Boatswain2PA Posted July 2, 2014 Share Posted July 2, 2014 Had a patient last night that was a great learning case. Any PA students want to play? 78 yo nursing home patient presents to VERY rural ED (4.5 hour drive from level 1 center) with decreased LOC throughout the day. Nursing staff reports he has been up going to the bathroom several times during the day, but they eventually found him slumped over on the toilet. Pt has significant left side weakness X 10 years apparently due to MS, however wife (who brings him coffee and donuts every morning) states he is typically ambulatory and communicative. He is somnolent, however wakens briefly to verbal for a few seconds before dozing off again. Initial vitals are 135/65, P133, R36, SpO2 94% on 4L, T 101.3. Lung sounds slightly diminished left side, abdomen soft and nontender. Large b/l inguinal hernias, but not ttp. What is your top 3 dx? What bad things must you rule out in the ED (if you want to work ED, you cannot miss one of these). What labs/imaging do you order? What initial treatment?? Link to comment Share on other sites More sharing options...
fakingpatience Posted July 2, 2014 Share Posted July 2, 2014 UTI, pneumonia/ plural effusion, stroke/bleed, hyperglycemia, other infection... Hitting a wall on obvious diagnosis, sure I'm missing something big here EKG, blood glucose. Blood and urine culture. ABG, CBC. Chest x-ray, head, chest and abd CT. How're his pupils? Skin signs? Does he have any wounds/ bed sores? Signs of recent trauma? What hx does he have besides the MS? Is he always on 02? Any missed/ accidental extra medication given? Initial tx leave him on the nasal cannula, get a line, bloods for testing, and NS 250ml fluid challenge, probably want a catheter to get the urine samples. Make sure he is maintaing his own airway Link to comment Share on other sites More sharing options...
delco714 Posted July 2, 2014 Share Posted July 2, 2014 Ohh, I deleted my statement after reading a good case for students. Think I know though, but I'll keep it shut and follow along :) Link to comment Share on other sites More sharing options...
Blue Goose Posted July 2, 2014 Share Posted July 2, 2014 Fakingpatience covered most of my immediate thoughts. Any indwelling devices that may be causing an infection? Can we get a look at his meds and history? I'm wondering about a Neurontin increase, mostly because I was on an ambulance call involving it-wouldn't explain the fever and tachycardia though. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
PYRITE Posted July 3, 2014 Share Posted July 3, 2014 good thoughts so far, add PE to DDX Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 UTI, pneumonia/ plural effusion, stroke/bleed, hyperglycemia, other infection... Hitting a wall on obvious diagnosis, sure I'm missing something big here EKG, blood glucose. Blood and urine culture. ABG, CBC. Chest x-ray, head, chest and abd CT. How're his pupils? Skin signs? Does he have any wounds/ bed sores? Signs of recent trauma? What hx does he have besides the MS? Is he always on 02? Any missed/ accidental extra medication given? Initial tx leave him on the nasal cannula, get a line, bloods for testing, and NS 250ml fluid challenge, probably want a catheter to get the urine samples. Make sure he is maintaing his own airway Ddx: You forgot cardiac (although you ordered EKG). And don't forget cardiac can be pipes (MI), electrical (arrhythmias), or structural (CHF/pericardial effusion). Labs: You ordered EKG which will help r/o STEMI and look for arrhythmia's, but what about troponin? You ordered blood sugar, but do you want to know about his electrolytes?? Why would you order the chest, abd and pelvis CT at this time? What is your indication? What are you looking for?? Sometimes we do shotgun tests in the ED because we have a sick person and have no idea what is wrong, or because we're busy and don't have time to adequately narrow down our ddx with a proper exam yet, but generally you want to have a significant pretest probability before you order a test, otherwise you will increase your false positive rate. Pupils were sluggish but reactive, no skin signs. Just an obtunded old guy. Fakingpatience covered most of my immediate thoughts. Any indwelling devices that may be causing an infection? Can we get a look at his meds and history? I'm wondering about a Neurontin increase, mostly because I was on an ambulance call involving it-wouldn't explain the fever and tachycardia though. Surprisingly few meds. Think it was only apap and a multivitamin. Confirmed this three times cause I didn't believe it. History fairly unremarkable. Put in skilled nursing 10 years ago after a flare of MS left him with a weakened left side. NO oxygen at home. Correct, neurontin increase wouldn't explain fever and tachycardia. Speaking of fever and tachycardia (and tachypnea)....what definition does that buy us? Okay, here's what I was thinking at the time. Old guy, nursing home, chronic left sided weakness, altered, febrile, tachy, tachypnic, requires 4L to maintain 94%, diminished left side breath sounds....I'm thinking sepsis from pneumonia. I ordered CBC, CMP (because we always do that in the ED, I had no indication of liver dz), EKG, troponins, CXR, and urine. I tried to order lactic acid, but it is a send out. ABG wouldn't be a bad idea, but I'm pretty sure it would tell me he was hypoxic and acidotic...I already knew that. Ordered a 500CC bolus of NS. First things back were the CXR, CBC and EKG. CXR showed a patchy infiltrate in RML, otherwise normal. CBC showed white count of almost 27K with 44% bands. EKG showed a RBBB, left bifasicular block, with no sign of S1Q3T3. Do you have a diagnosis? If so, what's your treatment?? Link to comment Share on other sites More sharing options...
