general session 6 ritchie - c.ymcdn.com file“not like this”. • mother has tried diaper creams...

4/10/2017

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Interesting Case Studies in Quick Care/Urgent Care

By Debbie Ritchie, FNP, GNP

and

Tara Flynn, MD

Conflicts of Interest: Disclosure

• No conflicts of interest: no disclosure

Objectives

• 1. Verbalize understanding of interesting cases that present in a quick care setting and urgent care setting.

• 2. Identify challenges that await nurse practitioners in a quick care setting.

• 3. Identify utilization of evidence based care in a quick care/urgent care setting.

• 4. Participate in open discussion of challenging cases encountered during a quick care setting.

4/10/2017

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Interesting Case Study #1

• 23 yo female presents to quick care with a rash that she has had for over 4 days. On dorsal surface of her fingers bilaterally, appears blistery and erythematous. 5 lesions on right hand, 2 lesions on left hand. Not painful. Bullae appearing: round. Not itchy.

Interesting Case Study #1 Continued

• She reports she has just finished Amoxicillin for strep throat 2 days ago: rash started before she completed her medication.

• Rash doesn’t itch: isn’t anywhere else on her body. No mucosal surfaces.

• Rash is only on dorsal side of her hands.

Case Study #1 Continued

• Exam reveals erythematous, raised, bulla type rash on dorsum of hands: otherwise normal.

• History reveals no medication allergies, no prior illnesses, no recent new products on hands/fingers.

• What are your differentials?

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Case Study #1

• Call placed to Dermatology• Dermatology report highly suspect dermal exanthem reaction to Amoxicillin, to put down as allergy to Amoxicillin (severe).

• Treated as drug allergy: benadryl, triamcinolone ointment to hands tid x 7 days.

• Percent risk of allergic response if has PCN allergy if I give Keflex for strep next time‐ 5% (by literature)

• Evidence: Essentialevidenceplus.com (July 7, 2016)

Table 1‐Most Common Meds Causing Cutaneous Reactions

• Amoxicillin 1.2‐8%• PCN 1‐4.4%• Cefaclor 1‐4.4%• Cephalosporins 1‐1.5%• Sulfa 2.5‐3.7%Incidence of cutaneous reactions is 10‐80/1000Adverse drug reactions account for 4.1% of hospital admissions.

Essentialevidenceplus.com (July 6,2016)


• 2 yo male presents with coughing all night. Accompanied per father. Father reports no fever. History of asthma. Father wants azithromycin‐always makes his cough go away. Cough x 1 night.

• VS‐pulse 120, oxygen saturation is 95%. R‐55, unlabored. Temperature‐37.2.

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• Differentials‐asthma exacerbation, bronchitis, upper respiratory infection, viral infection, croup, pneumonia.

• Physical exam:

lungs clear, heart normal sounds, tm’s normal, child active in clinic running around, respirations 50‐60.


• What would you do?

• What was done‐

• What happened‐


• 67 yo male presents with chief complaint of “cold s/s”. His wife died 2 weeks ago of PE. He’s been upset about this. Wants a Zpack.

• Reports sob when walking on exertion.

• VS‐Pulse 144 irregular, Respirations 22, BP 144/98, Temperature 38, oxygen saturation 99%.

• PMH: atrial fibrillation, thyroid cancer

• Meds: Levothyroxine, Coumadin

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Case Study #3

• PE‐ Lungs clear, Heart rate irregular, HEENT‐normal,

• Oxygen saturation left on during exam and patient asked to walk with oxygen sat on.

• Oxygen saturation desaturates down to 88 with having patient walk around room talking to you.

Case Study #3

• Differential‐atrial fibrillation, pneumonia, PE, bronchitis, hyperthyroid (TSH suppression)

• Plan‐patient sent to ER for further evaluation.

• What was found…..

www.nhibi.nih.gov


• 2 yo female child with diaper rash.

• Mother reports sudden onset yesterday: child screams with diaper changes: has had diaper rashes before but “not like this”.

