Help with a patient case

[Crayola227]

Case 3
(Case 1 link - Case 2 link)

Two cases from the ED.

1:
The DNP in the emergency department calls your service saying shes "Got one for ya." 64 y/o African American female suffered sprained ankle chasing her granddaughter around the house. No other complaints, but during triage her BP was found to be 198/127. Her medications include lisinopril and a multivitamin. Her primary care physician is out of town, and she hasn't seen him in 7 months since her lisinopril dose was increased owing to missed follow-up appointment due to work-related emergency.

There are no reported constitutional symptoms, nor is there any chest pain, SOB, headache, nausea/vomiting, visual changes, arm/leg weakness, or recent syncopal episode. Exam reveals pleasant woman in NAD. There is no papilledema, RR with mid systolic ejection murmur, normal S1/S2. Lungs clear. Neuro exam is normal. Her Epic problem list includes "Stage II primary hypertension," "Osteoporosis," and "Tobacco-use disorder." FH is positive for stroke at age 85, and father still alive at 86 in Alzheimer's ward at nearby NH with multiple medical problems. She has private insurance through her job as an administrative assistant at a local university. She lives at home with her husband and is the primary caretaker of two young grand children while her daughter-in-law and son are out of the country for a 2 week archaeology dig in Malaysia.

A variety of tests were ordered in the ED and are as follows: EKG which shows NSR with incomplete RBBB pattern (unchanged from her EKG in the EMR of 3 years ago) and borderline voltage criteria for LVH. CXR is unremarkable. Troponin was 0.01 ng/mL. Serum Mg2+, TSH and free T4 were within normal ranges. Her calcium level is 8.7 mg/dL and Hgb is 11.6 g/dL. BUN/Cr are essentially the same as they were on the CMP done by her primary physician 7 months ago. You recheck BP in both arms and find 195/121 on left, 197/124 on right. Other vitals are normal.

After your exam, patient asks nurse for Advil due to a mild headache which she asserts she recently developed, citing her 8 hour stay in the ER without food and two screaming grand children. The NP wants to give her 20mg IV hydralazine and obtain non-contrast CT head since you are taking an excessive amount of time looking through the EMR and answering other pages.

I also, specifically what you think about new onset HA in this woman.

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[shookwell]

No MLP in my shop would ever order all those tests on a patient with asymptomatic hypertension. If an NP orders all that stuff I would yell at them and make sure they never do it again. I would have discharged with a refill of lisinopril after her ankle xrays were negative. The nurses have been instructed not to do ECGs in patients with asymptomatic hypertension and generally won't even put them in a bed because we tend to discharge them straight from triage.

 

[shookwell]

Also, giving her IV hydralazine is a terrible idea. If you really want to give her something, give her PO lisinopril, even though it's really unnecessary.

 

[lymphocyte]

Link to Case 3 below. I'm just a MS4 and probably messed up this case (and others), but I'd rather be made a fool over the internet than in real life. Can any attendings or residents pop over to the Allopathic forum to set us straight? I (and I'm sure others) would really appreciate your thoughts.

http://forums.studentdoctor.net/threads/intern-nf-case-3.1217005/

 

[BoardingDoc]

I also, specifically what you think about new onset HA in this woman.

I don't care about her HA at all. New onset HA in the ED which is minor (read: not thunderclap and without neuro deficits) and in the setting of HTN in a patient who has a known hx of HTN? Here is your tylenol and your discharge papers. Also agree with the above about the NP ordering a slew of unnecessary tests.

 

[BoardingDoc]

Also, even a quick review of the primary care literature doesn't seem to support doing much else here.

http://www.aafp.org/afp/2010/0215/p470.html

It talks about how this workup would be unwarranted even in an outpatient setting and how "headache not been shown to be a risk factor for end-organ central nervous system damage; therefore, imaging is generally not recommended."

 

[emergentmd]

For unreasonable pts, i usually throw the pt a clonidine, check chemistries, and send them home when BP better. Refill meds

For reasonable pts, I would prob just refill the meds if they are happy with this.

