Transcript II_PROCARYOTIC CELL STRUCTURE

? ... See how the font is RED when you type your answers after
the "prompt" (the red "?") ... Every "?" means that you have to
answer a question in the text box that is provided, which will
expand to fit the material that is added ... This to facilitate
corrections by the course instructor, who will make comments to
you in BLUE font.
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
NAME OF YOUR CASE: A Day at the Fair
CASE: A Day at the Fair
LEVEL 1
Mr. Burgas is acutely ill – He is a 75-year-old male who
presented in the ER of Flamingham General Hospital with fever,
nausea, and acute abdominal pain that had persisted for 5 days.
Along with the abdominal discomfort, the patient complained of
watery diarrhea for the last 2 days with a slight appearance of
blood in the stools. The patient was awake but lethargic. He
mentioned that he had been to a country fair in their town 6 days
ago. Their son-in-law, who had accompanied him, is also
exhibiting similar symptoms, while his wife is fine.
Hospital Admission - On admission, your initial examination of
Mr. Burgas revealed the following: T 39.1oC, Pulse 110/min, BP
80/40 mm Hg, and Respirations 22/min. An examination of the
head and neck revealed pale mucosae. There was moderate
diffuse abdominal tenderness without masses or rebound
tenderness.
This PowerPoint is a tutorial demonstrating the basics of an ID case study …
The complete example is available as the MSWord document
“06_EXAMPLE CASE STUDY_FAIRGROUND”
LEVEL 1 QUESTIONS
Questions must be answered completely – Demonstrate that you
have mastered the readings and understand the infectious
process occurring in your patient and the physiological responses
of the patient – Define "uncommon" medical terms, give examples,
etc.!
1A. After the preliminary examination of the patient and the
possibly incomplete history of the illness, you must make an
ANATOMICAL DIAGNOSIS and a DIFFERENTIAL DIAGNOSIS
…
The following questions entail the ANATOMICAL DIAGNOSIS; to
do so, you must first look up the following vocabulary:
Define the term “Symptom” and give an example of a typical
symptom Provide an answer that explains this!
Define the term “Sign” and give an example of a typical sign Provide an answer that explains this!
Define the term “Syndrome” -
Provide an answer that explains this!
1B. What is the general, clinical name for the Illness or
Syndrome …
Include a brief description …
What are the typical SIGNS and SYMPTOMS …
Syndrome – Brief description
List of SIGNS and SYMPTOMS (define each)
? SYNDROME: GASTROENTERITIS
Gastroenteritis is the GENERAL syndrome …It’s your job to find the description
SIGNS & SYMPTOMS:
Fever and chills: is a frequent medical symptom that describes an increase in internal body temperature to levels
that are above normal (the common oral measurement of normal human body temperature is 36.8±0.7 °C or
98.2±1.3 °F). Fever is most accurately characterized as a temporary elevation in the body’s thermoregulatory setpoint, usually by about 1-2°C.
Headache: A headache is pain or discomfort in the head, scalp, or neck.
Diarrhea: (may be bloody) Diarrhea is loose, watery, and frequent stool. Diarrhea is considered chronic (long-term)
when you have had loose or frequent stools for more than 4 weeks.
SYNDROME: Based on the oral history taken as well as the signs and symptoms, it appears that the patient is
suffering from FOOD POISONING.
…It’s your job to find the description
SIGNS & SYMPTOMS: The symptoms from the most common types of food poisoning generally start within
2 to 6 hours of eating the food responsible. That time may be longer (even a number of days) or shorter,
depending on the toxin or organism responsible for the food poisoning. The “delayed” onset of the
symptoms indicates that the food poisoning is due to food infection versus food infection.
The possible symptoms include: …
(I-A: 1[1] of 30[35] pts)
1C. Begin to consider the EPIDEMIOLOGICAL DIAGNOSIS. List
any "environmental" or host factors that may have
“PREDISPOSED” the patient …
Patient's recent visit to a county fair is suspicious … the timing is
“right” for something at the fair being involved in his illness … his
son-in-law’s similar symptoms reinforce the connection … His age
(75 years) might also be of importance (why?) …
2. What is the DIFFERENTIAL DIAGNOSIS (“The List of the Usual
Suspects”)?
 So for now, list the usual microbes that typically can cause this
illness or syndrome …
… Spend the time to carefully research the microbes that are
frequently associated with your patient's syndrome(s)
 Very, VERY briefly describe the possible involvement of each
microbe with the patient’s anatomical diagnosis:
- Use this EXACT format: Genus species: Brief mention of
syndromes and situations. Reason to Consider: Brief
explanation (or Reason to Disregard: Brief explanation).