• Mother has tried diaper creams but she screams with them.

• No fever.

• VS stable and all normal.

• PE‐ erythematous, raised rash in diaper area. Appears vesicular, wet . Covers large area: entire diaper area.

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Case Study #4

• Differential: diaper rash, allergic response to unknown exposure.

• Plan‐sent out on mix of hydrocortisone, clotrimazole, A and D ointment

• What this ended up to be………

Essentialevidenceplus.com


• 52 yo male presents with otorrhea and otalgiaL ear x 48 hours, now with bloody drainage from ear. C/o decreased hearing for 48 hours. No prior history of ear problems.

• PMH: HTN, smokes 2ppd, denies etoh use, sole caregiver for his wife .Works 2 jobs.

• VS‐P‐112, R‐22, BP 144/88, oxygen sat 99%

• T‐36.8.

Case Study #5

• Physical Exam:

– Ruptured tm left‐6pm‐15%.Odorous bloody drainage, yellow and thick. Jagged TM edge with rupture. Right tm clear

– 0ral cavity‐large ulcer on left lateral tonsil site: firm. Tonsil left plus 3, tonsil right 1. Enlarged left neck node, level II, 2cm, firm. Non‐painful.

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Case Study #5

• Differential: ruptured tm, oral cancer, ulcer on tonsil site, reactive neck node or metastasis?

• Plan‐referred on to the ER

• What happened from there……….


• 55 yo female with PMH of hyperthyroidism presents with c/c of 2 weeks of dizziness. Has been to see her pcp and was given meclizine‐hasn’t helped. Went to ER 2 days ago‐told her labs were normal and to continue her meclizine. She’s worse today. Dizzy all the time‐unrelated to head movement, standing.

• VS‐R‐18, BP 122/68, P‐52, T‐36.7. O2 sat‐99%.

• Meds: methimazole.

Case Study #6

• Exam‐normal except for dizziness with ambulation‐has to hold onto walls to walk. No nystagmus with change in head movement. Orthostatics negative.

• Any ideas? What is next?

• What was done and what was found!

www.nhibi.nih.gov

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• 74 yo male presents with chief complaint of hiccups for 3 days: worse each day. Can barely talk without hiccupping. Frustrated with answering questions. Denies any other s/s.

• VS‐P‐82, R‐18, T‐36.7, BP 112/68, O2 sat 98%.

• PMH: negative, lives alone, comes in with son

• Has no primary care doctor

• He only wants a medicine to stop his hiccups.

• Meds: none.

Case Study #7

• Differentials ?

• What would you do?

• What actually happened…….

• Outcome………………………………..

Case Study #7

• Sezen, Y et al. Hiccups As a Sign of Myocardial Ischemia. South Med J 2010, 103(11), 1184‐85.

• Hiccups are one of the signs of myocardial ischemia along posterior wall of myocardium.

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• 18 yo female prostitute presents with severe headache of 5 days duration: having dizziness, feels confused, chilling. Has history of being given Bactrim 1 week ago for recurrent UTI (has received Bactrim every other week for 3 months for UTI‐has history of allergies to ciproand macrobid). Cultures all receptive to Bactrim (E‐coli). Stiff neck today. Is nauseated.

Case Study #8

• VS‐P‐88, R‐16, BP 98/52, O2 99%, T‐38.6.

• What actions do you take?

• What actually happened……………………


• Bactrim is the antibiotic most associated with aseptic meningitis

• Drug induced meningitis can mimic the clinical features of infectious meningitis

• Proposed mechanism of cause: acute hypersensitivity reaction with involvement of meninges.

• Repeat exposure to one drug will demonstrate a quicker onset of symptoms of.

• Treatment: discontinue the drug.

Bai, M and Glass, S. Drug Induced Aseptic Meningitis: An Uncommon, Challenging Diagnosis.MD: Dec, 2007.