Unless there is another reason to admit, I would not do it.

My hospitalists are super easy too, but I can't burn all my connections with noncompliance. But if I really had to, I would prob get the pt to complain of chest pain (not difficult) and admit for rule out.

 

[alpinism]

Agree with BoardingDoc.

We see these patients in the ED literally every day.

Unless she met Ottawa ankle criteria she'd be promptly discharged with a script for Naprosyn.

 

[alpinism]

Link to Case 3 below. I'm just a MS4 and probably messed up this case (and others), but I'd rather be made a fool over the internet than in real life. Can any attendings or residents pop over to the Allopathic forum to set us straight? I (and I'm sure others) would really appreciate your thoughts.

http://forums.studentdoctor.net/threads/intern-nf-case-3.1217005/

"72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED."

I'd need more info to give you a helpful response. How fast is he breathing? Is he reliable to take his meds? Does he have good PCP follow up?

Look up CURB-65 on MDCalc.

 

[lymphocyte]

"72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED."

I'd need more info to give you a helpful response. How fast is he breathing? Is he reliable to take his meds? Does he have good PCP follow up?

Look up CURB-65 on MDCalc.

1. Happy to send out the door with lisinopril (if not compliant) or add on a thiazide with next day PCP follow-up. Here's the problem: falls risk with nobody at home makes me worried to mess around with antihypertensives, and this patient doesn't seem good with follow-up. The neurologists I've worked with are much more keen to treat (slowly and sanely) hypertensive urgency, especially in the context of CV risk factors, of which this woman has several. But the EM consultants mostly want her out the door with PCP follow-up, but not too sussed about when (ideally next day, but there's next day and there's "next day"). Both seem reasonable to me, and the neurologists don't have great evidence to support their view (certainly no mortality benefit).

Regarding the headache: Who did the neuro exam? I'm personally double-checking before discharge, but in the absence of any acute neurological deficits, I'm happy to send home without CT.

2. Azithro is weak sauce. Not adequate coverage and this guy has risk factors for macrolide resistant strains of Strep pneumonia anyways. He's also presumed septic with risk factors for progression to septic shock. I'm expanding coverage with ceftriaxone, getting a lactate, and clinically assessing fluid status. (I don't agree with the SS guidelines in this regard and think the literature argues against getting then too wet.) Happy to let SpO2 to sit at 95% but backup is HFNC as per FLORALI if desats < 88. Want a baseline EKG for this guy with CAD. If he's on the ward, I'm not at all convinced this is a stable admit. Clinically unwell with a pile of co-morbidities makes me worry this guy is crump-tastatic. Don't need a calculator for this one.

Two caveats: 1) on phone and 2) in Australia so we're really stingy, even about things like CT.

If anything I said strikes anybody as particularly stupid, please comment on the Allopathic forum so everybody can learn.

 

[goodoldalky]

First one can go home immediately, feel free to give some IV hydralazine if you want to try and stroke her out. Second one is an easy admit, add rocephin.

 

[Crayola227]

"72-year-old male nonsmoker with a history of diabetes, coronary artery disease, and hypertension who presents with pneumonia and needs to be admitted to the hospital per the ED staff. The patient is febrile and tachypneic, has a blood pressure of 145/65, and has an oxygen saturation of 95% on room air. Physical examination is significant for rhonchi in the right lower lung fields, and a chest x-ray shows a right lower lobe infiltrate. Laboratory studies show a white blood cell count of 14,000 and no evidence of acute renal failure. Blood cultures have been obtained and he is given 500mg IV Zithromax in ED."

I'd need more info to give you a helpful response. How fast is he breathing? Is he reliable to take his meds? Does he have good PCP follow up?

Look up CURB-65 on MDCalc.

Yeah, I did look it up and according to what we're given in the prompt he doesn't meet criteria for admission using CURB-65 or PORT score (in the case of PORT, it call for pH and PO2) . However, if he was tachypneic to the 30s, he would qualify based on that, but I'm making a few assumptions for both scores since the prompt is sorta ****ty.

