGNOSIS THE RESULTS AVAILABLE TO DATE, WHO IS THE "MOST LIKELY SUSPECT?" DISCUSS IN DETAIL HOW WHY YOU HAVE REACHED THIS DECISION.

55 - You’ll be asked to explain your current thoughts on the case… WHAT IS YOUR PATIENT’S PROGNOSIS FOR RECOVERY? WILL THE PATIENT “GET BETTER;” WILL THERE BE LASTING EFFECTS OF THE INFECTION? EXPLAIN IN DETAIL. PROVIDE STATISTICS TO JUSTIFY YOUR "OPINION" AND CITE THE SOURCE(S) OF YOUR INFORMATION.

56 YOUR NAME: Dr. ? YOUR ADDRESS: ? CASE: A Day at the Fair. LEVEL 5 At the same time that you get the Level 4, you’ll also get the “invitation” to teach a lab class to the 1 st year med students … … And you’ll be expected to completely discuss each type of bacteriology growth media that you used 

57 Show-n-Tell Day in the Bact Lab! YOUR NAME: Dr. ? YOUR ADDRESS: ? CASE: A Day at the Fair. LEVEL 5 For each specimen that was ordered (using the "Flamingham General Hospital - Specimen Request Form" [Level 1 / Question 3]), which bacteriological growth media were actually inoculated? The inoculation protocols, below, explain the media that are always used; keep reading … … This is discussed in detail in the next PowerPoint tutorial

58 Upon receipt of these answers by the instructor, you will be sent the “CONCLUSION” of this case.

59 YOUR NAME: Dr. CASE: A Day at the Fair. CONCLUSION Hospital Course: Mr. Burgas developed “hemolytic-uremic syndrome” (HUS); he was treated with antibiotics, peritoneal dialysis, and by blood and platelet transfusions. His urine output gradually increased from 100 to mL/day by the seventh day of hospitalization, so peritoneal dialysis was discontinued. He was discharged 17 days after admission. The patient’s stool tested positive for verotoxin (shega toxin) produced by Escherichia coli 0157:H7, as did his son-in-law’s stool. After discussing these finding with the patient, it was determined that they had shared a medium-rare hamburger at the town fair.

60 THESE QUESTIONS MUST BE COMPLETELY ANSWERED TO “CONCLUDE” EACH CASE MUST BE SUBMITTED TO THE INSTRUCTOR No Rest for the Weary - After another “hard day at the office,” you checked your voice mail. There was a message from the secretary of the chairperson of the Department of Medicine. You were thrilled to hear that Dr. Blowhard would not be able to speak at “Grand Rounds” this Friday; but then you were overwhelmed to hear that you were chosen as her replacement. You checked your notes from prior rounds and decided to use the following format to present this case while it is still fresh in your mind. In an OUTLINE FORMAT, summarize the following information, yet PROVIDE A DETAILED DISCUSSION OF EACH ITEM. Prepare it as if you had to stand in front of an audience and give an oral presentation. Even though you’re presenting to “seasoned physicians,” there are also several new residents like yourself! So prepare the material as if it was the “everything you should know about this microbe” - a review for a question on a board certification exam! Also, explain all “MEDICAL TERMS” and tests (their significance) – Many terms are new to you; do not expect that your fellow doctors will be familiar with them.

61 The conclusion questions are available from the beginning of the case study (via your flash memory or the course web site) As suggested, make yourself aware of what they require as you do every step of the case … The answers to these questions must be completed and sent to the course instructor and they will guide you in the preparation of your Grand Rounds PowerPoint Presentation The example of a PowerPoint based on this case study (“Fairground”) is available as “07_MODEL_Case_Study_Presentation” It is based on the “Conclusion” questions and should give you a good idea of how the answers are to be used to present the case

62 Congratulations, your patient’s health insurance carrier is thankful for your cost-effective handling of the case. Doctor, go home and enjoy the satisfaction of your skillful use of years of training. However, rest up! There will be new challenges for your skills tomorrow! Thanx for not falling asleep!

63 LEVEL 1 QUESTIONS To properly answer these questions, be certain that you have completely read and understand the course documents entitled: “CLINICAL CASE STUDIES - GENERAL INSTRUCTIONS” and “INTRODUCTION TO INFECTIOUS DISEASES - CASE STUDY STRATAGIES.” Your successful completion of this and subsequent Case Levels (i.e. your grade) will depend on your ability to follow instructions! Questions must be answered completely – Demonstrate that you have mastered the readings and understand the infectious process occurring in your patient and the physiological responses of the patient – Define "uncommon" medical terms, give examples, etc.! Point Value of Answers Is Based Upon “Difficulty” - Information Gathered From Texts, etc.(e.g. Definitions) - Analysis Demonstrating Understanding Of The Material This LEVEL 1 Is Worth 30% of Case Study Grade for “Microbiology” [35% for “Medical Microbiology”]

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