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.

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.

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.

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

Primary Hypertension

Our talk this evening was given by Jake Decker, PGY2 in Primary Care on a specific facet of hypertension discussed the previous week: Primary Hypertension.

Case:

A 58 y/o M with no significant PMH comes in with an elevated BP of 148/88 today.

HTN Definition and Goals:

• Elevated BP: a reading of elevation or not.
• HTN: a diagnosis, disease state. The average of 2+ properly measured reading at each of two or more visits after initial screen.
• Clinically we use these guidelines of whether patients are at these goals:
• ages 18-59: <140/<90
• ages >60: <150/<90

• DM (all ages): 
• <140/<90 because of comorbidities
• Cutoff still controversial because not sure if want to be aggressive with older patients' BP because it might be harmful.
• Kidney disease (all ages): <140/<90

HPI:

• Diet, obesity
• Episodic/constant
• Associated with other conditions?
• Recent caffeine intake
• Kidney problems
• What meds patients is on (NSAIDs, steroids, SSRIs, TCAs, OCPs)
• Smoking, alcohol, and cocaine use (raises BP)
• HA, dizziness
• Vision change
• chest pain, palpitations
• snoring, daytime tiredness
• Sweating, tremors

Physical exam: 

• General impressions
• Take vitals at least twice
• Eye exam (retinal hemorrhages)
• Vascular exam (asymmetric or diminished pulses)
• Cardiac (stenosis, dilated heart muscle)
• Lungs (crackles)
• Basic metabolic panel; creatnine reading to assess end organ damage.
• Urinalysis; CKD can cause HTN, chronic HTN causes CKD.
• EKG: conduction abnormalities, previous/current ischemia or infarction, LV hypertrophy.

Treatment:

• 1) Lifestyle modification 
• Diet/exercise, quitting smoking/drinking. 
• Dash and Mediterranean diets are most largely studied for HTN. 
• Limit sodium to <2400 mg/daily.  
• If end organ damage and reading of 160/90, skip to step 2.

• 2) Pharmacotherapy
• Thiazide diuretics
• Calcium channel blockers
• ACE inhibitors
• ARBs
• For non-black patients: all equal choices
• For black patients: thiazide or CCB
• For CKD patients: ACEi or ARB because they reduce pressure in glomerulus.
• For women of childbearing age: CCB

Hypertension: Another Way to Look at It

Tonight's talk was delivered by Tomi Jun, MS IV on the hypertension areas we can pay attention to specifically in the CCC clinic.

Hypertension cutoffs:

• Stage 1: >140/90
• Stage 2: >160/100

Method:

• 3 measurements, each 1 week apart.
• Consistent pattern.
• Be mindful of activity and white coat measurements.

Primary HTN: treating HTN directly

Secondary HTN: Blood pressure elevated because of secondary causes like a tumor that secretes epinephrine (rare case). The treatment is not to manage the BP but to remove the tumor.

When BP is >180/120:

• Hypertensive urgency: Regular checkup finding asymptomatic HTN. 
• Emergency: when people are showing symptoms like chest pain, altered mental status. If people have a high BP but asymptomatic we still want to send them to the ER.

What we are worried about

•  End organ damage
• Brain
• Heart
• Kidneys
• Vasculature
• Long term damage

________________________________________________________________________
Atherosclerosis: 

• injury to vasculature. 
• plays role in other areas of HTN. 
•  Buildup over time leading to lack of oxygen or rupture
• Achemia and strokes occur. 
• Coronary artery disease occurs, which leads to...

Heart disease: 

• Heart attack leads to heart failure
• Left ventricular hypervole: thickening of left ventricle. The muscle gets bigger and stiffer as it pumps against high systemic resistance.

Kidney disease:

• HTN big risk factor for end stage renal disease --> dialysis. 
• HTN makes substances squeeze through kidney vessels, damaging them.

________________________________________________________________________

Case 1:

• 50 yo F African American with obesity, HTN, DM.
• BP 150/90
• BMI 45.1
• 3 HTN meds: metropolol, losartan, chlotalidone
• Worried about: risk factors such as smoking and DM for kidney disease, heart failure, athero, and stroke.
• Think about changing metropolol to a medication that acts upon calcium channels.