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• 72 yo male presents with c/c of diarrhea and loose stools for 3 weeks. Has seen his PCP and Gastroenterology: all tests were normal. Today he’s had 8 loose stools‐he feels weak and dizzy. He’s taking Loperamide: hasn’t helped any.

– VS‐ BP 152/88, P‐88, R‐12, T‐36.7

What do you want to check next?

Case Study #9

• Meds: Lantus Insulin, Metformin, Lisinopril

• PMH: DM, HTN

• Diarrhea occurs after eating, has cramping with.

• What do you do next?

• What happened?

Case Study #9

• Discovered cause of his diarrhea??

• Essential Evidence Plus:

– Drugs most likely associated with prolonged diarrhea (longer than 3 weeks duration) are laxatives, antibiotics, magnesium containing antacids, iron, metformin, NSAIDS, and cytotoxic drugs.

Essentialevidenceplus.com

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• 30 yo male presents with a penis itch.

• Duration of 10 days: tried OTC clotrimazoleand neosporin‐hasn’t helped.

• Tells you he isn’t sexually active: wife is chronically ill.

• Has no insurance: had to pay $89 to come in.

• Itches all day and night: miserable with

Case Study #10

• Area measures 2x2 cm: erythematous.

• No other lesions noted

• Dermatology Consultation per Phone

• What was recommended……

• Phone Call per Patient one day later…….


• 23 yo female presents with sore throat. Was seen 1 week ago with sore throat. Strep negative at that time: no antibiotic given. Sore throat on one side only.

• Today comes in because she can barely open her mouth: throat worse‐only on right side. Has to sit up to breath at night.

• T 37.2, P 112, R‐18, BP 140/88, Pulse ox‐99%. • PE‐trismus‐fullness of right soft palate. Unable to see tonsil site. Tender neck node under right neck at Level 1.

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• What do you suspect?

• What is the importance of the one sided sore throat?

• What happened………

Peri‐tonsillar Abcess

• 0.3 new cases per 1000 persons yearly

• Accounts for 30% of all soft tissue abscesses

• No gender difference. Found most commonly in ages 20‐40.

• Estimated to result in at least 150 million in heath care expenditures annually.

• Common anaerobes include Fusobacterium, Peptostreptococcus, Bacteroides

• No reliable clinical predictors of.

Uptodate.com


• 25 yo male with c/c of tiredness, mucus in lungs, feels like he can’t catch his breath. Just returned from a week’s vacation in LA: wife 20 weeks pregnant. PMH: negative. No meds. Tells you he gets bronchitis and allergies every year at this time (June). Worked all day‐comes in at 6 pm after work.

• VS‐Pulse 125, irregular. R‐22. BP 80/40, O2 sat‐95%, T‐37.0

4/10/2017

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Case Study #12

• Differentials?

• What actually happened

• One year later……..

Giant Cell Myocarditis

• Idiopathic cause• Affects young adults‐mean age 42: female /male• s/s include rapid onset of chest pain, heart palpitations, fatigue, sob: rapidly progress into tachycardia or bradycardia

• Cause CHF‐time from onset to life threatening complications leading to death or transplant in 5 months

• Characterized by inflammation of heart muscle: inflammation caused by infiltration of giant cells which cause destruction of the heart muscle.

www.rarediseases.org/uptodate.


• 27 yo female presents with a rash on bilateral lower legs from knees down. Burns, itches. Has been there over a week. Worsening daily.

• Now feeling like her knees are swollen: ache.

• PMH: acute leukemia 3 years ago: did get stem cell transplant. In remission since: still on prograf.

• Has used vaseline and lotions: nothing working on her rash.

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Case Study #13

• VS‐ BP 122/84, P‐112, R‐18, T‐36.0, O2 sat 99%.

• Rash appears erythematous, patchy, eczematous. Sloughing of skin noted on bottom of feet. Knees tender to palpation. Rash no where else.

• What is your differentials?

• What we did………..

