Patient Encounter 1 Part 2 Cellulitis Medical History Physical Examination and Diagnostic Tests

PMH: Hypertension. He is not aware of any other illnesses.

FH: Father died of stroke at age 72. Mother, age 79, is alive with diabetes and a history of breast cancer. One brother, age 59, is alive and healthy.

SH: Works as a college professor; married; three grown children. Denies tobacco use; drinks approximately four glasses of wine on weekends; denies illicit drug use.

Meds: Atenolol 100 mg by mouth daily, multiple vitamin 1 tablet by mouth daily.

Allergies: No known drug allergies.

ROS: (+) pain and swelling in the right lower extremity; (-) headache, chest pain, shortness of breath, cough, nausea, vomiting, diarrhea, and weight loss.

Gen: Patient is in no acute distress. Wt 95 kg (209 lb); ht 5 ft, 11 in. (180 cm).

Chest: Lungs bilaterally clear to auscultation.

CV: Regular rate, rhythm. No murmurs/rubs/gallops.

Ext: Right lower extremity with erythema and edema from the ankle to just below the knee. Warm to the touch. LLE within normal limits.

Labs: WBC 17.3 x 103/mm3 (17.3 x 109/L), serum creatinine 0.8 mg/dL (70.7 pmol/ L) The patient is diagnosed with cellulitis and admitted to the medical floor.

What are the most likely causative organisms in this case of cellulitis?

What are the goals of therapy for this patient?

What nonpharmacologic interventions would you recommend for him?

What antimicrobial therapy would you recommend? Include drug, dosage, route, interval, and duration of therapy.

How would you monitor your selected regimen for safety and efficacy?

If CA-MRSA represents 35% of all S. aureus isolates at your hospital, would you change your pharmacologic recommendation? If so, how?

Table 73-3 lists some recommended antibiotic regimens for the treatment of cel-lulitis. Because antimicrobial susceptibilities vary considerably between geographic locations, clinicians should select empirical treatment based on the antibiograms at their respective institutions. To decrease the spread of resistance, antibiotic therapy should be narrowed based on culture and sensitivity results whenever possible. The duration of therapy for uncomplicated cellulitis typically ranges from 7 to 10 days. For complicated cellulitis, therapy with IV antibiotics is generally initiated and a switch to oral therapy can be made once the patient is afebrile and skin findings begin to resolve. Typically, this is done after 3 to 5 days. The complete duration of therapy can range from 10 to 14 days and longer in cases where abscess, tissue necrosis, underlying skin wounds, or delayed response to therapy are involved.1,14

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