A 64-Year-Old Man Comes to the Emergency Department After Developing

question 130

Multiple Choice

A 64-year-old man comes to the emergency department after developing fever and chills during hemodialysis.  He still feels feverish but has no sore throat, cough, abdominal pain, nausea, or diarrhea.  Temperature was 38.9 C (102 F) at the dialysis center.  The patient has a history of poorly controlled type 2 diabetes mellitus and hypertension, which led to end-stage renal disease.  He was initiated on long-term intermittent hemodialysis 2 months ago.  The patient has no known drug allergies.  He does not use tobacco, alcohol, or illicit drugs.  Temperature is 38 C (100.4 F) , blood pressure is 120/62 mm Hg, pulse is 105/min, and respirations are 22/min.  Oxygen saturation is 96% on room air.  There is a tunneled central venous catheter in the right internal jugular vein, and the skin around the insertion site is not erythematous or tender.  Cardiopulmonary auscultation reveals clear lung fields and normal heart sounds.  The abdomen is soft and nontender.  No skin rash or neck stiffness is present.  Leukocyte count is 14,000/mm³ with 90% neutrophils.  Chest-x ray reveals no infiltrate or consolidation.  Two sets of blood cultures, one from a peripheral vein and the other from the central venous catheter, are obtained.
Which of the following is the most appropriate immediate next step in management of this patient?

• A)Remove the catheter, send tip for culture, and await culture results for antibiotic management
• B)Start vancomycin and cefepime and leave the catheter in place
• C)Start vancomycin and cefepime and remove the catheter
• D)Start vancomycin and exchange the catheter over a guidewire
• E)Start vancomycin, cefepime, and caspofungin and leave the catheter in place

---

Definitions:

Third South Carolina Regiment

An infantry regiment from South Carolina that served in the Continental Army during the American Revolutionary War, noted for its diversity and integration efforts.

Prisoner-of-War Status

A designation given to soldiers and other combatants captured by an enemy during wartime, affording them certain protections under international law and conventions.

President Lincoln

Abraham Lincoln, the 16th President of the United States, who led the country through its Civil War and emancipated the slaves through the issuance of the Emancipation Proclamation.

Captured Black Soldiers

Refers to African American soldiers who were taken as prisoners of war, often facing harsher treatment and discrimination compared to their white counterparts.