SOAP NOTE WEEK 6

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Internal Medicine 21: 78-year-old male with fever, lethargy, and anorexia User: Yulak Landa Email: [email protected] Date: January 8, 2021 4:25AM

Learning Objectives

The student should be able to:

Differentiate between the types of shock and their presentations. Discuss the common causes for and symptoms of lower gastrointestinal blood loss. Propose appropriate empiric therapy for urosepsis based on an understanding of urinary tract infection pathogenesis and resistance patterns. List elements of physical exam in patient with suspected GI bleed. Take an accurate blood pressure. Interpret a urinalysis. Propose laboratory and diagnostic tests to evaluate GI bleeding. Define the physician’s role when a patient is no longer capable of making medical decisions.

Knowledge

Fever

Fever can be associated with infection, malignancies, and autoimmune conditions.

Lethargy

Lethargy is a form of drowsiness. Drowsiness is defined as not perceiving the environment fully and responding to stimuli appropriately but slowly or with delay. The patient may be roused by verbal stimuli but may ignore some of them. The patient is capable of verbal response unless aphasia, aphonia, or anarthria is present.

Anorexia

Anorexia is defined as loss of appetite. Anorexia can be seen in depression; malaise, with febrile illnesses; gastroenteritis; dementia; as well as alcohol and drug addiction. Many medicines may also have the undesired side effect of suppressing appetite.

Sepsis

Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection

Septic Shock

Septic shock is a subset of sepsis in which there are profound circulatory, cellular, and metabolic abnormalities and are associated with a greater risk of mortality than sepsis alone. Patients with septic shock can be clinically identified when presenting with sepsis and persistent hypotension requiring vasopressors to maintain a MAP (mean arterial pressure) ≥ 65mmHg and have a serum lactate level >2 mmol/L (18mg/dL) despite adequate volume resuscitation. With these criteria, hospital mortality is in excess of 40%. Patients with suspected infection who are likely to have a prolonged ICU stay or to die in the hospital can be promptly identified at the bedside if they have a positive quick Sequential Organ Failure Assessment (qSOFA) score characterized by at least two of the following: alteration in mental status, systolic blood pressure ≤100 mm Hg, or respiratory rate ≥22/min.

Anion Gap

The anion gap is calculated using the formula: Na - (chloride + bicarbonate). The result should be 12 or less.

An elevated anion gap is consistent with a metabolic acidosis caused by various ingestions, lactic acidosis from poor organ perfusion, diabetic ketoacidosis, or significant uremia (very elevated BUN).

Organisms Responsible for UTI-Associated Sepsis

Although gram-positive organisms account for most cases of sepsis, gram negatives are responsible for the majority of UTIassociated sepsis.

Usually the community-acquired pathogens (E. coli, Klebsiella, and Proteus) would be the most likely (70 to 80%); a negative nitrite on UA would make them less likely, however.

Although Citrobacter and Pseudomonas are gram negatives, they are typically associated with hospital or health care-related infections.

Enterococci are a possible cause. Staph saprophyticus is uncommon in males (< 10%) due to the length of the urethra. Group B Strep can sometimes been seen in patients with diabetes.

Delirium - Definition, Associated Symptoms

Definition: Relatively acute decline in cognition that fluctuates over hours or days.

Hallmark: A deficit of attention, although all cognitive domains-including memory, executive function, visuospatial tasks, and language-are variably involved.

Associated symptoms: Altered sleep-wake cycles, perceptual disturbances such as hallucinations or delusions, affect changes, and autonomic findings including heart rate and blood pressure instability.

Diverticulosis vs Diverticulitis

Diverticulosis is the presence of multiple diverticuli (small pockets in the colon due to defects in the wall). Diverticulosis should be distinguished from diverticulitis, when diverticuli fill with stagnant fecal material setting up the inflammatory cascade. Diverticulitis can cause obstruction or perforation. Bleeding usually occurs in a non-inflamed diverticulum (i.e., in the setting of diverticulosis).

Upper vs. Lower Gastrointestinal Bleeds

Upper GI Bleed Lower GI Bleed

Melena: black, sticky, and tarry stools, typically associated with upper GI bleeding.

Hematochezia: the passage of visible blood in the stool, typically associated with lower GI bleeding.

Above the Ligament of Treitz

Below the Ligament of Treitz

Typically, upper bleeds are from erosive esophagitis, varices, gastritis, gastric, and duodenal ulcers.

Bleeding below the Ligament of Treitz is almost always from the colon; jejunal or ileal sources of bleeding are rare. Conditions such as ulcerative colitis, diverticulosis, infectious colitis, and colon cancer are common causes. In the elderly, we must also consider angiodysplasia (degenerative or congenital structural abnormality of the normally distributed vasculature), mesenteric ischemia, and ischemic colitis.