JNC8 Guidelines:

• For people <60, goal is >150/90
• Previously 140/90 from JNC7
• Recently found that there is no additional benefit from goal of 140/90, which takes more meds to achieve.

Lifestyle modification:

• Weight reduction: every 10 kg lost can bring down diastolic BP by 20. 
• Cut dietary salt, reduce alcohol intake, exercise.

________________________________________________________________________

What to ask:

• Meds adherence
• PMH
• Lifestyle (smoking, exercise, diet, alcohol)
• Symptoms (cardiac, neuro)

What to examine:

• Signs of heart failure
• Fundoscopy
• Labs
• basic metabolic panel
• kidney function
• electrolytes
• lipid profile
• urinalysis
• screen/eval DM
• Look for evidence of end-organ damage or other relevant risk factors.

Interprofessional Education

Today's installment of the Inter-Professional Education series was delivered by Kristi Larned, pharmacist, on situational awareness in the clinic between our IPE members. Our clinic consists of attending physicians, med students, nursing students, pharmacists, and other related healthcare professionals such as administrative assistants and patient recruiters.

Situational awareness: 

• Understanding of, or knowledge about, a situation or process that is shared among team members through communication.
• Being attentive to the environment.
• Technique used in decision-making in settings that need quick action.
• A skill that can be improved over time.

Situational monitoring:

• Pay attention to the status of the patient
• Cross-monitor team members
• Survey environment
• Preventing errors that may be caused
• Fosters mutual respect and communication for team members
• Ensures everyone on the team has an idea of what it should look like
• Enables team members to predict and anticipate better
• Creates commonality between members
• Progress toward goal

Barriers:

• Distraction
• Workload
• Fatigue
• Misinterpretation
• Failure to share information (forgot, distracted)

Shared mental model: 

• Perception
• Understanding of or knowledge about a situation or process that is shared among team members through communication.
• Increased accountability

Situation Monitoring Prescribed to:

• Rounds, which are quick
• When more attention is given to patients with more acute conditions.
• People are talking over the team so it's easy to miss information

Strategies to overcome this:

• Checklists
• Engage the patient when discussing regimen
• Helping others with a heavy workload
• Cosigner making sure you're doing everything complete
• Huddles, debriefs, more communication
• Cross-monitoring

Clinical encounter:

• 47 year old female
• History of coronary artery disease, diabetes, mild hypertension
• Status post CABG (Coronary Artery Bypass Grafting) and NSTEMI (Non-ST segment elevation myocardial infarction).
• Chief complaint: shortness of breath and intermittent substernal discomfort.

Our plan to address patient:

• Getting a set of vitals to figure out tests to run
• Approaching the pt directly to identify the cause of SOB
• Survey the scene for any helpful people around
• Notifying the appropriate personnel
• Start triaging

Infectious Disease Case

Our talk this evening was on an infectious disease (ID) case by Sarah Housman, Primary Care Resident at BIDMC.

Case:
A 21M patient who is otherwise healthy complains of a sore throat, fevers, and chest pain. He had a fever 3 days prior. A nurse told him he had strep throat and started him on penicillin. The patient says it feels like someone is sitting on his chest.

In clinic:

• Has strep throat, no remarkable physical exam
• WBC 12
• 70% Neutrophils
• Trop 0.32
• CRP 91
• EKG: ST elevation everywhere
• Day 2 Labs showed Trop 1.09
• Echocardigram shows focal myocarditis and myoregional systolic dysfunction.

Differential Diagnosis:

• Myocarditis (inflammation of muscle tissue, enzyme count increases)
• Pericarditis (inflammation of lining of heart, ST and PR elevation on EKG)
• Myopericardits (heart tissue inflammtion and damage --> CRP elevation)

Diagnosis:
The patient has myopericarditis. Diagnose for both pericarditis and myocarditis conditions by EKG changes, auscultation, pleuric chest pain, cardiac enzymes elevated, depressed injection fraction certain areas are hypokinetic, and look at the MRI.

Treatment:

• NSAIDs (for 2 weeks)
• Cholchicine to prevent recurrence by inhibiting microtubule formation (for 3 months).
• The most common side effect is diarrhea.
• Patients who are at risk of peptic ulcer disease, kidney disease don’t tolerate NSAIDs.

What about the Strep Throat?