C - confusion. (I'll say no because in most of these prompts if they don't say it you usually can assume normal)
U - BUN> 19 mg/dl - (we're told renal fxn nl)
R - RR - (tachypneic is over 2o, however for this criteria and PORT must be > 30. The prompt doesn't tell us HOW tachypneic)
B -BP < 90/60 (BP 145/65)
65 - >65 (1 pt, his is 72)

He gets 1 point using the assumptions I've made from a ****ty prompt because they don't actually give enough pertinents to know for sure his RR. The degree of his tachypnea would be useful if we assume he's not confused. So CURB-65 he gets 1 point, and you need more than 1 point for admission, which as I see it depends on RR using CURB-65.

Step 1: Stratify to Risk Class I vs. Risk Classes II-V
Presence of:
Over 50 years of age Yes/No YES
Altered mental status Yes/No
Pulse ≥125/minute Yes/No
Respiratory rate >30/minute Yes/No
Systolic blood pressure <90 mm Hg Yes/No
Temperature <35°C or ≥40°C Yes/No
History of:
Neoplastic disease Yes/No
Congestive heart failure Yes/No
Cerebrovascular disease Yes/No
Renal disease Yes/No
Liver disease Yes/No

If all "No" then assign to Risk Class I
If any "Yes", then proceed to Step 2

He got it for age, and the rest of the questions don't assign points,
So I'll continue for Step 2 and not focus on the above which was just meant to indicate whether we need Step 2 or not

Step 2: Stratify to Risk Class II vs III vs IV vs V
Demographics Points Assigned
If Male +Age (yr) 72
If Female +Age (yr) - 10
Nursing home resident +10 (we're not told this, gonna assume no)
Comorbidity
Neoplastic disease +30 (assume no, cancer isn't *that* common and prompt doesn't say)
Liver disease +20 (based on him getting his renal fxn tested, I might assume he had a BMP at least, not sure if CMP, but it's not given as a pertinent positive so assumed no)
Congestive heart failure +10 (prompt said CAD was all)
Cerebrovascular disease +10 (prompt doesn't say, will assume no)
Renal disease +10 (prompt said was normal)
Physical Exam Findings
Altered mental status +20 (assumed no)
Pulse ≥125/minute +10 (they never said! will assume <125 as I would assume they would say if not)
Respiratory rate >30/minute +20 (this is where I am pissed at the prompt, I'll calculate a score that is plus or minus 20 to see what the score is in either case) (+/- 20)
Systolic blood pressure <90 mm Hg +20 (BP 145/65)
Temperature <35°C or ≥40°C +15 (we are never told just how febrile he is, I don't want to assume he's 40 degress C or 104 F)
Lab and Radiographic Findings
Arterial pH <7.35 +30 (we aren't given this, I will assume normal so my next question is whether or not he needs an art stick? I would expect he's able to blow off his CO2 despite his PNA as he has no underlying lung dz to assume from prompt, non-smoker,if anything I would expect an acute respiratory alkalosis, he is satting fine and tachypneic, so no reason to think he's holding onto CO2 and is likely blowing it off with hyperventilation, and I'm not assuming he's in DKA based on prompt not mentioning elevated glucose) Any thoughts here appreciated.
Blood urea nitrogen ≥30 mg/dl (9 mmol/liter) +20 (we were told renal fxn WNL)
Sodium <130 mmol/liter +20 (I think to test renal fxn we likely have Na, will assume WNL)

Glucose ≥250 mg/dl (14 mmol/liter) +10 (he has DM (they didn't specifiy 1 or), but for reasons stated will assume WNL)
Hematocrit <30% +10 (they got a white count, so I assume a CBC, and I assume WNL aside from leukocytosis)

Partial pressure of arterial O2 <60mmHg +10 (this depends on whether or not you stick him, I was gonna ask this, however he is satting 95%)
Pleural effusion +10 (he has a CXR and that wasn't noted)

∑ <70 = Risk Class II 0.1% mortality
∑ 71-90 = Risk Class III 0.9% mortality
∑ 91-130 = Risk Class IV 9.3% mortality
∑ >130 = Risk Class V 27% mortality

So by my calculation 72 + 20 if tachypnea >30 = 92, moderate risk Class IV, 9.3% mortality
However if he is tachypneic but less than 30, his score is 72, Risk Class II 0.9% mortality

I think my assumptions are reasonable, but we need RR, temp (which I assumed less than 40 but still febrile), and Pao2 & pH to fully risk stratify. If those two are normal, and he's not at the extreme edge of temp & RR, than PORT would put him in low risk. However, RR, temp, and PaO2 and pH could put him over.

