maverick
Surgery Resident
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Q ID 919 - division: ID - Infective endocarditis
The answer given in USMLEWORLD is that antibiotics
should be started immediately after drawing 3 blood
culture sets and not wait for specific microbiological diagnosis
Harrison 15th edition states:
In hemodynamically patients with subacute
endocarditis, emperical therapy should not be
administered, as additional blood cultures may be
needed.
In acute endocarditis or with deteriorating
hemodynamics emperical therapy should be started after
the 3 blood culture sets.
In the question patient was hemodynamically stable
with low grade fever and subungual hemorrhages
pointing towards subacute infective endocarditis.
kaplan also says the same thing
So isnt the answer wrong
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Q Id 911 Division: ID - OSTEOMYELITIS
answer says that technitium scan is preferred over MRI
however CMDT says "MRI is believed to be the most
sensitive and is particularly helpful in demonstrating
the soft tissue involvement. Radionuclide bone
scanning is most valuable when osteomyeltis is
suspected but no site is obvious"
kaplan also says the same thing
so shouldnt answer be MRI?
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" There comes a time when for every addition of knowldege you forget something that you knew before. It is of the highest importance, therefore,not to have useless facts elbowing out the uselful ones." - Arthur Conan Doyle
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| docpink
Forum Newbie
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well mri is the gold standard
and bone scan is 90% sensitive
i would go with MRI.
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| docpink
Forum Newbie
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also MRI is more specific..so it is the best test
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| docpink
Forum Newbie
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prior to the results of blood cultures,therapy can be started if
the pt is very il or there is very lear evidence of endocarditis such as 1)FEVER2)a new or changing murmur3)and embolic phenomena
so clearly int his case we would begin treatment.but after the specific microbiologic agent is known you must ALTER therapy acoordingly.
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| maverick
Surgery Resident
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nope u cannot start emperical treatment for IE even if Duke's major criteria is satisfied, as one is sure of the diagnosis of infective endocarditis but not the organism causing it, so one has to wait for the blood culture report.
emperical treatment only if patient is hemodynamically unstable or clinical features are of acute inf. endocarditis
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" There comes a time when for every addition of knowldege you forget something that you knew before. It is of the highest importance, therefore,not to have useless facts elbowing out the uselful ones." - Arthur Conan Doyle
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| maverick
Surgery Resident
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that is what all books and kaplan also says. only usmleworld differs
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" There comes a time when for every addition of knowldege you forget something that you knew before. It is of the highest importance, therefore,not to have useless facts elbowing out the uselful ones." - Arthur Conan Doyle
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| bm
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mmm... how long does a culture take? how long before you know the causative organism? how long before the patient gets worse? what are the complications of IE and how long before they could manifest? if you don't give the treatment now, and wait for the culture, would it kill the patient before the culture arrives? would the prognosis be worse? if waiting for the culture would make things worse for the patient, give the antibiotics first.
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| maverick
Surgery Resident
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well what if the antibiotics dont fully cure the patient and you end up with very less levels of the microorganisms in the serum (but are not able to fully eradicate) because of suboptimal treatment. then wont it be difficult finding out what the causative agent is, and how to proceed?
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" There comes a time when for every addition of knowldege you forget something that you knew before. It is of the highest importance, therefore,not to have useless facts elbowing out the uselful ones." - Arthur Conan Doyle
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| bm
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i knew you were gonna ask that . accdg. to dr. fischer, give the antibiotics and do the culture all in one patient visit. that way, you are trying to solve the problem while waiting for the confirmation from the lab. by the time the patient comes back to you and tells you the drugs didn't work, you'll have the lab results in hand. on the other hand, if the drugs did work, you'll save your patient from further complications of IE.
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| maverick
Surgery Resident
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well what i meant (actually what harrison says) is that suppose culture comes negative or contaminated etc. then u would need to reculture. but if you have already given antibiotics, then u r in trouble. kaplan books also say this. so why did Dr. Fischer say differently. very fishy!! 
stupid problem i guess. forget it. other important stuff to study. Good luck
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" There comes a time when for every addition of knowldege you forget something that you knew before. It is of the highest importance, therefore,not to have useless facts elbowing out the uselful ones." - Arthur Conan Doyle
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| bm
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 i myself am confused (you could see my post in "comeback"). i guess we have to try and absorb the facts and make a wise guess on the actual exam, and hope it's the right one. good luck to you too
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| img21
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