Chief’s Case 10-11-16

First Chief’s case of the season is over and done.  The focus was on clinical reasoning and going through the steps of creating an appropriate problem representation, that leads to a differential diagnosis, which then triggers illness scripts.

Clinical Reasoning Tips to take away:

  1. Problem Representation-  Create an effective “1-liner” about the patient and their story
    1. Salient features- i.e. fever, rash, lab abnormalities
    2. Temporal relation of conditions
    3. Syndrome
  2. Illness Scripts- mental summary of a provider’s knowledge of a disease
    1. Predisposing conditions
    2. Pathophysiological insult
    3. Clinical consequences

Example from Chief’s Case (Malaria):

Problem Representation:

  • 29 year old pregnant female, recently traveled to Sudan, presents with ~1 week of fever, shortness of breath, epigastric pain, found to have elevated total bilirubin, metabolic acidosis, anemia and thrombocytopenia.

Illness Script:

  • Malaria
    • Pathophysiology- plasmodium infection, transmitted by mosquitos, going to liver and then invading RBCs
    • Epidemiology- endemic areas (Sub-Saharan Africa and Southeast Asia), increased infection for young children, immunocompromised, pregnant women.
    • Time Course- days to weeks, can lie dormant (P. vivax or P. ovale) for months in liver
    • Salient symptoms/signs- fever, chills, nausea/vomiting/diarrhea, abdominal pain, tachycardia, tachypnea, headache
    • Diagnostics- anemia, thrombocytopenia, LFT abnormalities, U/S with hepatosplenomegaly.  Thick/thin smear (x3 to completely rule out).
    • Treatment- depends on resistance pattern and pregnancy status.  Will need definitive treatment for dormant liver parasites.

Thank you for the expert opinion from Drs. Dan Mueller and Bizath Taqui!

Endocarditis

Definition: Infection involving the inner lining of the heart, often involving the valves.

TUH In-Hospital Mortality- ~23%

5-Year Mortality- 40%

Risk Factors: Prosthetic valve, history of IE, intracardiac devices, rheumatic heart disease, age, hemodialysis, IV drug abuse, HIV (?), diabetes

Valves affected (TUH): Aortic 34%,Mitral 36%, Tricuspid 33%, Pulmonic 2%

Microbiology (TUH): S. aureus 58%, Viridans strep 9%, Coag. neg staph 5.5%, Enterococcus 6%

Clinical and Laboratory Findings on Admission (most common): Fever >38C, Elevated ESR/CRP, Worsening of old murmur, New murmur, Vascular embolic event, Hematuria

Complications: Cerebral (CVA, TIA, brain abscess, meningitis), Intracardiac abscess, CHF, conduction abnormalities, Osteomyelitis/Distant abscesses

Modified Duke Criteria:

Major-

  • Positive blood culture for typical IE
  • Echo with intracardiac mass, abscess, prosthetic valve dehiscence, new valvular regurgitation

Minor-

  • Predisposing heart condition
  • IV drug abuse
  • Temp >100.4
  • Vascular phenomena: arterial emboli, pulm infarcts, Janeway lesion
  • Immunologic phenomena: Osler nodes, Roth spots
  • Other positive blood cultures

Diagnosis:

  • Blood cultures (2 sets)
  • CXR
  • ECG
  • Echo (TTE vs. TEE)
    • Especially with S. aureus
  • CBC, Basic met, Coags
  • ID consult, +/- CT surgery and cardiology

Treatment:

Empiric coverage- Vancomycin

MRSA-

  • Vancomycin 30mg/kg BID x 4 weeks

Viridans strep-

  • Penicillin G q4h x 4 weeks
  • Ceftriaxone 2g daily x 4 weeks
  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Pen-Allergic Patients: Vancomycin 30mg/kg BID x 4 weeks

MSSA-

  • Oxacillin 2g q4h x 4-6 weeks
  • Cefazolin 2g q8h x 4-6 weeks
  • Pen-Allergic Patients: Cefazolin 2g q8h x 4-6 hour OR Vancomycin 30mg/kg BID x 4-6 weeks