Graft Versus Host Disease

• S/s:– Acute (within 6 months of transplantation):

• Abdominal pain• Jaundice (from liver damage)• Skin rash

• Chronic (after 3‐6 months of transplantation to years):– Dry eyes, dry mouth– Chronic pain, fatigue– Joint stiffness– Skin rash with discolored, raised area– Sob due to lung damage– Weight loss

Graft Versus Host Disease

• ‐May occur after bone marrow or stem cell transplant

• Does not occur when people receive their own stem cells: occurs when they receive another donor’s stem cells

• Chance of GVHD:

– 30‐40% risk when donor is related

– 60‐80% risk when donor is unrelated

– Treatment‐increase immune suppression/prednisone.

www.lls.org/treatment/types of treatment/stem‐cell‐transplantation/graft‐versus‐host‐disease.

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• 54 yo female presents with her third UTI s/s in the past 3 months.

• Describes feeling like she has a UTI all the time: cultures have all been negative in the past: no relief with meds.

• Feels pelvic heaviness, dullness.• Wants antibiotic to make her feel better.• PMH: negative. VS‐T‐36.0, P‐87, BP 124/77. • UA reveals trace of leukocytes, negative nitrites, trace of blood

Case Study #14

• Would you treat her with an antibiotic?

• What could be in your differential?

• What happened……………

• Where we referred her……………………

Pelvic Floor Dysfunction

• Essentialevidenceplus.com‐

– Recurrent urinary tract infections may be sign of pelvic floor dysfunction:

• Excellent treatment with biofeedback and electrical stimulation treatment.

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• 12 yo female presents with dysuria, frequency of 24 hours. Accompanied per mother. Mother didn’t want her perineum evaluated.

• PMH: negative

• VS‐T‐36.0, R‐17, BP 120/66, P 58, O2 sat 99%.

• UA is positive for nitrites, leukocytes, blood.

• Do you treat for UTI?

• What do you need to do yet?

Case Study #15

• Mother did not want me to evaluate the girl’s vaginal region

• Both denied sexual activity

• PE‐tender bladder region. Examination of vaginal/perineal region reveals lesions suspicious for herpes.

• Treated for herpes as well as UTI.


• 19 yo college student presents with chief complaint of dyspareunia. Wants checked for UTI. Tells me she is unable to use tampons.

• VS all normal.

• UA‐negative nitrites, leukocytes, blood

• PE‐ normal genitalia. Vaginal entrance narrow‐unable to get even 1 finger in. Very painful.

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Case Study #16

• Diagnosis of vaginismus• Referred to Urogynecology Clinic

• Vaginismus– Incidence is 2 out of 1000 women.

• 18%‐less than age 25• 35%‐ages 26‐35• 26%‐ages 36‐50• 9%‐age more than 50.

– Treatment is multi‐focused.– Vaginismus: A Review of the Literature. Women’s Health. 2010. 705‐719.


• 58 yo male presents with chief complaint of feeling like his left eye isn’t moving right‐feels caught in place. Feels swollen.

• c/o sinus infection for over a week: thinks it settled behind his left eye.

• PMH: HTN• VS‐T 37.2, R‐16, BP 110/72, P‐66, O2 sat 98%.• PE‐left eye CN VI paralysis, left orbit appears pushed forward compared to right orbit. Tender left maxillary sinus region.

Case Study #17

• Referred on to ER

• What CT of sinuses/orbits revealed

• What happened after this……….

Herchline, T. Cellulitis Treatment & Management. Emedicine.medscape.com. 8/15/16.

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• 20 yo male, visiting from out of state, presents with a sore under his nose. Admits to picking at a hair in this region (has a mustache). Feels like its infected. Has swelling right at that region and tenderness.

• His father comes with him: requests he be treated with Bactrim. Father was a physician out of state.

• PMH: negative

• VS‐T‐36.4, P‐65, BP 118/58, R‐16, Ox sat 99%.