Transfusion Requirements

Transfusion of red blood cells is usually reserved for patients with a hemoglobin less than 7 g/dL who are hemodynamically stable.

Transfusions at higher hemoglobin levels is individualized based on factors such as hemodynamic stability, active hemorrhage, symptoms of blood loss and acute coronary syndrome.

Ischemic Colitis vs Acute Mesenteric Ischemia

Ischemic colitis must be differentiated from the more immediately life-threatening condition of acute mesenteric ischemia. These can often be distinguished clinically.

Ischemic colitis Occlusive mesenteric ischemia

Ischemic colitis is often found in older adult patients with underlying atherosclerotic cardiovascular disease (ASCVD). Prolonged hypotension and decreased perfusion affect blood supply to the colon. This often affects the "watershed areas" near the splenic flexure and sigmoid colon where blood is supplied from terminal branches of several arteries. There often is little or no pain, and bleeding is usually self-limited once circulation is restored.

Occlusive mesenteric ischemia also occurs in older adult patients with ASCVD. Acute occlusive mesenteric ischemia is a catastrophic event resulting from complete occlusion of an artery or branch. It is usually due to thromboembolic disease - risk factors include valvular heart disease, atrial fibrillation or recent vascular catheterization. Pain is often out of proportion to the examination findings. In other words,

Recovery is often complete. This is also known as nonocclusive mesenteric ischemia.

patients have severe pain while their exam can appear quite normal.

Surrogate Decision-Makers

Once a patient is determined to be incapable of making a medical decision, a surrogate decision-maker is identified to make medical decisions on his or her behalf. Thirty-one states have laws listing a legal hierarchy of surrogate decision-makers.

The order in Washington State, for example, is as follows: court-appointed guardian, DPOA for healthcare, spouse, adult children, parents, and adult siblings. If a patient is married, the spouse becomes the legal surrogate, unless he has completed a DPOA for health care or the court has appointed a legal guardian.

Physicians assess decision-making capacity as a part of routine clinical care. Any physician, not just a psychiatrist, has the authority to determine if a patient has decision-making capacity for a specific medical decision.

In contrast, "competence" is a legal term. Only the courts can determine if a patient is competent to make one or more decisions. Physicians do not determine if patients are competent but often testify at competency hearings.

When courts determine competency, they rely on state laws that define incapacity, which differ slightly across states.

Clinical Skills

Recommendations for Blood Pressure Measurement

The "ideal" cuff should have a bladder length that is 80% and a width that is at least 40% of arm circumference (a length-to-width ratio of 2:1). A recent study comparing intra-arterial and auscultatory blood pressure concluded that the error is minimized with a cuff width of 46% of the arm circumference.

The recommended cuff sizes are:

Arm circumference: Cuff size should be:

22 to 26 cm "small adult" size: 12X22 cm

27 to 34 cm "adult" size: 16X30 cm

35 to 44 cm "large adult" size: 16X36 cm

45 to 52 cm "adult thigh" size: 16X42 cm

The optimum ratios of width and length to arm circumference are shown for the small adult and standard adult cuffs. For the large adult and thigh cuffs, the ideal width ratio of 46% of arm circumference is not practical, because it would result in a width of 20 cm and 24 cm, respectively. These widths would give a cuff that would not be clinically usable for most patients, so for the larger cuffs, a less than ideal ratio of width to arm circumference must be accepted. The ideal ratio of length to arm circumference is maintained in all four cuffs.

In practice, bladder width is easily appreciated by the clinician but bladder length often is not, because the bladder is enclosed in the cuff. To further complicate the issue for clinicians, there are no standards for manufacturers of different sizes of blood pressure cuff. This has led to significant differences in which arm circumferences are accurately measured by individual manufacturers' standard adult and large adult cuffs.

Individual cuffs should be labeled with the ranges of arm circumferences, to which they can be correctly applied, preferably by having lines that show whether the cuff size is appropriate when it is wrapped around the arm. In patients with morbid obesity, one will encounter very large arm circumferences with short upper arm length. This geometry often cannot be correctly cuffed, even with the thigh cuff. In this circumstance, the clinician may measure blood pressure from a cuff placed on the forearm and listening for sounds over the radial artery (although this may overestimate systolic blood pressure) or use a validated wrist blood pressure monitor held at the level of the heart.

Management

Fluid Challenge

The best immediate treatment for sepsis is a fluid challenge or bolus, typically 10 to 30 cc/kg of normal saline (NS) or lactated ringer's (LR) over 30 minutes depending on the patient's status and associated conditions.

