Part I â The PA
It had nally arrived! e day Margo had been waiting forâretirement day. And given that the temperature had hovered around 40 degrees the last week of March in Ohio, retirement along with the move to the warm south couldnât come soon enough. Most of Margoâs belongings had been boxed up and sent on to Florida the previous week, but a few remaining items, including her wide screen TV, would be transported in the car.
Week of April 7th
The drive to Bradenton, Florida, went smoothly. After spending three days on the road, Margo arrived at the condo retirement community. It had all the luxuries one could imagine, including a spa-like pool area, a nail salon providing manis and pedis, a beauty shop, yoga studio, nutritionist, and therapeutic massage service. But before any of those amenities could be enjoyed, final moving efforts had to be undertaken. Although family had o ered to help with the move, Margo wanted to do this solo, and felt there was nothing she couldnât lift or move herselfâso she spent the rest of the afternoon rearranging and positioning the furniture, rugs, stereo, and computer equipment.
Week of April 14th
As she surveyed her new place the following week, Margo felt satisfied that her decision to move to Florida had been the right one and that her new condo suited her perfectly. One final move of the television away from the window and closer to her replace would be her last task. Unfortunately, while positioning the large at screen, she caught her right index finger on the plastic trim, resulting in a painful cut that bled a little more than expected. But after washing the wound with soap and water, things seemed to be under control and the warm sun and balmy 80 degree temperatures made her think it was time for a swim. After the swim, a nice massage would prevent any aches and pains that might result from overdoing the furniture moving, and a manicure to repair the damage the manual labor had done to her nails would be the perfect end to the day.
Week of April 28th
Margo had been enjoying Florida-living for two weeks now. The only down side was the fact that the area where she had cut her ngertip was painful, swollen, appeared red, and felt warm to the touch. If the pain didnât go away soon, Margo was going to have to have her finger looked at by a physician. Then, in the middle of the next night, the throb- bing became unbearable and she knew it was time to head to the doctor. Unfortunately, she hadnât had the time to
find a personal physician in the area and so her only option was to go to the urgent care facility not far from her condo.
May 3rd
At the urgent care center, a physicianâs assistant (PA) asked Margo a variety of personal health questions and carried out his clinical assessment, noting the following details:
Age: 65
BP 134/80
Weight 120 lbs., Height 5 Ì5 Ì
HR 59
Respiration rate 18
O2 sat. 99
Type 2 diabetes (diagnosed 3 years prior)
Following careful cleaning and examination of Margoâs wound, the PA prescribed an antibiotic called Bactrim DS (trimethoprim/sulfamethoxazole-double strength) in a tablet form to be taken by mouth two times a day for 10 days. The patient information sheet that Margo received from the clinic identified her diagnosis as cellulitis, which was curious because the person who had examined her had not mentioned that particular word. Margo dutifully followed prescribing instructions, taking her medication as suggested, but after five days the wound continued to swell, her pain had increased, and moving her finger had become dificult.
Part II â The ARNP
May 8th
The next day, Margo went to another urgent care facility where she hoped she would nd some relief. John, an Advanced Registered Nurse Practitioner (ARNP), took her history and performed his clinical assessment, noting a normal body temperature and normal-size lymph nodes. While examining the injured finger, he observed significant
swelling, mild erythemia, and a small wound with minimal clear exudate. Other than the index finger, the rest of Margoâs hand appeared normal. Upon completing his examination, John cleaned the wound, numbed the area, and injected a medication called Depo-Medrol into Margoâs finger. Afterwards, he talked to Margo about wound infections, including the redness and swelling she had been dealing with. John told Margo to clean her wound three times a day with soap and water and then to dry it thoroughly. He gave her a prescription for the antibiotic Keflex to be taken two times a day for 10 days. He also gave her a visit summary/discharge instruction paper that identified the clinical impression/diagnosis as âcellulitis/foreign body/fungi.â John further instructed Margo to return in 72 hours if her symptoms did not improve.
Once home, Margo closely read the written information she had been given and noted that the document mentioned she had been taking the drug Septra since May 3rd without improvement. Also, her medical services/charge sheet noted âforeign body removalâ as a procedure carried out, yet she had no memory of such a procedure. Although at the end
of her clinical visit Margo had signed the paper acknowledging her treatment, she was now more confused than ever regarding the cause of her wound and the course of her treatment.
Questions
1. What is the function of Depo-Medrol? Speculate on the reasoning/consequences of its use in this particular case. 2. What pathogens are targeted by Ke ex (the newest prescription)?
3. What types (genus/species) of fungal pathogens typically cause wound infections?
4. If a fungal pathogen was implicated, would Ke ex eliminate that particular infectious agent?
5. Why did Margoâs recent documents mention she was taking Septra rather than Bactrim as her earliest (May 3rd) documents listed?