- Genus species* (or Genus species*): Brief mention of the
syndromes caused by the microbe and the situations in which the
typically occur.
* Use the proper taxonomic style (binomial nomenclature) for
writing the species name.
- Reason to Consider: Brief explanation regarding why the
microbe that is a likely cause of the illness, i.e. for which infectious
agents should the patient specimen(s) be tested. Think of the
illnesses or syndromes that you suspect; explain why you decided
to continue the microbe in the prioritized list of "Likely Suspects?"
- or Reason to Disregard: Brief explanation regarding the
microbe is an unlikely cause of the illness. Explain why you
initially considered this microbe and why you decided to exclude it
from your prioritized list of "Likely Suspects?"
NOTE: In certain cases, the following might be an acceptable
answer:
“There are no microbes (Bacteria, Fungi, Parasites, and/or
Viruses) that are typically associated with the symptoms that
were observed in the patient.”
Do not use this answer to avoid properly researching all the
potential pathogens associated with the patient’s syndrome!
…Below are just a few examples of the microbes that can cause
invasive gastroenteritis
Gram-Positive Bacteria:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief
explanation (or Reason to Disregard: Brief explanation).
? Listeria monocytogenes: Although an uncommon cause of illness in the
general population, is an important pathogen affecting pregnant patients,
neonates, elderly individuals, and immunocompromised individuals. It typically
is a food-borne organism. Listeria also is a common veterinary pathogen, being
associated with abortion and encephalitis in sheep and cattle. It can also be
isolated from soil, water, and decaying vegetation.
Reason to disregard: … Why?
Other Gram-Positive Bacteria associated with food poisoning were considered
but quickly disregarded given the vastly different symptoms … Perhaps discuss
those that are suspicious …
Gram-Negative Bacteria:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to
Disregard: Brief explanation).
? Escherichia coli O157:H7: one of many species of bacteria living in the lower
intestines of mammals, known as gut flora. When located in the large intestine, it assists
with waste processing, vitamin K production, and food absorption. Known to cause food
poisoning. Strain O157:H7 was first recognized as a cause of illness in 1982 during an
outbreak of severe bloody diarrhea; the outbreak was traced to contaminated
hamburgers. The bacteria can also contaminate raw fruits, particularly melons, and
vegetables, such as lettuce, sprouts, tomatoes, spinach and green onions. Prepackaged
vegetables and salad mixes may present a particular risk. Symptoms are usually
characterized by severe abdominal pain, cramps, nausea, vomiting, diarrhea and
occasionally fever. The onset period for E. coli O157:H7 infection is generally 1 – 6 days.
An incubation period of less than 24 hours is, however, very unlikely.
Reason to consider: The illness that O157:H7 causes is often a severe and bloody
diarrhea and painful abdominal cramps, without much fever. Patient is showing signs of
food poisoning for 4 days, including bloody diarrhea.
Gram-Negative Bacteria:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason to
Disregard: Brief explanation).
Campylobacter jejuni: Campylobacteriosis is an infectious disease caused by bacteria
of the genus Campylobacter. The common routes of transmission are fecal-oral, person-
to-person sexual contact, ingestion of contaminated food or water. It produces an
inflammatory, sometimes bloody, diarrhea, periodontitis or dysentery syndrome, mostly
including cramps, fever and pain. The infection is usually self-limiting and in most cases,
symptomatic treatment by reposition of liquid and electrolyte replacement is enough in
human infections. The use of antibiotics, on the other hand, is controversial. The onset
period for Campylobacter is generally 2 – 5 days but can vary between 1 and 10 days.
Symptoms usually last between 2 days and 1 week.
Reason to consider: Most people who become ill with campylobacteriosis get diarrhea,
cramping, abdominal pain, and fever within 2 to 5 days after exposure to the organism.
The diarrhea may be bloody and can be accompanied by nausea and vomiting. The
illness typically lasts 1 week.
Gram-Negative Bacteria:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief
explanation (or Reason to Disregard: Brief explanation).
In cases if gastroenteritis there are numerous other Gram-negative bacteria that
can cause disease
… They should be discussed if there is an outside chance that they are the
causative agent
… The Reason to disregard option should be addressed, e.g. The following
bacteria were reviewed as possible causes of the patients symptoms, but were
disregarded due to …..
"Non-Gram-Stainable" Bacteria:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason
to Disregard: Brief explanation).
? IF YOUR EXTENSIVE SURVEY OF THE PATIENTS SYNDROME(S) DOES
NOT TURN UP ANY MICROBES, THIS IS THE APPROPRIATE ANSWER:
There are no Non-Gram-Stainable Bacteria that are typically associated with the
symptoms that were observed in the patient
Fungi:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason
to Disregard: Brief explanation).
