Urosepsis in Diabetic Patient

Case: 70 year old M complaining of bilateral back pain and nausea.

PMHx:

• DM II
• HTN
• 2008 colon cancer surgery
• Weakness
• Chills
• Urinary symptoms

Vitals:

• BP 88/68 (Hypotensive)
• HR 112 (Tachycardic)
• RR 22 (Tachypneic)
• Blood glucose elevated
• 94% O2 sat a little low
• Temp 38.6 C (a little febrile)

Social Hx:

• Not eating a lot
• Not traveling
• Denies drugs/etoh
• Low BP, HR high together give you a sense of cardiac output (Preload issue). 

Labs:

• BUN/Cr ratio = 30 elevated 
• Bacteria in urine (3+ bacteria)
• Positive nitrites

DDx: 

• Think of systems like GI (apendectomy, apendicitis, colitis, diverticulitis), Respiratory (pneumonia), CNS (meningitis)
• Infection, inflammation, cancer, ischemia, vasculitis
• Diabetes patients more susceptible to infections because immune system is down, sugary environment for bacteria, and poor circulation. He could have an infection, metabolic acidosis, was given fluids and antibiotics (cetrax) and admitted to the hospital.
• RR rate high—> compensating for anion gap metabolic acidosis that was found on ABG. 
• Diagnosed with pyelonephritis.

What causes shock (end organ issue): 

• Septic infection (distributive, anaphylaxis)
• Hypovolemic (dehydration)
• Cardiogenic (obstructive, pump not working, pneumothorax, MI, blood loss)

Anion gap acidosis: 

• Lactate caused by poor perfusion (end organ issue), 
• Ketone acidosis (DKA, pH, urine ketones, blood ketones), 
• Nmeumonic: MUDPILES (methanol, uremia, diabetic ketoacidosis, propylene glycol, iron poisoning or isoniazid, lactic acidosis, ethylene glycol, salicylates)

Treatment: 

• Vasopressers
• 100 cc fluids (start low to avoid pulmonary edema)
• Lisinopril
• Antibiotics
• Source control (controlling infection itself)

Take Home Points:

• Sepsis = inflammatory defense against bacteria, defined by HR, RR, Temp, and white count. 
• BUN creatinine ratio >20 = possible pre-renal. Patient was around 30. He is being perfused poorly; there is nothing intrinsically wrong with the kidney. 
• Having low BP, high temp, HR and RR, nausea raises probability of infection. 
• Early goal directed therapy is treatment for sepsis. Sore throat, common cold can cause sepsis, but not necessarily make you sick. 
• Severe sepsis is end organ damage issue. Signs of severe sepsis are urine output (whether kidneys function), UTI went back up to the kidneys and caused back pain—> caused severe sepsis. 1) Give fluids. 2) Give pressors. 
• End organ damage caused by low cardiac output which is broken up into HR, BP, etc. HR was preload, anatropy (heart), then afterload. Shock = poor perfusion caused by heart not working (no pump to heart), preload issues (decreased blood, volume, vasodilation), and anaphylaxis/sepsis, increased afterload (resistance) is rare for really hypertensive people who can’t perfuse.
• Treat this with fluids (fill tank with fluid, press and make sure they are carrying enough hemoglobin (12 and higher good level), give something for anatropy.
• Fix perfusion on one end and control infection on the other.

Image of the Week 3/24/2015

What is the following condition and what are some possible treatments?

Live Blog: Hyperthyroid Storm

Case: A 25 year old male presented to the Emergency Department with palpitations.

