A 34-Year-Old Man Comes to the Emergency Department Due to 2

question 105

Multiple Choice

A 34-year-old man comes to the emergency department due to 2 days of fever, chills, and drenching sweats.  He has had no sore throat, cough, shortness of breath, chest pain, or dysuria.  The patient has a history of Crohn disease and recently underwent abdominal surgery to remove a bowel stricture.  The postoperative course was complicated by an enterocutaneous fistula, which has been treated over the past 6 weeks with antitumor necrosis factor therapy.  This treatment has reduced the amount of drainage from the fistula.  He has had no recent abdominal pain or diarrhea.  The patient takes nothing by mouth and receives daily total parenteral nutrition.  He has no other medical problems and does not use tobacco, alcohol, or illicit drugs.
Temperature is 38.3 C (101 F) , blood pressure is 110/60 mm Hg, pulse is 112/min, and respirations are 18/min.  The patient is ill-appearing and diaphoretic.  The lungs are clear to auscultation.  Cardiac examination reveals tachycardia but is otherwise unremarkable.  The abdomen is soft and nontender with clear discharge from the infraumbilical fistula site.  The right upper arm peripherally inserted central catheter site has no erythema or tenderness.
Leukocyte count is 18,000/mm³, and serum creatinine is 0.9 mg/dL.  Chest x-ray reveals no infiltrates.  Urinalysis is normal.  Blood cultures are obtained, and empiric broad-spectrum intravenous antibiotics are initiated.
Within the next 24 hours, both sets of blood cultures grow budding yeast.
Which of the following is the most appropriate next step in management of this patient?

• A)Change the catheter via guidewire and begin intravenous fluconazole
• B)Keep the catheter and begin intravenous liposomal amphotericin B
• C)Remove the catheter and await species identification of the yeast
• D)Remove the catheter and begin intravenous caspofungin
• E)Repeat blood cultures and continue broad-spectrum antibiotics

---

Definitions:

Token Economy

A behavior modification method that uses tokens as a form of positive reinforcement for desired behaviors, which can be exchanged for rewards.

Aversive Conditioning

A form of behavioral learning where a noxious stimulus is associated with unwanted behavior in order to reduce or eliminate that behavior.

Preventive Mental Health

Approaches or practices aimed at reducing the incidence, prevalence, and recurrence of mental health disorders and their associated risks.

Psychological Disorders

Mental health conditions characterized by disturbances in thought, emotion, or behavior, leading to personal distress or impaired functioning.