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  1. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Chief Complaint A 50-yr-old male of mixed-race states that over the past six months he has been experiencing mood swings and outbursts of anger. “I’m out of control. One minute I’m happy and the next I’m furious. I’ve been screaming at my poor husband. The other day I even pushed him, and all he did was break my favorite coffee mug. I didn’t push him hard, but it frightened me. My dad used to knock my mother around and I don’t want to be like him. If I sit still for too long, I start thinking about all the bad things in my life and my heart starts racing. It feels sometimes like the world is coming to an end. I don’t understand what’s going on – I’m a happy person. I hope I don’t have a brain tumor or something.” History of Present Illness Patient states that after pushing his partner last week, they sat down and talked about the incident. “My husband helped me realize that I’ve been getting worse. I hadn’t realized it, but when I think back I can recall these feelings being around for at least 6 months. I think I’ve been in denial.” Patient has gained 20 lbs since his last visit 9 months ago. General Appearance Patient appears tired and is tearful. His skin is light brown in color, and he appears to be slightly overweight, though he is also muscular. He has male pattern baldness and wears glasses. His hair is cut short and he is clean-shaven and appropriately dressed. Speech is rushed at times, but content is normal. Patient has difficulty making eye contact during assessment. Past Medical History Unremarkable Family History Father died from colon cancer 5 years ago at the age of 67. Patient states his friends from back home report his mother is alive and well. His only sibling, a brother died of an opioid overdose at age 41. No other known family history of mental illness. Social History The patient has been married to his partner for over ten years He and his partner are physically active and enjoy hiking and gardening together. Eighteen months ago, his brother died of an overdose. He became estranged from his parents fifteen years ago after coming out. “My brother kept me posted about my father’s illness, but they didn’t want me to visit. I wasn’t invited to the funeral. Now there’s no chance for reconciliation. I don’t even know if my mother knows where I live. I really wish she could accept me for who I am. I was close to my brother – I really miss him. The last few years have been hard.” Patient drinks 1-2 beers several times a week, has never smoked. “I used to party pretty hard in college, but I don’t use drugs anymore, not with my brother’s situation. It just seemed wrong.” The patient is an attorney for a low-cost legal service in his county. His partner is an elementary school teacher. They are very active in their Unitarian Church. Medications He takes loratadine for allergies and atorvastatin for high cholesterol. Allergies NKA Questions Is there a mental health diagnosis that fits these symptoms? If not, what’s causing his mood swings and outbursts of anger? What about the weight gain, racing heart and feelings of worry? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  2. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Chief Complaint An 85-yr-old Cherokee woman living in a skilled nursing facility in Western North Carolina (WNC) has been reluctant to socialize or join in activities. She has lost 10 lbs in the month since she has been admitted. Her hair is unwashed and the aids state she often refuses a bath. She takes her meals in her room saying, “I just don’t feel comfortable here. I want to go home.” The patient has complained of not liking the food. Staff members have reported overhearing her talking about getting messages from “plant people.” The cafeteria staff have reported that she questions them constantly about the ingredients in the food and how it is prepared. The cafeteria manager states, “She keeps asking for a bunch of weird TEAS we don’t have, and I don’t know where to get them.” History of Present Illness She was admitted to the facility one month ago due to multiple falls in her home. Her most recent fall resulted in loss of consciousness when she hit her head on the bathroom sink. She currently uses a rolling walker for ambulation. The patient has been observed sleeping or sitting in chair for 90% of day; she refuses to participate in physical activity. Past Medical History Depression x 3 years, osteoarthritis x 12 years and GERD x 3 years Family History One child, alive and well who lives in Oklahoma. Mother died in her 80s from stroke, father died at 60 from acute MI, two sisters, ages 78 and 80 are alive and well and living in Oklahoma. Husband died of MI 6 months ago. Social History After she married her husband 50 years ago, they moved from Oklahoma to WNC where her husband’s family lives. After he died, she tried living on her own in their small home, but she fell several times and her daughter insisted she move into a SNF. No alcohol or tobacco use, no reports of using recreational drugs. She has a history of not taking her medications saying, “I don’t believe in taking a pill for everything that is wrong. A pill can’t teach you anything.” Medications OTC ibuprofen, Esomeprazole and Citalopram. Allergies Cephalexin – severe hives Questions 1- Why is this patient talking about "Plant People"? 2- How would you approach a diagnosis for this patient? 3- What strategies will you need to use for patient centered care? 4- What labs do you want? 5- What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  3. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills. Presentation A 45-yr-old, white, premenopausal woman presents for her annual exam. About 5 weeks ago, she noticed a small, painless lump in the upper outer quadrant of her left breast. “I didn’t think much about it because I’ve had so many lumps – they always pop up when I get my period.” She states that usually the lumps become palpable and bother her about 10 days before her menses, but then they go away. Right now, she is about 4 days from her expected date of menstruation. She is a nonsmoker, nondrinker and denies recreational drug use. She only takes PRN medications occasionally. She has a supportive partner and two children ages 13 and 17. Chief Complaint “My breasts have always been cystic, but I found a new lump in my left breast that has me worried.” History of Present Illness She has no history of dysmenorrhea, but the lump hasn’t gone away and seems to have grown in size. She denies tenderness, pain, nipple discharge and skin changes in her breasts and no masses in the axillary region of her left arm are found. She states that she practices breast self-exams, “but not as often as I should.” She has never had a mammogram. Several years ago, she had a breast biopsy that was consistent with fibrocystic changes. Her only Pap smear was done two years ago, and the result was normal. Past Medical History Her medical history is unremarkable except for a broken arm in grade school. Menarche was at age 11. Her first pregnancy was at age 27 and her second at age 32 – both pregnancies were full term and deliveries were vaginal with no complications. Family History Paternal grandmother diagnosed with breast cancer before menopause at age 48. Mother died of breast cancer at age 75, though the cancer was diagnosed when she was 45. She had two periods of long-term remission, but it recurred again 16 years ago. Her father is 88 and has HTN, history of stroke, type 2 DM and Alzheimer’s disease. He lives in a nursing home. Social History Drinks 6-8 cups of coffee weekly, exercises 3x weekly, has a degree in communications from a local college, but she now works as a personal life coach. Allergies Latex and adhesive tape cause a rash. Questions What are the possible reasons for this lump? Is it just another cyst? How many reasons for breast lumps can you come up with off the top of your head? How many risk factors for breast cancer can you spot? What labs do you want? What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  4. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint A three-day old male infant is brought to the ER with vomiting and diarrhea by his 22-yr-old white mother. The mother states, “It started yesterday. He sleeps all the time, but when he’s awake he just won’t stop crying and I can’t get him to stop throwing up after he eats.” This is the mother’s first pregnancy. The infant was full term and there were no complications during the vaginal birth. A full assessment is performed, and the infant is admitted to the hospital. Assessment Findings Depressed fontanels High-pitched cry lasting more than 5 minutes. Moro reflex is hyperactive. Mild tremors when disturbed. Increased muscle tone, no excoriation of chin, knees, elbows, toes or nose, myoclonic jerks present. Yawns frequently. No nasal stuffiness, nasal flaring or sneezing apparent. Skin is dry with no mottling. Vital Signs BP 89/60 RA, lying HR 110 bpm RR 70/min with no retractions T 101o F O2 sat 98% Weight at birth 5 lbs 6 ounces Current weight: 5 lbs 4 ounces What’s going on here? What other information do you need? What labs do you want? What other diagnostic tests should we run? REMEMBER: DON’T post the ANSWER HERE! Please post your answer in the Admin Help Desk. Ask questions and I’ll give you more information.
  5. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint R.W. is a married, 34-year-old Hispanic female with two young children who presents to her primary care provider with a productive cough, stiffness and pain in her hands and feet that comes and goes. She states, “It moves around from joint to joint. I’m worried I’ve got RA like my sister.” Her PCR test for COVID-19 has come back negative. History of Present Illness Five years ago, R.W. went to her PCP after four months of rashes that appeared on her arms and legs whenever she went into the sun. She had lost several small patches of hair on her scalp and stated she thought it was related to stress. She also complained of fatigue that required her to take daily naps. She had mild arthritic pain in her fingers and elbows but thought it was related to aging. A tissue biopsy of one of the multiple rash-like lesions from her arm revealed vasculitis (white blood cells within the walls of blood vessels). Her CBC indicated mild anemia, but microscopic examination of a peripheral blood smear revealed that red blood cells were normal in shape size and color, ruling out iron, folate and vitamin B12 deficiencies. A two-month course of prednisone caused all signs and symptoms to resolve. Past Medical History Unremarkable, current with all vaccinations including influenza. Family History She has two brothers and one sister. Her older sister has rheumatoid arthritis, and an aunt has pernicious anemia. Her mother has Graves’ disease. Social History No smoking or drinking Medications Naproxen for joint pain, antacid for heartburn, no other over the counter drugs Allergies NKA Vital Signs BP 141/90 sitting, RA HR 105 RR 20 T 100o F HT 5’6” WT 105 lbs Review of Systems (only abnormal values presented) Skin: Slight jaundice HEENT: yellowing of the sclera Lungs/Thorax: Auscultation reveals abnormal lung sounds Musculoskeletal: joint stiffness and pain Immune: enlarged axillary and inguinal lymph nodes Questions What is causing the lung symptoms, jaundice, joint stiffness and pain? What happened 5 years ago? Imagine you only get 5 questions. What information should you ask for that will give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  6. juan de la cruz

    Case Study: An OB Catastrophe

    Case Study Objectives Present a simulated case as it evolves over time. Encourage open discussion from nurses that represent a variety of specialties. Promote learning based on the: details of the case evaluation of the data known interventions in order to provide holistic care Recognize maternal morbidity and mortality as a serious public health issue facing the world. Introduction The initial presentation that will proceed is meant to set the tone for the next set of events that will occur. I would like to preface by saying that this particular part of the case is where I have no actual nursing experience so I encourage colleagues who work in this specialty area to chime in with their responses. Let's keep this lively, but also make sure we are respectful of each other. Remember that we work in different hospitals and protocols may be different. Also, be aware that while the following scenario seems "garden variety", it will get more "exciting" as we move along. Case Specifics History / Presentation EJ is a 32-year old, Gravida 4 Para 2, at 34 weeks and 2 days gestational age. She has no chronic medical problems but admits to current tobacco smoking since age 17. She says that she has been trying to quit and has cut back her smoking to 2-3 cigarettes a day. She lives with her husband and two children ages 3 and 5 in a 2-bedroom apartment. She receives prenatal care at an urban Federally Qualified Healthcare Center (FQHC). She previously worked as a server at a restaurant but has become unemployed for a couple of months due to restaurant closures from the coronavirus pandemic. She has good family support from her parents and her husband, RJ, who is a delivery truck driver. She is insured through her husband's coverage. Today, she called her Women's Health Nurse Practitioner (WHNP) when she experienced a gush of watery fluid from her vagina while playing with her children. She was told to come to OB Triage at the nearby Tertiary Medical Center Antepartum Unit. Upon presentation, she was seen by the OB Triage nurse who found her anxious but well-appearing. Vital Signs Temperature: 36.7 degrees C Heart Rate: 84 Respiratory Rate: 16 Blood Pressure: 112/74 O2 Saturation: 96% RA Fetal Heart Rate (FHR): 140 Physical / Pelvic Examination An OB-Gyn resident saw EJ and performed a physical examination that revealed clear, pale yellow, odorless fluid leaking out of her endocervical canal with pooling in the vaginal vault. Diagnostic Studies The OB-Gyn resident performed ultrasonography which revealed: oligohydramnios a fetus that is small for its age, without birth defects, in no distress a placenta that does not cover the cervix Recommendation The OB-Gyn team recommended admission to the Antepartum Unit. Diagnosis At this point, EJ's diagnosis seems obvious but you are welcome to state it in your response to the thread. 1 - As EJ's nurse, state some assessment findings that would make you concerned. 2 - As the nurse in that unit, what laboratory tests and monitoring procedures would you anticipate in this case, and why?
  7. If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. Chief Complaint Fever of 101o F, fatigue and lethargy, stiff neck and jaw, chills and sweating with fever, muscle aches and pains with fever. “I feel like I have the flu. I’m worried I might have Covid-19.” History of Present Illness Lakeith awoke on Saturday morning feeling exhausted. As the morning progressed, he began to have aches and pains. He took an oral temperature that was 101o F. His first thought was that he had contracted Covid-19. He is a home health physical therapist who specializes in geriatric physical therapy. He sees four to five patients each day. Several of his patients have tested positive for Covid-19. When working with any of his patients, Lakeith wears an N-95 mask and gloves and practices strict hand hygiene. Before calling his primary care provider, Lakeith went online and took the Mayo Clinic Covid-19 Self-Assessment Tool to see if his symptoms fit with those for Covid-19. Here are the questions with his response Have you been within 6 feet of a person with a lab-confirmed case of COVID-19 for at least 5 minutes, or had direct contact with their mucus or saliva, in the past 14 days? YES Does the person with COVID-19 live with you? NO In the last 48 hours, have you had any of the following NEW symptoms? Check all that apply. Response Symptom Yes Fever of 100 F (37.8 C) or above Yes Fever symptoms like alternating chills and sweating No Cough No Trouble breathing, shortness of breath or severe wheezing Yes Chills or repeated shaking with chills Yes Muscle aches No Sore throat No Loss of smell or taste, or a change in taste No Nausea, vomiting or diarrhea Yes Headache No None of the above Do you have any of the following possible emergency symptoms? Check all that apply. Response Emergency Symptom No Struggling to breathe or fighting for breath even while inactive or when resting No Feeling about to collapse every time you stand or sit up (floppiness or a lack of response in a child under age 2) No None of the above Is the person with a fever younger than 3 months old? NO Have you traveled in the past 14 days to regions affected by COVID-19? NO Do you live in a care facility? NO Do you work in healthcare? YES After taking the test, he called his primary care office and the triage nurse directed him to come in for a Covid-19 test. General appearance The patient arrived at clinic for a Covid-19 test wearing a mask, shoulders drooping, eyes heavy-lidded. Speech is slow and measured. While the nurse prepped for the test, she noticed the patient repeatedly attempting to scratch his back. Past Medical History Uncomplicated appendicitis at age 12 Family History Father, age 56, and mother, age 52 both have HTN and hypercholesterolemia. Thirty-three-year-old sister with obesity and type 2 diabetes. Social History Occasional marijuana use, drinks alcohol 1-2 times weekly. Non-smoker. Lives alone. Patient has a girlfriend of three years. He has been socially isolating since March 15th due to his high-risk job. Medications Takes Tylenol or ibuprofen for aches and pains. Daily Allegra for seasonal allergies. Allergies NKA This case study is different from others in that I am letting you know from the start that Lakeith has Lyme disease, Covid-19 or both. What information do you need to determine his diagnosis? He’s had a nasal swab for Covid-19, but the results won’t be available for another three days. What else would you check before he leaves the primary care clinic? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information. References Merck Manual Professional Edition: Lyme Disease
  8. juan de la cruz

