Team 2: Wild Wild West

Elizabeth Acord

Jason Baldick

Miriam Beecham

Jenny Murray

Background• Our Case 

• A patient returns from a trip to Costa Rica and about 8 days later starts experiencing flu-like symptoms 

• Patient sees their primary care doctor and is diagnosed with the flu, told to take ibuprofen and get some rest 

• Patient’s condition worsens 

• Patient consults WebMD

Web MD

Web MD

Web MD

Web MD

Vitals/History

Health Maintenance/Disease Management

Templates/Zynx

Medications/Allergies

Workflow in System 2(Cerner)

• Start of Physician Note • Documentation is mix of both structure and Free text

Note Continued• Information such as Allergies and Current Medications pre-populate Note• This Information is updated at admission but should be non-encounter specific

Physician Note Conti• Physical is documented within not utilizing structured and non-structured documentation

Note ContinuedAfter Eval; The diagnosis is made of an upper Respiratory Infection. (This is linked to ICD-9 code) This will be encounter specific and not travel with the patient as a problem would.

Next Steps

• Patient returns to primary care doctor, questioning diagnosis given recent travel history.  Primary care doctor tells them to increase dosage of ibuprofen. 

• Patient seeks out infectious disease specialist.  Patient is tested for malaria. 

• Patient shows decreased kidney and liver function, and severe dehydration.  Patient is hospitalized.  Patient shows decreased kidney and liver function, and severe dehydration.  Patient is hospitalized.  Correct diagnosis of leptospirosis is made. Patient is given appropriate antibiotics.  

Chart Review

Progress Notes (Dragon)

Dxplain

Gideon decision support

Gideon Diagnosis Results

Gideon decision support 2

Gideon potential diagnoses

Diagnosis Codes

Dynamed

DynaMed

What is Leptospirosis?• What is leptospirosis?

Leptospirosis is a bacterial disease that affects humans and animals. It is caused by bacteria of the genus Leptospira. In humans it causes a wide range of symptoms, and some infected persons may have no symptoms at all. Symptoms of leptospirosis include high fever, severe headache, chills, muscle aches, and vomiting, and may include jaundice (yellow skin and eyes), red eyes, abdominal pain, diarrhea, or a rash. If the disease is not treated, the patient could develop kidney damage, meningitis (inflammation of the membrane around the brain and spinal cord), liver failure, and respiratory distress. In rare cases death occurs.

Many of these symptoms can be mistaken for other diseases. Leptospirosis is confirmed by laboratory testing of a blood or urine sample.

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

How do people get it?• Outbreaks of leptospirosis are usually caused by exposure to water contaminated with

the urine of infected animals. Many different kinds of animals carry the bacterium; they may become sick but sometimes have no symptoms. Leptospira organisms have been found in cattle, pigs, horses, dogs, rodents, and wild animals. Humans become infected through contact with water, food, or soil containing urine from these infected animals. This may happen by swallowing contaminated food or water or through skin contact, especially with mucosal surfaces, such as the eyes or nose, or with broken skin. The disease is not known to be spread from person to person.

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

How long is the latent period?

• The time between a person's exposure to a contaminated source and becoming sick is 2 days to 4 weeks. Illness usually begins abruptly with fever and other symptoms. Leptospirosis may occur in two phases; after the first phase, with fever, chills, headache, muscle aches, vomiting, or diarrhea, the patient may recover for a time but become ill again. If a second phase occurs, it is more severe; the person may have kidney or liver failure or meningitis. This phase is also called Weil's disease.

The illness lasts from a few days to 3 weeks or longer. Without treatment, recovery may take several months.

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

Where is it found?• Leptospirosis occurs worldwide but is most common in temperate or tropical climates. It

is an occupational hazard for many people who work outdoors or with animals, for example, farmers, sewer workers, veterinarians, fish workers, dairy farmers, or military personnel. It is a recreational hazard for campers or those who participate in outdoor sports in contaminated areas and has been associated with swimming, wading, and whitewater rafting in contaminated lakes and rivers. The incidence is also increasing among urban children.

• Travelers participating in recreational water activities, such as whitewater rafting, adventure racing, or kayaking may be at increased risk for the disease, particularly following periods of heavy rainfall or flooding and even in areas not previously considered endemic (3). Recent outbreaks of leptospirosis in the US have occurred in Illinois and Florida (CDC, unpublished data), while leptospirosis is endemic to Hawaii (4,5). Outbreaks in which US residents acquired leptospirosis have also occurred recently in Malaysian Borneo and Costa Rica (2,6).

Re-emerging Disease

• Infection in U.S. seems to be on the rise in urban areas and due to increased water recreation  (Reemerging Leptopsirosis, California 2004) 

• In the U.S. 100-200 cases reported per year, but still the most widespread zoonotic disease globally (Reemerging Leptopsirosis, California 2004) 

• CDC issued an alert after Hurricane Katrina  (CDC) 

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

• http://wwwn.cdc.gov/travel/yellowBookCh4-Leptospirosis.aspx

How do you treat it?• Leptospirosis is treated with antibiotics, such as doxycycline or penicillin, which should

be given early in the course of the disease. Intravenous antibiotics may be required for persons with more severe symptoms. Persons with symptoms suggestive of leptospirosis should contact ahealth care provider.

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

Can it be prevented?• The risk of acquiring leptospirosis can be greatly reduced by not swimming or wading in

water that might be contaminated with animal urine.Protective clothing or footwear should be worn by those exposed to contaminated water or soil because of their job or recreational activities.

• http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

Rare Diseases

• About 6000-7000 rare diseases, compared to about 600 common conditions.  (Keuhn 2008) 

• Rare disease is defined as affecting fewer than 200,000 in U.S. (Keuhn 2008) 

• NIH has just launched NIH Undiagnosed Diseases Program this year to help patients get diagnosed (Keuhn 2008) 

• Delay in diagnosis can have long-term impact on patient’s health.  According to the European Organization for Rare Diseases (EURORDIS): “the period between the emergence of the first symptoms and the appropriate diagnosis involves unacceptable and highly risky delays, as well as the wrong diagnosis lead to inaccurate the treatments…”   

Sources

• Bohan, Suzanne. June 7, 2007.  Rare Diseases Hard for Most Docs to Diagnose Oakland Tribune http://findarticles.com/p/articles/mi_qn4176/is_20070608/ai_n19294750  

• Keuhn, Bridget. July 2, 2008.  US Launches Undiagnosed Disease Program  JAMA; 300(1):27 

• Meites, Elissa et al. March 2004. Reemerging Leptospirosis, California. Emerging Infectious Diseases Vol 10. No 3. 

• “Leptospirosis” NORD www.rarediseases.org 

• Outbreak of Leptospirosis Among White-water Rafters, Costa Rica, 1996. CDC.

• http://wonder.cdc.gov/wonder/prevguid/m0048052/m0048052.asp  

• FAQ for Hurricane Katrina and Leptospirosis, September 7, 2005. http://emergency.cdc.gov/disasters/hurricanes/katrina/pdf/leptofaqs.pdf  

• “Rare Diseases: Understanding this Public Health Priority” EURODIS www.eurordis.org

• http://www.eurordis.org/IMG/pdf/princeps_document-EN.pdf  

• Veenema, Tener Goodwin and Joanna Toke (April 4, 2006). Early Detection and Surveillance for Biopreparedness and EID, Online Journal of Issues in Nursing,  http://www.medscape.com/viewarticle/528307_1 

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