• A week ago, the patient experienced racing heart, diaphoresis that are progressive and constant. 
• Patient has:
• loose stools
• weight loss
• loss of appetite
• PMHx: 
• asthma
• is a smoker
• uses alcohol
• has history of drug use
• Family Hx: 
• Diabetes Mellitus
• Cardiovascular disease
• Arthritis
• Pertinent negatives: 
• drug use
• infection
• fever
• recent illness

Physical Exam:

• HR 150
• RR 20
• BP 91/50
• Temp 31.8°C 
• O2 sat 91%, patient was put on mask
• Pulmonary crackles on lung exam
• Chem 7 and CBC labs were normal
• Thyroid: markedly low TSH
• Cardiac EKG: a-fib
• Tox screen negative

Interventions and Results:

• Given IV fluids
• Given Propanolol (beta blocker) —> decrease in HR but slight increase in BP
• Iodide
• PTU/methimazole
• Decrease in O2 sat

Ddx: 

• Endocrine
• CNS/autonomic
• Cardiac

Take Home Points: 

• 25 year olds don’t normally get a-fib. 
• HR and BP together tells what the cardiac output is. 
• Giving fluid could help make the diagnosis of Overflow and Cardiogenic Shock because you could get high output heart failure from all the extra stimuli. 
• Presence of antibodies would help diagnose Grave's Disease. 
• Give iodine last because will make things worse if you haven’t blocked things downstream—> called the Wolff Chaikoff effect. 
• Thyroid toxicosis: 
• Elevated thyroid function
• Temperature nearly febrile
• Endocrine system: 
• Antibody caused increased TSH production. 
• Thyroid overproducing T4 and T3, which are binding to tissue and triggering feedback to inhibit TSH. 
• The ideal drug design would be to block conversion from T4 to T3. 
• PTU, meth, iodine stop this production

For more cardiac EKG practice, visit BIDMC Wave Maven.

Image of the Week 3/17/2015

What does the following radiograph show and what is the diagnosis and treatment?

The Radical Becomes Viable in Primary Care

Christine Bishundat
Med Ed Committee

It is not often that radical plans be made possible, especially in the healthcare field. Rebecca Onie, co-founder and CEO of Health Leads, spoke about the result of prescribing food to patients, outlandish at the time but utterly revolutionary. Two people have inspired her: advisor Dr. Tom Lee who helped her keep a positive outlook on venturing the frontier of healthcare reform and Dr. Jack Geiger who in 1965 founded one of the first two health centers in the US that prescribed food to patients.

The Office of Economic Opportunity who funded the clinic found out about this and was livid. They wanted the dollars to be used toward medical care. Dr. Geiger, tenaciously maintaining that malnutrition needs to be treated with food, invented the prescription for food. Several decades later, Health Leads reused that idea.

Dr. Jack Geiger and Dr. John W. Hatch during construction on the Delta Health Center, 1968

Only 10% of health outcomes are dictated by medical care. Patient social needs actually have a significant effect on their medical outcomes at a whopping 60%. A patient Carlos who was recently seen by a Health Leads site needed help with insulin administration, Multiple Sclerosis treatment, transportation services, and on top of that he couldn’t communicate in English because he was Spanish-speaking.

The medically complex, non-compliant patient is what doctors dreaded. This story is frequently heard by Health Leads. The real issue is that there is no food at home or other social issues that doctors don’t know how to address. Systematically addressing patient social needs seemed radical because doctors weren’t trained about this in medical school. There is a tradeoff between doing the right thing for your patients and recognizing the reality of the patients' situations. Electricity, heat, and food are just as important as putting in a stent in STEMI patients as fast as possible.

Fortunately, healthcare transformation task forces have been formed to extend better care to patients including low income populations. In the clinics that Health Leads works with, patients can be prescribed social needs and be connected to these resources. Carlos connected to a bilingual transportation company and secured vouchers for transportation. His doctor said that she can refer him to Health Leads instead of spending hours figuring out the root of his true medical issues— his social needs. Without this opportunity he would have been seen as a non-compliant patient.

Health Leads' biggest concern is that there is still a passive voice problem; something should be done about the social determinants of health. We need a system invested in whether a patient has the resources to maintain a healthy lifestyle instead of struggling to managing the totality of her health. Health Leads argues that the role in responsibility of the healthcare system is to break the cycle, ask their patients about their social needs, and help them access those solutions. This is where the radical and viable start to meet.

