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  #1  
Old 08-21-2012
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Default your antibiotic of choice ?

A 75-year-old man with type 2 diabetes mellitus is evaluated in
the emergency department for a draining chronic ulcer on the
left foot, erythema, and fever. Drainage initially began 3 weeks
ago. Current medications include metformin and glyburide.
On physical examination, he does not appear ill. Temperature is
37.9C (100.2F); other vital signs are normal. The left foot is
slightly warm and erythematous. A plantar ulcer that is draining
purulent material is present over the fourth metatarsal joint. A
metal probe makes contact with bone. The remainder of the
examination is normal.
The leukocyte count is normal, and an erythrocyte
sedimentation rate is 70 mm/h. A plain radiograph of the foot is
normal.
Gram stain of the purulent drainage at the ulcer base shows
numerous leukocytes, gram-positive cocci in clusters, and gramnegative
rods.
Which of the following is the most appropriate
management now?
(A) Begin imipenem
(B) Begin vancomycin and ceftazidime
(C) Begin vancomycin and metronidazole
(D) Perform bone biopsy
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  #2  
Old 08-21-2012
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Default

Rule out osteo --> get bone sample.
Start treatment with vanc (cover MRSA) and cefta
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Old 08-21-2012
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hmm I was thinking of C ..... as pt has infecting reaching the bone as shown by the metal probe + x ray usually normal till 2 to 3 weeks

still C becoz vancomycin for MRSA and metronidazole for anaerobic infections
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Old 08-21-2012
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Quote:
Originally Posted by Hitman View Post
hmm I was thinking of C ..... as pt has infecting reaching the bone as shown by the metal probe + x ray usually normal till 2 to 3 weeks

still C becoz vancomycin for MRSA and metronidazole for anaerobic infections
ans is bone bx. btw, vanco-metro is not cool combo because gm negative not covered. and bone infection is mixed infection ...mcc is stap but we have to cover, (+)(-)(anerobes).
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Old 08-26-2012
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why not B? A would be good but it wont cover MRSA.
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Old 08-26-2012
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Ans B .vancomycin and ceftazidime as it will cover MRSA as well as gram negative
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Old 08-27-2012
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Ans is bone bx.


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Old 08-27-2012
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But why bone Bx ??

Can somebody explain
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Old 08-27-2012
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Quote:
Originally Posted by step_enhancer View Post
But why bone Bx ??

Can somebody explain
Because we have to know what organism has caused osteomyelitis.Ulcer site may contain multiple organisms; anaerobic, gram +ve or gram -ve but what specific organism has caused the osteomyelitis.It is important to know before starting treamtment.
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Old 08-27-2012
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This is the type of question that always gets me pissed off! One would think of vanco-cefta, since it's logical, but then they want us to go ahead and do a bone biopsy... It is so subjective... It scares me that I might make simple mistakes like this..
I really don't like the way the manage the "most appropriate step in management". It could either be diagnosis or treatment! Why don't they ask it plain and simple?
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Old 08-27-2012
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Quote:
Originally Posted by aknz View Post
Because we have to know what organism has caused osteomyelitis.Ulcer site may contain multiple organisms; anaerobic, gram +ve or gram -ve but what specific organism has caused the osteomyelitis.It is important to know before starting treamtment.
Thanks .But wouldn't bone biopsy take long time ? wouldnt it be better to start broad spectrum antibiotics.I am not saying i disagree with u ,i just want to make it clear coz i get these Qs often wrong.Thanks again
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Old 08-27-2012
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Quote:
Originally Posted by step_enhancer View Post
Thanks .But wouldn't bone biopsy take long time ? wouldnt it be better to start broad spectrum antibiotics.I am not saying i disagree with u ,i just want to make it clear coz i get these Qs often wrong.Thanks again
its not nice idea giving emperic therapy for a month. bone bx is therefore done first.
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Old 08-27-2012
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Quote:
Originally Posted by step_enhancer View Post
Ans B .vancomycin and ceftazidime as it will cover MRSA as well as gram negative
but it won't cover Gr -. so wrong.Cultures obtained from a sinus tract do not reflect the bacterial etiology of osteomyelitis; bone biopsy is correct ans to guide antibiotic therapy.
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