? You got the idea of how to answer this question … Mushrooms were reviewed
as a possible cause of the patient’s symptoms, but were disregarded due to the
unlikelihood that …
Parasites:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason
to Disregard: Brief explanation).
? You got the idea of how to answer this question … The following parasites
were reviewed as possible causes of the patients symptoms, but were
disregarded due to the intoxication nature of the food poisoning: Giradia and
Cryptosporidium
Viruses:
Genus species: Brief mention of syndromes and situations. Reason to Consider: Brief explanation (or Reason
to Disregard: Brief explanation).
? You got the idea of how to answer this question … The following viruses were
reviewed as possible causes of the patients symptoms, but were disregarded
due to the intoxication nature of the food poisoning: Calicivirus, Rotavirus,
Astrovirus, Adenovirus
3. Begin to consider the ETIOLOGICAL DIAGNOSIS by first
determining which specimen(s) should be collected and analyzed.
Use the request form (below) to order the specimen(s) that you
wish to request "TODAY.“
 Remember that hospitals and insurance companies “frown upon
unnecessary testing” - So, “thoughtfully” request samples and
tests that will “economically” permit you to deal with your patient’s
situation, but do not make your patient a victim of “downsizing!”
 Therefore, only order the tests that are “logical.” There will be
other opportunities (in other LEVELS of this case study) to order
additional tests, i.e. “TOMORROW” when the preliminary lab
results from "TODAY" become available.
 Note that the requests for several specimens require additional
information as indicated by a “ " in the Request Form. Do not fail
to provide the appropriate information.
3A. So firstly, what specimen(s) should be obtained from your
patient? Request the specimen(s) using the “ - Specimen
Request Form” (below)
- In this example, let’s suppose that you are going to request a
specimen of BLOOD and a GI STOOL
Specimen Request Form
X Blood
 CSF
 Catheter Tip
 Bone Marrow
 Dialysis Fluid
 Miscellaneous
Specimen
(e.g. Aspirate,
Abscess, Fluid,
Tissue, Wound,
Ulcer, etc.) *
* Specify source of
sample
EENT - Upper
Respiratory
 Eye
 Ear
 Nose,
Nasopharnyx
 Throat
Genital – Urinary
Tract
 Ulcer Swab
 Vaginal Swab
 Cervical Swab
 Midstream Urine
 Catheter Urine
 Urethral Swab
Lower Respiratory
Tract
 Sputum
 Alveolar/Bronchial
*
 Aspirate*
Gastro – Intestinal
Tract
X GI Stool
 Vomitis
3B. Explain the value of each specimen that you requested as part
of your ETIOLOGICAL DIAGNOSIS. For each specimen that was
requested, correlate the “logic” behind the request with the
DIFFERENTIAL DIAGNOSIS (question 2). Demonstrate how
these specimens will be “sufficient” to allow you to diagnose your
patient’s syndrome.
? Blood - The infection may have spread from a localized one to a
systemic one, it may be possible to isolate bacteria from the
bloodstream. However, it is also possible that the patient's own
immune reaction is the cause of the systemic effects, not
circulating bacteria.
Stool – A stool culture is done to identify bacteria, viruses, fungi,
or parasites that may be causing an infection. This test will assist
in isolating and identifying the microorganism causing the
gastrointestinal distress of this patient.
3C. Describe EXACTLY IN DETAIL how each specimen should be
taken. Include in the discussion any special measures ("quality
control") necessary to ensure that each specimen(s) is
appropriate, including quantity and quality of the specimen,
transport to the lab, etc.
SPECIMEN: ?
SAMPLING METHOD (i.e. HOW SPECIMEN IS OBTAINED): ?
MINIMAL QUANTITY (IF CRITICAL): ?
SPECIMEN QUALITY (e.g. CONTAMINATION WITH
MISCELLANEOUS MATERIAL, OF SPECIMEN): ?
TRANSPORT & STORAGE (e.g. SPECIAL MEDIA,
TEMPERATURES, etc.): ?
4A. In detail, describe and discuss the concept of “Normal Flora”
(i.e. “Microbiota”).
? Provide a detailed answer that explains this!
4B. The presence of microbiota, in or around the site(s) of
infection (or in specimens that you requested) may complicate
efforts to determine the causative agent of an illness.
Are microbiota normally found in specimens that you requested?
If so, name some of the relevant species that may be present in
each specimen that might complicate the determination of causes
of the patient’s illness.
