Respondents.

G.R. No. 127590

February 2, 2010

Facts:

Enrique Agana told his wife Natividad Agana to look for their neighbour, Dr. Ampil, a
surgeon staff member of Medical City General Hospital, a prominent and known hospital, owned
and operated by Professional Services Incorporated (PSI). Natividad Agana underwent medical
surgery in said Hospital. The attendant doctors were Dr. Ampil and Dr. Fuentes. Natividad
suffered from injury due to two (2) gauzes left inside her body during the operation. Despite the
report of the (2) two missing gauzes, PSI did not initiate an investigation.

This case consolidated three (3) other cases previously decided and became final and
executory. Hence, this case is limited only to the second motion for reconsideration filed by the
PSI in an attempt absolve itself from liability.

Issue:

Whether or not PSI is liable for tort?

Whether or not Dr. Ampil and Fuentes are liable for medical malpractice and the PSI for
damages due to the negligence of the said doctors. Presentence investigation report
Ruling:

Yes. PSI is liable. Firstly, under the principle of Ostensible Agency, according to the Court,
ample evidence that the hospital held out to the patient that the doctor was its agent.  Present are
the two factors that determine apparent authority: first, the hospital's implied manifestation to the
patient which led the latter to conclude that the doctor was the hospital's agent; and second, the
patient’s reliance upon the conduct of the hospital and the doctor, consistent with ordinary care
and prudence the decision made by Enrique for [his wife] Natividad to consult Dr. Ampil was
significantly influenced by the impression that Dr. Ampil was a staff member of Medical City
General Hospital, and that said hospital was well known and prominent.  Enrique looked upon
Dr. Ampil not as independent of but as integrally related to Medical City. The Supreme Court
also held that the hospital’s “consent for hospital care” - required to be signed prior to the
surgery - affirmed that the surgeon was of the hospital.

Secondly, under the principle of Corporate Negligence, which was self-imposed liability
because of the statements made by the PSI which constituted judicial admission in its Motion for
Reconsideration. Its statements revealed that it had the power to review or cause the review of
what may have irregularly transpired within its walls strictly for the purpose of determining
whether some form of negligence may have attended any procedure done inside its premises,
with the ultimate end of protecting its patients.

The Court also noted the hospital admitted “the standards of its corporate conduct under the
circumstances of this case, specifically: (a) that it had a corporate duty to Natividad even after
her operation to ensure her safety as a patient; (b) that its corporate duty was not limited to
having its nursing staff note or record the two missing gauzes and (c) that its corporate duty
extended to determining Dr. Ampil's role in it, bringing the matter to his attention, and
correcting his negligence. The Court held that the case is “not intended to set a precedent and
should not serve as a basis to hold hospitals liable for every form of negligence of their doctors-
consultants under any and all circumstances.”

JARCIA JR VS PEOPLE 666 SCRA 336

Facts:

Private complainant Belinda Santiago lodged a complaint with the National Bureau of
Investigation against the petitioners, Dr. Emmanuel Jarcia, Jr. And Dr. Marilou Bastan, for their
alleged neglect of professional duty which caused her son, Roy Alfonso Santiago, to suffer
serious physical injuries.

Upon investigation, the NBI found that Roy Jr. Was hit by a taxicab; that he was rushed to
the Manila Doctors Hospital for an emergency medical treatment; that an X-ray of the victim’s
ankle was ordered; that the X-ray result showed no fracture as read by Dr. Jarcia; that Dr. Bastan
entered the emergency room and, after conducting her own examination of the victim, informed
Mrs. Santiago that since it was only the ankle that was hit, there was no need to examine the
upper leg. Despite Mrs. Santiago's protest the doctors did not examine the upper portion of the
leg of Roy. That eleven (11) days later, Roy Jr. Developed fever, swelling of the right leg and
misalignment of the right foot; that Mrs. Santiago brought him back to the hospital; and that the
X-ray revealed a right mid-tibial fracture and a linear hairline fracture in the shaft of the bone.

After trial and applying the doctrine of res ipsa loquitor the RTC found petitioners to be
guilty of simple negligence. The decision was affirmed in toto by the CA.

Issues:

Whether of not the petitioner physicians are negligent, hence liable for damages.

Ruling:

Petitioners were negligent in their obligation. It was proven that a thorough examination was
not performed on Roy Jr since as residents on duty at the emergency room, Dr. Jarcia and Dr.
Bastan were expected to know the medical protocol in treating leg fractures and in attending to
victims of car accidents.