Reportedly, a growing number of healthcare systems are trying to address this issue. After working with hundreds of providers and helping tens of thousands of patients and help them access these needs, Health Leads found you have to commit to the following:

1. Clinical integration by adding to your EMR a few basic social fields--like physical activity and financial resources-- to approach your clinical encounter with a wider picture to enhance your care.
2. Having a dedicated workforce with the responsibility of addressing patient social needs. 
3. A resource database for things like income assistance based on patient population needs. Social workers, patient  navigators, and community health clinics have access to this as well. 
4. There also needs to be consistent follow-up for successful resource connections. 
5. Finally we need data collection and analysis to have access to a different patient population. It shows that addressing patient social needs greatly influences patient medical outcomes. 

Dr. Tom Lee said to be the kind of doctor the patient hopes for. The ultimate goal of Health Leads is to ensure that the most creative people have the freedom and tools to come up with big ideas to be the ideal doctors that patients want them to be: to have radical ideas for their healthcare.

Image of the Week 03/10/2015

What conditions does the following individual have?

Emergency Simulation Case: Aspirin Overdose

A 65 year old male complains of nausea, vomiting, abdominal pain.

HPI: ringing ears, dizziness over 2 days.

PMHx: Osteoarthritis

Meds: Bayer aspirin, no known drug allergies (NKDA)

Social Hx: 

• Alcohol in recent past
• Quit smoking
• Denies drug use
• No travel hx
• No new foods
• No thoughts/attempts of suicide

Physical:

• HR: 129
• BP: 111/66
• SpO2: 98
• Temp: 38.1 C
• Dry mucous membranes
• Ok turgor
• Breathing worsening
• No peripheral edema
• Took 2 Bayer pills every 2-3 hours over the past few days

Labs Ordered:

• Bolus normal saline
• Chem 7
• CBC
• Amylase
• Lipase
• Urinalysis
• Toxicology
• ABG
• Chest and abdominal X-ray

Results:

• High lymphocytes 55%
• High fever
• Salicylate level: 141
• Clear chest/abdominal x-ray

DDx: 

• salicylate overdose
• respiratory alkalosis
• issues spleen
• duodenal ulcers
• kidney

Assessment & Plan: 

• Gave fluids and sodium bicarb
• Repeat salicylate levels
• Chest & abdominal xray
• Dialysis

Take Home Points:

• Look at likelihood ratios from tests that will point you in certain directions when making a diagnosis.
• WBC could be a stress response, a way to rule out infection.

Live Blog: Blood Glucose

Today's didactic was on blood glucose monitoring in Type II diabetes presented by Jennifer Allen, PharmD here at Healthcare Associates.

What it Does:

• Helps patients to assess diet and exercise habits
• Guides changes in medication therapy
• Provides tool to confirm signs and symptoms of hypo/hyperglycemia

When to Start Using:

• Right at diagnosis
• Helpful guide for those with blood sugar little high
• When initiating meds that potentially cause hypoglycemia
• Any symptoms supported with hypoglycemia

Goals of Therapy:

• Educate patients on what the numbers mean
• Aim for fasting blood sugar of 70-130
• 2 hours after meals >180
• Goals should be individualized 
• Duration of disease
• Life expectancy
• Co-morbidities
• Hypoglycemia unawareness

When to Test:

• With oral meds only: once a day
• Start with checking fasting sugar and getting that down to goal
• Next work on getting post-prandial readings down
• With basal insulin +/- oral meds:
• Min once daily before breakfast
• Occasional 2 hr post-prandial readings helpful
• Use a blood glucose log to track progress

Technique:

• Wash hands
• Insert new test strip and insert lancet into device
• Press lancing device firmly to side of finger
• Press actuation button to fire needle
• Apply blood sample to tip to test strip
• Await result and log numbers

Patient Counseling Points:

• Take blood glucose more regularly
• Drink water
• Consult your doctor on symptoms
• Make sure test strips are insured
• Recommended machines: 
• Onetouch Ultra 2
• Freestyle Freedom Lite (portable)

Live Blog: Interprofessional Education

The newest installment of the Interprofessional Education series was presented by Maria Dolce and Jessica Hollman of Northeastern University School of Nursing, focusing on communication in the clinic. The TeamSTEPPS system was used as a guide.

