Signing off

As it was my last official morning report on Friday, 

I thought i would jsut bring up the topic of safe sign over, as I sign off to Amin.

An effective handover is crucial for safe patient care. 

The mneumonic "SIGNOUT?" can be used to remind us what should be included. See this article for more details.  

S - Is the patient sick? Stable? Code Status? 
I- ID 
G - General Hospital Course 
N - New events of the day 
O - Overall clinical condition 
U - Upcoming possibilities (those that can reasonably anticipated) with plan/rationale 
T - Tasks to complete overnight (explicit instructions) and rationale 
? - Any questions

Thanks for reading, 
I hope this was helpful.

-Alyse

Alyse, Amin & Leslie

joints, kidneys and minimal tsh

Yesterday we discussed approach to a patient with a single angry joint. 

Although the history and physical exam is crucial, there are no physical exam findings that reliably rule in or out septic arthritis according JAMA Rational Clinical Exam paper linked HERE.

For the Joint aspirate:

WBC over 100,000- Positive LR 28

WBC over 25,000- Positive LR 2.9

WBC less than 25,000- Negative LR 0.32

PMN over 90%- Positive LR 3.4; Negative LR 0.34

This isn't perfect either. 

◦    The absolute leukocyte count can be used to differentiate inflammatory from non-inflammatory fluid; however, it cannot be used to differentiate between inflammatory conditions, such as septic arthritis and crystal arthropathy!

◦    Traditional teaching suggests that cell counts greater than 50,000 WBC/mm3 are indicative of septic arthritis. THIS IS NOT TRUE! Crystal arthropathies and rheumatic disorders may present with cell counts this high.

AND septic arthritis may have cell counts < 50,000 WBC/mm³

Polymorphonuclear cell (> 90%) suggests the presence of an inflammatory condition, regardless of the total cell count!!

Also, the culture and sensitivty aren't perfect either.

Gram stain: sensitivity is  75%; Culture up to 90%

--> A special thanks to Dr. Ali Kara for discussing a case of AKI this morning. Click here for a NEJM CPC that goes over the approach to ARF

-->Although we didn't talk about it today, a patient was admitted last night with thyroid storm.
Here is a previous post on Thyrotoxicosis, with a good article on thyroid emergencies. 

DKA

Today we reviewed a case of ?syncope which turned out to also involve DKA.


We reviewed: What are the problems going on in DKA: (and how to manage)

1.     dehydrationà3-6L deficit: Must restore extravascular and intravascular fluid, increase renal perfusions and clearance of glucose

2.     electrolytes (K!!!!) Total body depletion! (initially may be shifted because of hypo-insulin)

3.     hyperglycemia: insulin  to get rid of ketones and stop lypolisis

4.     acidosis

Treat:

1.     Iv NS à a lot!!!!

2.     Replace K when <5.3 and run in fluid, Hold insulin if until K>3.0;

3.     Insulin drip at 0.1 U/kg; add sugar to your saline if AC<15

4.     Acidosis: don’t give bicarb if >6.9; not helpful (? Increase in intracellular CNS acid)

*** keep a close eye on sugar (q1h), lytes and gas (q2-4h) ****

What can KILL in DKA:

1.     Low K

2.     Too MUCH insulinàhypoglycemia

3.     UNDERLYING cause

(Ischemia, iatrogenic, intoxication, insulin non compliance, initial presentation, intra-abdominal process)

When to consider transitioning to subcut insulin:

·      -->follow AG since takes longer to stop ketogenesis and clear ketone than correct glucose

·      -(Bicarb will trail behind because non-AG acidosis from the NS)

-->patient is EATING

  Here is a review on DKA. 

anaphylaxis take 3

Today we discussed a case of a women who had an anaphylactic reaction post gold infusion.

Typically we think of the following drugs in association with anaphylaxis (although a lot of drugs can cause rare reactions)

- Antibiotics (75% of all fatal anaphylactic reactions are due to penicillin)

• Non-steroidal anti-inflammatory agents (including aspirin)

• Anesthetics

• Latex

• Iodine (contrast)

Our previous talks on anaphylaxis can be viewed HERE and HERE, review articles and doses can be found on those pages. 

On D/C a good plan would consider the following:

• Ensure that the patient understands she has a serious allergy, and Document it in the medical chart

• EpiPen Rx and instructions for use 
• MedicAlert bracelet 
• Written action plan if anaphylaxis recurs outside the hospital setting6 
• Notification of any outside providers 
• Consideration of referral to an allergist 

CPR or not to CPR

Today we discussed some issues of attaining code status.

Thanks to Allen Greenwald to providing us with video footage that the current R2's did for their holiday rounds.

As we mentioned today, this is a tough discussion, and there are many patient and family factors that complicate this.

Key things to express to the family: 

• DNR does NOT mean do not treat
• Goals of care can be readdressed at ANY time
• decisions should be made as per what the PATIENT's wishes are 

In general this is a hard and complicated discussion to have with families who may never had any exposure to this concept. Giving a 'menu' of options is confusion and typically not helpful.

Encourage discussion between family and patients and try to advise what medically makes sense. 

Some interesting articles:

This is an interesting NEJM article on the influence of television code on people's perceptions.

This article shows how our discussions influence the decisions of our patients.