Thus, simple negligence is resent if: that there is lack of precaution on the part of the
offender, and that the damage impending to be caused is not immediate or the danger is not
clearly manifest.
 Dr. Jarcia and Dr. Bastan, explained the court, cannot pass on the liability to the taxi driver
who hit the victim. It may be true that the actual, direct, immediate, and proximate cause of the
injury of Roy Jr. Was the vehicular accident when he was hit by a taxi. The petitioners,
however, cannot simply invoke such fact alone to excuse themselves from any liability. If this
would be so, doctors would have a ready defense should they fail to do their job in attending to
victims of hit-and-run, maltreatment, and other crimes of violence in which the actual, direct,
immediate, and proximate cause of the injury is indubitably the act of the perpetrator/s.

In failing to perform an extensive medical examination to determine the extent of Roy Jr.’s
injuries, Dr. Jarcia and Dr. Bastan were remiss of their duties as members of the medical
profession. Assuming for the sake of argument that they did not have the capacity to make such
thorough evaluation at that stage, they should have referred the patient to another doctor with
sufficient training and experience instead of assuring him and his mother that everything was all
right

DR. NOEL CASUMPANG vs.

CORTEJO
G.R. No. 171127
March 11, 2015

BRION, J.:

STATEMENT OF FACTS:
Edmer Cortejo (Edmer) was brought to the emergency room of San Juan de Dios Hospital
(SJDH) by his mother, Mrs. Jesusa Cortejo (Jesusa) due to difficulty in breathing, chest pains,
stomach pain, and fever. Dr. Ramoncito Livelo (Livelo), a family doctor, initially attended to
Edmer and after a few tests had the initial impression of Bronchopneumonia. Dr. Livelo then
gave Edmer some antibiotics to lessen his fever and loosen his phlegm.

Jesusa did not know anyone from SJDH. Jesusa used her fortune card and was referred to a
Fortune Care Coordinator, who was then absent. She got assigned to Dr. Noel Casumpang
(Casumpang) who appeared to be an employee of the hospital. Dr. Casumpang examined Edmer
for the first time and merely used a stethoscope and determined that it was Bronchopneumonia.
Not satisfied, she stated that Edmer had high fever, no colds or cough; Dr. Casumpang that it was
normal for Bronchopneumonia. The following day early morning, Edmer had now a fever, throat
irritation and even stomach and chest pains. Despite being known to such information, Dr.
Casumpang mere inquired if Edmer had asthma, reassured that the illness was
Bronchopneumonia.

Later in the morning, Edmer began vomiting phlegm with blood streak. Nelson Cortejo
(Nelson), Edmers father, thus called for a doctor and Dr. Ruby Miranda-Sanga (Sanga) came to
their
call. Dr. Sanga examined Edmer and found that he had a low grade non continuing fever, rashes
that were not typical of dengue fever. Dr. Rubi had told Dr. Casumpang of the symptoms.

She failed to positively diagnose the patient immediately because the blood streak was
washed by the Nelson, thus she ordered the next time it occurred Nelson should preserve the
same.
Upon acquiring a sample she positively determined that it was Dengue Hemorrahgic Fever. Dr.
Casumpang advised that Edmer be bought to the ICU, to which the spouses Cortejo agreed to but
the ICU was full, thus they opted to go to Makati Medical Center. Upon arriving it was declared
that
it was already at stage IV and thus irreversible. Edmer died.

STATEMENT OF THE CASE:

Nelson instituted an action for damages against Dr. Casumpang, Dr. Sanga, SJDH before
the RTC of Makati City for the negligent and erroneous diagnosis of his doctors. RTC ruled in
favor
of Nelson and deemed Drs. Casumpang and Sanga liable since Dengue was foreseeable based on
the medical record of Edmer, and that their testimonies were self-serving providing no other
evidence. The CA affirmed the decision of the RTC in toto, hence this petition.
Petitioners defenses:
1. Dr. Casumpang : gave edmer medical treatment accdg. To the best of his
abilities; dengue fever only occurs after several days of confinement; dr.
Jaudian, credible?

2. Dr. Miranda : dr. Casumpang was the doctor assigned; she exercised prudence;
no causal rel. Between the initial diagnosis to the cause of death; dr. Jaudian
no evidence of cert. Of formal residency or fellowship inalso not credible
pediatrics

3. Sjdh : dr. Casumpang and dr. Miranda are mere independent contracttors; no
eer; they don’t hire consultants, only grant privileges towards them; don’t
pay them wages; no power of control: observed proper diligence of a good
father of the family

4. Respondents: they raise factual issues, not reviewable by this court; the
failed to timely diagnose, their medicaldoctors WERE NEGLIGENT
examination was not comprehensive, employed a guessing game; sdjh has no
proper paging system, no bronchosope, ratio of doctors to patients low

Issues:
1.) Whether Drs. Casumpang and Sanga committed inexcusable lack of precaution in
diagnosing and in treating the patient
2.) Whether SJDH is solidarily liable with the doctors
3.) Whether there is a causal connection between the doctor’s negligence and the patient’s
death.