Communication:

• A two-way process making sure each person understands what is conveyed.
• Most medical errors come from communication. 

Evidence-Based Tools/Techniques:

• Ensuring communication is complete
• Concise
• Timely

Barriers:

• Language
• Distractions
• Physical proximity
• Personalities
• Workload
• Varying comm styles
• Conflict
• Lack of info verification
• Shift change
• Family has fear of healthcare providers

Consequences:

• Conditions getting worse
• Adequate medication not prescribed

Info Exchange Strategies:

• SBAR:
• situation
• background
• assessment
• recommendation :
• Call-out
• used to communicate critical info to an entire emergency team 
• Checkback:
• closing the loop
• receiver accepts/confirms info
• Handoff: 
• transition of care 
• convey all pertinent info
• allow for period of time where person can ask questions

What is SBAR?

• Framework for team members to effectively communicate info to one another.
• Situation: whats going on with the patient?
• Background: what is the context?
• Assessment: what is the problem?
• Recommendation: what do i need from you?

Think-Pair-Share:

• Think about team.
• What are opportunities to improve communication?
• What strategies would you use to overcome communication breakdowns?

Primary Care Teams Should:

• Make sure patient's voice is being heard.
• Allow time for open/honest communication.
• Make the patient the center of the team.
• Make sure patients share fully in decision-making.
• Speak to patients in a way they can understand and enable them to feel empowered to be control of their care.

Equipping the Patient:

• Encourage patient to ask questions so pts can improve their care by taking an active role in the process.
• Inform them of questions they should ask the doctor.

Image of the Week 1/20/2014

A 51-year-old man with hypertension told his physician that in the past five hours his right arm and leg and the right side of his face felt weak. He had no sensory, cognitive, or language deficits, and an MRI was performed. What does the MRI show?

Live Blog: Hypertensive Patient Case

Today’s talk was given by Dr. Lindsey Hintz, 3rd year primary care resident here at Healthcare Associates. She discussed one of her former patients, a 28 year old African American male who comes in for routine checkups. Dr. Hintz noticed that his blood pressure was 148/95 both times it was checked. He also has sleep apnea, snores, and goes to bed at 6PM.

When to work up for Secondary HTN: 

• Young age (under 30 with risk factors)
• Has no risk factors (including family history)
• African American less likely to look for secondary HTN
• Drug use 
• Illicit 
• OTC stimulants
• NSAIDs
• Oral contraceptive pills
• SSRIs
• EtOH use
• People with resistant HTN (uncontrolled with 3 meds with adequate doses)
• People who have severe HTN
• Stable blood pressures with abrupt change
• Renal artery stenosis
• Pheochromocytoma
  

  • Headache
  • Palpitations
  • Sweats
  • HTN
• Endocrine
• Hypothyroidism
• Cushing’s Disease
• Hyperparathyroidism
• Hypertensive before puberty

• Sleep apnea
• Kidney disease
• Coarctation of aorta with decreased femoral pulses and hypotensive legs
• Primary hypoaldo (low K+ with HTN)

Questions to Ask:

• What’s causing the 2° HTN? 
• How do we change the treatment?

First Line Treatment:

• Chlorthaladone
• Diuretic
• ACE inhibitor
• Ca2+ channel blockers (Lodipine)

Take Home Points: 
Check for secondary HTN when

• Person under 30 has no risk factors
• HTN before puberty
• People with good doses and HTN still not controlled

Image of the Week 1/13/15

A 45-year old woman with diabetes comes in with concerns about lesions on her foot. What is the diagnosis and why has it occurred?