No Right Answer.

Abstract

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Adler), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. Patient presentation: Mr H is a 61-year-old man with a medical history significant for hypertension, hyperlipidemia, and benign prostatic hyperplasia who was admitted to the medical service with a chief complaint of fevers. Eleven years before presentation, the patient underwent a prostate biopsy for a rapidly rising prostate-specific antigen, and there was no evidence for malignancy. The biopsy was complicated by septicemia, which was treated with antibiotics. Four months before admission, the patient presented to the urology clinic with worsening urinary retention, and the decision was made to proceed to transurethral resection of the prostate. A preoperative workup was significant only for a urine culture growing 1000 colonies of enterococcus, and no antimicrobial treatment was given. He underwent a technically successful transurethral resection of the prostate and was discharged home the next day after passing a voiding trial. Two days after being discharged, the patient had fevers to 102°F and was readmitted to the hospital. He was found to have an Enterococcus faecalis urinary tract infection and was treated with 1 day of intravenous cefepime before being discharged the next day on a 7-day course of amoxicillin–clavulanic acid. On the day after discharge, blood cultures that were drawn on admission grew E faecalis with the same susceptibility pattern cultured from the urine, but there was no alteration in the treatment plan. The patient’s fevers resolved. One month before admission, the patient presented to an outside emergency department with decreased exercise capacity, pleuritic back pain, and malaise. Computed tomography of the chest with contrast identified a right …