? Normal flora are not usually found in the blood. So, from the
blood sample, normal flora will not complicate my efforts to find the
pathogen.
Stool is not normally sterile; there are lots of normal bacteria, and
the pathogens may be rare among them. Therefore, it is essential
to use selective media, atmosphere, and temperature to try to
isolate the pathogens.
5. Next, to determine the possible microbial cause of your patient's
disease, request a series of tests (inoculation on growth media,
serology, etc.) to be performed on each specimen that you
requested as part of your ETIOLOGICAL DIAGNOSIS.
- Additional tests will often be needed and may by ordered
(questions 5 and 6) from the following laboratories:
bacteriology, mycology, parasitology, virology, hematology, and
chemistry; specific serological and molecular tests are performed
in each of those laboratories.
BACTERIOLOGY
5A. What is meant by Bacteriology?
? Provide an answer that explains this!
What is the function of the Clinical Bacteriology Laboratory, i.e.
what information does the Bacteriology Laboratory provide that
might be useful in the diagnosis and management of infectious
diseases?
? Provide an answer that explains this!
Once the microbes grow on media, they will be routinely subjected
to additional tests to identify them to the level of genus and
species; the physician does not need to request those tests.
Exactly, yet generally, how does the laboratory normally identify a
bacterium to the level of genus and species?
? Provide an answer that explains this!
SEROLOGY
5B. Each of the various clinical labs participates in the diagnosis
of an infectious disease via microscopic observations and cultures
of specimens; additionally, immunological methods are often part
of the diagnostic process.
What is meant by Serology?
? Provide an answer that explains this!
What is the function of the Clinical Serology Laboratory, i.e. what
information does the Serology Laboratory provide that might be
useful in the diagnosis and management of infectious diseases?
? Provide an answer that explains this!
This is what’s gonna “automatically” happen to each of the specimens that are sent to
the bacteriology laboratory …
Flamingham General Hospital
INOCULATION PROTOCOLS FOR THE ISOLATION OF BACTERIAL
PATHOGENS
Note: These are the protocols for bacteria only (there are other laboratories that deal with other microbes, i.e. virology, mycology, and parasitology
(question 6, below)
This series of inoculation protocols was designed to ensure that the typical bacterial
pathogens, which might infect a particular body site, are provided with the appropriate
nutritional and environmental conditions for growth. The Director of the Microbiology
Laboratory chose those tests and media because they will allow the most efficient
detection and/or isolation of the typical bacterial pathogens that are usually associated
with each type of clinical specimen. …
The routine inoculation protocols followed in FGH are below; these protocols are a list
of the media that according to your hospital’s protocols MUST be used to isolate
BACTERIAL pathogens from EACH SPECIMEN that has been ordered. EACH
SPECIMEN MUST BE INOCULATED ONTO EACH OF THE MEDIA AS “ASSIGNED” TO
THAT TYPE OF SPECIMEN IN THE TABLES, below.
Abbreviations of the Names of TESTS and GROWTH MEDIA
BROTH – Brain Heart Infusion Broth
BLOOD – Agar Containing 5% (vol/vol) Sheep RBCs (Red Blood Cells)
CAMPY - Campylobacter Agar
MAC - MacConkey Agar
MTM - Modified Thayer Martin Agar
PEA - PhenylEthylene Alcohol Blood Agar
… etc.
Note: Certain specimens [e.g. Blood, CSF, etc] should also be sent to the Chemistry and
Serology laboratories for additional, NECESSARY testing!
Flamingham General Hospital
INOCULATION PROTOCOLS FOR THE ISOLATION OF
BACTERIAL PATHOGENS
SOURCE/TYPE OF
SPECIMEN
BLOOD *
* An Automated (Anaerobic
and Aerobic) Blood Sample
System, e.g. “BACTEC” will
be used in addition to these
media
MEDIUM and SPECIAL INSTRUCTIONS
NO SMEAR – This Specimen is NOT Routinely Gram Stained
BLOOD
CHOC
MAC
ANA
Note: The Serology, Hematology, and Clinical Chemistry Laboratories, and
perhaps others should also analyze this specimen.
NO SMEAR – This Specimen is NOT Routinely Gram Stained
STOOL
VOMITIS
Upon Special Request - EXAMINATION FOR LYMPHOCYTES
BLOOD
MAC
HE
SS
CAMPY - Incubate at 42oC
SELENITE - Place Remaining Specimen on Swab in Selenite
Broth
5C. Bacteria typically considered to be pathogens (not normal flora
or environmental contaminants) that are isolated on any of the
media above will be identified to genus and species (when
possible/practical) using - BIOCHEMICAL and/OR ENZYMATIC
TESTS - usually via the Microscan Combo Panel
- If appropriate, the antibiotic sensitivities (MICs) will also be
determined
- Those tests do not have to be ordered; they will be performed
automatically by the lab
 Use the form below to request any additional tests that would not
be routinely performed in the Bacteriology Laboratory
 Note that the requests for several specimens and tests require
specific additional information.