• Group A strep can cause myocarditis.
• This patient could have rheumatic fever.
• Use JONES Criteria to help diagnose.

JONES Criteria:

• J- joint pain and migratory polyarthritis
• O- (represents a heart) carditis
• N- painless nodules on achilles tendon
• E- erythema
• S- Sydenham's chorea

For diagnosis: one major criterion (chorea, carditis, migratory arthritis) PLUS two minor criteria (fever, arthralgias, elevated ESR and CRP, prolonged PR). Our patient has 1 major and 2 minor criteria.

Why not Rheumatic Fever?

• 2-4 weeks after developing strep throat, rheumatic fever develops.
• This patient's timing is 2 days, making rheumatic fever an unlikely case.

Conclusion:

• Because he met the criteria, the patient should go to the ID clinic and be treated for rheumatic fever. 
• Patient is on long term penicillin (5 yrs while he’s in college since he’s at the risk of getting strep again). 
• Also treated for myopericarditis with NSAIDs for 2 weeks and Colchicine for 3 months.

Interprofessional Education Using TeamSTEPPS

Today’s talk and interactive session were delivered by Amy Weinstein on IPE Teams in Primary Care.

TeamSTEPPS 

• The program our clinic uses for inter-professional education.
• Provides an opportunity to learn about them to enhance patient care. 
• Created by the AHRQ that provides skills in 4 areas for us to work in teams. 
• Performance
• knowledge
• skills
• attitudes
•  This nationally studied program works. 
• We can see a 50% reduction in weight adverse outcome score which describes the adverse event score per delivery. 
• We also see significant improvement in teamwork outcomes, communication, supportive behavior, reductions in turnover rate, increases in employee satisfaction, and better continuity of care.

IPE teams consist of attending physicians, med students, nurses, pharmacists, social workers, case managers, admins, medical assistants, front desk. The physician and nurse workflows sometimes do not line up. Some of them, such as the phone scheduling staff, are never seen when working with patients yet they are all part of patient care. How do we interact with all of these team members? TeamSTEPPS is designed to break down the barriers and come together as a team.

Barriers to teamwork:

• people: workload, distraction, conflict 
• systems: hiearchy, lack of coordination, miscommunication, lack of role clarity.

Case— Background: 
The patient is a 49 y/o F with Type 2 diabetes and depression comes in for follow up care. She takes Lantus and Humalog. The patient also takes insulin morning and evening, but rarely at lunch. She's been getting increasingly depressed.

MD: Biggest concern is depression
PharmD: Wants to review medication regimen and discuss action plan for hypoglycemia

Case— Clinical encounter: It’s a busy IPE night and the team rushes off to see the patient before huddling. The attending goes in with her own agenda about depression and the PharmD doesn’t get to talk to the patient about hypoglycemia and changes to the medication regimen. The MD thought the visit went well but not the PharmD.


Strategies for addressing breakdowns: 

1.  Leadership: 
• Process of motivating people to work together
• Anyone can be a leader
• They are role models who shape teamwork through open sharing of info
• Give constructive and timely feedback
• Faciliates briefs, huddles, debriefs, and conflict resolution. 
• Organize ppl to achieve common goal.
• Involves planning, processing, and improvement.
2. Planning: 
• form the team and huddle
• designate team roles and responsibilities
• establish climate and goals
• engage in short and long term planning
3. Problem solving: 
• touch base
• discuss critical issues and emerging events
• anticipate outcomes and likely contingencies
• assign resources
• express concerns.
4. Debrief:
• brief and information information exchange and feedback session
• occurs after event or shift
• designed to improve teamwork skills
• designed to improve outcomes
• recognize what good teamwork is

Case— Solutions: deal with pt chief complaint, pt centered; have a plan in advance, finding time to debrief after; knowing what the pt thinks about the plan, making sure pt understands regimen and offer perspective on big picture. have pts repeat directions back to ensure understanding, checking in mid visit. debriefing afterward. otherwise it wont be a good set up for teamwork. keep in mind that we’re all here for the pt.

Take home points: 

• Everyone can be a leader
• Hold huddling sessions
• Hold debriefs to bring the team together

Smoking Cessation Pharmacotherapy Options

Dr. Jake Decker delivered this evening's talk on smoking cessation with an emphasis on pharmacotherapy options.