For instance, if the patient suffers from congestive heart failure, give a smaller bolus, such as 10 cc/kg. If there are no other underlying problems, such as chronic kidney disease, then give him the larger bolus. Use NS or LR because they are isosmotic and will provide immediate restoration of intravascular volume while also providing tissue rehydration.

Empiric Antibiotic Treatment of Community-Acquired UTI-Associated Sepsis

Ampicillin may still be effective treatment; however, high resistance rates preclude its use as empiric first-line therapy. TMP/SFX is also an alternative, but resistance rates against this agent vary and make it, too, less desirable as first-line treatment. Both third and fourth generation cephalosporins are good choices because of their broad gram-negative and partial gram-positive coverage. An aminoglycoside is not a good choice of empiric drug, primarily due to its nephrotoxicity, but it should be considered if Pseudomonas is a possibility.

Ideally, knowledge of your hospital's antibiogram for isolated pathogens can provide the best information in helping choose empiric therapy.

After the organism and its sensitivities are known, antibiotic therapy can be better directed toward the offending pathogen.

Choosing Empiric Antibiotics for Gram-Negative Source

In general, if a gram-negative source is suspected, choose a third- or fourth-generation cephalosporin, piperacillin/tazobactam, ticarcillin/clavulanate, imipenem, meropenem, or aztreonam. Consider adding an aminoglycoside if the patient is immunocompromised.

Advance Care Planning

Advance directives are a way to help a patient's family make decisions about their health if they are too sick to make decisions for themselves.

Studies

Recommended Evaluation of Suspected UTI-Associated Sepsis

CBC with differential

A CBC with differential is important to look for leukocytosis. Leukopenia can also indicate a poor prognosis. Low platelet count might indicate DIC. Peripheral smear can also be helpful if microangiopathic hemolytic anemia suspected. Would expect to see schistocytes and helmet cells associated with hemolysis.

Chemistry panel

A chemistry panel is necessary to evaluate suspected metabolic derangement. When the physical exam is suspicious for dehydration, information about electrolytes and renal function are needed to administer appropriate IV fluids. Elevation of the hepatic transaminases (AST/ALT) may indicate hepatic dysfunction due to sepsis.

PT/PTT PT/PTT are important in assessing the presence of disseminated intravascular coagulation (DIC).

Lactic Acid A serum lactic acid level is important in the initial evaluation of a patient with suspected sepsis. An elevated level (e.g. >2 mmol/L) in the presence of hypotension may indicate organ hypoperfusion due to sepsis, and is associated with poor prognosis.

A UA can be done quickly once urine is obtained. Examination of sediment can determine the presence of WBCs, indicating infection; WBC casts, indicating pyelonephritis; and RBCs and RBC casts indicating possible glomerulonephritis. Gram stain of an unspun specimen can confirm the presence of bacterial infection as well as morphology of the offending bacteria and help direct appropriate therapy. Specific gravity can aid in confirming dehydration.

Blood and urine cultures

Blood and urine cultures are necessary in isolating the causative organism(s) and determining sensitivities to direct appropriate antibiotic therapy.

Elevated PT/INR and PTT

Elevated PT/INR and PTT indicates there are multiple issues with the coagulation cascade. This can be seen in disseminated intravascular coagulation (DIC) due to sepsis.

Recommended Initial Workup of Hematochezia

CBC It is important to determine how severe the hematochezia is. A CBC will help you determine how much blood has been lost. One must be cautious, as very acute blood losses may not be evident on a CBC until after IV fluid has been given. An elevated white count can be present with ischemia or infectious colitis.

C. difficile toxin Clostridium difficile infection should be excluded in hospitalized patients exposed to antibiotics. This infection produces marked thickening of the colon on CT scan as well as very high total white blood counts. However, bloody stools are quite rare in C. difficile infection and also it typically does not develop for at least 48 hours after initiation of antibiotic therapy.

Type and screen

Type and screen should be performed on any patient you suspect you may need to transfuse with blood products, such as packed red blood cells. A type and cross minimizes the risk of transfusion reactions by matching the patient's blood type and potential antibodies to donor blood. Some hospitals prefer to obtain a type and screen first, since if a type and cross is done, the blood will be wasted if not administered to the patient.

Plain abdominal x- ray

A plain abdominal x-ray is a good initial imaging choice for severe abdominal pain, but is frequently non-specific. Plain films of the abdomen can be helpful in ruling out perforation (seen as free air under the diaphragm) or obstruction (seen as air-fluid levels). Distention or pneumatosis (gas in the bowel wall) can be seen in advanced ischemic colitis.

Electrolytes Electrolytes will likely be abnormal with bowel ischemia. Lactic acidosis may be present, manifesting as an elevated anion gap.

Coagulation studies

Elevated PT and aPTT are likely suggestive of disseminated intravascular coagulation.