    Case Study: Fever

    The following is a case involving a young male who presents with fever associated with respiratory symptoms. This is based on a real case. The events leading to his hospitalization and his course in the hospital will be portrayed in an attempt to stimulate discussion on ways to approach his care not only from a nursing standpoint but also to understand the complexity of his care from the perspective of other disciplines who will be involved in his care particularly his medical management. Background HistoryRolando is a 19-year old college student who is the son of first generation immigrants from the Philippines. His parents are divorced and he lives with his mother in a coastal town close to where he attends college. He decided to skip the fall semester and live with his father in California's Central Valley region to help him run a small business. He presented to his family physician with complaints of productive cough for about 7 days and feeling warm and flushed. He said his phlegm looked white in color and not excessive. He appeared healthy and has no medical history other than having had his appendix removed at age 14. The physician prescribed him Azithromycin and cautioned him to seek further care if his symptoms do not improve. He recalls having some tests done at the clinic but was not sure what they were. Three days later, Rolando was feeling worse. He feels he is warmer and may have a high fever, is having chest discomfort with coughing while not expectorating any phlegm, and is experiencing joint pains and muscle aches. He has no appetite and is feeling weaker. His father was concerned and brought him to the nearest ED at a community hospital setting. Social HistoryHis social history is notable for being a college student with an undecided major. He admits to drinking alcohol occasionally but denies binge drinking, he does not smoke, he admits to having smoked marijuana in the past but not recently. He has a girlfriend in college and is sexually active. You are Rolando's first contact in the ED as the triage nurse. After gathering the above, you obtained the following dataSubjective complaints: "feeling warm, headache, little short of breath".Temperature 39 C, HR 112, RR 32, BP 110/65, O2Sat 88% on room airNeuro: AOx3, moving all extremities, pupils equal and reactive.CV: EKG showed Sinus Tachycardia with no ST changes, no murmurs were heard on auscultation, no edema in extremities.Pulm: Harsh breath sounds bilaterally but no accessory muscle use. He does breathe fast as you noted in his respiratory rate.Skin: Warm and flushed, you notice what looks like a red rash in his bilateral shins.Rest of the system exam is WNL.QuestionsHow would you triage Rolando and what tests would you expect to be done in his case?What would you tell the next ED nurse who will take care of Rolando once you determined the appropriate ED treatment area he should be treated at?What concerns do you have about what is likely the reason for his symptoms?
  9. SafetyNurse1968

    Case Study: Sudden Severe Pain

    If you think you know the correct diagnosis for this Case Study (CSI)... DO NOT POST ANSWER HERE. Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below. History of Present Illness: D. C., a 52-year-old, married, white college professor, woke up to severe and increasing pain in his right flank this morning. He came to the ER in acute distress with pallor, diaphoresis and significant anxiety (over his pain and over having to come to ER during coronavirus pandemic). He was in so much pain, he couldn’t sit still on the bed in the ER but continued to move around, constantly repositioning himself, groaning in pain and grimacing. He even vomited twice from the pain. He was given promethazine hydrochloride IV for nausea by the nurse. Due to his allergy to meperidine he was also given morphine IV for pain. Okay super sleuths, what are all the possible reasons for right flank pain? As always, imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions! A few other fun questions to think about: What is the pathophysiology behind pallor and diaphoresis? How does promethazine relieve nausea and vomiting? REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  10. SafetyNurse1968

    Case Study: My Stomach Hurts

    DIFFUSE ABDOMINAL PAIN“Mr. Halpert, what seems to be the problem today?” you ask as you scroll through his unremarkable medical history on your tablet. On paper he looks completely healthy. His heart rate is slightly elevated -- probably due to the pain --but all of his other vital signs are within normal range. He looks pale and slightly diaphoretic. His face is tight with pain as he says, “Please, call me Jim.” He groans and continues through a grimace, “Sorry about this. This is really embarrassing. I’ve been having pain for a few days. I thought it was just a bad burrito or something. I don’t normally come to places like this, but the pain seems to be getting worse.” Abdominal pain is the most common cause for hospital admission in the US. It represents a wide spectrum of conditions from food poisoning to appendicitis. Jim’s pain could be caused by something as mild as emotional upset over his annoying coworkers, or it could be as serious as a perforation of the gut that needs immediate emergency surgery. You’ve got plans for a barbecue right after work, and in fact, your friends have already started without you. They’ve been texting you to get moving and join the fun. The last thing you want this evening is a prolonged session with a patient. You know from experience that an efficient assessment is the key to clocking out on time. What questions could you ask to get to the root of the problem as quickly as possible? THE ROOT OF THE PROBLEMI’ll bet you’re thinking of one question, in particular, …one that makes you want your pathophysiology textbook. There’s a picture in there that will help. You know the one…it’s an image of a torso with a tic-tac-toe board drawn over it. Each quadrant has a list of possible problems related to…LOCATION! Before you click on either of the references below for help solving this problem, take out a sheet of paper and see how many possible problems you can list (no peeking!) A THOROUGH PAIN ASSESSMENTYou feel Jim's forehead with the back of your hand, even though you’ve already taken his temperature. It’s cool to the touch. “Where, exactly is the pain?” Jim says, “In the middle, right here” and clutches his abdomen right above the umbilicus. “It’s up above your belly button?” You ask and he nods in affirmation. “Not down below.” You point to your own belly, circling the area below your umbilicus. He shakes his head back and forth. “Is it worse on either side?” You point to your right and left abdomen as you ask the question. “Maybe just a little bit worse on the left, but I’m not really sure.” He lightly pats his stomach with his left hand right below his breast bone. “On a scale of 0-10, with 10 being the worst pain you’ve ever had and 0 being no pain, what is your pain right now?” Jim thinks for a moment and then says, “I broke my leg playing football in college, and it’s nowhere near that bad. I guess it’s around a five or a six?” You feel a sense of relief that his pain isn’t severe. You know that in mildly ill patients watchful waiting and diagnostic evaluation is often the best approach. THE OPTIONSHere’s a list of the more common reasons for diffuse abdominal pain (we’re going to look at these first…though it is possible he could have typhoid fever, it’s not very likely!) PancreatitisGall stones/CholelithiasisGastroenteritisPeritonitisGastritisPeptic ulcerWhat else do you need to know to narrow this down? Make a list of questions you’d like to ask Jim. HISTORY LESSONI’m hoping your list of questions looks something like this: Pain: location (check!), severity (check!), radiation, movement, onset, duration, severity, quality, exacerbating and remitting factors.Associated symptoms: fever, anorexia, vomiting, syncope, GI blood lossMedications: NSAIDs, prednisone, anticoagulantsPsychosocial: Drug and alcohol use, prolonged stressJim asks, “What do you think is wrong with me? Could it be food poisoning?” You respond, “That depends. Let me ask you a few questions to help me narrow down what it might be. First off, does the pain radiate at all?” Jim shakes his head back and forth. You continue, “Does it get worse with movement?” Jim replies, “No, not at all. It comes and goes. There’s nothing that really seems to make it worse… or better for that matter.” You continue, “You said it started a few days ago? Is the onset of the pain linked to anything you were doing?” Jim pauses to think for a moment, “I can’t think of anything. I guess I mentioned I went out for Mexican food with some friends.” You ask, “Did any of them get sick?” He shakes his head no. “Have you had any vomiting or diarrhea?” “Yeah, a little diarrhea, but I haven’t thrown up. I do feel a little sick to my stomach occasionally. I guess that means it’s not food poisoning, huh…It’s weird…I haven’t wanted to eat at all. Every time I try to eat something, I feel full right away. I guess that’s why I thought it was something I ate.” You add, “Food poisoning usually comes on pretty quickly with some fairly unpleasant side effects, but we’re not ruling anything out yet. Have you noticed any blood in your stool?” Jim turns slightly red and says, “No, I mean, not that I’ve noticed.” You ask, “Have you ever had anything like this happen before?” He shakes his head back and forth. You continue, “Try to describe the pain for me. What is it like?” Jim replies, “It's horrible!...but I don't think that's what you mean...” You give a sympathetic smile and say, “Is there any cramping? Is the pain sharp, or more like a dull ache, does it come in waves?” Jim responds, “No, there’s no cramping, no waves. My stomach is tender though if I press on it, it hurts. I guess the best way to describe it is kind of a gnawing or burning pain, if that makes any sense? And it comes and goes…and I have lots of indigestion like I said…no appetite and feeling nauseated. I’m just so tired…” You look up from typing in Jim’s symptoms to ask, “Tired of being in pain?” Jim answers, “Yes that, but also just tired all over. All I want to do is sleep, but I can’t because of my stomach.” You nod and pick up the tablet, “I hear you, it’s hard to be in pain for a few days. It’s good that you came in. I’m going to have the physician come in here in a sec, and she’s going to do a more thorough exam. I just have one final question.” What Is It????There’s one question that will really seal the deal here. What’s one thing from this patient’s history that might give you a big clue to what is causing his abdominal pain and get you out of work on time? Stay tuned for the exciting conclusion! I’ll post the final puzzle piece of Jim’s history, and give you some diagnostic clues as well. Feel free to ask questions and make comments below.
  11. SafetyNurse1968

    Case Study: Unexplained Bruises

    History of Present Illness Ann is a 6 yo girl who is brought to the pediatric clinic. For the last week, her mother says she has been very tired, lacks energy, sleeps more than usual, and has not had much appetite. Upon assessment, you discover bruises on the little girls’ arms and legs that Karen can't explain. She says, "I had no idea those were there!" and looks embarrassed and worried. Past Medical History Ann was full-term from an uncomplicated pregnancy and delivery. All immunizations are current. Ann had measles at age 3 yo. Family History Ann has one brother, age 8 years, who is in apparent good health. The maternal grandmother died at age 55 from rectal cancer. Social History Developmental milestones on target. Medications None Allergies NKDA General Appearance Alert, interactive, pale, height and weight normal for 6-yr-old Vital Signs BP 108/68 HR 130/min RR 20/min T 98.7oF HT 41 inches WT 37 lbs What are all the possible reasons for these signs and symptoms? Do you remember normal values for pediatrics vital signs? What information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run?
  12. SafetyNurse1968

    Case Study: What’s Causing This Cough?