Many of our chronic disease patients smoke. Smoking is a learned behavior and a physical addiction to nicotine. Combining counseling with pharmacologic therapy is most effective.

Nicotine Withdrawal Syndrome:

• Depressed mood
• Insomnia
• Irritability, frustration, anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Increased appetite
• Weight gain

Options

Nicotine Replacement Therapy:

• Provides nicotine without using tobacco 
• Reduce withdrawal allowing breaking of behavior
• Dependence to NRT is rare
• In general NRT use is recommended for 2-3 months
• longer use is ok if risk for relapse
• Combinations of different NRTs are more effective than either alone.

Transdermal Patch:

• Dose the strength of patch by how much the patient smokes
• Use patch on nonhairy part of body as it's changed each morning. 
• They should quit smoking while on the patch because patients can't self regulate their own nicotine toxicity, results in symptoms of nausea.
• There can be irritation at the skin site so don't put it in the same spot each day.

Gum:

• Dosed based on how much patients smoke, use as needed to keep a basal level of craving. 
• A certain amount of nicotine is released when chewed, "park" it in your gums until nicotine is absorbed via buccal mucosa and taste goes away, chew again. 
• Acidic beverages should be avoided before and during.

Lozenge:

• Like the gum, dosed based on how many cigarettes in a day. 
• More user-friendly but chalky and not palatable.

Inhaler:

• Different than the e-cigarette, used as an inhaler puff as needed
• Delivers vapor to oropharynx and absorbed into buccal mucosa
• Fights craving and addresses behavioral addiction. 
• Patients love this method but is costly and not covered by insurance.
• Must be prescribed and not available OTC
• Helpful to patients with pulmonary disease.

Nasal Spray:

• puffs in nose
• not as well tolerated by patients as it causes runny nose, sneezing, and tearing.

Comparing Methods of NRT:

• The NRT patch high dose is twice better than placebo. The gum is a little less effective, followed by inhaler. 
• Combining patch and gum/spray is much more effective.
• The patch will give continuous nicotine but people will have cravings so the gum counters that. 
• Chantix has abstinence rate of 33.2% and can be used in combination with NRT but the safety is not yet clear.

Surgery in the Clinic

Tonight's presentation was by Kyle Checchi, MSIV, on surgery in the clinic. We see a lot of surgery in the OB/GYN setting but there are other instances in which surgery is done.

Case Study #1:
A 37 year old female with a BMI of 30 has abdominal pain with the following:

• RUQ
• steady and severe
• nausea/vomiting
• diminished appetite, worse with fatty food
• 1+ hr after meal, prolonged > 4-6 hrs). 
• Unremarkable medical history.  

 Based on this information, we think it is obstruction of the cystic duct.

Cholecystitis:

• RUQ pain with contraction of gallbladder against stone in the cystic duct
• colicky pain after fatty intake
• no signs of obstruction or infection
• fear of perforation of gallbladder

Reasons to send in to be seen:

• Cannot maintain PO intake
• Pain not adequately controlled
• Charcot's triad (fever, jaundice, RUQ pain)
• Reynolds pentad (triad plus shock and altered mental status)

Case Study #2:

A 25 year old male complains of discomfort and bulge in the abdominal wall.

• Heaviness and dull discomfort
• History of open appendectomy
• Located at scar
• Cosmetic concern
• Appearance and discomfort worsened with coughing or straining
• Distinguish hernia from ischemic pain

Rational clinical abdominal exam:

• Murphy's signs: cessation of inspiration when pressure applied over gallbladder
• Rovsing's signs: pain in RLQ with deep palpation of LLQ
• Psoas sign: pain with passive/ active extension and flexion at hip, lie on side and grab leg, flex/extend at hip joint and check for discomfort. Bring leg in and kick out to move core muscles, see if anything on the peritoneal muscles inflamed.
• Obturator sign: pain with adduction and external rotation at hip
• Peritoneal signs:
• rebound: increase in pain with quick withdrawal of hand from deep palpation
• guarding: tensing of the abdominal muscles at initiation of palpation
• tap tenderness: pt reacts when percussing

Other Surgery in Clinic:

• Scratch test (hepatomegaly)
• Assessing size of liver, for hepatitis
• Used instead of percussing.