Case Study #18

• PE‐erythematous lesion 12 mm under right nares‐slight swelling under nasal ala. Very tender

• Discussed with student in depth that this is in the danger zone: will treat with Bactrim DS x 7 days. Discussed with father that Clindamycin would be my first drug of choice on the face in this area.

• To go to ER if no improvement or worsens in next 24 hours.

• To use heat packs on area 3x daily. Avoid picking. To rub with bactroban ointment 3x daily.

Case Study #18

• Called patient next am to check on sore area under nose‐had to leave message

• Mother returned call at noon‐reports swelling of entire nose now‐what should he do??

• Instructed to go to ER immediately.

• What happened from there………………

Pubmed.gov: Miller, et al. Clindamycin versus Trimethoprim Sulfamethoxazole for uncomplicated skin infections. N. Engl J Med 2015, March19: 372(12): 93‐103.Medicalnewstoday.com: MacGill, M. Sepsis: Causes, Symptoms & Treatment. 1/20/17

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• 25 yo female presents with groin and tailbone pain: now swelling down her left leg. Horseback riding a few days ago for a first time (6 days).

• Distracting historian. Had a cut on her swollen leg.

• No Oxygen saturation on patient available.

• PMH: on cycling BCP‐no period but every 3 months or so.

Case Study #19

• Physical Exam:– Unilateral leg swelling left lower extremity noted through skinny leggings.

– Neurovascularly intact: pain significant with any movement of her leg. Good pulses. Affected foot cool to touch. Tender in her inguinal region on this side. Exam limited by pain

– Walks purposefully dragging her leg. Sitting uncomfortably on table.

– Lateral thigh numbness

– Heart rate 116, BP and R normal.

Case Study #19

• What would be your differentials?

• What would your recommendations be?

• What happened…………………………

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• 27 yo male with sore throat, headache, nausea, fever (39 degrees).

• Strep Positive, Influenza negative.

• Placed on Amoxicillin.

• Came back 2 days later‐wanted extended work excuse‐just felt like he couldn’t go back to work.

Case Study #20

• Was told he would have to come in for reassessment‐

– c/o midsternal chest pain, 9/10 at 0450 that am, 7/10 after Tums. Felt it was GERD‐he ‘d had that before. VS normal.

– Reluctantly went to ER after much discussion.

Case Study #20

• Convinced to go to ER:

– Found to have ESR 41, troponin 0.61, CRP 20.6, BNP 822.60.

– ECH0‐ejection fraction of 30%

– Diagnosis of myocarditis

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• 49 yo female with fever, 39.5, cough, vomiting, profound weakness.

• BP 84/50, P‐89, R‐16, O2 sat 93%.

• Very weak, couldn’t walk alone.

• Recommended she go to the ER

• Tested positive for Influenza A.

• Rapidly deteriorated in the ER: found to have sepsis.


• 19 yo male presents with painful left ear: can’t hear out of it.

• Reports just returned from Caribbean: deep sea diving for 3 straight days.

• No otorrhea. Pain started after the last deep sea dive.

• No fever, no prior cold. Has had dizziness and vomiting‐started this am. Thinks he has the flu on top of the ear problem.


• PE:

• Left ear‐tm bulging: purple hue behind TM

• Weber lateralization to Left

• Diagnosis‐ Barotrauma

• What we did…………………………………………….

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• Barotitis:

– Acute hearing loss associated with vertigo and vomiting is suggestive of barotrauma‐induced rupture of the round or oval window in the inner ear‐a true emergency.

www.essentialevidenceplus.com.


• 80 yo male presents with chief complaint of non healing lesion on posterior scalp. Has had for 6 weeks: growing. Bleeds if he hits it on something. Not sore.

• VS Normal.

• Has no other lesions anywhere else.

• PE‐ lesion 4x5 cm: raised, cauliflower appearing. Friable. Non –tender.


• What would you do next?

• What Was Done….. What It Was………

4/10/2017

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Questions?

general session 6 ritchie - c.ymcdn.com file“not like this”. • mother has tried diaper creams...

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