- The laboratory technologists must know exactly which tests are to be
performed on which specimens; their question is, “What (exactly) do you want
us to look for?”
- For the specimens and tests indicated by either “*” or “**” in the Request Form,
you must specify the exact version of the test to be performed.
- Do not fail to provide the appropriate information; without it, the specimen(s)
will not be processed.
 All
tests are performed in the lab using commercially-
available/ FDA-approved kits (THE TEST MUST BE COMMERCIALLY
AVAILABLE AND FDA-APPROVED; A TEST THAT DOES NOT EXIST CANNOT BE
ORDERED! )
ADDITIONAL BACTERIOLOGY TEST REQUEST FORM
(Tests in addition to those specified in the “INOCULATION PROTOCOLS FOR THE ISOLATION OF
BACTERIAL PATHOGENS”)
Bacteriology:
 Acid-Fast Stain
 Special Microscopy**
 Anaerobic Culture
 Special Culture**
 Molecular Probe**
 PCR**
** Specify the specific tests to be
performed and/or pathogens being
sought
Serology - Antibody Detection:
 Syphilis Serology Screen
 Borillia Serology Screen
 Other**
Serology - Antigen Detection:
 Mycobacterial Detection
 Chlamydia Detection
 Legeionella Detection
 Francisella Detection
 Toxin Assay**
 Other **
 No Tests Are Required At This Time
Explanations – Justify (according to your differential diagnosis) if you are (or are
not) requesting additional testing. Indicate which patient specimen(s) is to be
tested.
Explain the value of any of any of these tests that you want to request!
6. Aside from the bacteriology laboratory, there are several other
clinical labs that can potentially provide information that will be
useful in the diagnosis of your patient’s illness
In the next step of the ETIOLOGICAL DIAGNOSIS, request any
additional tests (e.g. mycology, parasitology, virology, hematology,
clinical chemistry) that should be ordered "TODAY" using the Test
Request Forms (below)
MYCOLOGY
6A. What is meant by Mycology?
? Provide an answer that explains this!
What is the function of the Clinical Mycology Laboratory, i.e. what
information does the Mycology Laboratory provide that might be
useful in the diagnosis and management of infectious diseases?
? Provide an answer that explains this!
Flamingham General Hospital
MYCOLOGY LABORATORY TEST REQUEST FORM
Mycology:
 Direct Exam - Stain
 Culture
** Specify the specific tests to be
performed and/or pathogens being
sought
Serology - Antibody Detection:
 Antibody Detection**
Serology - Antigen Detection:
 Cryptococcus Antigen Detection
 Other **
 No Tests Are Required At This Time
Explanations – Justify (according to your differential diagnosis) if you are (or are
not) requesting additional testing. Indicate which patient specimen(s) is to be
tested.
Explain the value of any of any of these tests that you want to request!
PARASITOLOGY
6B. What is meant by Parasitology?
? Provide an answer that explains this!
What is meant by “Parasitology,” particularly, medical (or
veterinary) parasitology as performed on a clinical Parasitology
Laboratory; what types of organisms are studied in Parasitology
Laboratory?
? Provide an answer that explains this!
What is the function of the Clinical Parasitology Laboratory, i.e.
what information does the Clinical Parasitology Laboratory provide
that might be useful in the diagnosis and management of
infectious diseases?
? Provide an answer that explains this!
Flamingham General Hospital
PARASITOLOGY LABORATORY TEST REQUEST FORM
Parasitology:
 Direct Examination**
 Direct Exam – Stain**
 Culture**
 Pneumocystis Detection
 Molecular Probe**
Serology - Antigen Detection:
 Antigen Detection **
** Specify the specific tests to be
performed and/or pathogens being
sought
 No Tests Are Required At This Time
Explanations – Justify (according to your differential diagnosis) if you are (or are
not) requesting additional testing. Indicate which patient specimen(s) is to be
tested.
Explain the value of any of any of these tests that you want to request!
VIROLOGY
6C. What is meant by Virology?
? Provide an answer that explains this!
What is the function of the Clinical Virology Laboratory, i.e. what
information does the Virology Laboratory provide that might be
useful in the diagnosis and management of infectious diseases?
? Provide an answer that explains this!