    Chief Complaint: Provided by caregiver: “My grandfather is confused and pretty sick. He was up most of the night coughing.” History of Present Illness: H.T. is an 82-year-old Hispanic male who is widowed and a retired grocery store owner. His 28-year-old granddaughter lives with him. He uses a walker and takes daily walks in the neighborhood with her. He can perform most ADLs, but his granddaughter prepares his meals. He presents to the clinic with his caregiver who reports that about a week ago, Mr. T. came down with a cold and had a runny, stuffy nose. He visited the curandero and has been drinking gordolobo tea with honey, lemon and a generous dollop of tequila. He appeared to be getting better, but then several days ago he developed a cough. Over the last two days, the cough has become worse and he can’t seem to catch his breath. He was confused last night and nearly fell getting out of bed. General Appearance: The patient’s age is consistent with that reported. He is well-groomed and neat, uses a walker for ambulation and walks with a pronounced limp. He is lethargic, frail and thin oriented to self only. Patient is coughing and using accessory muscles to breathe. Appears uncomfortable and in moderate respiratory distress. Past Medical History: Tobacco dependence x 60 years Chronic bronchitis for 10 years Urinary overflow incontinence for 10 years HTN x 5 years, BP averages 140/80 with medication Mild right hemiparesis caused by CVA 3 years ago Bipolar x 50 years Constipation x 6 months Influenza vaccination 3 months ago Family History: (+) for HTN and cancer, (-) for CAD, asthma, DM Social History: Lives with granddaughter in his home Smokes ½ ppd Some friends recently ill with “colds” Occasional alcohol use Medications: Atenolol 100 mg po QD HCTZ 25 mg po QD Aspirin 325 mg po QD Aripiprazole 15 mg po QD Combivent MDI 2 puffs QID (caregiver states patient rarely uses) Albuterol MDI 2 puffs QID PRN Docusate calcium 100 mg po HS Allergies: Penicillin (rash) Okay, super sleuths, what are all the possible reasons for a cough? What’s causing his confusion? I think the most fun way to play is to imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!
  13. If you think you know the correct diagnosis for this Case Study (CSI)...Do not post the answer here.Instead, post your answer in the Admin Help Desk. We don't want to spoil it for others who are late in joining us. In a few days, after the diagnosis is posted, Admins will announce the names of those who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You can ask questions and comments below. Chief Complaint“My son died a month ago. He was stationed in Afghanistan. I think I’m still in shock. For the last few weeks I haven’t slept well. I keep waking up in the middle of the night, my heart pounding, out of breath, and now on top of that I’ve been feeling nauseated. I even threw up yesterday. I wonder if I have the stomach flu. I’m just praying I don’t have another migraine coming on.” History of Present IllnessA.W. began to experience shortness of breath and racing heart approximately two weeks ago, primarily at night. Nausea began two days ago with two episodes of emesis yesterday. Admits to burning pain in her throat that she attributes to heartburn. Ms. W. has been depressed and anxious since learning of her youngest son’s death. Ms. W. states she has been feeling more tired than usual, but attributes it to lack of sleep and stress over her son’s death. Most recent migraine was over a month ago. General AppearanceLooks anxious. Eyes wide, blinks a lot, shoulders tense, diaphoretic, occasionally rubs stomach just under sternum. Pt appears female, skin is brown in color, appears stated age, looks slightly overweight with weight carried around the middle. Okay super sleuths, what’s going on here? What information do you need? What would you do first? What labs do you want? What other diagnostic tests should we run? Ask me some questions! REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.
  14. You are a new graduate nurse on your second rotation in a 30-bed medical ward. It is 0800hrs during a morning shift, and you have been allocated the care of a 70-year-old female, who has been on your ward for the last week, recovering from an acute infective exacerbation of chronic obstructive pulmonary disease (copd). Past medical history: ischaemic heart disease (ihd) and severe copd (with type ii respiratory failure). When assisting the patient with breakfast you notice she has become increasingly breathless, only speaking in single words, and not interested in eating. A set of observations are taken: SAO2 88% on np at 2l/min bp 160/90, hr 144 resp rate 45 b/min, and Temperature 37.2. auscultation of the lung fields reveals wide spread expiratory wheeze bilaterally. lab results: abg uec's fbc ph 7.33 na 144mmol/l hb 155 g/l pa02 55 mmhg k 4.5 mmol/l wcc 11 x 109/l pac02 70 mmhg cl 109 mmol/l plt 400 x 109/l hc03 36 mmol/l urea 8 mmol/l creat 90 µmol/l Questions 1. Using the information given in the (above) case study start by prioritizing and justifying your immediate care of this patient? 2. You also need to interpret both clinical and lab results, and 3. what physiological processes may be responsible for the abnormal clinical or lab results?
  15. BACK STORYRead the full story HERE. A few years ago, my cousin Ruth came to live with us for the Summer and be a nanny to my four kids. While she was living with us she presented with increasing fatigue and listlessness. Eventually she admitted to having hallucinations, describing lights flashing on the ceiling as she tried to sleep, and of seeing our family dog wearing a grey fedora. She had always been pale and thin, she was a vegetarian, and she had recently stopped taking her birth control pills, which had led to intermittent bleeding for several months. In addition, she had a family history of suicide and manic depression. I suggested she try to eat more iron rich foods, and keep me posted on her fatigue level, but she didn't tell me much - typical of a teenager. Finally, we ended up taking her to the ER when she admitted to having thoughts of harming herself. I had considered anemia as the source of her fatigue, but when I questioned her about the amount of bleeding she was having, she had denied that it was excessive. In my experience anemia doesn't cause hallucinations, so when she started telling me about seeing our dog in a hat, given her family history, I started worrying about a mental health disorder, especially schizophrenia, which typically presents in early adult-hood.1 NOT THE USUAL SUSPECTSRuth was in the psych ward for four days, and during that time they did a full history and physical, including a psychological evaluation, medication reconciliation and a wide panel of lab tests. Though they found signs of depression, that didn't explain seeing my dog in a fedora. What they did find was severe iron deficiency anemia. She had been bleeding longer and more heavily than she had previously admitted, and I could have kicked myself for not taking her to see a doctor sooner. This article is my penance for not picking up on it sooner. I review risk factors, signs and symptoms of the various types of anemia, as well as diagnostic tests and treatments, and there are great resources for further learning. I still don't think I would have put iron deficiency anemia with hallucinations - I have looked far and wide for case studies or research discussing a link between the two. I Googled anemia and hallucinations multiple ways and got nothing. I tried hypoxia and hallucinations as well. I looked on Google Scholar, PubMed and hematological websites, but found very little linking the two. There is an article about a woman with very low iron who thought she was infested with spider eggs (Delusional parasitosis secondary to severe iron deficiency anemaia).2I also found a link between mountain climbing and psychosis, but the authors haven't found a direct link between hypoxiafrom mountain climbing and hallucinations.3 There's also a link between Vitamin B-12 deficiency caused anemia and hallucinations. Some people diagnosed with dementia or Alzheimer's are actually suffering from B12 deficiency.4 Ruth wasn't a mountain climber, she wasn't vegan or lacking intrinsic factor or producing inadequate stomach acid. She was slowly bleeding to death. ANEMIAAnemia is common and affects one-third of the world's population, and more than 3 million Americans. Anemia is defined as any pathological condition leading to significant decrease in total body erythrocyte (Red Blood Cell) mass. Red blood cells (RBCs) carry hemoglobin, an iron-rich protein that binds and carries oxygen to tissues in the body. Anemia occurs when you don't have enough red blood cells or when your red blood cells don't work correctly.5 SAFETYGiven the prevalence of anemia, you would think it would be easy to get all the information you need to know on the internet, but not so. I found myself longing for my old nursing school Med/Surg textbook. I found a lot of information for the layperson, describing signs and symptoms, but very little information on diagnostic lab values, and how to do a work-up on someone suspected of having anemia. As a patient safety specialist, I know that multiple organizations recommend up-to-date, easily accessible information be available to healthcare providers. It is often nurses who spot valuable details: patterns in vital signs, low lab values, patient behaviors, family stories, empty vitamin bottles found in a purse (can you hear the patient's voice? "oh, I didn't think it was important to tell the doctor about my vitamins!") When we have access to knowledge, we are better detectives, and have a better chance of keeping our patients safe. TYPES OF ANEMIA 5,6,7Ruth had iron deficiency anemia, the most common type of anemia worldwide, affecting 10-30% of world population; in the U.S. 11% of women and of 4% men have iron deficiency anemia, but there are many other types of anemia.6 Iron deficiency anemia caused by a shortage of iron in your body. Your bone marrow needs iron to make hemoglobin. Without adequate iron, your body can't produce enough hemoglobin for red blood cells. It occurs in many pregnant women, and is also caused by blood loss - like Ruth's, from heavy bleeding. Ulcers, cancer and regular use of aspirin can cause it as well. Vitamin B12 Deficiency caused by a lack of folate and vitamin B-12.Both are needed to produce health red blood cells. A diet lacking in these nutrients can cause decreased RBC production. In addition, if your body doesn't make intrinsic factor, you can't process the vitamin - leading to pernicious anemia. Chronic diseases Cancer, HIV/AIDS, rheumatoid arthritis, kidney disease and Crohn's can interfere with production of red blood cells. Aplastic anemia Caused by underproduction of red blood cells due to infection, medication, autoimmune disease and exposure to toxic chemicals. Bone Marrow Diseases leukemia and myelofibrosis can cause anemia by affecting blood production in the bone marrow Hemolytic Anemia when RBCs are destroyed faster than bone marrow can replace them. It can be inherited or develop later in life, includes Sickle cell Anemia which is an inherited defective form of hemoglobin that causes RBCs to form a crescent or sickle shape - they die prematurely. Thalassemia A rare inherited blood disorder in which the body makes an abnormal form of hemoglobin SYMPTOMS 5,6,7When you have anemia, your body tissues lack oxygen, so you may have one or more of the following symptoms: TirednessDizzinessWeaknessHeadachesPale skinFast heartbeatShortness of breathPounding or whooshing in earsCraving for ice or clay (picophagia)Sore or smooth tongueBrittle nailsHair lossDifficulty concentratingGrumpinessPoor cold toleranceDecline in renal functionOsteoporosisSarcopenia (loss of muscle tissue)RISK FACTORS5,6,7There are many risk factors for anemia: major surgery or trauma, menstruation (especially if periods are heavy) recently given birth, pregnant or breast feeding, GI disease like celiac, IBD, ulcerative colitis or Crohn disease, peptic ulcer, bariatric or gastric bypass, vegetarians, people who don't each iron-rich foods. DIAGNOSIS5,6,7,8Diagnosis of anemia involves asking many questions. You will want to know: severity; rate of onset; the patient's overall health and oxygen demand; past medical history (menstruation, duration, frequency, flow, pregnancy, blood in stool, blood loss - acute vs. chronic); family history. You will also do a complete physical exam (Pallor, conjunctiva, oral mucosa, nail beds, palmar creases, orthostatic BP changes - intravascular volume shift), lab workup and medication reconciliation. LAB VALUES8,9Diagnosing iron deficiency anemia is simple. Start with the CBC and look at the RBC count, and Hematocrit and Hemoglobin levels. If those are low, get an order for TIBC, iron and ferritin. A comprehensive list of lab values related to anemia is included, and where it's applicable I have included Ruth's values as well as normal values in parenthesis. Red blood cell size and color: with iron deficiency anemia, RBCs are smaller and paler in color Red Blood Cell count: how many RBCs you have. It's also known as an erythrocyte count. The test is important because RBCs contain hemoglobin, which carries oxygen to your body's tissues. Your tissues need oxygen to function. Ruth: 3.1x1012/L (3.9-5.2x1012/L) Hematocrit: the percentage of blood volume made up by RBCs. Ruth: 23.1% (34.9-44.5 % women; 38.8 - 50.0 % men). Hemoglobin: the oxygen carrying molecule found in RBCs. Lower than normal hemoglobin levels indicate anemia. Ruth: 7.0 g/dL (13.5-17.5 g/dL men; 12.0-15.5 g/dL women). Mean corpuscular volume(MCV): the average volume of red cells. It can be directly measured by automated hematology analyzer, or it can be calculated from hematocrit (Hct) and the red blood cell count (RBC) as follows: MCV in fl = (Hct [in L/L]/RBC [in x1012/L]) x 1000. Ruth 73 fL (78-102fL) Ferritin: a protein that contains iron and is the primary form of iron stored inside cells. The amount released and circulating in the blood reflects the amount of iron stored in the body. When your iron level is low, your body will pull iron out of storage to use it. A low level of ferritin usually indicates a low level of stored iron. Ruth: 4 ng/mL (12-156 ng/mL) Total iron binding capacity (TIBC): tells how much transferrin (a protein) is free to carry iron through the blood. If TIBC is high, more transferrin is free because there is less iron. Ruth: 550 mcg/dL (200-450 ng/mL). Serum Iron: The amount of iron in your blood may be normal, even if the total amount of iron in your body is low - which is why other tests are needed (like the TIBC and Ferritin levels). Ruth: 10 umol/L (10-30 umol/L)7 If it's not iron deficiency anemia, further tests are needed. Click on THIS link for more lab values and images of blood smears.9 And check out this Powerpoint based on Hazzard's Geriatric Medicine and Gerontology.8 It has flow charts for diagnosis, case studies, and a discussion of microcytic vs. macrocytic anemia (too much for this article!) TREATMENT5,6,7,8Iron deficiency anemia: taking iron supplements (take on an empty stomach to increase absorption, don't take with antacids, take with Vitamin C, watch out for constipation) and making changes to your diet (red meats, leafy-dark green vegetables, beans, molasses, liver, grains). If the underlying cause of iron deficiency is loss of blood, the source of the bleeding must be located and stopped. In Ruth's case, she had to get back on contraceptives to lighten her heavy menstrual flow. She also had to take iron, and it takes a long time to get iron levels up to normal, unfortunately they can't be corrected overnight, and may take months to replenish. Vitamin deficiency anemia: Dietary supplements and increasing these nutrients in your diet. If your digestive system has trouble absorbing vitamin B-12 from the food you eat, you may need vitamin B-12 shots. At first, you may receive the shots every other day. Eventually, you'll need shots just once a month, which may continue for life, depending on your situation. Anemia of chronic disease: No specific treatment for this type of anemia. You have to treat the underlying disease. If symptoms become severe, a blood transfusion or injections of synthetic erythropoietin, a hormone normally produced by your kidneys, may help stimulate red blood cell production and ease fatigue. Aplastic anemia: Blood transfusions to boost levels of red blood cells. You may need a bone marrow transplant if your bone marrow is diseased and can't make healthy blood cells. Anemia associated with bone marrow disease: Medication, chemotherapy or bone marrow transplantation. Hemolytic anemias: Avoiding suspect medications, treating related infections and taking drugs that suppress your immune system, which may be attacking your red blood cells. Depending on the severity of your anemia, a blood transfusion or plasmapheresis may be necessary. Plasmapheresis is a type of blood-filtering procedure. In certain cases, removal of the spleen can be helpful. Sickle cell anemia: Administration of oxygen, pain-relieving drugs, and oral and intravenous fluids to reduce pain and prevent complications. Doctors also may recommend blood transfusions, folic acid supplements and antibiotics. A bone marrow transplant may be an effective treatment in some circumstances. A cancer drug called hydroxyurea (Droxia, Hydrea) also is used to treat sickle cell anemia. Thalassemia: Blood transfusions, folic acid supplements, medication, removal of the spleen (splenectomy), or a blood and bone marrow stem cell transplant. REFERENCESSchizophrenia Facts and Statistics Delusional parasitosis secondary to severe iron deficiency anemia Mountain Climbing Can Actually Cause Psychosis, And We Don't Know Why https://www.hsph.harvard.edu/nutritionsource/b-12-deficiency/ Iron deficiency anemia - Diagnosis and treatment - Mayo Clinic Iron-Deficiency Anemia | National Heart, Lung, and Blood Institute (NHLBI) Laboratory Evaluation of Anemia
  16. Clinical Scene Investigators (CSI) are nurses who utilize the CSI format to solve a problem. Fiona Winterbottom, DNP, MSN, ACNS-BC, ACHPN, CCRN recently discussed this topic at the American Association of Critical Care Nurses with allnurses.com’s Content and Community Manager, Mary Watts, BSN, RN. Dr. Winterbottom is a Clinical Nurse Specialist at Ochsner Health System. How can nurses be innovators and change agents? Mary asked, “In what ways are nurses ideally positioned to be innovators and leaders of positive change?” Dr. Winterbottom replied, “Nurses are able to make change happen on the units. At Ochsner we have a lot of activities that empower nurses, especially with the practice councils. Practice change is so very important. About 2-3 years, I got involved with CSI so that nurses can make changes so that things that bother them can be changed.” What is CSI Academy? CSI is Clinical Scene Investigation Academy is a structured program that empowers nurses to look at something in their practice that bothers them and gives them tools to address the problem by creating solutions and lead change. Fiona got a grant to look at new ways to look at CSI and get more tools and add structure to some of the projects they are working on. AACN has booklets and stats to provide a structured plan to look at ways to change - it's a problem-solving process. She had 9 ICUs participating in the project - they had a lot of problems with staffing and turnover which has been challenging. She credited her leaders with stepping up to remove barriers to practice. Why is the CSI process important? Mary then asked why was this process so important to Ochsner? Dr. Winterbottom discussed that “Nurses have all the problems and all the solutions.” Creativity is stressed for the solution. Then this creativity is moved to the next step in an orderly manner. Ochsner Health System is an organization of 9 hospitals. They had to design solutions that worked for many different sizes of facilities and situations. Nurses can and do make a difference and can affect change. Utilization of CSI provides a methodical roadway from problem to solution. Here is the full interview in which Dr. Winterbottom discusses the CSI program in greater detail.
  17. juan de la cruz