Curb-65 was easier and degree of tachypnea is needed to fully assess.

1) Do you do an art stick on this guy? Why or why not? What is a VBG good for? This might be a stupid question, I know.
Seems like doing that would just to be to use PORT over CURB-65 for admission, and I hate to art stick this guy to justify an admission I plan on doing anyway, especially if his tachypnea makes the CURB-65 indicate need for admision. But if it was the difference between admitting based on PORT vs not, then would it be reasonable? Or do we say **** PORT and it's call for pH an P02?

2) Another poster said as it stands he meets critieria for sepsis and should be admitted based on that.

3) Would the following be a good source for assessing this?

Special Communication | February 23, 2016 Caring for the Critically Ill Patient

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

Mervyn Singer, MD, FRCP1; Clifford S. Deutschman, MD, MS2; Christopher Warren Seymour, MD, MSc3; Manu Shankar-Hari, MSc, MD, FFICM4; Djillali Annane, MD, PhD5; Michael Bauer, MD6; Rinaldo Bellomo, MD7; Gordon R. Bernard, MD8; Jean-Daniel Chiche, MD, PhD9; Craig M. Coopersmith, MD10; Richard S. Hotchkiss, MD11; Mitchell M. Levy, MD12; John C. Marshall, MD13; Greg S. Martin, MD, MSc14; Steven M. Opal, MD12; Gordon D. Rubenfeld, MD, MS15,16; Tom van der Poll, MD, PhD17; Jean-Louis Vincent, MD, PhD18; Derek C. Angus, MD, MPH19,20

JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287
http://jama.jamanetwork.com/article.aspx?articleid=2492881#Results/Recommendations

Or say **** all of the above, he's getting admitted?
I hope none of this is taken to be argumentative, just for my own learning.

 

[Janders]

First one goes home. Start her on HCTZ or Norvasc to be nice. Call her PCP coverage and ask them to see her in a few days to be really nice. DO NOT GIVE IV MEDS TO MAKE THE NUMBERS PRETTY. Do not pass Go. Do NOT collect $200.

 

[Janders]

1) Do you do an art stick on this guy? Why or why not? What is a VBG good for? This might be a stupid question, I know.
Seems like doing that would just to be to use PORT over CURB-65 for admission, and I hate to art stick this guy to justify an admission I plan on doing anyway, especially if his tachypnea makes the CURB-65 indicate need for admision. But if it was the difference between admitting based on PORT vs not, then would it be reasonable? Or do we say **** PORT and it's call for pH an P02?


Don't do art sticks. a VBG will give you the pH within a couple percent. A VBG will give you a pCO2 within a couple percent. A pulse oximeter will give you oxygen sat. Art sticks are for rare/odd case, not deciding if a run of the mill CAP needs admission.


2) Another poster said as it stands he meets critieria for sepsis and should be admitted based on that.

"Sepsis" just means infection + SIRS, yes? Every college kid with strep throat (Fever 102, HR 115 on arrival, RR20) has "sepsis". They don't get admitted most of the time, eh?

3) Would the following be a good source for assessing this?

You should review sepsis-3. One thing you will learn is tachypnea is bad, and tachypnea is predictive of badness.


Anyway this case presentation is incomplete and you can't make a good argument either way. It is not a slam dunk admission (i.e. requiring supplemental oxygen, hypotensive, altered, many medical comorbidities) however tachypnea is concerning, and without known the RR or a complete set of labs, I can't tell you the answer. Likely he could go home in a low risk group if the RR is up just a little bit, he's tolerating PO, and looks good and has family support. As well, Azithro is not my favorite mono therapy for this group...