Flamingham General Hospital
VIROLOGY LABORATORY TEST REQUEST
Virology:
Serology - Antibody Detection:
 Electron Microscopy
 Antibody Screen
 Respiratory Antibody Screen
 Culture**
 Hepatitis Screen
 Mono Spot/Epstein-Barr
 Molecular Probe**
 HIV Serology Screen
 **
 Viral Exanthems Antibody Screen
 Other**
** Specify the specific tests to be
performed and/or pathogens being
sought
Serology - Antigen Detection:
 Antigen Detection**
 No Tests Are Required At This Time
Explanations – Justify (according to your differential diagnosis) if you are (or are
not) requesting additional testing. Indicate which patient specimen(s) is to be
tested.
Explain the value of any of any of these tests that you want to request!
6D. Other clinical laboratories often provide information that is
helpful or essential in the diagnosis of infectious diseases.
HEMATOLOGY
What is meant by Hematology and what is the function of the
Clinical Hematology Laboratory?
? Provide an answer that explains this!
Name and briefly discuss several tests performed by the
Hematology Laboratory that might be useful in the diagnosis and
management of infectious diseases? (Via the request form below,
you will order appropriate tests that may shed light of your
patient’s illness.)
? Provide an answer that explains this!
CLINICAL CHEMISTRY
What is meant by Clinical Chemistry and what is the function of
the Clinical Chemistry Laboratory?
? Provide an answer that explains this!
Name and briefly discuss several tests performed by the
Chemistry Laboratory that might be useful in the diagnosis and
management of infectious diseases? (Via the request form below,
you will order appropriate tests that may shed light of your
patient’s illness.)
? Provide an answer that explains this!
RADIOLOGY
What is meant by Radiology and what is the function of the Clinical
Radiology Laboratory?
? Provide an answer that explains this!
What information might the Radiology Laboratory provide that
might be useful in the diagnosis and management of infectious
diseases? (Via the request form below, you will order appropriate
tests that may shed light of your patient’s illness.)
? Provide an answer that explains this!
HEMATOLOGY, CLINICAL CHEMISTRY, & RADIOLOGY
TEST REQUEST
Hematology:
 Cell Count*
* Specify source of sample
** Specify the specific tests to be
performed
Clinical Chemistry:
 Clinical Chemistry*/**
 Other*/**
Radiology:
 X-Ray**
 Other**
 No Tests Are Required At This Time
Explanations – Justify (according to your differential diagnosis) if you are (or are
not) requesting additional testing. Indicate which patient specimen(s) is to be
tested.
Explain the value of any of any of these tests that you want to request!
… But remember, very often you will want to order a “Cell Count” from
Hematology!
Upon receipt of the “Level 1” answers by the instructor,
you will be sent “Levels 2 and 3” of this case.
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
CASE: A Day at the Fair
LEVEL 2
- Here’s the 1st set of results of some of the lab tests that you
(should have) ordered …
 After admitting Mr. Burgas to the ICU, you immediately ordered
that he be given intravenous fluids and the antibiotic ceftriaxone as
a preventative measure. You requested standard analysis of the
following samples:
- For bacteriology - STOOL and BLOOD
- For serology and hematology - BLOOD
- For chemistry - URINE
 No urinalysis could be performed since he was unable to provide
a sample at time of admission. Later that day, Mr. Burgas
continued to display symptoms such as lethargy, pale skin, very
low urine output, vomiting, and continual bloody diarrhea.
- You’ll also be given more info about your patient and asked to
explain the results of some of the lab tests …
 Since you were also the bacteriology stat lab tech that night and
it was not busy, you decided to amuse yourself by Gram-staining
the stool specimen. You observed many Gram-positive bacilli,
many Gram-negative bacilli, and moderate Gram-positive cocci.
However, the microscopic examination of the feces was
remarkable for the presence of WBCs (fecal leukocytes).
EXPLAIN WHY THE "FGH PROTOCOLS" DO NOT ROUTINELY
INCLUDE GRAM-STAINING OF SPECIMENS SUCH AS
THROAT, MIDSTREAM URINE, STOOL, etc.
EXPLAIN THE SIGNIFICANCE OF THE GRAM STAIN OF THE
STOOL SPECIMEN. WHAT MIGHT IT BE TELLING YOU ABOUT
WHAT’S GOING ON WITH YOUR PATIENT?
- You’ll be given more info and asked to explain your current
thoughts on the case…
 By the end of your shift, the BLOOD culture showed “no growth.”
The results of the STOOL specimen are still pending.
BASED ON YOUR INITIAL DIFFERENTIAL DIAGNOSIS AND ALL
THE RESULTS AVAILABLE TO DATE, WHO IS THE "MOST
LIKELY SUSPECT?" DISCUSS IN DETAIL HOW AND WHY YOU
HAVE REACHED THIS DECISION.