HELD:

1.) Only Dr. Casumapang was negligent; Dr. Sanga was not

DR. CASUMPANG WAS NEGLIGENT IN DIAGNOSIS: It will be recalled that during

Dr. Casumpang's
first and second visits to Edmer, he already had knowledge of Edmer's laboratory test result
(CBC),
medical history, and symptoms (i.e., fever, rashes, rapid breathing, chest and stomach pain,
throat
irritation, difficulty in breathing, and traces of blood in the sputum). However, these information
did not lead Dr. Casumpang to the possibility that Edmer could be suffering from either dengue
fever, or dengue hemorrhagic fever, as he clung to his diagnosis of broncho pneumonia. This
means that given the symptoms exhibited, Dr. Casumpang already ruled out the possibility of
other
diseases like dengue.

In other words, it was lost on Dr. Casumpang that the characteristic symptoms of dengue
(as Dr.
Jaudian testified) are: patient's rapid breathing; chest and stomach pain; fever; and the presence
of
blood in his saliva. He was selective in appreciating the symptoms.
DR. CASUMPANG WAS NEGLIGENT IN THE TREATMENT AND MANAGEMENT OF
DENGUE: Dr.
Casumpang failed to measure up to these standards. The evidence strongly suggests that he
ordered
a transfusion of platelet concentrate instead of blood transfusion. The tourniquet test was only
conducted after Edmer's second episode of bleeding, and the medical management (as reflected
in
NO ANTIBIOTICthe records) did not include antibiotic therapy and complete physical
examination
THERAPY AND COMPLETE PHY. EXAMINATION

DR. MIRANDA IS NOT LIABLE FOR NEGLIGENCE: the medical care required is that
of reasonably
careful physicians or hospital emergency room operators, not of interns or residents; Although
she had greater patient exposure, and was' subject to the same standard of care applicable to
attending physicians, we believe that a finding of negligence should also depend on several
competing factors, among them, her authority to make her own diagnosis, the degree of
supervision
of the attending physician over her, and the shared responsibility between her and the attending
physicians; Dr. Miranda likewise duly reported to Dr. Casumpang, who admitted receiving
updates
regarding Edmer's condition. There is also evidence supporting Dr. Miranda's claim that she
extended diligent care to Edmer. In fact, when she suspected - during Edmer's second episode of
bleeding - that Edmer could be suffering from dengue fever, she wasted no time in conducting
the
necessary tests, and promptly notified Dr. Casumpang about the incident. Indubitably, her
medical
assistance led to the finding of dengue fever.

2. YES, under the doctrine of vicarious liability (apparent authority).

SJDH’S LIABILITY BASED ON THE DOCTRINE OF APPARENT AUTHORITY NOT

RESPONDEAT
SUPERIOR

We hold that, under the doctrine of apparent authority, a hospital can be held vicariously
liable for the negligent acts of a physician providing care at the hospital, regardless of whether
the
physician is an independent contractor, unless the patient knows, or should have known, that the
physician is an independent contractor.

The doctrine of apparent authority, a plaintiff must show that:

(1) the hospital, or its agent, acted in a manner that would lead a reasonable person to
conclude that the individual who was alleged to be negligent was an employee or
agent of the hospital;
(2) where the acts of the agent create the appearance of authority, the plaintiff must also
prove that the hospital had knowledge of and acquiesced in them; and
(3) the plaintiff acted in reliance upon the conduct of the hospital or its agent, consistent
with ordinary care and prudence. (Emphasis supplied)

The first factor focuses on the hospital’s manifestations and is sometimes described as an
inquiry whether the hospital acted in a manner which would lead a reasonable person to conclude
that the individual who was alleged to be negligent was an employee or agent of the hospital. In
this regard, the hospital need not make express representations to the patient that the treating
physician is an employee of the hospital; rather a representation may be general and implied.
The second factor focuses on the patient's reliance. It is sometimes characterized as an
inquiry on whether the plaintiff acted in reliance upon the conduct of the hospital or its agent,
consistent with ordinary care and prudence. (Citation omitted)

1. HOSPITAL’S MANIFESTATIONS: In this case, the court considered the act of the
hospital of holding itself out as provider of complete medical care, and considered the
hospital to have impliedly created the appearance of authority.