• Drains from surgery such as a mastectomy. If red, swollen, warm, tender skin, it could be fluid or an infection.

Live Blog: Diabetes Examination

This week we welcomed back Dr. Paige Comstock, PGY3, for a talk on the diabetic examination. 

At the start of a diabetic exam, the vital signs-- specifically blood pressure targeted at 130/80-- are the most important.

Skin findings in diabetics:

• Velvety, hyperpigmented areas called Acanthosis Nigracans
• Diabetic dermopathy found in 50% of diabetics. They have microvascular complications like neuropathy.

Eye complications of diabetes:

• diabetic retinopathy
• cataract
• glaucoma.

The foot examination:

• Necessary because there is a 25% lifetime risk to develop ulcers due to neuropathy, deformity, and trauma.
• Look for 
• sweating
• ABI (Ankle Brachial Index) if indicated
• callouses because of neuropathy
• nail dystrophy
• paronychia
• areas of abnormal erythema
• check interdigitally.
• Deformities (rigidity, claw toe, hammer toe, charcot foot) lead to increased pressure in some points of the foot which leads to more trauma. 
• For the neurologic exam, perform the microfilament test on various pressure points on the foot. 
• Other neurologic tests include ankle reflexes, pin prinks, and tuning fork on the foot.
• Vascular exam includes palpating the distal pulses to check whether there is poor blood supply. This is a risk factor for recurrent ulcerations.

Live Blog: Anorectal Malformations

Today's talk was given by chief medical resident Rebecca Glassman on anorectal malformations.

At times in clinic we can be presented with a patient complaining of rectal pain. As a clinician, you perform a rectal exam to  feel the prostate and rectal muscles when there's a suspected GI bleed, complaints of prostate enlargement symptoms, concern about prostatitis, and also when patients have  lower back pain to test for tone of cord compression.

Some common anorectal complaints are itching and bleeding. To do a rectal exam, Dr. Glassman recommends having patients lying on the bed in a fetal position with draping, using lubricant when necessary. Looking for nodules and elevated PSA levels.

Case Study:

A 34 y/o M with a history of painless bleeding from hemorrhoids in the past presents with severe anal itching. You would think hemorrhoids, incontinence, fungal infections.

This is Pruritus ani, the differential of which is very large. There are systemic illnesses (diabetes, thyroid disease), mechanical factors (chronic dirarrhea, anal fissure), dermatologic factors (psoriasis), skin sensitivity from food (tomatoes, beer, milk products), infections (scabies, syphilis), and medications (bacitracin).

Take Home Points:

Anorectal pain: 

• The patient history tells you a lot about the condition. 
• Among the possible variations of anorectal pain are fissures, constipation, hernia, internal hemorrhoids, prolapse, thrombosed external hemorrhoids, fistulas, and proctalgia fugax.
• It's important to stop the itch cycle by identifying the underlying cause and then soothing the area with the appropriate medication.

Anal fissure 

• The stretching of the anal mucosa beyond capacity
• The internal sphincter muscle is exposed causing spasm
• Spams pulls apart the edge of fissure causing pain and impairing healing. 
• Goals are to relax the interal sphincter, maintaining bowel movements, relief the pain. 
• Medical therapy includes topical nitroglycerin, topical nifedipine (less side effects), injected botulinum toxin (decreases spasm), or surgical therapy (sphincterotomy).
• Management includes either stool softeners (Miralax) or contractile agents (senna).

Fissures are hard to treat to referring the pt to surgery is really helpful for if it comes to sphincterotomy. These patients are so miserable that if they don't respond to the topical treatment, you want them to have other options.

Hemorrhoids 

• Thrombosed blood vessels
• The cushion composed of arterio-venous chall and connective tissue is swollen. 
• Complications: thrombosis (acute pain with large mass) which need surgery to open up the hemorrhoids bringing instant relief. Other complications are bleeding, prolapse, pain, abscess, incontinence.
• Management: fiber supplementation, Preparation H suppositories, analgesic creams, sitz baths (soaking hemorrhoids in warm water) for soothing and decreasing irritation.

Anorectal abscess:

• Infection starts in crypts of Morgagni --> extends along anal gland. 
• Over 50% of abscess will result in fistulas. The patients need to have abscess drain. 
• Think about other potential underlying diseases such as Crohn's and diabetes.