    Case Study: Solve A Neurologic Mystery

    Background / Social History RS is a 70-year-old female who lives independently in a first-floor apartment in the city. She has no close relatives but has neighbors who know her very well and check in on her from time to time. She hires a cleaning lady that does her house cleaning and laundry every week. Her nearest relative is a niece who lives in the same state but is 8 hours away by car. Past History Her medical history includes anxiety disorder, hypertension, hyperlipidemia, COPD, and mild kidney insufficiency. She has a 40 pack/year history of smoking. She has no known allergies. Medications Paroxetine 20 mg daily Lorazepam 1 mg daily as needed for anxiety Losartan 100 mg daily Amlodipine 10 mg daily Simvastatin 40 mg daily Tiotropium 18 mcg inhaled daily Albuterol MDI 2 puffs 4 times a day as needed Present History / CC On the day of her ED admission, her niece had been calling her phone and had been unable to get hold of her. Her niece called a neighbor who stated that she has not seen RS in 3 days. Concerned about RS's condition, the neighbor knocked on her door and heard no response. Luckily she was able to open the door as it was unlocked. Upon entering the living room, the neighbor found RS lying unconscious on the floor. She had frothy secretions from her mouth and had urinated on herself. She immediately called 911. She was intubated at the scene by EMS responders for airway protection due to her altered mental status. Vital Signs BP 180/100 HR 110 RR 32 T 38.5 C O2sat 88% on RA prior to intubation Diagnostic Studies In the ED, RS pertinent labs showed a WBC of 15,000 mm3, a lactate of 2.5 mmol/L, and CPK of 20,000 U/L. Neurologic exam was significant for agitation and inability to follow commands with sedation wean. She was hyperreflexic with increased muscle tone. She is moving all her extremities equally and has no abnormal pupillary response. She is sedated on Propofol. CV exam reveals sinus tachycardia with BP of 110/50, her skin is warm to touch. Respiratory exam reveals rhonchi in upper lung fields with moderate white secretions via ET tube ABG: 7.36, 38, 82, 19, -3, 100% on ACVC: 16X400, FiO2 of 0.5 PEEP of 5. CXR reveals mild cardiomegaly, a hyperinflated lung silhouette and mild RLL opacity. Non-contrast CT Scan of her brain showed focal vasogenic edema in the basal ganglia. The remainder of the exam revealed normal findings. The ED was particularly busy that evening so RS was immediately transferred out to ICU without further testing in the ED. Because of her complex medical condition, she was transferred to the MICU under your care as her primary RN. What thoughts run in your head that could possibly explain what caused RS's presentation? What further testing would you anticipate? How would you care for RS as her nurse? For this exercise to be fun and informative, answer in the following manner: List possible explanations you would expect to hear from her medical team that could explain her neurologic presentation and why. Tests you would anticipate. Interventions you would provide as the bedside nurse and why. Note: This is an actual case and the outcome is already established.
  18. Hospice: 3 Ways Hospice at the end of life is focused on the whole person and their needs for symptom management, their psychosocial needs as relates to their significant others, and their spiritual care at the end of life. In these three case stories by a Faith Community Nurse, we see how hospice can be about much more than simply physical comfort at the end of life. A hospice team composed of nurses, aids, social workers, administration, chaplains and more, can play a part in helping the patient and family to the point of death and beyond. Hospice nurses work in different settings, often during the course of the same day, often visiting in a home, then in a nursing home, hospital or an assisted living facility. Sometimes facilities do develop a preference for one hospice agency over another, but according to the law, hospice agencies are to be presented fairly by case managers, physicians and others who have an opportunity to refer to hospice. 1. Hospice in the Nursing Home There are some nursing homes that resist hospice care. Since hospice services are included in Medicare, it is difficult to understand why there would be any resistance. Nursing homes often do a great job taking care of patients in rehab and those who are under long term care but most could benefit from expanding their care to include hospice expertise as the end of life approaches. (The Gerontologist, Vol 46, Number 3, p325-333) The FCN, Stephanie, caught up with Edward as he walked along the sidewalk with his walker outside the assisted living facility. After exchanging greetings and small talk about the weather, she asked him how his wife was doing. Mary had been suffering from Alzheimer’s Disease for several years and had experienced a recent decline with a significant loss of interest in her surroundings, as well as diminished energy, appetite and less recognition of her family and caregivers. The family had called in their Faith Community Nurse to discuss hospice but found that Edward was hesitant to take the step. As they walked along on the late summer afternoon, enjoying a cool breeze they talked about Mary’s condition. He said, “I think she would do better if she tried harder. She just needs more stimulation.” The couple had been married for over 60 years, and his longing for her, and the grief that he was already experiencing at the thought of her impending departure from this earth were clear. Mary lived at an adjacent nursing facility so they kept moving in that direction as they talked about the recent changes. “Edward, I know your family has been talking about hospice. Are you interested in talking about that? Are there any questions that I can answer for you?” “I don’t want to do that!” He exclaimed with a flash of anger. “I want to get her into rehab. That would help more than anything.” She let the topic go for the time-being as we finished the short walk and headed into Mary’s room. In subsequent days, as Mary continued to decline and spend more and more time asleep or unresponsive, the path forward became even more clear. His daughter said, “The facility is managing the end of life symptoms well, but we need hospice for dad. Hospice might give him the support he needs to change directions and let her go.” The daughter brought up the excellent point that sometimes hospice is as much for the family and the staff as it is for the patient. Sometimes there are minimal symptoms to manage, and physical problems are not the primary concern, making the support for the family a priority. Also, in a situation with a long-term resident of a nursing home, the transition to hospice can help everyone at the facility change directions to a more palliative care frame of mind with less interventional care considered. Hospice can assist the patient, the family and the facility in being on the same page. 2. Hospice in the Hospital Shirley had experienced a difficult year:a broken hip with a stay in a rehab facility, another fall with broken ribs and pneumonia, chronic pain from degenerative changes, diagnosis of atrial fib with anticoagulation therapy, a loss of mobility and function as well as a loss of many of the activities she enjoyed in life. Her husband, Carl, was a diligent caregiver, installing ramps, assistive devices, chair elevators and much more, to make their home navigable for her. In their mutual devotion they faced each day together, not without frustration but generally glad to have more time with each other. Their FCN provided support, helping to coordinate their congregation’s attention so they it decreased their sense of isolation and helped them to stay involved as much as possible. After a long stint in rehab, Shirley was finally getting out and about more and beginning to feel a little more like herself when one day she felt sick to her stomach, vomited blood and passed out. She was rushed to the hospital where she coded and was placed on life support. Her husband knew that she did not wish to have advanced interventional care but at the moment of crisis could not face “letting her go,” as the staff said. After several days on a vent with valiant attempts to prolong her life, it became abundantly clear that the end was near. The medical staff talked with Carl and the children who had gathered. They wept and mourned there in the ICU as respiratory therapy came to disconnect the ventilator. The FCN was with them and tired to provide information, assistance and support. Shirley continued to breathe after the discontinuation of life support so she was transferred to a hospice unit where their professional help aided the family during the time of transition. Shirley continued to receive optimal symptom management for respiratory distress before passing peacefully a few days later with the children and her beloved, Carl, standing at the bedside. Hospice in the hospital plays a strong role in helping make death easier and in bringing everyone together as they transition from the hyper-active interventional mode to the slower pace of accompanying someone who is on their final journey. The hospice team during this time can help the family who may struggle with how the whole end of life process has gone and who may worry about whether or not they have done the right thing in choosing hospice. 3. Hospice at Home The FCN got a call from the family. Arnold was ready for hospice care. After a 2 month battle with metastatic esophageal cancer, he and his wife were ready to change directions from interventional care to comfort care and hospice. His cancer, found in an already advanced stage, threw out complications faster than they could be addressed and brought under control so that he could qualify for any type of therapeutic regimen. After dealing with hypercoagulability that brought about ischemic pain in his feet to breathing problems related to tumor growth, they realized their time was too short to spend it in the cramped bays at the emergency room. He wanted to be at his country home, enjoyed the views from the front window, basking in the warmth of family and friends during whatever time he had left. While 27% of hospice patients are in a facility, 66% participate in hospice from their own home. (2013, National Hospice and Palliative Care Organization) Home care is truly the most common model of hospice care and when engaged early enough, allows for the time for the organization to fully deploy its range of helpful care options. After visiting with the family, the FCN let them know how to initiate hospice services with the company of their choice, smoothing the way for hospice care to come into the home after a referral from the primary doctor. Hospice at home, in the hospital or in the nursing home can serve the patient and family well as they look for ways to help everyone involved come to terms with the separation caused by death.
  19. Presentation / Patient History It's 11:34 a.m. The triage complaint is listed as a possible stroke, with dizziness and facial droop listed as secondary complaints. A fifty-six-year-old female still in her street clothes is partially curled up on her right side scrolling through her phone. Patti arrived six minutes ago via private vehicle, walked in from the parking lot, and was brought to the room in a wheelchair. She doesn't appear to be in any acute distress, moving freely while repositioning herself on the gurney, breathing easily, with good skin color, and strong fine motor skills going into the phone-work. Her husband is leaning back in his chair at the bedside with his left ankle crossed over his right knee, reading a magazine. Nothing in this room conveys a sense of urgency. "The triage note says, 'possible stroke.' Can you tell me what happened today that brought you to the hospital?" I slide on a blood pressure cuff and a pulse oximetry clip as we talk. "I've been having headaches for a couple of months. But they've been worse for maybe two weeks now. And I've had some dizziness too." Her facial movements are symmetrical. She speaks clearly, without difficulty. Her vital signs are all within normal limits. "The note also says, 'facial droop'. Can you tell me about that?" The husband takes over. "She was just sitting at the table after breakfast this morning at about nine o'clock. The left side of her face kind of pulled to the left, and she was having a hard time talking. It happened twice, about ten minutes apart, and it only lasted for a minute or two both times. She's had seizures so we didn't know if it was a seizure or what? Her face just pulled to the left." His description of pulling to the left doesn't sound like the "facial droop" described in the triage note. "Can you demonstrate how it looked to you?" The husband uses the muscles in his left cheek to pull the left side of his mouth laterally toward his ear." The patient adds, "I was having a hard time swallowing and I couldn't talk." "Any new or different medications recently?" "No," they say in unison, shaking their heads. Sudden Change About an hour later, we have normal findings on her EKG, chest x-ray, CBC, CMP and coagulation labs. Her repeated vital signs are also normal, and she's in sinus rhythm with no ectopy on the monitor. She breezed through her NIH stroke scale with no neuro deficits. I'm headed to the room to let them know her CT has been