Christopher Manacci, MSN, ACNPChristopher Manacci, MSN, ACNPDirector, ACNP Flight Nursing ProgramDirector, ACNP Flight Nursing ProgramFrance Payne Bolton School of NursingFrance Payne Bolton School of Nursing

Case Western Reserve UniversityCase Western Reserve University

Acute Care Nurse PractitionerAcute Care Nurse PractitionerCritical Care TransportCritical Care Transport

Cleveland ClinicCleveland Clinic

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

Positive Negative

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.

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

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

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 -

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 -

Alk phos 99 -

AST 27 - ALT 32 - GGT 42 - Bili Total 1.0 Bili Direct .3 - TSH .2

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)

Hypoxia * Weakness Azotemia Dehydration Hypoproteinemia Anemia Drug abuse Infection *

Gonococcal Endocarditis Bacteremia Sepsis Mitral Regurgitation Chromosonal Deficiencies Dehydration

Sed Rate VDRL Blood Cx Chlamydia Cx C- Reactive Protein Complement C

CXR EKG TTE TEE Duplex Doppler

Subacute Bacterial Infection