2. PATIENT’S RELIANCE: SDJH CLOTHED DR. CASUMPANG W/ APPARENT

AUTHORITY
Based on the records, the respondent relied on SJDH rather than upon Dr. Casumpang,
to care and treat his son Edmer. His testimony during trial showed that he and his wife
did not know any doctors at SJDH;they also did not know that Dr. Casumpang was an
independent contractor. They brought their son to SJDH for diagnosis because of their
family doctor's referral. The referral did not specifically point to Dr. Casumpang or
even to Dr. Miranda, but to SJDH.

Significantly, the respondent had relied on SJDH's representation of Dr. Casumpang's

authority. To recall, when Mrs. Cortejo presented her Fortune Care card, she was
initially referred to the Fortune Care coordinator, who was then out of town. She was
thereafter referred to Dr. Casumpang, who is also accredited with Fortune Care. In
both instances, SJDH through its agent failed to advise Mrs. Cortejo that Dr.
Casumpang is an independent contractor.

Mrs. Cortejo accepted Dr. Casumpang's services on the reasonable belief that such
were being provided by SJDH or its employees, agents, or servants. By referring Dr.
Casumpang to care and treat for Edmer, SJDH impliedly held out Dr. Casumpang, not
only as an accredited member of Fortune Care, but also as a member of its medical
staff.