PYRITE Posted July 3, 2014 Share Posted July 3, 2014 Severe Sepsis, 1. be prepared to support airway and give fluid support 2. get blood, urine and sputum for culture 3. start empiric ABX (antipseudomonal PCN + FQ + vanco) Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 Severe Sepsis, 1. be prepared to support airway and give fluid support 2. get blood, urine and sputum for culture 3. start empiric ABX (antipseudomonal PCN + FQ + vanco) Allright, kinda what I was thinking too. Figured we had a little aspirational pneumonia going on. As I was waiting for the CMP and trop to come back we hung levaquin I was writing admission orders for pneumonia. Then the CMP came back. ALT 350, AST 250, Alk Phos 200. Otherwise normal. Trop negative. Now what are you thinking?? Link to comment Share on other sites More sharing options...
PYRITE Posted July 3, 2014 Share Posted July 3, 2014 Ascending cholangitis? Link to comment Share on other sites More sharing options...
Blue Goose Posted July 3, 2014 Share Posted July 3, 2014 Allright, kinda what I was thinking too. Figured we had a little aspirational pneumonia going on. As I was waiting for the CMP and trop to come back we hung levaquin I was writing admission orders for pneumonia. Then the CMP came back. ALT 350, AST 250, Alk Phos 200. Otherwise normal. Trop negative. Now what are you thinking?? Could this be secondary to the sepsis and not the original disease pattern? Without elevated bilirubin, is biliary obstruction a possibility? Link to comment Share on other sites More sharing options...
MedicinePower Posted July 3, 2014 Share Posted July 3, 2014 Any pain or guarding when palpating the RUQ? Any jaundice? Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 Ascending cholangitis? That suddenly jumped up on the list didn't it! Any pain or guarding when palpating the RUQ? Any jaundice? No pain at all to deep palpation anywhere in the abdomen. When I got this I went back and reexamined to make sure. Nothing. Sorry to all, forgot to post the elevated tbili. Can't remember the specific number, but it was mildly elevated. What about the alk phos. What does that make you think about?? Link to comment Share on other sites More sharing options...
cinntsp Posted July 3, 2014 Share Posted July 3, 2014 What about the alk phos. What does that make you think about?? Liver/biliary vs. bone, but with the LFTs elevated it's less likely bone. GGT or isoenzymes can confirm but I don't think there is a need. I'm not sure that the alk phos is particularly telling here. Link to comment Share on other sites More sharing options...
MedicinePower Posted July 3, 2014 Share Posted July 3, 2014 Increased alkaline phosphatase makes me think of a possible obstruction of the bile duct. Since his WBC is so high I suspect there is a bacterial infection occurring. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 Alk phos in old guy almost always = CA. So with his LFTs and alk phos, and hx of constipation, I'm thinking he's got pneumonia and a CA in Hus belly. CT reversed that for me. Choledocolithiasis with dilatation + mesenteric lymphadenopathy. And the infiltrate looked more like a mass on CT. So, what does he have? What is ER tx and next step?? Link to comment Share on other sites More sharing options...
MedicinePower Posted July 3, 2014 Share Posted July 3, 2014 It's also possible he has a bone infection or bone cancer, thus requiring electrophoresis to distinguish the ALP as liver or bone. Link to comment Share on other sites More sharing options...
PASASM92 Posted July 3, 2014 Share Posted July 3, 2014 I love this. Keep going! Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 It's also possible he has a bone infection or bone cancer, thus requiring electrophoresis to distinguish the ALP as liver or bone. Could be. But I think we usually bypass the electrophoresis and go to CT or MRI to look for, and determine extent of, any bone infx/CA. so, with that ct report, whats he got, and what do we do? Link to comment Share on other sites More sharing options...
MedicinePower Posted July 3, 2014 Share Posted July 3, 2014 Could be. But I think we usually bypass the electrophoresis and go to CT or MRI to look for, and determine extent of, any bone infx/CA. Right, I just remembered the very rural part. When scanning for infection or cancer of bones how does one choose where to start? Is he complaining of pain from a particular limb or body region? Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 No, no complaint of pain at all. After a half liter of NS he became more alert and more conversational. Despite being asked scores of times he never said he hurt anywhere. Link to comment Share on other sites More sharing options...
delco714 Posted July 3, 2014 Share Posted July 3, 2014 why does your lactate get sent out? We have a 2 minute istat for pretty much everything important including BMP and HnH Link to comment Share on other sites More sharing options...
cinntsp Posted July 3, 2014 Share Posted July 3, 2014 why does your lactate get sent out? We have a 2 minute istat for pretty much everything important including BMP and HnH It may get sent out if ordered as an individual test in a smaller rural lab but an ABG(or a VBG if wanting to avoid the arterial stick) would have given the same info. Occasionally you will find an ABG analyzer that doesn't do lactate but I would expect even a small facility to have the capability to run a lactate in one way or another. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted July 3, 2014 Author Share Posted July 3, 2014 why does your lactate get sent out? We have a 2 minute istat for pretty much everything important including BMP and HnH heck if I know....it was a locums job. Link to comment Share on other sites More sharing options...
medic25 Posted July 3, 2014 Share Posted July 3, 2014 I tried to order lactic acid, but it is a send out. That's a tough one. You might want to ask the hospital about point of care lactate testing as an alternative. We use IStat lactic acids all the time. There is also a small lactic acid meter similar to a glucometer; we did a trial with it for EMS and it was very accurate. Link to comment Share on other sites More sharing options...
Blue Goose Posted July 3, 2014 Share Posted July 3, 2014 There is also a small lactic acid meter similar to a glucometer; we did a trial with it for EMS and it was very accurate. Not trying to derail the thread, but what were the results of the trial, in terms of patient outcomes? Do you have a sepsis protocol? Was it just used to rule in suspected sepsis, or were there broader indications? My EMS system was supposedly creating a trial of the same device, but it got scrapped with an explanation that the meters were no longer available. Link to comment Share on other sites More sharing options...
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