Proctalgia fugax: 

• Episodes can occur yearly or 4x/week. Associated with sweating, pallor, incredibly distressing to pts. Urgency to defecate but pass no stool. 
• Treatment: warm water, ice, valium, deep breathing. 
• A lot of patients have spontaneous onset.

Live Blog: Hypertension

Our talk today was delivered by Dr. Paige Comstock of BIDMC on hypertension. Hypertension is one of the most common chronic diseases seen in non-pregnant adults in our clinic at BIDMC.

Hypertension is the most common risk factor for a myocardial infarction (heart attack) and stroke. Blood pressure should be measured two times and have at least two visits after the initial screen.

Blood Pressure Ranges

Normal: less than 120/80
Pre-hypertension: 120-139/80-89

Hypertension stage 1: 140-159/90-99

Hypertension stage 2: greater than 160/100

People get hypertension because of increased sympathetic activity (increased beta adrenergic responsiveness), genetics, increased angiotension II activity, increased cardiac output, or increased systemic vascular resistance.

Some risk factors are being of African American race, hypertension in both parents, ingesting too much salt or alcohol, inactivity, and being overweight.

The consequences of this disease are stroke, myocardial infarction, congestive heart failure, chronic kidney disease, and ventricular arrhythmia.

To diagnose, take measurements over multiple visits with the patient seated for 5 minutes, legs uncrossed, arm at level of heart. Measure both arms at first visit and be sure to have the appropriate cuff size.

Interestingly, our clinic at Healthcare Associates can set up blood pressure monitors for patients at home so patients can track measurements of their blood pressure before coming into clinic.

Some secondary causes of hypertension are onset at young age, absent family history, severe hypertension at diagnosis, resistance to antihypertensive therapy, and spontaneous hypokalemia (low potassium).

Some examples of these causes are primary renal disease, excessive NSAID use, sleep apnea, Cushings syndrome, renovascular disease, and pheochromoctyoma.

The Joint National Committee-8 reviewed all the literature and published these treatment goal recommendations:

General population age > 60, goal < 150/90

General population age <60, goal <140/90

Diabetes and age >18, goal <140/90

Chronic kidney disease and age >18, goal <140/90

For patient counseling, the healthcare professional should give specific advice, recommend lifestyle changes and gradually increase activity, suggest 1-2 changes in eating habits, and refer patients to resources such as action plans sponsored by AMA and fitness and diet apps such as My Fitness Pal.

Live Blog: Low Back Pain

Our didactic was done by Dr. Kristin Remus, a clinician educator at BIDMC and one of CCC's faculty preceptors.

Low back pain (LBP) is the second most common cause of disability in US adults. Many people miss work because of LBP. This disease has a 10% population prevalence with LBP for more than 2 weeks prevalent in 14%. Factors associated with LBP are work (exposure to high vibrations such as truckers and jackhammer constructioners), obesity, physical inactivity, arthritis/osteoporosis, age greater than 30, bad posture, and stress or depression.

In acute and chronic LBP, some mechanical causes are dislocation, compression, muscle strain and sprain, herniated disk. Non-mechanical causes are aortic aneurysm, infection, epidural abscess, ectopic pregnancy, diseases of the bone, metastases, and fibromyalgia.

Can we prevent it? In the physical exam check the spinous processes, check the greater trochanter on the hip. The ischial tuberosity and paraspinal muscles are usually tender. Do some maneuvers to see how well someone can bend or move, muscle strength testing in toes and ankle. Also do a neuro exam for numb dermatomes which all end in the feet, check patellas, do the straight leg raise for pain, and test gait such as toe walking and heel walking.

Lasegue's Sign: a straight leg raise physical exam finding. When you stretch the sciatic nerve you can decide if the patient has some sort of LBP. Symptom severity does not correlate well with outcome, so the pain can go away at any time.

Waddell's signs: inappropropriate tenderness superficial or widespread, LBP on axial loading of the head, inconsistent straight leg raise test seated or standing, sensory deficit without nerve root innervation, 3/5 psychological distress.

Discerning what the red flags are will let you know who to look at under an x-ray.