Bacillus: O2 requirement? -Aerobic

Bacillus: Gram status?- Gram positive
Bacillus: Spore forming? -Yes
What are the symptoms of ingestion anthrax?- Nausea, vomiting, fever, bloody diarrhea.
(rare)
What are the Bacillus anthracis toxins?- PA- protective antigen, EF- edema factor, LF-
lethal factor
Bacillus anthracis: capsule?- Some, only virulent strains have capsule
Symptoms of cutaneous anthrax?- 1 - 7 days: pruritic papules --> lesions --> black
eschar. Lymphangitis, lymphadenopathy, fever malaise, headache. 7 - 10 days: eschar
dries, loosens and separates, heals by granulation, leaves a scar. 20% of patients die of
sepsis
Symptoms of inhalation anthrax?
Incubation of up to 6 weeks. Early symptoms: edema and widening of mediastinum,
subpleural pain. Late symptoms: hemorrhagic pleural effusions, sepsis, hemtaogenous
spread to GI, hemorrhagic spread to meninges. High fatality rate
What specimens are used for inhalation anthrax tests?
Fluid or pus from lesion, blood, pleural fluid and CSF
What specimines are used for ingestion anthrax?
Stool or intestinal contents
Lab test for B. anthracis
Blood agar- gray/white tenacious colonies w/ rough texture and ground glass
appearance with comma shaped undergrowths (medusa head)
Gram stain- large gram positive rods, typically in chains
Motility agar- non motile
Definitive ID- lysis by anthrax bacteriophage, detection of capsule by fluorescent
antibody, ID of toxin genes by PCR
Bacillus anthracis treatment?
Cipofloxacin or Penicillin G + gentamycin/streptomycin
Bacillus cereus types of disease?
Emetic or diarrheal food poisoning
What are the causes and symptoms of the 2 types?
Emetic is from fried rice, causes nausea, vomiting, abdominal cramps. Diarrheal is from
meats or sauces, causes diarrhea, abdominal cramps and pain
Systemic B cereus infections?
Endocarditis, meninigitis, osteomyelitis, pneumonia
How do you get a systemic B cereus infection?
Medical device or IV drug use
Is B cereus antibiotic resistant? If so, which antibiotics is it resistant to?
Yes: Penicillins (B cereus produces B-lactamases) and Cephalosporins
Which antibiotics are used to treat a B cereus infection?
Vancomycin or clindamycin +/- aminoglycosides
Which of the following is an important virulence factor of Bacillus anthracis?
A) Protective antigen (PA)
B) Lipopolysaccharide (LPS)
C) Pili
D) Lecithinase
E) EF-‐2 toxin
a
Bacillus cereus food poisoning is typically associated with eating...
a) Fried rice
b) Baked potato
c) Hot, freshly steamed rice
d) Green beans
e) honey
a
1. Which of the following is NOT associated with impetigo?
a. Pus-‐filled vesicles
b. Erysipelas
c. Streptococcus pyogenes
d. Pyocyanin
d
2. Which of the following pairs of diseases may be associated with Streptococcus
pyogenes?
a. Impetigo and acne
b. Erysipelas and necrotizing fasciitis
c. Anthrax and blackheads
d. Black piedra and papillomas
b
3. Which of the following bacteria can have these virulence factors: coagulase,
hyaluronidase, lipase, and protein A?
a. Staphylococcus
b. Streptococcus
c. Clostridium
d.Bacillus
a
4. Staphylococcal scalded skin syndrome is caused by _______ toxins produced by
Staphylococcus aureus.
Exfoliative toxins: ETA and ETB
5. "Flesh-‐eating strep" disease is formally called _________.
Necrotizing fasciitis
6.Name 2 types of folliculitis caused by Staphylococcus.
Folliculitis and Furuncles (boil, deep folliculitis, infection of hair follicle)
7. Clostridium perfringens can be the causal agent of
a. Gas gangrene
b. Anthrax
c. Necrotizing fasciitis
d. Botulism
e. Toxic shock syndrome
a
8. Group A Streptococcus is camouflaged from phagocytes by
a. M protein
b. A hyaluronic acid capsule
c. Pus resulting from the action of streptokinase
d. Streptolysin
b
9. The action of streptolysin results in
a. Breaking down ofhyaluronic acid capsule around cells
b. Inhibition of complement protein and decrease in the number of leukocytes at the site
of infection
c. Disruption of the membranes of erythrocytes and other types of cells
d. Destruction of streptococcal bacteria
c
10. Streptococcal pharyngitis
is _________________.
Sore throat associated with a streptococcal infection (strep throat)
11. Which of the following causes gastrointestinal illness/disease?
a. Listeria
b. Bacillus
c. Clostridium
d. All of the above
e. None of the above
d
12. A patient is showing the symptoms of a sore throat, fever, rash on the face and
neck, and white spots on the back of the throat and tonsils. Based on these symptoms,
what is the probable (bacterial) cause of the illness?
This patient has streptococcal pharyngitis. It is likely S. pyrogenes
13. Describe laboratory tests to confirm if the suspected organism is indeed the cause.
Give the results you would expect for each test.
The best test is a throat culture. When plated on blood agar (10% CO2 will speed the
growth), S. pyrogenes colonies are B-hemolytic, discoid colonies and are 1-2mm in
diameter. S. pyrogenes can also be confirmed by inhibition of growth on bacitracin-
containing media. more p 71 of lecture 4
14. Christina adds canned black beans to her pot of chili. After eating her chili, her
family started showing symptoms of double vision, dizziness, weakness, slurred
speech, and drooping eyelids. Based on these symptoms, what is the probable
(bacterial) cause of the illness?
Clostridium botulinum
15. Describe laboratory tests to confirm if the suspected organism is indeed the cause.
Give the results you would expect for each test.
The best way to test for botulism is a mouse bio-assay. You inject 2 mice with
specimens from the patient, and one additionally with anti-toxin. If the patient has
botulism, the mouse that gets the specimen only will die, but the mouse that gets the
specimen and the anti-toxin will live.
Clostridium O2 req?
Anaerobic
Clostridium gram status?
Positive
Clostridium agar motility?
Motile
Do Clostridium produce toxins?
Yes
Do Clostridium form spores?
Yes
What is the Clostridium spore morphology?
Spore is larger diameter than cells and is central
What do Clostridium colonies look like?
Large raised colonies
Does Clostridium produce hemolysis on blood agar? If so, what pattern?
yes- B-hemolytic
How does the Clostridium botulinum toxin work (molecular level)?
It is absorbed through the gut and binds presynaptic motor neuron membranes so that
Ach doesn't release. Results in flaccid muscles.
How does the Clostridium botulinum toxin work (symptom level)?
Symptoms begin 18-24 hours after injestion. Visual disturbances, inability to swallow,
speech difficulty- signs of paralysis are progressive. Death occurs from respiratory
paralysis or cardiac arrest (no fever)
C. botulinum lab tests
Bact recovered from feces, gastric secretions and serum (infant: bowel contents, no
serum). Mouse bio-assay gold standard, also ELISA, PCR.
C. botulinum treatment
