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The patient's bacterial infection is no longer responding to the antibiotic regimen and she is showing signs of sepsis
2%
4/163
The patient is having an allergic reaction to the antibiotic regimen
6%
9/163
The patient is now showing signs of a pulmonary embolism as a result of a deep vein thrombosis
1%
2/163
The patient is most likely withdrawing from an opiate that she uses chronically
80%
131/163
The patient has acquired a nosocomial enteritis, as a result of her hospitalization and her antibiotic regimen
9%
14/163
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The patient in this vignette is most likely suffering from opiate withdrawal, seen classically as symptoms of nausea, vomiting, and abdominal pain, as well as fever, piloerection, and mydriasis. One of the most common situations in which opiate withdrawal presents is in the hospital setting, when a patient is admitted for another health reason and no longer has access to a source of the drug. Other symptoms may include anxiety, insomnia, stomach cramps, and diarrhea. Importantly, opiate withdrawal is unpleasant but is not life-threatening. Short-term medical treatment for symptom control includes clonidine or reintroduction of chronic opioid dose if using as a prescription at home. Additionally, naloxone and bupreniorphine (Suboxone) can be used acutely and methadone can be considered for maintenance. Krambeer et al. describe methadone maintenance therapy in the setting of opioid dependency. Goals of therapy include prevention of abstinence syndrome, reducing narcotic cravings, and reintegrating the patient into society by removing the illicit drug-seeking behavior. Amato et al. performed a meta-analysis of twenty-three trials involving 2467 people to analyze the role of long-acting opioids (like methadone) in the treatment of heroin withdrawal. They confirm that slow tapering with temporary substitution of long-acting opioids, can reduce withdrawal severity but most patients relapsed. Illustration A displays a classic timeline of opiate withdrawal. Incorrect Answers: Answer 1: The patient has had an improvement in the site of cellulitis and is therefore unlikely to have become septic. Also, the mydriasis and piloerection is rather specific for opiate withdrawal. Answer 2: This would be a very atypical presentation of an allergic reaction, and is therefore not the best choice. Answer 3: Typically a DVT resulting in a pulmonary embolism occurs after several days of immobilization, not just 2 as in this case. Answer 5: This patient has too short of a time course for a hospital-acquired enteritis.
2.9
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