Enterococcus-

  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Ampicillin 2mg q4h PLUS Gentamicin q8h x 4 weeks
  • Vancomycin 30mg/kg BID x 4 weeks PLUS Gentamicin q8h x 4 weeks
  • Ampicillin PLUS Ceftriaxone

HACEK-

  • Ceftriaxone 2g IV daily x 4 weeks
  • Ampicillin 2g q6h PLUS Gentamicin q8h x 4 weeks

Prosthetic Valve Endocarditis- Viridans Strep

  • Penicillin G x 6 weeks +/- Gentamicin x 2 weeks
  • Ampicillin x 6 weeks +/- Gentamicin x 2 weeks
  • Vancomycin 30mg/kg BID x 6 weeks

Prosthetic Valve Endocarditis- S. aureus

  • MSSA
    • Oxacillin 2g q6h x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks
  • MRSA
    • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks

Prosthetic Valve Endocarditis- Enterococcus

  • Ampicillin 2g q6h x 6 weeks PLUS Gentamicin x 6 weeks
  • Penicillin G x 6 weeks PLUS Gentamicin x 6 weeks
  • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 6 weeks

Valve Replacement Indications

  • Major
    • Heart Failure
    • Uncontrolled Infection
    • Prevention of Embolic Events
  • Other Indications
    • Fungal
    • Pseudomonas species
    • Perivalvular abscess
    • Valve Dehiscence

Prophylaxis

  • Prosthetic cardiac valve
  • Previous episode of IE
  • Unrepaired cyanotic congential heart disease
  • Heart transplant recipients with cardiac valvulopathy

Sepsis

Thank you Dr Erin Narewski for a shocking lecture!

  • Start antibiotics within one hour of recognition of severe sepsis or septic shock. Remove any lines or debride any tissue which may serve as a source.
  • Initial resuscitation efforts
    • CVP 8-12mmHg, MAP >65, Urine output >0.5 mL/kg/hr, Central venous or mixed venous oxygen sat 70 or 65%, respectively.
  • Patients with elevated lactate levels targeting resuscitation to normalize lactate
  • Transfusion goal of >7 g/dL in those without other circumstances (MI, severe hypoxemia, acute hemorrhage, ischemic heart disease).
  • Transfuse platelets with counts <10,000 in absence of bleeding. Prophylactic platelets when counts <20,000 with significant risk of bleeding. Counts greater than 50,000 when active bleeding is occurring, surgery or invasive procedure are planned.
  • Glucose goal <180 mg/dL. Be wary of point-of-care testing of capillary blood (maybe falsely low)
  • Do not use sodium bicarbonate in patients with hypoperfusion induced lactic academia with pH >7.15
  • Vasopressor therapy is to target a MAP of 65mmHg. Norepinephrine is the first choice, followed by epinerphine.
  • Discuss goals of care and prognosis with patients as early as is feasible.

Common Infections – Dr Moyer

Darilyn Moyer started off our Intern Summer Conference Series with her essential Common Infections lecture.  Here are the highlights:

Below are The Daily Three, the top three points of each lecture:

  1. Pharyngitis DDx:
    • Group A Strep (5-10% in adults–not close to 100%!)
    • Other Bacteria (mycoplasma, C. pneumoniae, GC, anaerobes)
    • Resp viruses (adenovirus, influenza, parainfluenza, rhinovirus, RSV)
    • Other viruses (Coxsackie, Echo, HSV, **EBV**, **HIV**)
  2. Centor Criteria: (determines probability of GAS pharyngitis; if 4 criteria met: then can treat; 3 criteria: throat swab or treat; 2 criteria: no treatment though can test if personal preference; 0-1 criteria: unlikely GAS)
    1. Fever (by history)
    2. Tonsillar exudates
    3. Tender anterior cervical adenopathy
    4. Absence of cough
  3. UTI:
    • Uncomplicated cystitis: dysuria, urinary frequency/urgency; no fever or flank pain; (non-pregnant females only)
    • Complicated: same diagnostic s/s as uncomplicated; (all others: males, any medical illness such as DM, pregnant)
    • Acute Pyelonephritis: cystitis criteria with flank pain and/or fever
    • Females with h/o UTI have relatively high specificity for self-diagnosing UTI–> so you can treat over the phone if uncomplicated!

Check out the lecture powerpoint here! (password: same as the amion password)