anti toxins for types A, B and E. Prompt administration IV. Most infants recover from
supportive care, but anti toxin therapy is recommended. Respiratory assistance may be
necessary. Mortality has been reduced from 65% to 25%
How do patients get botulism?
Usually home canned or preserved foods. Infant botulism is usually from jarred baby
food or honey
What is the name of the toxin produced by Clostridium tetani bacteria?
tetanospasmin
Diagnosis of tetanus?
Anaerobic culture of tissue, detection of toxin via neutralization using specific anti toxin
Tetanus prevention?
Active immunization- booster every 10 years. Proper wound care, prophylactic use of
antitoxin, administration of penicillin
A 45--‐year old man sustained a puncture injury to the lower part of his right leg when is
law mover threw a small stick into his leg. At six days post--‐injury, spasms occurred in
the muscles of his leg. On day 7, the spasms increased. On day 8, he had generalized
muscle spasms, particularly in his jaw. On day 9, he goes to the ER. As he is lying in
the ER bed (alert, yet quiet), he suddenly has a general muscle spasm and his back
arches. What is he suffering from?
a) Botulism
b) Anthrax
c) Gas gangrene
d) Tetanus
e) Toxic shock syndrome
d
Movement of Listeria monocytogenes inside host cells is caused by
a) Inducing host cell actin polymerization
b) The formation of pili (fimbriae) on the listeria surface
c) Pseudopod formation
d) The motion of listeria flagella
a
An 8 year old boy develops a sore throat. He has a grayish exudate (pseudomembrane)
over the tonsils and pharynx. What is the probable bacterial cause of the boy's
pharyngitis?
a) A gram--‐negative bacillus
b) A catalase--‐positive gram--‐positive cocuss that grows in clusters
c) A club--‐shaped gram--‐positive bacillus
c
A 36--‐year old male patient has an abcess with a strain of S. aureus that is b--‐
lactamase positive. This indicates that the organism is resistant to which of the following
antibiotics?
a) Penicillin G, ampicillin, and piperacillin
b) Trimethoprim--‐sulamethoxazole
c) Erythromycin, clarithromycin, and azithromycin
d) Vancomycin
e) Cefazolin and cetiriaxone
a
A 16--‐year old bone marrow transplant patient has a central venous line that has been
in place for 2 weeks. He also has a urinary tract catheter, which has been in place for 2
weeks as well. He develops fever while his white blood cell count is very low and before
the transplant has engratied. Three blood cultures are done, and all grow S.
epidermidis. Which of the following statements is correct?
a) The S. epidermidis is likely to be susceptible to penicillin G
b) The S. epidermidis is likely to be from the surface of the urinary tract catheter
c) The S. epidermidis is likely to be resistant to vancomycin
d) The S. epidermidis is likely to be from a skin source
e) The S. epidermidis is likely to be in a biofilm on the central venous catheter surface
d
During brain surgery of a 40--‐year old woman, a brain abscess if found. Culture of the
abscess fluid yields a catalase--‐negative, gram--‐positive cocci that grow in pairs and
chains. The organism is --‐hemolytic, forms very small colonies, and gives a
butterscotch odor. It also agglutinates with Lancefield group F antisera. What is the
organism most likely to be?
a) Streptococcus pyogenes
b) Enterococcus faecalis
c) Streptococcus agalactiae
d) Streptococcus anginosus
e) Staphylococcus aureus
d
A 48--‐year old man is admitted to the hospital because of stupor (near--‐
unconsciousness). Attempts to rouse him result in moans. His body temperature is
slightly elevated (38.5°C). A rust--‐colored sputum is aspirated. The sputum also reveals
gram--‐positive, lancet--‐ shaped diplococci. A smear of the sputum also shows
numerous PMNs. More tests need to be performed, but what might the cause of his
symptoms be?
a) Pneumonia caused by Staphylococcus aureus
b) Pneumonia caused by Streptococcus pyogenes
c) Pneumonia caused by Streptococcus pneumoniae
d) Pneumonia caused by Enterococcus faecalis
e) Pneumonia caused by Neisseria meningitidis
c
Treatment of tetanus
IM antitoxin, muscle relaxants, sedation, assisted ventilation, surgical debridement,
administration of penicillin
Clostridium perfringens symptoms?
nausea, vomiting, fever
What causes gas gangrene?
C. perfringens from a contaminated wound
Clostridia gram status?
Positive
Clostridia spores?
not usually
Lab tests for clostridia
material from wounds, pus and tissue is inoculated onto chopped meat glucose media,
thioglycolate medium and/or blood agar and anaerobically grown. Produce large gram
positive rods, spores are unusual. Hemolysis, carboyhdrate fermentation, lecithinase
activity and toxin production
C perfringins treatment
surgery to remove contaminated tissue (possibly amputation), penicillin, hyperbaric
oxygen, antitoxin, early and adequate would cleansing
Corynebacteria O2 requirement?
aerobic
Corynebacteria spores?
no
Corynebacteria cell shape?
club shaped
C diptheriae morphology
granules stain differently from cells- look like green clubs with purple ends. Stains lie
parallel or at acute angles
C diptheriae blood agar colonies?
Small granular gray colonies with irregular edges
C diptheriae tellurite agar
brown/black with brown/black halo (staph and strep produce black colonies)
C diptheriae toxin production?
yes
respiratory diptheria symptoms
early: sore throat, low-grade fever, weakness, dyspnea due to pseudomembrane,
enlarged lymph nodes (bull neck). late: myocarditis, liver disease, tubular necrosis,
adrenal gland damage, demylination
cutaneous diptheria symptoms
temperate climates in alcoholic or homeless people. Membrane forms on a would which
does not heal.
C diptheriae lab tests
specimens collected from nose, throat or lesion swab. Smears stained with alkaline
methylene blue or gram stain (beaded rods), blood agar to rule out hemolytic strep,
selective agar: tellurite forms black/brown colonies w/ black/brown halos, anti toxin test,
PCR, ELISA
C diptheriae treatment?
antibiotics; penicillin, erythomycin. antitoxin
C diptheriae prevention?
immunization
Listeria sources?
soil, vegetation, sewage, feces, raw milk, pasteurized milk, cheese, ice cream, raw
veggies, sausage and meats
Listeria O2 requirement?
Facultative anaerobe
What do Listeria look like under the microscope?
short rods
Listeria gram status?
Positive
Why is Listeria easy to get on our food?
It is very hardy- large temperature and pH range, aerobic or anaerobic, halotolerant
Listeria form spores?
No
Listeria catalase test?
positive
Listeria plating? what type of media? What do colonies look like?
Use oxford agar (contains bile and esculin). Colonies cause esculin hydrolysis, which
looks like black halos. Also use ChromAgar plates- L. monocytogenes and L. ivanovii
are blue green with a white halo, and other Listeria are blue with no halo
SLIDE 11
...
Corynebacterium gram status
positive