read as "no acute intracranial findings." Intuitively, the husband's recreation of her face pulling to the side is still dogging me when he suddenly bursts through the privacy curtain, running toward me. "She's doing it again." Patti is sitting up at a ninety-degree angle, gripping both side rails. She's clearly anxious now; her eyes are wide, and she rocks rapidly back and forth. She's still in sinus rhythm, but her heart rate is up to 110, and she's breathing fast. Her lower jaw is pulled laterally as far to the left as it can go, confirming the husband's choice of words in his description that "her face just pulled to the left." Somewhat relieved, I feel her tight muscles displacing her lower jaw radically to the left. "Can you move your jaw?" She shakes her head and tries to talk, but her voice is throaty, and her articulation is predictably muddled. "Is there anything else that feels wrong to you right now, other than your jaw being locked off to the side like this, making it hard for you to talk?" She looks at me and shakes her head, mumbling a garbled "no." "Patti, I can see you're really anxious. This doesn't look like a stroke or a seizure. I think it's a much lesser evil. Try to relax while I get the doctor in here to look at you." Dr. Spicer agrees that her presentation is consistent with a dystonic reaction causing a spasm of her jaw, lips, and tongue muscles. She's allergic to Benadryl, and, after considering Cogentin, he gives me a verbal order for 0.5 mg of IV Ativan. Her symptoms resolve rapidly, and, instead of being sleepy, she's just loopy enough to be happy and fun as we process her admission and move her to the observation unit. Etiology and Differential Patti's case is interesting for a couple of reasons. In looking for a potential cause, the most likely culprit appears to be her carbamazepine. They said 'no' when I asked about any new medications, but it turns out that her husband had changed jobs two months ago, forcing a change in insurance and doctors. The new doctor took her off Dilantin, which she had taken for years without incident, and put her on carbamazepine. The headaches had started a few days later, but they hadn't made the connection between the medication change and the headaches until we explored the timing together. Usually, a dystonic reaction happens after the first dose of a new medication or after an increase in dosage, neither of which applied in Patti's case, unless she had accidentally taken extra medication. We add a carbamazepine level to her labs, and the result comes back a little over the high end of the therapeutic range. Acute dystonic reactions are relatively rare in our flow of ER patients. Acute dystonic reactions to carbamazepine are also rare. Carbamazepine is sometimes prescribed to treat dystonia from other causes. The real key to the story was the husband's description that "her face pulled to the left." More specifically, just her jaw pulled to the left, but he was accurate in describing something that didn't sound like facial droop. (Try looking in the mirror and alternate between using your facial muscles to pull only your cheek or your jaw laterally. It's easy to see how he got his description.) Outcome It's unfortunate for Patti that she became one more causality of a system that forces changes in medical care because of a change in employment. The good news: there's no facial droop, no stroke, and no seizure. The simple longer-term fix for drug-induced acute dystonic reactions is to discontinue the offending agent.
  20. This article is the last in a 3-part series on connection between mind and body with childhood trauma #1: Why Is This Patient Smelling Music? #2: Does Childhood Abuse Prevent Weight Loss? MAGIC MUSHROOMSAs a former oncology nurse, and a home health nurse, I have witnessed many times how people with a terminal diagnosis experience anxiety, anger and fear over death. Some folks cope fairly well, but I’ve seen people so crippled by a terminal diagnosis that they push friends and family away. Instead of a beautiful, light filled, dignified death, they experience terror, darkness and pain. So, imagine my excitement when I heard about a research study in which psilocybin (the active ingredient in “magic mushrooms”) in conjunction with psychotherapy was used to treat anxiety and depression in patients with terminal cancer. The results were promising - many subjects felt uplifted, connected, unified, precious and even sacred. The results of the study showed decreased depression and anxiety in cancer patients for 8 months following a single dose of psilocybin, compared with a placebo.1 IN DEFENSE OF PSYCHEDELICSOne of my favorite authors, Michael Pollan, who wrote In Defense of Food (the one that told us to, “Eat food, not too much. Mostly plants.”) has written a book about the use of psychedelics like LSD, psilocybin, MDMA/ecstacy, ayahuasca, and 5-MeO-DMT (From the venom of the Sonoran Desert toad) in medical research. Though his book, How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression and Transcendence, was a bit dry, I found it interesting to read about the history of psychedelics in the U.S, and how their use was criminalized in the 1970s.2 The most interesting part of the book was about Pollan’s guided “trips” with psychedelics. He wrote honestly and openly about his experimentation with psilocybin, toad venom and LSD. I admit that when I was younger, I tried LSD and psilocybin, and probably would have tried the toad venom if I could have gotten my hands on it, but I did it to “party.” Pollan’s journey was one of self-exploration. He had recently lost his father, and he was looking for some resolution. For thousands of years, native peoples have traditionally used these drugs for these very same purposes. It wasn’t until the 1960s in American that the use of psychedelic drugs began to be perceived as criminal activity; however, Pollan and others are quick to point out that no one in the medical community is suggesting that they are legalized. We are talking about approval for medical use.3 PTSDEvidence is mounting that these drugs, when administered in controlled therapeutic settings, may be able to succeed where traditional medications have fallen short. The Multidisciplinary Association for Psychedelic Studies (MAPS) is currently engaged in FDA approved, phase 3 trials for the use of MDMA (known as 3,4-methylenedioxy-methamphetamine, and also as ecstasy)-assisted psychotherapy for PTSD. The goal of MAPS is to train at least 300 therapists in this modality before 2021 in anticipation of completion of the phase 3 trials.4 MDMA can increase feelings of trust and compassion (why it’s popular on the party scene), making is an effective part of psychotherapy for patients with a PTSD diagnosis. Researchers have found that the drug, administered for two eight-hour psychotherapy sessions spaced about a month apart, can reduce symptoms for the majority of participants, and the effects may last up to six years. This is good news because PTSD is incredibly difficult to treat. Thirty to forty percent of people with PTSD get no relief from current therapies, including cognitive behavioral therapy, group therapy, and antidepressants. PTSD affects 8 percent of Americans; almost 25 million people, many of them veterans. In 2016, approximately 868,000 veterans received disability benefits for PTSD, at a cost of $17 billion to the Veterans Administration.1&4 However, MDMA isn’t just for PTSD in veterans. In the references there’s a link to a story about a woman who used MDMA-assisted therapy to recover from PTSD after being raped.5 DEPRESSIONRecent research has pointed to the effect of psilocybin (the active ingredient in magic mushrooms) on blood flow to the amygdala, an area of the brain associated with emotional regulation (I wrote about this in great detail in part 2). Folks with depression tend to have higher blood flow in the amygdala than those who do not have depression. After being given a dose of psilocybin, MRI scans of 19 patients with treatment-resistant depression showed reduced blood flow to the amygdala. This reduced flow correlated with a decrease in depressive symptoms in all 19 subjects one week after treatment, and in nearly half of participants five weeks later. Research is being planned for an experimental study of psilocybin as compared to existing standard-of-care antidepressant medications.1, 2&4 ALCOHOLISM LSD (I wrote about it in a previous article), also known as lysergic acid diethylamide, is a semisynthetic compound first developed in 1938 by Dr. Albert Hofmann at the Sandoz pharmaceutical company in Basel, Switzerland. In the 1940s LSD became recognized for possible therapeutic effects, and was even used by Bob Wilson, founder of alcoholics anonymous. It played a role in the discovery of the serotonin neurotransmitter system. From the 1950s through the early 1970s, LSD was used as a treatment for alcoholism as well as for anxiety, depression and for people with advanced stage cancer. Now, thanks to MAPS, there is increasing evidence for LSD as a treatment modality. A recent MAPS study found a reduction in anxiety following two LSD-assisted psychotherapy sessions for 12 patients.1&4 MAPPING THE WAYGo to the MAPS site to learn more about psychedelic research studies, including how to enroll in clinical trials.4 Current MAPS studies: Medical marijuana (the first clinical trial of marijuana for PTSD in veterans)LSD-assisted psychotherapyIbogaine (naturally occurring chemical found in West African shrubs) for drug addictionAyahuasca-assisted treatment for addiction and dependence (ayahuasca is derived from a South American vine, containing naturally occuring MAOIs – it is legal in the US for religious uses)MONEYAs you might expect, research on psychedelics is funded mainly by academic institutions and nonprofits. Drug companies won’t be making money off of these treatments since MDMA and psilocybin, the active ingredient in magic mushrooms, are off-patent substances that exist in the public domain. I’d like to encourage you to support organizations like MAPS with financial donations, and to share their research with others who might be able to support funding.1 ADVOCATINGI’m not advocating for legal, recreational drug use (though the legality of alcohol, one of the most toxic, addictive, lethal substances around does give me pause for concern…and where’s the medical benefit of drinking? Don’t get me started…). I am advocating that nurses share this information with patients. As the most trusted healthcare provider in the U.S. we have a duty to share these potentially life-altering, maybe even life-saving treatment modalities with those who are most vulnerable: veterans, sexual assault survivors, victims of childhood trauma, those with treatment-resistant depression, people addicted to drugs and/or alcohol and those with a terminal diagnosis.6 I’m hoping for a good discussion here. What are your thoughts, experiences and ideas surrounding the use of psychedelics to support treatment of those with mental illness? REFERENCES 1. How a Psychedelic Drug Helps Cancer Patients Overcome Anxiety 2. Pollan, M. (2018). How to change your mind: What the new science of psychedelics teaches us about consciousness, dying, addiction, depression and transcendence. Penguin Press: New York, NY. 3. Will These Psychedelic Drugs Soon be Legal? 4. Multidisciplinary Association for Psychedelic Studies (MAPS): 5. My Story of MDMA-Assisted Psychotherapy after a Life Changing Rape 6. Journal of Palliative Medicine: taking psychedelics seriously
