An illustrative case study imprecision in external information leading to catastrophic internal outcome
Case study below illustrating initial imprecision's in "external" informational continuity leading to near catastrophic "internal" outcomes:
Speaker Note, suggestions and discussion:
Slide-1
Good morning one and all. Today, we will be sharing our experience of a case which has helped us in learning many things about a case based approach. Our discussion for the next one hour will be around a case of urinary and abdominal discomfort
- Suggestions and discussion:
KIMS Salma: How to do that?
Rakesh Biswas: https://www.ncbi.nlm.nih.gov/m/pubmed/19018901/
Slide- 2
- Suggestions and discussion: The urologist made another diagnosis based on his history on the last line of his notes, thin stream of urine
Slide- 3
The lady then presented to the urology where the above complaints were noted.
Slide 4-
She was diagnosed to be having a structured urethra for which a dilatation was done with the hegar dilator followed by Foley's catheterization. She was then started on antibiotic Oflox after sending a urine c/s sample.
Suggestions on slide 5 (and in retrospect also on slide 4)-
Suggestion 1: I am adding how Salma can present the 5th slide that discusses post menopausal urinary tract infection and stenosis but before that remember we need to sign out of the 4th slide in a manner that will tie it in sequence with the intro to the 5th.
Suggestion 2: 4th last line: So to summarize her Urology encounter her urinary symptoms were found to be associated with urethral stenosis along with possible urinary tract infection which brings us to this question 5th slide, "What could be the cause of postmenopausal urinary tract infection and stenosis? Well it appears logical that if post menopausal women suffer from estrogen deficiency leading to atrophy of the periurethral tissues then it is all perhaps due to estrogen deficiency and this fact was spectacularly illustrated by an Israeli epidemiologist in the world's highest impact factor medical journal in 1993 demonstrating an astonishing effect size with application of vaginal estriol reducing incidence of uti to 0.5 in comparison with 5 times per year with placebo. Just imagine the amount of estriol that would have flowed after the publication of this landmark and it is surprising to note the same author publishing again in 2011 in Korean Journal of Urology saying that the efficacy of estrogen in preventing UTI remains questionable. 🙂
Suggestion 3: These are the 2 articles regarding the effect of estrogen in postmenopausal women and it's association with urethral stricture. Both the studies have the same author but the conclusion of both the studies are negating each other. We need more studies to study the effect of estrogen in post menopausal women especially in India where hygiene is a issue in the rural areas. We can as well study our local area narketpally .
Suggestion 4: Your point about doing an observational study here in Narketpally to understand if there is a causal association with hygiene or estrogen deficiency is quite good and should be added.
Suggestion 5: She was asked to come after 1 week for another procedure of dilatation but she turned up quiet later. She probably is the best example for most of our patients who are asked to review after a particular time for review, but as they feel symptomatically better they never turn up.
Slide 7:
The lady then presented 3 days later to the urology opd again. Her Foley's was removed. Her c/s report which was sent 3 days back had not been collected by the attenders. And her antibiotic of the same group was continued. An estrogen ointment for local application had been started as her stricture was attributed to the lack of estrogen in post menopausal state.
Slide 8:
This is another duplicate report of c/s which we have collected retrospectively. This shows that the pus cells have increased and she retrospectively has told us now that she had milky colored urine for which she had come to the hospital. Some department which is unknown to us has sent the urinec/s sample, which probably had not been seen by the care provider as we could not find any op card suggesting it.
Slide 9:
This again is another duplicate report sent by someone and probably not seen by anyone. This particular e.coli has been turning more virulent with a different sensitivity and resistance pattern each time she gave the sample. We are not sure whether it is a organism causing the white discharge per vaginum she presented initially with and it has been grown in urine as she never understood the importance or probably had not been explained the importance of catching a mid stream urine.
Excellent notes in 7-10 Salma. No suggestions except we need to introduce another Journal baser slide here around information continuity (and how to resolve it's lack such as in this case)
Penultimate slide 11a)
Problem:
Informational continuity (lack of)
Solution:
Both clinical departments, Department of Clinical Microbiology and Department of Urology may have been supported with an ecosystem that promotes online communication?
Illustrative example : Department of Medicine and clinical Microbiology have a common online platform where clinical microbiologists and physicians routinely discuss their patients. For example in this particular case the clinical microbiologists would have communicated us the report even if we couldn't collect it"
Patient came in the casualty where salma and i were present with chief complain of fever,
Decreased urine output, Abdominal pain, Shortness of breath For 15 days. We examined the patient and patient had tachypnea and on auscultation there were normal vescicular breath sounds.so we thought that the patient must be in metabolic acidosis.so we quickly sent for abg and rft which showed.
Slide- 12:
Slide 12 urea 184, Creatinine 5.5, potassium of 7, Abg showed metabolic acidosis
Slide 12 suggestion:
Start with
"We examined the patient and patient had tachypnea and on auscultation there were normal vescicular breath sounds.so we thought that the patient must be in metabolic acidosis.so we quickly sent for abg and rft which showed...
Slide 12 urea 184, Creatinine 5.5, potassium of 7, Abg showed metabolic acidosis
Slide- 13:
We took the patient for dialysis on 28/3/18 and it was found that the post dialysis b.p was not maintaining . fluid challenge was given following which b.p did not improve . so in view of septic shock noradrenaline was started.
Slide 14:
After the dialysis we saw this debris in the Foley's on 29/3/18
Slide 16 and 17
Here We see gas shadows in the ureter , erector spini and spinal canal
Slide 18:
Here is an article that was reviewed in jama network which shows a case of emphysematous pyelonephritis which shows multiple foci of gas shadows in epidural space from T10 to L1. The T12 L1 intervertebral disc space , vertebral body and ant soft tissue were dissected by gas. Ours may be the first case where the gas shadows were seen in erector spini muscle.
Slide 19:
This is the urine culture sensitivity report that we received on 29 march evening that shows sensitivity to gentamycin and intermediate sensitivity to piperacillin tazobactum but by then after seeing the ct report we had started the patient on meropenem. Comment on meropenem sensitivity was not made as the meropenem disc was not available.
Slide 20:
This is the blood c/s report we received on 29 which showed sensitivity to gentamycin,piperacillin tazobactum and chloramphenicol.
Slide 15:
Ct scan was done because the radiologist saw debris in the pelvicalacyal system and patient attenders were giving history of hematuria or high colored urine . so we suspected stone. This is the ct image of the patient. Air pockets with density of air in the right kidney is seen.
Slide 21:
On 1st of April the patient complained of heaviness of throughout the day . this is the ECG of the patient on 1st April which was with in normal limits. Then the patient had chest pain at night 2am and we did an ECG which showed deep t wave inversions globally. Ck mb was sent at 2am which showed a value of 13. Then we repeated ckmb at 8 am and that report had a value of 151.
Slide 22:
This is an ECG taken on 4th April and it is seen that the t waves are reverted.
Slide 23
On April 6 the patient had first episode of seizure in the morning at 5 am. The patient had multiple episodes of seizures over the next 4 days.
Reference:
Olsen R, Hellzén O, Skotnes L, Enmarker I. Breakdown in informational continuity of care during hospitalization of older home-living patients: A case study. International journal of integrated care. 2014 May 12;14(2).
Agarwal G, Crooks VA. The nature of informational continuity of care in general practice. Br J Gen Pract. 2008 Nov 1;58(556):e17-24.
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