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
CASE: A Day at the Fair.
LEVEL 3
At the same time that you get the Level 2, you’ll also get the
results of the WBC count of the patient …
 The hematology lab reported that the hematocrit and platelet
count were "normal," and the following: a total WBC count of
15,500/mm3, consisting of 58% “segs” (segmented neutrophils),
27% “bands,” 1% basophils, 1% eosinophils, 10% lymphocytes,
and 3% monocytes.
… And you’ll be expected to completely discuss each cell type in
the WBC count 
USING THE TABLES BELOW, COMPLETELY EXPLAIN THE NATURE IMPORTANCE OF EACH WBC TYPE
THAT’S FOUND IN HUMAN BLOOD. INCLUDE IN YOUR DESCRIPTION:
Immunological Functions - DETAILED DISCUSSION OF GENERAL FUNCTION(S) OF
EACH TYPE IN THE MAINTENANCE OF NORMAL HEALTH IN THE PREVENTION
OF/RECOVERY FROM INFECTIOUS DISEASES.
BE CERTAIN TO ADDRESS:
WBC Type
(Normal Values)
- THEIR TYPICAL TARGET(S), (i.e. WHAT TYPES OF MOLECULES, PATHOGENS,
CELLS, etc. DO THEY TYPICALLY RECOGNIZE
- THEIR MECHANISM(S) OF ACTION, i.e. EXACTLY THEY FUNCTION TO ELIMINATE
FOREIGN MATERIALS FROM THE HOST (WHAT IMMUNE-MEDIATOR COMPOUNDS
DO THEY PRODUCE; WHAT PHYSIOLOGICAL PROCESS DO THEY PERFORM?)
Disorders Associated With Deviations – (Which Illnesses
Your Patient’s Status - WHAT DOES THE SURVEY
Or Disorders Are Associated With Deviations From The
OF THE POPULATIONS OF WBCS IN YOUR
Normal Range?)
PATIENT INDICATE REGARDING THE POTENTIAL
- IN GENERAL, UNDER WHICH SITUATIONS WOULD THE INFECTIOUS PROCESS THAT IS/MIGHT BE
NUMBER OF CELLS OF EACH TYPE BE LESS/GREATER OCCURRING?
THAN THE NORMAL RANGE
(Enter Patient’s Value For Each Cell Type and
- i.e. WHAT WOULD DEVIATIONS FROM THE NORM
Discuss Its Importance)
INDICATE ABOUT WHAT IS GOING ON IN PATIENTS IN
GENERAL?
The final question regarding your patient’s WBC count …
IN SUMMARY, WHAT DO THE WBC COUNTS (ABOVE)
INDICATE ABOUT WHAT IS GOING ON IN YOUR PATIENT?
(REMEMBER THAT YOUR PATIENT IS SICK! EVEN IF THE
COUNTS “NORMAL,” WHAT DOES THIS TELL YOU ABOUT
YOUR PATIENT’S ILLNESS?)
?
Upon receipt of these answers by the instructor,
you will be sent the next level(s) of this case.
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
CASE: A Day at the Fair
LEVEL 4
- You’ll be asked to explain your patient’s condition and the
decisions you’ve made about his/her treatment, etc. … e.g.
 You decided to admit your patient for further diagnostic testing,
and begin a regimen of antibiotic therapy!
WAS THAT THE CORRECT MANAGEMENT OF THE CASE? IS
IT NECESSARY TO ADMINISTER ANTIBIOTICS TO YOUR
PATIENT? EXPLAIN WHY. IF NO, EXPLAIN WHY NOT. CITE
THE SOURCE(S) OF YOUR INFORMATION.
- You’ll get a 2nd set of results of lab tests that you (should have)
ordered and will learn more about your patient’s illness …
 By the next morning, his urine became dark and “smoky” and he
voided only twice in the last twenty-four hours. You decided to
have him placed on peritoneal dialysis.
 The causative agent that was recovered from the FECES
(STOOL SAMPLE). The Gram-stained colonies consisted of
Gram-negative bacilli.
BASED ON YOUR INITIAL DIFFERENTIAL DIAGNOSIS THE
RESULTS AVAILABLE TO DATE, WHO IS THE "MOST LIKELY
SUSPECT?" DISCUSS IN DETAIL HOW WHY YOU HAVE
REACHED THIS DECISION.
- You’ll be asked to explain your current thoughts on the case…
WHAT IS YOUR PATIENT’S PROGNOSIS FOR RECOVERY?