  21. OBESITY CLINIC DROPOUTS It was the Summer of 1985. People were drinking New Coke, the Unabomber had just claimed his first victim, and the pop industry had united to sing “We Are The World” to raise money to relieve famine in Africa. I was a senior in high school and trying to solve the problem of which college to attend after receiving two good offers. Halfway across the United States, Dr. Vincent Felitti, head of the Department of Preventive Medicine at Kaiser Permanente had a problem as well. Since 1980, more than half of the people in his obesity clinic had dropped out. The clinic was designed for people who were 100 to 600 pounds overweight. Felitti wondered why people who were successfully losing hundreds of pounds were dropping out of the program. He started digging into the medical records of the dropouts and found that all of them had been born a normal weight. The dropouts had all gained weight abruptly and then stabilized. If they lost weight, they gained it back - or more - in a very short time. Nothing in their medical records explained this problem, so Felitti decided to do face-to-face interviews with the dropouts. Weeks passed and he found nothing unusual until he accidentally asked a loaded question.1 In previous interviews, Felitti had asked, “How old were you when you were first sexually active?” However, at his most recent interview, he had asked a nervous young woman, “How much did you weigh when you were first sexually active?” The woman had responded, “40 pounds.” Felitti was confused and asked the question a second time. The woman gave the same answer, then burst into tears and said, “It was when I was four years old, with my father.” As Felitti continued the interviews, about 50% of the people he talked with provided information about childhood sexual abuse. He wondered how this could be happening. Nothing he had been taught in medical school had prepared him for this. Out of concern that he was biased, he asked colleagues to do some of the interviews, but reports of childhood abuse continued.1 Of the 286 dropouts interviewed, most of them had experienced childhood sexual abuse. The findings suggested that weight gain might be a way for the participants to cope with the depression, anxiety and fear that can go with being a survivor. He hypothesized that the obese people he was interviewing were overweight because eating was a solution to emotional pain. They didn’t see obesity as a problem but as a solution. Eating soothed anxiety and depression, and the weight helped them feel invisible to possible abusers. A woman who had been raped at the age of 7 by her father reported that he told her that the only reason he wasn’t raping her 9-year-old sister was because she was fat. For many of the dropouts, losing weight increased anxiety, depression and fear to levels that were intolerable.1 One woman who participated in the obesity clinic dropped out because she consistently regained any weight she lost. The woman reported she was sexually abused by two uncles and a school bus driver; the first time occurred when she was four years old. She then married a man who abused her repeatedly. The woman stated, “I imagine I’ve lost 100 pounds about six times and gained it back.” She would lose weight, but as soon as someone commented on her attractive appearance, she would gain it back again.1 In 1990, Felitti felt he had enough information to present at a conference for the North American Association for the Study of Obesity. He flew to Atlanta and gave a speech on the results of his interviews. When he finished, one of the experts in the audience told Felitti that he was naïve to believe his patients, stating that it was commonly understood by those more familiar with such matters that patient statements about abuse were fabrications to provide a cover explanation for their failed lives.1 Luckily for the rest of the world, Felitti met two sympathetic researchers at the conference. Dr. David Williamson and Dr. Robert Anda were epidemiologists from the U.S. Centers for Disease Control and Prevention. Together, they framed the idea for the Adverse Childhood Events (ACEs) study.1 HOLDING ALL THE ACES While Felitti and colleagues were formulating the ACEs study, I was struggling through my first few years of college. Away from home for the first time, I found navigating adult relationships to be painful and difficult, I was experiencing bizarre dissociative events in which I would leave my body and float up to the ceiling and I had a newly diagnosed duodenal ulcer. I eventually came to realize that the way my stepfather had treated me when I was living at home had a label - childhood sexual abuse. I was one of the 20% of girls and 5% of boys in the U.S. who are victims of a crime that at the time wasn’t much talked about. I went through some dark times learning to cope with what happened to me. Many years of therapy have brought me to this time and place where I now type these words, hoping to provide some hope and healing to others.2 Since then, I’ve done a lot of healing and a lot of learning about my childhood. I’ve tried to live my life to the fullest, though I don’t always have the skills to get where I want to go. I’ve had my share of relationship, financial, health, and employment issues, but I had never linked those issues to what happened to me as a kid. A few years ago, at the suggestion of a colleague, I attended a conference on the Adverse Childhood Events (ACEs) Study. I was stunned to learn that some of my problems might be linked to the abuse I suffered as a child. I had been a nurse for more than 10 years when I attended the conference; why had I never heard of this groundbreaking research? In the ACEs study, over 17,000 patient volunteers were surveyed (demographics: half were female, 74.8% white, average age 57, 75.2% attended college, all were in employed and in good health). The participants were asked if they had experienced any of the following ACEs:3 Physical abuse Sexual abuse Emotional abuse Physical neglect Emotional neglect Exposure to domestic violence Household substance abuse Household mental illness Parental separation or divorce Incarcerated household member ACE STATISTICS3 28% of study participants reported physical abuse 21% reported sexual abuse 66% reported one ACE 40% reported two or more ACEs 12.5% experienced four or more ACEs The number of ACEs is strongly associated with adulthood high-risk health behaviors like smoking, alcohol, drug abuse, promiscuity, and severe obesity. High ACE scores correlate with ill-health including depression, heart disease, cancer, chronic lung disease, and shortened lifespan.3 Compared to an ACE score of zero, having four ACEs was associated with a 700% increase in alcoholism, doubled risk of cancer, fourfold increase in emphysema. An ACE score of above 6 was associated with a 30-fold increase (3000%) in attempted suicide. Subsequent studies have confirmed the high frequency of ACEs and have found even higher incidences in urban populations.3 In one study, as many as 80% of young adults who had been abused met the diagnostic criteria for at least one psychiatric disorder at age 21, including depression, anxiety, eating disorders, and suicide attempts. Neglected and abused children are 25% more likely to experience delinquency, teen pregnancy, low academic achievement, being arrested as juveniles. They are less likely to graduate from high school. Abuse and neglect increased the likelihood of adult criminal behavior by 28% and violent crime by 20%.3&4 Just taking a peek at the CDC website on the ACEs study that lists publications by year, I found articles on sleep disturbances (2011), frequent headaches (2010), premature death and autoimmune disease (2009), prescription drug use, COPD (2008), and on and on.3 NEUROBIOLOGY Maltreatment during childhood can cause important regions of the brain to develop improperly with long term consequences. The stress of chronic abuse may cause hyperarousal in certain areas of the brain, which may result in hyperactivity and sleep disturbances.4 Exposing the developing brain to stress hormones exerts consequences by affecting gene expression, myelination, neural morphology, neurogenesis, and synaptogenesis. There are four factors involved in the severity of outcomes from childhood abuse: genes, timing, type of ACE, and protective factors. Traumatic stress can be associated with lasting changes in the amygdala, hippocampus and prefrontal cortex. It is associated with increased cortisol and norepinephrine responses.5 In a normal brain, the interaction between the hippocampus and the amygdala is important for processing emotional memory. Disruption of memory consolidation and retrieval may be involved in generating dissociative states. An impaired hippocampus has been shown to be involved in the pathophysiology of depression.4 In one study, brain scans from women with a history of severe childhood sexual abuse and a diagnosis of current PTSD were compared to women without childhood abuse. The study simulated a fearful state and those with PTSD showed greater activation of the left amygdala, and decreased function in the prefrontal cortex during fear conditioning.5 In other studies of recent military veterans and coal miners with PTSD, smaller volumes were found in both the hippocampus and amygdala.6 PTSD patients with ACEs have shown significantly decreased gray matter volume, including a reduced area in the corpus callosum. A smaller corpus callosum makes it difficult to integrate left and right hemisphere information. This provides a possible model for the genesis of dissociation and multiple distinct identities. At best, the outcome is a rapid and uncontrolled shifting between a logical and rational state to a highly emotional state. This may be associated with dysfunctional emotional memory processing leading to symptoms of hyper-arousal or avoidance.7 Childhood trauma can even cause temporal lobe seizures (Why Is This Patient Smelling Music? - The Mind-Body Connection Pt. 1) TAKING THE ACEs QUIZ I found an NPR article on the ACEs study and took the ACEs quiz for free. I was sad to see my score is a 6. With that kind of score, statistically speaking, I should be depressed, or anxious, or overweight, or financially ruined, or alone. I’ve been all of those things at one time or another, but I’ve always bounced. I’ve got resiliency like nobody’s business, making me wonder why I continue to be okay while other people, statistically speaking, are not? I think it’s important to consider that the ACEs score doesn’t measure the positive things that can help build resilience and protect a child from trauma. Having one person who gives you unconditional love (like my grandma did) can make all the difference. A teacher who believes in you or a trusted friend can all decrease the effects of early trauma. Resilience builds throughout life and close relationships are key. HOPE There is hope. There is research showing that antidepressants can cause the hippocampus and amygdala to increase in size. Trauma-informed therapy centering on art, yoga or mindfulness training can help. I’ve written about the successful use of EMDR in the treatment of PTSD and childhood trauma (Keep What You Love, Return the Rest: Healing from Trauma with EMDR), and EMDR: Another Tool for Your Mental Health Toolbox). I’ve recently been reading about other treatments that are controversial, but promising. Please consider reading part 3 which discusses the use of psilocybin to treat PTSD, depression and anxiety. Please also know, that no matter what happens to you, you can be okay and that there is help. If you are struggling, consider reaching out. Call the National Domestic Abuse Hotline: 1-800-799-7233 or 1-800-787-3224 (TTY). You can go to their website and chat online if you don’t want to talk on the phone. There is also a 24/7 crisis text line: Text HOME to 741741 anytime day or night to connect with a human who cares. References The Adverse Childhood Experiences Study — the largest, most important public health study you never heard of — began in an obesity clinic Adverse Childhood Experiences (ACEs) Limbic system tool and ACES study presentation.pdf Traumatic stress: Effects on the brain6/ Amygdala volumes decrease in veterans with PTSD PTSD, the Hippocampus, and the Amygdala – How Trauma Changes the Brain
  22. I'm teaching nursing fundamentals right now, and one of the things I tell my students over and over again is the importance of observation. Assessment and inspection are two of the fundamentals of Fundamentals. I tell them the job of nursing will never get boring if you think of each patient as a mystery. "Try to be like Sherlock Holmes (yes, they still know who that is, much to my joy) or House (from the TV show) and solve the mystery". No matter what your patient says, I want you to think, "What's really going on here?" I'm going to tell you a true story (names and relationships have been changed to protect the innocent). It has a beginning, a middle, and an end, but I am leaving off the end, for now. Because I believe you can solve this mystery, I really do. So read on, and see if you can unravel the Mystery of The Dog in a Fedora. My Cousin Ruth It's been a few years since this happened, and it concerns my cousin Ruth. I hadn't seen her in a few years - we live on opposite ends of the country, but out of the blue she called to ask if she could come to live with us for a few months. She was 18 and living a vagabond life, driving around the country in a PT cruiser with her dog, Mavis, exploring, meeting weird people, and working odd jobs. She had just finished picked oranges in Florida, and was looking for a break from living rough until a job opened up for her on the west coast picking apples. We weren't happy with our nanny, and I loved the idea of connecting with actual family, so we agreed she would stay for a few months and keep and eye on our four children, taking them places, keeping them safe, and bonding. The version of Ruth who showed up on our doorstep was thin for her 5'9" frame. She had cropped her hair short and dyed it purple. She has piercings and tattoos in odd places, but is a smart and very funny girl. I've known her all her life, and I trust her, despite her appearance. You might think from the description that Ruth is into drugs and alcohol, but I believe her when she adamantly denies using any mind-altering substances, because she lost her father at a very young age to suicide. Ruth is my cousin by a second marriage, and before her mom married my uncle, her dad had been an addict with a diagnosis of manic depression. When she found out he had killed himself, she hadn't seen him in years, but she had memories of him coming home drunk and high. The kids adored her, probably because at the time she was staying with us she was just a really big kid herself. One of their favorite things to do was take a fresh pack of markers and draw all over each other. I would come home from work and find Ruth with a pink mustache, lovingly drawn on by my 5 year-old daughter. I never knew what each of my four kids would have on their arms, backs, legs and tummies when I arrived home. One day it would be cartoons of dogs and cats, another day it would be an entire Shell Silverstein poem. We all thought it was hilarious, and it washed off in the bath. Ruth did a great job