 1. 
A patient presents with a brain abscess. The dominant organism is an anaerobe
normally found as part of the oral flora. Which of the following best fits that
description?

o A. 

Nocardia

o B. 

Actinomyces

o C. 

Mycobacterium

o D. 

Pseudomonas aeruginosa
 

 2. 
A 23-year-old male who has recently started working on a sheep farm in Nova
Scotia develops pneumonia shortly after helping with lambing. His cough
produces little sputum,  and a saline-induced sputum sample shows no
 predominant organism either with Gram stain or with acid-fast stain. It is
established that he acquired the pneumonia from parturition products from the
sheep. Which agent is most likely to be the cause of his pneumonia?

o A. 

Rickettsia akari

o B. 

Rickettsia typhi

o C. 

Rickettsia rickettsii

o D. 

Coxiella burnetii

o E. 

Anaplasma phagocytophila
 

 3. 
A 3 year old presents with difficulty breathing and will not lie down to be
examined. You suspect acute bacterial epiglottitis and examine the child’s
epiglottis, which is highly inflamed. Which vaccine are you most likely to find that
the child is missing?

o A. 

Diphtheria

o B. 

Neisseria meningitidis

o C. 

Polio

o D. 

Streptococcus pneumoniae (conjugate vaccine)

 o E. 

Haemophilus influenzae
 

 4. 
A 22-year-old cystic fibrosis patient presents with fever and increasing dyspnea.
A Gram-negative organism is found in unusually high numbers in the mucus.
Which virulence factor is most important in colonization and maintenance of the
organism in the lungs?

o A. 

Exotoxin A

o B. 

Pyocyanin (blue-green pigment)

o C. 

Polysaccharide slime

o D. 

Endotoxin
 

 5. 
Exotoxin A most closely resembles the action of which other microbial toxin?

o A. 

Heat-labile toxin (LT) of Escherichia coli

o B. 

Shiga toxin

o C. 

Diphtheria toxin

o D. 

Vibrio cholerae toxin

 o E. 

Vero toxin
 

 6. 
A 36-year-old immigrant who lived in a crowded resettlement camp before
coming to the United States  now has a cough that has been bothering him for
several weeks. He has also lost 10 pounds. Which of the following factors is
known to be most important in triggering the granulomatous reaction to wall off
and contain the infection?

o A. 

Cord factor

o B. 

Mycolic acid

o C. 

Purified protein derivative (PPD)

o D. 

Sulfatides

o E. 

Wax D
 

 7. 
Patient develops diarrhea 5 days after starting antibiotic treatment for a serious
staphylococcal infection. What is the most likely causative agent?

o A. 

Clostridium perfringens

o B. 

Clostridium difficile

o C. 
 Pseudomonas aeruginosa

o D. 

Shigella sonnei
 

 8. 
A patient develops mild gastroenteritis a few days after having a variety of sushi
at a party. There is no blood or pus in the stool. Which causative agent is most
likely to have caused this illness?

o A. 

Vibrio cholerae

o B. 

Vibrio parahaemolyticus

o C. 

Salmonella typhi

o D. 

Shigella sonnei
 

 9. 
Yersinia pestis may be transferred by

o A. 

Dermacentor tick bite

o B. 

Human body louse bite

o C. 

Ixodes tick bite

o D. 