Red flags:

• Urinary retention, stool incontinence
• Neurologic symptoms such as tingling or loss of sensation. 
• People older than 70 often get imaged
• Unexplained weight loss, 
• Prolonged use of corticosteroids, 
• IV drug use, 
• Saddle anesthesia

Patient History:

• Does the patient have a systemic disease? 
• Do they have neurologic compromise or the need for surgery? 
• Do they have social or psychological distress?

Take home points: 

• In the physical exam, be systematic with palpation and inspection.
• Do a dorsi flex and plantar flex for any pain to confirm the straight leg raise test.

Live Blog: Cutaneous Manifestations of Chronic Disease

Christine Bishundat
Medical Education Committee

Our talk today was given by Jeffrey Cohen, MSIV, on cutaneous manifestations of chronic disease.

The three main chronic diseases we see in clinic are diabetes, hypertension, and obesity.  Today, Jeff discussed common skin conditions associated with diabetes and obesity.

Diabetes: The most common skin condition associated with diabetes is acanthosis nigricans, a velvety hyperpigmentation found in the folds of the skin. Acanthosis nigricans is a product of insulin resistance.

Diabetic patients also have an increased risk of bacterial and fungal infections. Generally, bacterial and fungal infections are differentiated by appearance: green pigment is indicative of bacterial infection with pseudomonas, while central clearing in red patches and flaky edges indicate fungal infection.

Diabetic ulcers are present in 15-25% of patients with Type 2 Diabetes.  These are a result of vasculitides and neuropathies due to chronically elevated blood glucose.

Diabetic bullae (blistering), dermopathy, and pigmented purpuric dermatosis are less common but notable because they correlate with high levels of hemoglobin A1C.

Obesity:

Patients with obesity are at increased risk of developing intertrigo, psoriasis, and stasis dermatitis.

Intertrigo is skin inflammation due to rubbing and abrasion in intertriginous zones.  Intertrigo can be complicated by candida infection.

Psoriasis is a common inflammatory skin disease characterized by scaly plaques.

Stasis dermatitis is a chronic inflammatory skin condition that typically presents on the lower extremities.  The hemostasis that causes stasis dermatitis is the result of venous hypertension and venous valve insufficiency.

Take Home Points:
- Diabetes and obesity put patients at increased risk of developing certain skin conditions.
- It is important to perform a thorough physical exam in order to prevent and treat cutaneous lesions, some of which (like diabetic ulcers) can be life-threatening.

Live Blog - Hypertensive Crises

Today we heard from Alexa Carlson, Assistant Clinical Pharmacy Professor at Northeastern University, on hypertensive crises and emergencies.

We started by defining hypertensive crisis (severe elevations in blood pressure without target organ dysfunction) and hypertensive emergency (severe elevations in blood pressure accompanied by target organ dysfunction).

After covering the clinical presentation and evaluation of hypertensive emergencies, we moved to treatments for hypertensive urgency and emergency. In urgency, Alexa recommended that providers give oral therapy to reduce blood pressure (options include clonidine, labetalol, and captopril). While technically not recommended because it has a longer duration of action, is a potent vasodilator and it isn't easy to titrate it to the blood pressure, many people are on Hydralazine. Labetalol is an alpha beta blocker and a potent blood pressure lowering agent. This could be an issue for patients with asthma/COPD because we worry about how we would impact beta 2 receptors in the lungs.

In emergency, patients should be admitted to an ICU for parenteral medication administration and continuous blood pressure monitoring. This requires immediate blood pressure reduction. How do we choose which medication to use? This is based on any comorbid indications and what type of end organ dysfunction we are having.

We then practiced with two cases:

Case I: 
"I have a wicked headache." HPI: PB is a 67 year old male.
S/O: 
PMH - HTN, COPD, NSTEMI (2007)
Home Medications: Tiotropium for COPD, Fluticasone/Salmeterol for COPD, ASA for the MI, lisinopril for HTN/MI
VS: BP 182/100, HR 102, RR 18

We think this is a hypertensive urgency because his only symptom is a headache. We know he has a wicked headache -- could he be taking an NSAID that would worsen his hypertension? Has he been taking his ACE inhibitor? 

Given that this is an urgency and not an emergency, we recommend oral medications.