entertaining my kids, but a less than great job with the other duties of a nanny. She didn't wash the dishes, the guest room looked like a bomb had gone off in her suitcase, and the kids toys were always everywhere but in the toy box. You make exceptions for family members because you love them. But, Something Isn't Right As time went on however, I began to notice how tired RUTH seemed to be. She would sleep until 5 minutes before I needed her to watch the kids. She would go to bed the moment I got home. The kids started talking about how she was too tired to play. A neighbor called me one day to report my 2 year-old son was wandering in the front yard, alone, without any pants on. I called Ruth, who answered promptly, saying in a quiet voice that she was sitting down, leaning up against the front door frame, too tired to walk around with the little guy. His lower extremity situation was normal for him - he was a staunch nudist. It would have surprised me if his pants had been ON, but I was worried that the kids weren't getting the care they needed to be safe. That evening, after the kids went to bed, I knocked on Ruth's bedroom door. A faint murmur let me know she was awake and I entered the guest room. After moving aside a pile of clothing, I sat on the bed and said, "Ruth, what's going on?" She was quiet for a long time. Finally she mumbled "I'm just so tired...all the time." "Are you not sleeping?" "I feel like all I do is sleep, but it's never enough." I know teenagers need a lot of rest and sleep, but when it interferes with activities of daily living, my nurse radar goes up. I did a visual scan of Ruth and the room. She looked tired, with dark smudges under her eyes, and her skin was pale, but she was always pale, favoring the goth lifestyle of no sun at any time. I observed no signs of drug or alcohol use, but those could easily be hidden. "Is this normal for you? I mean, I haven't seen you in a few years, maybe this is how it is all the time?" She started chewing her lip, and looking at her chewed fingernails she said, "I feel like it's been for the last few months. I used to do stuff. I used to ride horses. I picked all that fruit." That was a good piece of evidence. She had successfully picked fruit all Spring - keeping a very physical job that was probably based on quotas. "What's changed?" I was trying not to pry too much, but it had to be done. "I went off the pill a while a go, and I've been bleeding a lot, on and off for a while now." Now we were getting somewhere! Sexually active, recently stopped birth control. "Are you bleeding a lot?" She shrugged and looked away. I could tell she was embarrassed. She shook her head indicating a negative. "Well you could be a little anemic, maybe you could try eating some spinach or broccoli. Heck, I could fry you up some chicken livers." She smiled at that, which was nice to see. "I'm a vegetarian, remember?" "We've got to figure something out - you have to be able to keep the kids safe, right? Do you need a few days off?" "No, I'll be OK. Sorry. I've probably just got a cold or something." "Keep me posted OK? Let me know if you feel worse, and just keep talking to me, OK?" "Sure." I left her then, sure that she went right back to sleep. I was worried about her. Her voice seemed flat and she didn't look like her usual cheerful self. Since depression runs in her family I wanted to keep an eye on her mood as well. "Ruth is her own person, as I am sure you know. Once she left home, she didn't want any more mothering. You know about as much as I do at this point." My aunt Nancy said in response to my phone call that evening. No insight was going to come from Ruth's mom, then. Hallucinations A few weeks went by, and I could tell Ruth was really trying, but I could also see that she wasn't feeling any better. She seemed listless, and tired, and had even stopped coloring my children. She was never one to chat much, but now she was practically silent. I decided to head into her room for another fact-finding mission. "So it seems like you aren't feeling any better. I see how hard you are trying. I'm worried about you. Are you feeling down?" As before, there was a long silence before the answer. "I'm having some weird thoughts." "What kinds of thoughts?" "I don't know. Just bad thoughts." "Ruth, you have to tell me what's going on. It's my job as someone who loves you to get you to open up. Please talk to me." Ruth took a deep breath and then said in a voice so quiet I could hardly hear her, "I'm seeing things." That wasn't what I was expecting. "How do you mean?" "When I lie down to go to sleep, I see lights on the ceiling. They move around. It's actually pretty cool." I didn't agree with that statement. "You're not taking anything, no drugs, no alcohol?" "Gross, no!" finally she showed a little spirit. She continued, with a small laugh in her voice. "There's a gray cat." "A grey cat." I repeated stupidly. We don't have a cat, much less a grey cat. "You've seen a grey cat around the property? "No, it just appears in my room, or in the kitchen sometimes." My whole body was tingling with this information. I was running through a list of things that could cause hallucinations, and none of them were good. Schizophrenia, tumors, brain injury, the list was not anything I wanted for my cousin. "I'm not sure I understand, Ruth. Are you saying you are seeing things that you know aren't really there?" I could see tears in her eyes as she looked away at the wall. "Yeah, I know it sounds crazy. Sometimes your dog comes in and sits down and she has a hat on. She's wearing a black fedora on her head." I sucked in some air and tried to get a handle on my thoughts. Etiology Of Hallucinations After doing some research, I was surprised that hallucinations in children are more common than you might think. An article I read states that most children ages 9-11 have had at least one psychotic-like experience, including hallucinations. There is an eight percent hallucination prevalence rate in children, however they tend to be transient and resolve spontaneously. In 50-95% of cases, after a few weeks or months.1 Causes of hallucinations include many organic problems, which I list below, but there are also some environmental factors I was unaware of including stress and anxiety, as well as childhood trauma. A positive relationship exists between hallucinations and sexual, physical and emotional abuse, but not parental death.2 Hallucinations are also related to drug use3 (LSD, psilocybin/mushrooms, mescalin/peyote), and a link has even been found between cannabis use and schizophrenia. Those who smoke cannabis are five times or more are more likely to develop schizophrenia, and researchers have found that if you are prone to schizophrenia, you are more likely to try cannabbis.4 Organic causes of hallucinations Schizophrenia Dementia Delirium Charles Bonnet Syndrome and Anton's syndrome (both involve vision issues.) Seizures (small, brightly colored spots or shapes that flash.) Migraines Peduncular hallucinosis (infarct of midbrain,) Sleep disturbances Tumors Inborn errors of metabolism Creutzfeldt-Jakob disease (a fatal, progressive neurodegenerative illness from prions.) Mood disorders (a significant relationship between hallucinations and suicidal behavior, those with MDD, and psychotic experience 14-fold increase in suicide plans or attempts.) Heading To The Emergency Room I will admit that I've seen things in the woods that I know weren't really there. I occasionally see things out of the corner of my eye after I've been running or biking for a long time. Once during an endurance race, I saw the little black dog I adored in college. She died many years ago, but we spent so many happy hours in the woods together. I don't think a trip to the ER is needed when I see things after pushing my body to its physical limits. Ruth, however needed to go. I questioned her further, "You said you are having bad thoughts. Is that what you meant, the hallucinations? Or is there something else? Are you having thoughts of harming yourself?" I know she's a cutter - I had seen the marks on her thighs under the very short dresses she wears, but the marks looked old and I hadn't brought it up, not wanting to pry into her private life at the beginning of the Summer. Now it was time to pry. Ruth replied, "I don't know." "Well I don't know either." I said with exasperation. I got up, went around to her side of the bed and gave her an awkward hug. She obviously didn't want it, but I was in full mom mode. "Can you promise me you won't hurt yourself?" Another long silence as I held her, and she did soften a little bit into the hug. She finally whispered, "No." OK then. I have never had to take anyone to the Emergency Room before. I called first, and they said to just drive up and bring Ruth inside, through the same doors that people with open head wounds, gunshots, and overdose travel. I called Ruth's mom while I was on the way, and she agreed I was doing the right thing. We didn't talk long because Nancy wanted to get moving on buying a plane ticket to come be with her daughter. Taking Ruth to the ER, not knowing if she would be admitted to the "psych ward" was one of the worst experiences of my life. Watching them wheel her away, not being able to protect her or keep her safe, and having to trust that the hospital would do the right thing - that was incredibly hard. She's OK! Lucky for all of us, it all turned out OK. They kept her for four, long days. After her mom arrived, she went and camped out at the hospital so she could be there for each and every visiting hour. I begged Nancy to bring me copies of all the lab reports. I wanted to get as much information as possible. We talked at least three times a day. I kept telling her what to ask, and imploring her to take copious notes. "If they see you taking notes, they'll take better care of her!" I shouted into the phone. I love my profession, and I love being a nurse, but I know how easy it is for well intentioned, highly trained healthcare workers to make an error. I was determined to keep Ruth as safe as she could be. I'm going to stop here for a little while. I wonder what you think was going on with Ruth? I've given you the same information I had. I still feel so guilty for not figuring it out sooner. Why was my dog wearing a fedora? The rest of the story will be in part 2. References 1. Hallucinations in Children, Adolescents: Psychiatric, Medical Causes, Assessments and Treatment | Psych Central Professional 2. Visual Hallucinations: Differential Diagnosis and Treatment 3. Common Hallucinogens and Dissociative Drugs | National Institute on Drug Abuse (NIDA) 4. Marijuana use and schizophrenia: New evidence suggests link
  23. Chief Complaint “Over the last few months I’ve been increasingly exhausted. I thought maybe I just needed some time off, but now that I’m actually taking a break from work, I’ve been feeling worse than ever. This last week I haven’t even been able to walk the dog.” History of Present Illness T.K. is a 51-year-old woman of mixed race who presents to her primary care provider with progressive fatigue, loss of appetite and mild nausea for the last 6 days. She has been at home for the last 5 days on leave from work but has been unable to take part in her usual activities including walking the dog and gardening. Her partner has insisted that she make an appointment with her primary care provider. General Appearance Looks fatigued: eyes and shoulders drooping, sighs deeply every few minutes, flat affect, moves slowly and with effort; pt appears female, skin is brown in color, appears stated age Past Medical History Broken clavicle from a fall from her bicycle, treated with surgery 10 years ago Latent TB, Positive PPD 4 years ago, treatment with isoniazid (INH) for 9 months High blood pressure, pre-diabetes and hypercholesterolemia for 2 years controlled with diet and exercise Mild depression diagnosed 4 years ago, treated with Prozac and counseling Family History Mother had Ductal Carcinoma In Situ 15 years ago Father had MI at age 65 One brother died from opioid overdose at age 21 One sister (age 45) with Graves disease Social History Born and raised in Asheville, NC Works in an insurance office doing medical coding, previously had been an RN, but quit R/T latent TB Partner teaches elementary school, no medical issues Drinks 1-2 alcoholic beverages per week, non-smoker, occasional cannabis use, denies other drug use Loves gardening and hiking with partner and dogs Tries to walk daily and follows low carb, low cholesterol, low salt diet Medications Prozac 40 mg PO daily for mild depression Acetaminophen 650 mg PO, every 4 hours PRN pain Loratadine 10 mg PO daily for allergies Benadryl 50 mg PO qhs PRN sleeplessness Multivitamin, Centrum, PO daily Allergies NKA Review of Systems (only abnormal systems are presented) Weight loss of 10 pounds in last month Salt cravings for several weeks until loss of appetite a week ago Several bouts of dizziness, one fainting spell in last 6 months Few aches and pains Very dry skin, subnormal turgor, sparse axillary hair, pigmented skin creases on palms of hand, elbows and backs of knees Breasts have very dark areolae, hyperpigmentation prominent along brassiere lines Moderately weak pedal pulses (1+) Vital Signs BP sitting, RA 96/72 HR 80/min RR 12/min T 98.7oF HT 5 ft. 8 in WT 170 lbs What else do you want to know? Feel free to ask questions and make comments below.
  24. juan de la cruz