Respiratory droplets
  

 10. 
A patient had surgery 2 months ago to put in a pace maker. He felt fine for 1
month, but over the past month, he has been feeling worse. He is running a low-
grade fever, tires easily, and has worsening heart  murmurs. Which of the
following staphylococcal organisms causes sub-acute bacterial endocarditis that
occurs 2 months or more after heart surgery?

o A. 

Staphylococcus aureus

o B. 

Staphylococcus epidermidis

o C. 

Staphylococcus haemolyticus

o D. 

Staphylococcus saprophyticus
 

 11. 
A previously healthy 6 month old now looks limp. He cannot hold his eyes  open,
pupils do not react, and he cannot hold his head up. What is the proper
treatment?

o A. 

Send him home on amoxicillin and clindamycin (to stop the toxin production quickly)

o B. 

Give him a dose of equine botulinum immunoglobulin

o C. 

Monitored supportive care with antibiotics, and botulinum immunoglobulin

o D. 

Monitored supportive care with human botulinum immunoglobulin

o E. 
 Monitored supportive care with no antibiotics and no antitoxin
 

 12. 
A 78-year-old man develops a high fever, cough producing a blood-tinged
sputum, and difficulty breathing. Sputum shows organism consistent with
Streptococcus pneumoniae. What is the most important virulence factor?

o A. 

Endotoxin

o B. 

A phospholipase allowing Streptococcus pneumoniae To escape the phagosome

quickly

o C. 

Polypeptide capsule

o D. 

Polysaccharide capsule
 

 13. 
Which of the following organisms grows in 40% bile?

o A. 

Enterococcus faecalis

o B. 

Streptococcus pneumoniae

o C. 

Group B streptococci

o D. 

Viridans streptococci
 

 14. 
 A patient recently returned from Africa has been febrile for several days and now
has abdominal pain. His blood cultures grow out Salmonella typhi. What was the
most likely source of his infection?

o A. 

Raw chicken

o B. 

Undercooked hamburger

o C. 

Contact with baby goats on a farm and then eating without washing hands

o D. 

A food preparer with bad personal hygiene

o E. 

Undercooked pork
 

 15. 
A (33-week) infant girl is born at home to a 16-year-old mom after 22 hours of
labor after the  rupture of the membranes. A friend helped the mother deliver the
baby. The now 4 day old infant now shows signs of sepsis. What is the best
description for the most likely causative agent? All organisms in the answer
choices are Gram-positive, catalase-negative cocci found in pairs or short
chains.

o A. 

Non-hemolytic organisms found as part of the normal fecal flora; resistant to bile and
optochin; carries a high level of drug resistance

o B. 

Alpha-hemolytic diplococcic sensitive to both bile and optochin

o C. 

Beta-hemolytic cocci in chains and carrying Lancefield’s Group B antigen

o D. 
 Alpha-hemolyticcocci in chains; resistant to bile and optochin
 

 16. 
A patient has a gastric ulcer not induced by non-steroidal anti-inflammatory
agents. Which characteristic appears to play a central role in the ability of the
organism to survive transit of the lumen to colonize the stomach?

o A. 

Phospholipase C production

o B. 

Urease production

o C. 

Micro aerophilic lifestyle

o D. 

O antigens
 

 17. 
A54-year-old man develops a pyogenic infection along the suture line after knee
surgery. The laboratory gives a preliminary report of a beta-hemolytic, catalase-
positive, coagulase-positive, Gram-positive coccus. The most likely causative
agent is

o A. 

Moraxella catarrhalis

o B. 

Staphylococcus aureus

o C. 

Staphylococcus epidermidis

o D. 

Streptococcus agalactiae
 o E. 

Streptococcus pyogenes
Related Topics
Hospital
 
In the first case, Professional Services Inc. v. Agana, GR No. 126297, filed on January 31, 2007,
I believe both physicians Dr. Ampil and Dr. Fuentes are guilty. Dr. Fuentes is the one who
performed the hysterectomy on the patient and failed to remove two gauzes that he used during
the procedure. Dr. Fuentes was a surgeon and already knows that what happened to the patient,
but he was assuring that everything is fine instead of explain the injury happened. PSI is also
liable, because they are also apparent authorities also the part of the hospital so it’s their
responsibility to know what is happening to the patient.

The cases were examples of doctor’s negligence and medical malpractice, which resulted in
suffering for the patients. According to the medical malpractice all 4 element (duty, breach of
duty, damage, cause) involved in this case. As a result, they should face legal consequences and
a fair trial for their malpractice and callous negligence, which resulted in the death of one of the
patients. This should not be allowed to continue, and it is the medical institution's responsibility
to ensure the safety of their patients. The physicians' negligence resulted in the death and
suffering of the patients. in my opinion such medical officials should be punished by law, and
hospitals should not allow such malpractice by physicians.