Main Discussion Post – Week 1 Case Scenario Mr. X is a 38-year-old obese male receiving in-home assistance with activities of daily living, as well as routine nursing visits and case management services as part of a Medicaid Home and Community-Based Services (HCBS) program serviced by this author's employer. The patient denies any significant past medical history besides obesity; details a familial history of obesity, hypertension, heart disease, and diabetes mellitus; identifies no known drug or food allergies; indicates no prescribed medications and occasionally uses of over-the-counter (OTC) drugs, including ibuprofen for joint pain and ranitidine for gastroesophageal reflux. Mr. X also suggests that geographic and socioeconomic factors limit his access to routine and preventative healthcare services, and as such, he does not see a primary care provider regularly. In this scenario, the patient develops an open wound on the lateral aspect of the left foot from an unknown injury, and utilizes a combination of Epsom salts soaks, OTC antibiotic ointments, and gauze dressings, to self-manage the wound for more than a week without improvement. During a routine home visit, this author receives information from the patient describing the newly developed injury, the current home-based treatment regimen, and new onset of fever, malaise, and warmth/erythema of the left foot, ankle, and calf. After assessing the wound, this author urges the patient to seek evaluation and treatment from the local urgent care center since he has no primary care provider. Upon assessment at the urgent care center, the provider obtains lab studies including a complete blood count, basic metabolic panel, and blood and wound cultures, and transfers the emergency department for wound evaluation and treatment. In the emergency department, the patient is started on IV vancomycin and piperacillin-tazobactam (Zosyn) to treat a suspected bacterial infection and cover for Methicillin-resistant Staphylococcus aureus (MRSA) while awaiting lab and culture results and is admitted to the hospital's medical service for further management and treatment. After admission, labs obtained at the urgent care center are received, revealing significantly elevated white blood cell (WBC), blood glucose, BUN, and creatinine levels, signaling an inflammatory process, hyperglycemia, and renal dysfunction. The medical team orders lab work after the third dose of vancomycin to measure peak drug levels for dosing effectiveness and decide to include a hemoglobin A1C and creatinine clearance levels. Peak vancomycin levels and
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