 

[lymphocyte]

1) Do you do an art stick on this guy? Why or why not? What is a VBG good for? This might be a stupid question, I know.
Seems like doing that would just to be to use PORT over CURB-65 for admission, and I hate to art stick this guy to justify an admission I plan on doing anyway, especially if his tachypnea makes the CURB-65 indicate need for admision. But if it was the difference between admitting based on PORT vs not, then would it be reasonable? Or do we say **** PORT and it's call for pH an P02?


Don't do art sticks. a VBG will give you the pH within a couple percent. A VBG will give you a pCO2 within a couple percent. A pulse oximeter will give you oxygen sat. Art sticks are for rare/odd case, not deciding if a run of the mill CAP needs admission.


2) Another poster said as it stands he meets critieria for sepsis and should be admitted based on that.

"Sepsis" just means infection + SIRS, yes? Every college kid with strep throat (Fever 102, HR 115 on arrival, RR20) has "sepsis". They don't get admitted most of the time, eh?

3) Would the following be a good source for assessing this?

You should review sepsis-3. One thing you will learn is tachypnea is bad, and tachypnea is predictive of badness.


Anyway this case presentation is incomplete and you can't make a good argument either way. It is not a slam dunk admission (i.e. requiring supplemental oxygen, hypotensive, altered, many medical comorbidities) however tachypnea is concerning, and without known the RR or a complete set of labs, I can't tell you the answer. Likely he could go home in a low risk group if the RR is up just a little bit, he's tolerating PO, and looks good and has family support. As well, Azithro is not my favorite mono therapy for this group...

Sepsis-3 is not uncontroversial and its first-contact clinical utility is questionable. Yes a SIRS-based definition has low-specificity, but the argument is that it's better from a systems of care perspective to have a higher-sensitivity screening tool that's easy to drill into people's heads. Infection + SIRS gets you about a 6-10% mortality, and the mortality for in-hospital AMI is around 5%. In both cases, early interventions matter, but which are we more assiduous about ruling out? Plus a lot of the treatment and outcomes data are grounded in the SIRS definition.

Still, this is an area that requires a lot of clinical judgement--bundles, calculators, and checklists be damned.

Simpson SQ. New Sepsis Criteria: A Change We Should Not Make. Chest. 2016;149(5):1117-8.

 

[WheezyBaby]

Iirc sirs misses about 1 in 8 true sepsis, so from a screening perspective not that wonderful in its own right

 

[lymphocyte]

Iirc sirs misses about 1 in 8 true sepsis, so from a screening perspective not that wonderful in its own right

You're absolutely right. In fact, it's 1 in 8 that ends up in the ICU, so it probably misses more. In Australia, SIRS isn't very popular for this reason. It still boils down to having a high index of suspicion regardless, since early interventions matter as per PROCESS, ARISE and PROMISE.

At the same time, qSOFA is kinda loopy, never meant for diagnosis only mortality, and all the data were retrospectively gathered from ICU patients who were already given antibiotics with cultures, so it's unclear about its utility in the EM world. From a systems of care point of view, I think SIRS + infection is the best we have (easy to teach with lots of data to support it), but the Sepsis 3 "organ dysfunction" definition is probably more physiological. Sepsis 3 still needs prospective validation though, especially outside the ICU.

Anyways, ACEP published an article explaining this a lot better than I can: https://www.acep.org/content.aspx?id=105419

 

[Crayola227]

1) Do you do an art stick on this guy? Why or why not? What is a VBG good for? This might be a stupid question, I know.
Seems like doing that would just to be to use PORT over CURB-65 for admission, and I hate to art stick this guy to justify an admission I plan on doing anyway, especially if his tachypnea makes the CURB-65 indicate need for admision. But if it was the difference between admitting based on PORT vs not, then would it be reasonable? Or do we say **** PORT and it's call for pH an P02?


