Sara Jager, PGY2

HPI: 3 month old female with 3 days of fever, fussiness, inconsolable episodes that are worse when lying flat. Tmax 100.6 with decreased PO; no vomiting. Mom feels like it might be painful for her to eat but it could also be positional as she is breastfed. 2 weeks ago had frequent loose runny stools with slight cough and runny nose and diagnosed with a viral syndrome. 1 day PTA was seen at instacare and had UA that was normal. PMH: Term NSVD following uncomplicated pregnancy. GBS negative. Hyperbili requiring phototherapy x 1 day.

FHx: liver cancer

Soc Hx: lives with 2 older siblings and her parents. Denies travel and sick contacts.

VS: T 37.7, HR 147, RR 27, BP 109/53, 97% RA Gen: Tired appearing but curious and interactive HEENT: AFOSF, EOMI, PERRL, TM pearly gray B, oropharynx normal, MMM Cor: RRR, no murmur Resp: No increased WOB, breath sounds symmetric. Abd: Soft, NT, ND, NABS GU: normal female Ext: nontender, no erythema or edema, not tender to palpation Neuro: Full ROM of all major joints, normal reflexes, CN intact

CBC: WBC 24.5, 52% N, 0 B, 39% L; Hgb 9.7, Platelets 633 CSF: 4 WBC, 3 N, 46 L, 51 M, RBC 27, Protein 12, Glucose 63; gram stain negative UA: SG 1.02, neg nitrite, LCE neg ESR 53 CRP 4.4 CMP normal KUB: moderate large and small bowel air; aerophagia, no obstruction, no mass CXR: normal

Treated with Rocephin with significant improvement in symptoms and feeding. Lateral neck X-ray normal. ENT consult no findings. Bone scan normal. WBC and CRP improved after 4 days of antibiotics. Discharged to home without antibiotics and able to PO requirements.

10 days after admission she is readmitted to PCMC ED for 2 days of fever to 102, refusal to PO, dehydration. Had bloody pus on her left lateral pharynx. WBC was 31 with a CRP of 13 upon readmission. CT scan obtained in ED.

2x2x2cm left tonsillar and parapharyngeal space abscess

 Neck

Mass 91% Lymphadenopathy 83% Agitation 14-50% Trismus 14-53% Swelling of face and neck, erythema, purulent oral discharge Dysphagia and odynophagia

Cx Results: 3+ Mixed Respiratory flora and 2+ S. Aureus

Polymicrobial

Strep Viridans Peptostreptococcus Fusobacterium Prevotella Actinomyces Staph Aureus Psudomonsa Enterobacter (including ESBL types) Strep pyogenes

 CT

scan ENT for incision and drainage Antibiotics Strep

Staph dont use PCN Clindamycin 93-100% Erythromycin 85-93% Oxacillin 91-100% Intermediate for TMP-SMX

Erythromycin 86-100%

 Unasyn

= ampicillin and sulbactam inhibitor with ampicillin.

Beta-lactamase Interferes

with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. Alternative to amoxicillin when unable to take medication orally. skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Covers

Happy Friday!