    Case Study: "A Case of Bad Blood"

    CJ is a 65-year old female who tripped and fell inside her home landing on her right side. She felt immediate excruciating pain in her R hip and couldn't manage to get herself off the floor. Fortunately, she had a mobile phone in her housecoat pocket and she was able to call her son who arrived in her home within ten minutes. She was taken by ambulance to the ED where an x-ray revealed that she had sustained a hip fracture. CJ is otherwise healthy aside from a medical history that is notable for HTN and hyperlipidemia that are adequately managed with oral medications. CJ was seen by an Orthopedic Surgeon who recommended surgical intervention to repair her fractured hip. She was cleared medically to undergo surgery. CJ was taken to the OR for an ORIF and was intubated for general anesthesia. She had significant blood loss from the surgical procedure and required blood transfusions during the case. At the conclusion of her 3-hour surgical procedure, she had received 3 Units of PRBC's. Additional 2 Units of FFP's were ordered because her surgical drain had significant output. CJ was transferred to the ICU intubated because she was slow to wake up from anesthesia. The nurse received report from the Anesthesiologist that CJ already received the first unit of FFP and the second unit is half-way transfused. After receiving the second unit of FFP, her nurse noted an acute onset of oxygen desaturation to 75% and tachycardia. She was triggering the high peak airway pressure alarm on her ventilator. The nurse and respiratory therapist noticed copious amounts of pink, frothy secretions coming out of her oral endotracheal tube. Her FiO2 and PEEP were increased to 100% and 10 cmH2O respectively in order to maintain oxygen saturations above 90%. Chest x-ray was immediately obtained and showed bilateral pulmonary infiltrates with a normal cardio-mediastinal silhouette. The Intensivist is concerned that CJ suffered a Transfusion Related Acute Lung Injury or TRALI. BackgroundAs nurses working in critical care, transfusing blood products is a common role we perform. While blood product transfusion reactions come in many forms, a distinct type of blood product transfusion reaction known as TRALI is a rare but life-threatening condition that we must be aware of because it is the leading cause of transfusion-related mortality described in the range of 40-60%. The true incidence of TRALI is difficult to estimate not only because cases of TRALI are under-reported but also because of previous disagreements among clinicians as to which cases meet the criteria for this diagnosis. PathophysiologyThe exact mechanism of TRALI is not well understood, however, experts accept the two-hit mechanism which involves: Neutrophil sequestration and priming - patient has intrinsic condition that causes neutrophil sequestration and priming in the lung microvasculature. This happens before the blood transfusion.Neutrophil activation - when patient receives blood product, factors present in the blood product causes the recipient's neutrophils to release cytokines that damage the lung microvasculature leading to pulmonary edema.Neutrophil Activation Can Happen in Two WaysImmune mediated - via anti-HLA antibodies and anti-HNA antibodies in the donor bloodBiological response - biologically active lipids present in WBC's, platelets, and red blood cell breakdown.TRALI Diagnostic CriteriaIn an effort to standardize this clinical diagnosis, a consensus by the National Heart Lung and Blood Institute of the National Institutes of Health defines TRALI as new acute lung injury (ALI) or ARDS occurring during or within six hours of blood product administration. Conventional criteria for the diagnosis of ALI/ARDS as defined by the Berlin Criteria Acute onsetBilateral infiltrates on chest x-rayPaO2 to FiO2 ratio (P/F ratio) less than 300 with a minimum PEEP of 5 cmH2OEtiology must not be fully explained by cardiac failure of fluid volume overloadPossible TRALIThe above clinical diagnosis is made using strict criteria that only implicates the blood product transfusion as the culprit in the development of ALI/ARDS. In cases where the development of ALI/ARDS coincide with blood product transfusion but other confounding events exist such as aspiration, infection, or trauma, then a diagnosis of Possible TRALI is preferred. TRALI vs TACOA similar presentation of transfusion related respiratory insufficiency is Transfusion-Associated Circulatory Overload or TACO. In order to distinguish from TRALI, TACO is associated with rapid blood product administration in the setting of fluid volume overload and compromised cardiac function. The mechanism for pulmonary edema is of a hydrostatic process in nature, that is, elevated pressures in the pulmonary circulation causes fluid to shift to the extravascular space into the lung parenchyma. Nursing Care PlanningNursing diagnoses that may apply to TRALI include: Impaired Gas Exchange related to alveolar fluid accumulation as evidenced by dependence on mechanical ventilation with increased oxygen and PEEP requirements.Anxiety related to difficulty breathing and increased respiratory effort as evidenced by inability to maintain adequate oxygen saturation without mechanical ventilator assistance.TreatmentTreatment for TRALI is supportive. Transfusion should be stopped immediately if TRALI is suspected. Follow your facility protocol in terms of triggering blood bank evaluation of a transfusion reaction. It is important that cases of TRALI are reported and confirmed to protect future recipients of the donor blood. In many cases, patients are profoundly hypoxemic enough to require intubation and mechanical ventilation. Traditional ARDS ventilatory strategies are employed. Hemodynamic monitoring is indicated as some patients develop hypotension and must be supported with fluid resuscitation and/or vasopressors. Education and emotional support to patients and families are important. The clinical course of TRALI has been described as short with quick resolution in mild cases to as long as 40 hours in severe cases though longer periods have been reported. PreventionIt should be noted that cases of TRALI have declined significantly in recent years due to efforts at prevention. Blood donors implicated in TRALI cases should be deferred from future blood donation. Also recall that the mechanism thought to trigger TRALI partly involves immune mediated antibodies present in the donor blood particularly anti-HLA and anti-HNA antibodies. Some specialty laboratories in the US have the capability for neutrophil antibody testing to detect the risk of reaction from donor to recipient though this testing is expensive and still not widespread. More importantly, blood products donated from multiparous women and individuals who received multiple blood transfusions in the past have been found to contain the antibodies implicated in TRALI. As a consequence of this finding, most centers preferentially obtain blood products from male donors and screen female donors in order to eliminate the possibility of donation by multiparous women and individuals who has a history of receiving multiple blood transfusions. Lastly, blood transfusions must be utilized with reasonable indication and with thorough consideration of its risks. Further ReadingTransfusion medicinel Transfusion-related acute lung injury surveillance (2003-2005) and the potential impact of the selective use of plasma from male donors in the American Red Cross [PDF] TRALI Risk Mitigation for Plasma and Whole Blood for Allogeneic Transfusion
  25. It’s an exciting time for microbiome research. There are implications for the use of FMT with colitis, IBS, obesity, depression, autism, cancer, and diabetes. This is the first in a series about the gut biome, also known as the microbiome and its impact on our health and well-being. CASE STUDY (I’ve added names to make it more interesting, you can read the full case study HERE.1 ) “I’ve been having diarrhea and terrible cramping since I finished my antibiotics,” Sally said with a grimace. She had returned to her primary physician’s office shortly after finishing a course of antibiotic treatment for bacterial vaginosis. The nurse took a thorough health history and discovered that Sally had been exposed to Clostridium difficile when visiting her aunt in the hospital. C. difficile infection (CDI) is the most frequent hospital-acquired infection in the US. It is a debilitating bacterial infection that strikes 500,000 Americans each year and kills 30,000. It is typically caused by antibiotics, which disrupt the normal intestinal flora, leading to an overgrowth of C. difficile bacteria in the colon.2 In an attempt to prevent a possible C. difficile infection (CDI), Sally was treated with a 14-day course of oral vancomycin, but the nausea and abdominal pain persisted.3 After doing a few tests, they discovered that Sally also had a Helicobacter pylori infection. The H. pylori was treated with triple therapy (amoxicillin, clarithromycin and a proton pump inhibitor.) Three weeks later Sally was back in the office with escalating abdominal pain and diarrhea. A PCR assay was positive for CDI.4 Sally was referred to a gastroenterologist who prescribed a 12-week tapering course of oral vancomycin and started showing some improvement. However, two weeks after finishing the vancomycin, diarrheal symptoms returned. Sally was then prescribed rifamaxin with Saccharomyces boulardii, a bacterium that has been found to be highly effective in treating CDI.5 She also underwent an esophagogastroduodenoscopy, which showed the H. pylori infection was still present as well. Sally returned to her gastroenterologist after the rifamaxin and S. boulardii treatment had ended saying, “I’m still having diarrhea. I’m not sure how much more of this I can take. I haven’t been able to work and my FMLA is about to end.” She then burst into tears. The nurse said, “It sounds like it’s been really hard for you. Would you like to hear about some other options?” Sally nodded and blew her nose, “As long as it’s not more antibiotics.” FECAL MICROBIOTA TRANSPLANT The nurse said, “The doctor wants me to chat with you about fecal microbial transplant or FMT” The nurse explained to Sally that FMT would involve the transfer of fecal material from a donor into Sally’s colon to restore the natural micro biotic environment.6 Sally made a face and said, “You want to put someone else’s….poop into me?” The nurse said, “I know it sounds unusual, but it’s a well-accepted practice. Remember, CDI has an almost 7% mortality rate. It’s important to consider all your options. The cure rate for FMT is much higher than with antibiotics. You can have a family member donate the stool if they meet the criteria.” The nurse also shared with Sally that in some larger cities there are nonprofit stool banks (there’s a large one in Cambridge, Massachusetts for example).4 After some resistance, Sally finally agreed to the idea and chose her 16-year old daughter, Amanda to be the stool donor. Amanda was screened for suitability and met all the criteria. She had no health problems, no recent exposure to antibiotics, no recent tattooing or body piercing and no history of drug or alcohol use. She was negative for HIV, syphilis, viral hepatitis A, B & C, C. difficile, and Giardia lamblia. A routine stool culture was performed for enteric pathogens, which was also negative. Prior to the FMT, Sally was treated for H. pylori with quadruple therapy (metronidazole, tetracycline, bismuth, and a proton pump inhibitor.) Sally stopped the antibiotic therapy two days before the procedure. On the day before the FMT, she was prescribed a liquid diet and an enema. Amanda took a laxative the night before to ensure a timely and adequate bowel movement. She collected her stool in a hat (a plastic basin that fits inside the toilet basin). As instructed, they suspended the stool in normal saline and used a disposable stick provided to break up the stool. Amanda and Sally then filtered the solution through a disposable coffee filter (This article from the NY Times has some great images if you want to see more of what FMT looks like). Upon arrival at the outpatient clinic, Amanda handed the nurse a specimen container holding 600 mls of brown liquid. Sally was given Imodium to help her hold the donor stool for as long as possible. Sally was then sedated with IV sedatives and the FMT was performed by colonoscope. The colonoscope was advanced through the entire colon and then it was withdrawn, the donor stool was delivered into Sally’s terminal ilium.7 Sally was overjoyed with the results. At a 16 month follow up visit, she reported no further recurrence of C. Difficile after the Fecal Microbial Transplant. POOP WARS There’s a war raging in health care…okay, several, actually, but this battle pits drug companies against doctors and patient advocates over the use of human excrement. It’s a question of classification. Are the fecal microbiota that cure C. difficile infection a drug, or are they more like organs, tissues and blood products? The answer determines how the FDA regulates the procedure, how much it costs and who gets to profit. In 2013, the FDA began attempts to regulate FMT as a drug but said it would continue to study the matter before making a final decision. A change in regulation could result in increased costs for patients, as well as some of the exciting new therapies that are attempting to harness the microbiome to treat diseases from diabetes to cancer. As this article is being published on allnurses.com, the FDA is nearing a final decision. You can find out more and weigh in at The Fecal Transplant Foundation (on facebook). The fear is that the FDA is favoring the interests of what Dr. Alexander Khorust, a gastroenterologist at the University of Minnesota calls the “poop drug cartel” – a group of companies seeing approval for new ways (think FOR PROFIT ways) to deliver the active ingredients in feces. He states, “An obscene amount of money is being thrown around by companies trying to profit off what nature made.”4 INSTANT COFFEE It’s important to consider that alternate delivery of fecal material might be crucial to saving lives. FMT is a time-consuming process, requiring coordination of care for both donor and recipient. FMT also requires IV anesthesia, which isn’t an option for all patients. One of the new delivery methods involves freeze-drying the material and giving it to the patient in pill form are already in the works. According to Dr. Herbert DuPont, director of the Center for Infectious Diseases at the University of Texas, frozen and freeze-dried microbiota are as effective in treating C. difficile infections as “fresh material” The only difference in outcomes appears to be the speed at which the patient is cured. Fresh material improves bacterial diversity in about a week, compared to 30 days for lyophilized material. The biggest benefit is convenience. Dr. DuPont compares the pill that his team is testing to “instant coffee” because it’s stable and can be transported easily.2 THE FUTURE The human body contains trillions of microorganisms. Humans are, by cell count, approximately 90% bacteria, with bacteria outnumbering human cells by 10 to 1. Because of their small size, however, microorganisms make up only about 1 to 3 percent of the body's mass (in a 200-pound adult, that’s 2 to 6 pounds of bacteria). Despite their small size, scientists are discovering they play a vital role in human health. Most of the research into the impact the microbiome has on health has occurred in the last five to ten years, and it is incredibly exciting.4 These trillions of organisms that colonize the body are increasingly being seen as critical for healthy brain development and immune function. Scientists have been inspired by the success of fecal transplants for CDI and are racing to develop similar treatments for an array of ailments like depression, obesity, autism, ulcerative colitis, Alzheimer’s and Parkinson’s diseases.4 My next article will revisit Sally and Amanda. Remember that Sally returned for a 16 month follow up visit with no signs or symptoms of C. diff, however, she now has another problem, a BMI of 33 (Sally’s weight before the FMT was stable at 136 pounds with a BMI of 26). “I’ve gained all this weight and I can’t seem to get it off. What’s happening to me?” Stay tuned for more! Read Part 2 - Using Bacteria to Control Your Weight REFERENCES Alang, N. & Kelly, C. R. (2015). Weight gain after fecal microbiota transplantation. Open Forum Infectious Diseases, 2(1). Retrieved from: Oxford University Press New Fecal Transplant Method Treats C. difficile "Like Instant Coffee" Oral vancomycin prophylaxis is highly effective in preventing Clostridium difficile infection in allogeneic hematopoietic cell transplant recipients. Drug Companies and Doctors Battle Over the Future of Fecal Transplants New advances in the treatment of Clostridium difficile infection (CDI) Fecal Transplantation (Bacteriotherapy) You Won’t Believe How This Works: Fecal Transplant