Don't do art sticks. a VBG will give you the pH within a couple percent. A VBG will give you a pCO2 within a couple percent. A pulse oximeter will give you oxygen sat. Art sticks are for rare/odd case, not deciding if a run of the mill CAP needs admission.


2) Another poster said as it stands he meets critieria for sepsis and should be admitted based on that.

"Sepsis" just means infection + SIRS, yes? Every college kid with strep throat (Fever 102, HR 115 on arrival, RR20) has "sepsis". They don't get admitted most of the time, eh?

3) Would the following be a good source for assessing this?

You should review sepsis-3. One thing you will learn is tachypnea is bad, and tachypnea is predictive of badness.


Anyway this case presentation is incomplete and you can't make a good argument either way. It is not a slam dunk admission (i.e. requiring supplemental oxygen, hypotensive, altered, many medical comorbidities) however tachypnea is concerning, and without known the RR or a complete set of labs, I can't tell you the answer. Likely he could go home in a low risk group if the RR is up just a little bit, he's tolerating PO, and looks good and has family support. As well, Azithro is not my favorite mono therapy for this group...

Thank you for your response. I agree with you on the SIRS thing.

Yes, using the old SIRS and sepsis criteria, he qualifies at least on basis of fever, RR, and WBC, and dx of PNA.

However, using med-calc, I don't have enough data from prompt for SOFA, but I do for qSOFA.
That criteria is RR greater than or equal to 22
Systolic < 100
New/worsened altered mentation

And reading it looks like all of this is meant for patients going to the ICU. Without knowing his RR it's hard to tell from the prompt if he should go to ICU but I'm guessing not. If he's tachypneic 20-22, he doesn't get a point but I'll assume his tachypnea isn't in that narrow a range. So he gets that point.

Quote from med calc after I did his qSOFA:
"Patient not high risk by qSOFA. If sepsis is still suspected, continue to monitor, evaluate, and initiate treatment as appropriate, including serial qSOFA assessments."

So still curious if we want to go down a more aggressive sepsis pathway with this guy, or just broaden coverage and see how he does? Maybe he could go obs instead of admit?

 

[Crayola227]

I will say this, these discussions are prompting me to buy a newer version of the Sanford Guide to Abx.

The one I have now is too old I think , and did say in some populations mono therapy with Azithro for CAP was fine. So I'm going to get the new guide.

In the absence of a hospital antibiogram or other local data, multiple ID docs have urged me to follow that guide. I'm interested in what it will say.

 

[VA Hopeful Dr]

I will say this, these discussions are prompting me to buy a newer version of the Sanford Guide to Abx.

The one I have now is too old I think , and did say in some populations mono therapy with Azithro for CAP was fine. So I'm going to get the new guide.

In the absence of a hospital antibiogram or other local data, multiple ID docs have urged me to follow that guide. I'm interested in what it will say.

Sanford is great for lots of things, but I prefer the IDSA guidelines for things you are going to see a lot of.

 

[TooMuchResearch]

Thank you for your response. I agree with you on the SIRS thing.

Yes, using the old SIRS and sepsis criteria, he qualifies at least on basis of fever, RR, and WBC, and dx of PNA.

However, using med-calc, I don't have enough data from prompt for SOFA, but I do for qSOFA.
That criteria is RR greater than or equal to 22
Systolic < 100
New/worsened altered mentation

And reading it looks like all of this is meant for patients going to the ICU. Without knowing his RR it's hard to tell from the prompt if he should go to ICU but I'm guessing not. If he's tachypneic 20-22, he doesn't get a point but I'll assume his tachypnea isn't in that narrow a range. So he gets that point.

Quote from med calc after I did his qSOFA:
"Patient not high risk by qSOFA. If sepsis is still suspected, continue to monitor, evaluate, and initiate treatment as appropriate, including serial qSOFA assessments."

So still curious if we want to go down a more aggressive sepsis pathway with this guy, or just broaden coverage and see how he does? Maybe he could go obs instead of admit?

Read the whole sepsis 3 paper. Read commentary from the authors in their intentions. And then stop using it to stratify patients.