One person suggested clonidine, a centrally acting alpha 2 agonist. Dr. Molina said that this could be difficult, given that the patient is already on many medications. He also added that he might increase the lisinopril, or add calcium channel blockers. A resident noted that adding a diuretic could be useful, although that could take days. She also said that she would have him come back for a nursing visit the next week and would make sure that he had a blood pressure cuff at home.

Case II:
"I ran out of my meds."
HPI: LI is a 38 year old female with a past medical history significant for HTN for hte pas 3 years.
S/O:
PMH - HTN x 3 years
Home Medications - Clonidine
VS: BP 185/98, HR 98, RR 22

We would start by asking if she is pregnant as we do not use ACE inhibitors in pregnant women. We would also ask how long she has been off the medication - hours, weeks, days? We would start her back on the clonidine as it is fast acting drug, then taper it, and then switch her meds if getting the clonidine is going to be an issue in the future.

Dr. Molina added that we would like to explore why she was on clonidine in the first place, as this is an odd choice.

By Michal McDowell, MS I

Didactic 2/19/2014

Situational monitoring was the topic of didactic session this past Wednesday, a continuation of the TeamSTEPPS program, which is an evidence-based national initiative to develop teamwork in healthcare professionals.

Situational monitoring involves medical professions at all levels of care, including administration, medical assistants, nurses, doctors, etc. When care providers at all levels engage with patients and aren't afraid to speak up if a situation seems out of the ordinary, patient safety nets are created. It encourages healthcare teams to check-in with each often, to communicate and ask questions when unsure, and to increase accountability within the team.

Some of the students present tonight gave examples of situational monitoring from their own experiences. One talked about doing surgical prerounds early in the morning and discovering a patient had aspirated overnight. The patient was able to be quickly transferred to the ICU. Another talked about an ICU nurse who had talked extensively with a patient and discovered some undocumented medical allergies. She was able to prevent a drug from being given that would have been detrimental to the patient's health.

Our final case of the night centered around a patient with a history of two heart attacks who presented to CCC clinic and was visibly short of breath and uncomfortable in the waiting room. When asked how the team would proceed, students were in agreement about disregarding the regular order of clinic nights and taking the following measures to make sure the patient received prompt care: 1) contacting the attending immediately, 2) evaluating vitals to make sure patient was stable, 3) rushing the patient to the ED if needed.

Some final clinical pearls for risk factors of high-risk patients who present with atypical heart attack signs:

1) diabetic/ patient with hyperlipidemia

2) males, younger than age 70

 Some of these atypical signs may be: abdominal pain, dyspnea, indigestion, and syncope.

-Yun Xue MSII

New to Didactics: An Innovative Interprofessional Curriculum

The CCC-BIDMC crew has been working hard over the last year to embody "interprofessionalism." When medical students work alongside nurse practitioner students, pharmacy students, and other healthcare professionals, they learn to value teamwork early in their professional careers. They say raising a child takes a village, and taking care of patients definitely takes a TEAM.

In this evening's didactic session, Dr. Amy Weinstein and senior director Megan Koster introduced a new interprofessional education (IPE) curriculum called Team Stepps to CCC-BIDMC.  In a series of four lectures, they hope to teach students how to work on a team of healthcare workers from different professional backgrounds. 

The first lecture focused on leadership, which they defined as "a process of motivating people to work together collaboratively to accomplish tasks." There are four main characteristics to effective leadership:

1. Role Modeling
2. Shaping teamwork through open sharing of information
3. Constructive and timely feedback
4. Facilitation of briefs, huddles, debriefs, and conflict resolution

What Team Stepps calls "briefs" are the same as our pre-clinic huddles, so we have that one covered. The use of mid-session "huddles" is something that we haven't fully incorporated in our clinic practice at CCC."Debriefs" or post-clinic feedback is something we've been talking about a lot on the medical education committee. We're hoping to pilot a new 360 degree feedback method for SC/JC teams.

 
Students shared several learning "pearls" at the end of the session, including the importance of agenda setting and communication flow. It was great to see the room rearranged into four tables to facilitate group discussion between our medical, NP, and pharmacy students.

Energy was high tonight, so we are all looking forward to our next IPE Teamwork session on "Situation Monitoring" on February 18th.

-Laura Cohen MSIV, Senior Director and Med Ed Committee Chair