WILL THE PATIENT “GET BETTER;” WILL THERE BE LASTING
EFFECTS OF THE INFECTION? EXPLAIN IN DETAIL.
PROVIDE STATISTICS TO JUSTIFY YOUR "OPINION" AND
CITE THE SOURCE(S) OF YOUR INFORMATION.
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
CASE: A Day at the Fair.
LEVEL 5
At the same time that you get the Level 4, you’ll also get the
“invitation” to teach a lab class to the 1st year med students …
… And you’ll be expected to completely discuss each type of
bacteriology growth media that you used 
YOUR NAME: Dr. ?
YOUR eMAIL ADDRESS: ?
CASE: A Day at the Fair.
LEVEL 5
Show-n-Tell Day in the Bact Lab!
For each specimen that was ordered (using the "Flamingham
General Hospital - Specimen Request Form" [Level 1 / Question
3]), which bacteriological growth media were actually inoculated?
The inoculation protocols, below, explain the media that are
always used; keep reading …
… This is discussed in detail in the next PowerPoint tutorial
Upon receipt of these answers by the instructor,
you will be sent the “CONCLUSION” of this case.
YOUR NAME: Dr.
CASE: A Day at the Fair.
CONCLUSION
Hospital Course: Mr. Burgas developed “hemolytic-uremic
syndrome” (HUS); he was treated with antibiotics, peritoneal
dialysis, and by blood and platelet transfusions. His urine output
gradually increased from 100 to 1000-2000 mL/day by the seventh
day of hospitalization, so peritoneal dialysis was discontinued. He
was discharged 17 days after admission.
The patient’s stool tested positive for verotoxin (shega toxin)
produced by Escherichia coli 0157:H7, as did his son-in-law’s
stool. After discussing these finding with the patient, it was
determined that they had shared a medium-rare hamburger at the
town fair.
THESE QUESTIONS MUST BE COMPLETELY ANSWERED TO
“CONCLUDE” EACH CASE
MUST BE SUBMITTED TO THE INSTRUCTOR
No Rest for the Weary - After another “hard day at the office,” you checked your voice
mail. There was a message from the secretary of the chairperson of the Department of
Medicine. You were thrilled to hear that Dr. Blowhard would not be able to speak at
“Grand Rounds” this Friday; but then you were overwhelmed to hear that you were
chosen as her replacement. You checked your notes from prior rounds and decided to
use the following format to present this case while it is still fresh in your mind.
In an OUTLINE FORMAT, summarize the following information, yet PROVIDE A
DETAILED DISCUSSION OF EACH ITEM. Prepare it as if you had to stand in
front of an audience and give an oral presentation. Even though you’re
presenting to “seasoned physicians,” there are also several new residents like
yourself! So prepare the material as if it was the “everything you should know
about this microbe” - a review for a question on a board certification exam!
Also, explain all “MEDICAL TERMS” and tests (their significance) – Many terms
are new to you; do not expect that your fellow doctors will be familiar with them.
The conclusion questions are available from the beginning of the
case study (via your flash memory or the course web site)
As suggested, make yourself aware of what they require as you do
every step of the case …
The answers to these questions must be completed and sent
to the course instructor and they will guide you in the
preparation of your Grand Rounds PowerPoint Presentation
The example of a PowerPoint based on this case study
(“Fairground”) is available as
“07_MODEL_Case_Study_Presentation”
It is based on the “Conclusion” questions and should give you a
good idea of how the answers are to be used to present the case
Congratulations, your patient’s health insurance carrier is thankful
for your cost-effective handling of the case.
Doctor, go home and enjoy the satisfaction of your skillful use of years of training.
However, rest up! There will be new challenges for your skills tomorrow!
Thanx for not falling asleep!
LEVEL 1 QUESTIONS
To properly answer these questions, be certain that you have
completely read and understand the course documents entitled:
“CLINICAL CASE STUDIES - GENERAL INSTRUCTIONS”
and
“INTRODUCTION TO INFECTIOUS DISEASES - CASE STUDY
STRATAGIES.”
Your successful completion of this and subsequent Case Levels
(i.e. your grade) will depend on your ability to follow instructions!
Questions must be answered completely – Demonstrate that you
have mastered the readings and understand the infectious
process occurring in your patient and the physiological responses
of the patient – Define "uncommon" medical terms, give examples,
etc.!
Point Value of Answers Is Based Upon “Difficulty”
- Information Gathered From Texts, etc.(e.g. Definitions)
- Analysis Demonstrating Understanding Of The Material
This LEVEL 1 Is Worth 30% of Case Study Grade for “Microbiology” [35% for “Medical
Microbiology”]
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