Although not always part of the initial workup, a CT scan may be helpful if plain abdominal films are unrevealing. Although not very useful for acute GI bleeding, if ischemic colitis or obstruction is suspected, CT scan may confirm the presence of obstruction or show pneumatosis, bowel-wall thickening in a segmental pattern, and gas in the mesenteric veins consistent with ischemic colitis or mesenteric ischemia.

A colonoscopy can be considered if the diagnosis remains unclear after a CT scan and only if there is no clinical or radiologic evidence of peritonitis or perforation. A colonoscopy offers the opportunity to biopsy the colon to determine the underlying pathophysiology further. With suspected or known lower GI bleeding, a colonoscopy should be performed within 48 hours of onset. If a source of the bleeding is identified, colonoscopic procedures such as electrocautery or injection with epinephrine (depending on the identified cause) can be performed at the time of the initial procedure. Ischemic colitis may show pale mucosa with petechial bleeding; cyanotic mucosa can be seen in more severe disease. If ischemic colitis is identified, supportive measures can be instituted to restore intravascular volume and perfusion. If the bleeding is refractory despite colonoscopic intervention, a surgical consult should be obtained for possible resection of the ischemic segment. Pseudomembranous colitis is a hallmark of C. difficile infection and is seen as yellowish round plaques and membranes. Inflammatory bowel disease may also be diagnosed by pathology.

Clinical Reasoning

Differential of Shock

Septic shock commonly presents with delirium, a history of fever, and a suspected source of infection. Physical exam findings commonly seen with septic shock include fever or hypothermia (< 96.8F), tachycardia (> 90 beat/min), and tachypnea (RR > 20 breaths/min). Cardiogenic shock is associated with acute coronary syndromes and characterized by acute pulmonary edema and elevated jugular venous pressure (JVP). In hypovolemic shock there is typically a history of hemorrhage or significant volume loss (diarrhea, vomiting, or polyuria). Neurogenic shock is associated with severe spinal cord or central nervous system injury and bradycardia rather than tachycardia. Anaphylactic shock is typically associated with antigenic exposure and usually presents with urticaria, angioedema, and wheezing. Adrenal crisis often presents with abdominal pain, nausea, vomiting, weakness, lethargy, hypotension, and skin pigmentation.

References

American Medical Association. Council on Ethical and Judicial Affairs, American Medical Association. E-2.00 Opinions on Social Policy Issues. Code of Medical Ethics. Chicago: AMA Press; 2006.

Beauchamp TL, Childress JR. Principles of Biomedical Ethics. 4th ed. New York, NY: Oxford University Press; 1994.

Lo B, Steinbrook R. Resuscitating advance directives. Arch Intern Med. 2004;164(14):1501-6. DOI: 10.1001/archinte.164.14.1501.

Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill Companies, Inc.; 2012.

Napolitano LM, Kurek S, Luchette FA, et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. Crit Care Med. 2009;37(12):3124- 57. DOI: 10.1097/CCM.0b013e3181b39f1b.

National Hospice and Palliative Care Organization. http://www.nhpco.org/. Accessed March 22, 2019.

Opole, IO. Sepsis Syndrome. In: Alguire PC, ed. Internal medicine essentials for students: a companion to MKSAP for students 5. Philadelphia: American College of Physicians Press; 2011: 190-3

Pickering TG, Hall JE, Appel LJ, et al. American Heart Association Scientific Statement: Recommendations for blood pressure measurement in humans and experimental animals. Part 1: Blood pressure measurement in humans: A statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Hypertension. 2005;45(1):142-61. DOI: 10.1161/01.HYP.0000150859.47929.8e.

Quick Sepsis Related Organ Failure Assessment website. http://www.qsofa.org/. Accessed March 21, 2019.

Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10. doi:10.1001/jama.2016.0287.

Smerud MJ, Johnson CD, Stephens DH. Diagnosis of bowel infarction: a comparison of plain films and CT scans in 23 cases. AJR Am J Roentgenol. 1990;154(1):99- 103. DOI: 10.2214/ajr.154.1.2104734.

Snyder L, Leffler C. Ethics and Human Rights Committee, American College of Physicians. Ethics manual: fifth edition. Ann Intern Med. 2005;142(7):560-82.

Swetz,KM, Kamal, AH. Palliative care. Ann Intern Med. 2018;168(5):ITC33-ITC48. DOI: 10.7326/AITC201803060.

Tools and Training for Clinicians | Palliative Care Programs. Center to Advance Palliative Care. http://www.capc.org. Accessed March 22, 2019.

Wayne JT. Approach to fever. In Internal Medicine Essentials for Clerkship Students 2007-2008. Alguire PC, ed. Philadelphia: ACP Publishing: 2008.