Tuesday, July 17, 2018

Funky Lab

Asked to see a young man who had been admitted 5 days earlier with what appeared to be extreme alcohol induced hepatitis.  In addition to an extreme liver panel, but not so bad ultrasound, his proteins were very low for a young previously healthy man and his sodium was only 123.  The residents had the presence of mind to address the hyponatremia in the usual way.  Osmolality 335 in serum, 691 in urine, sodium 150 in urine.  This is pseudohyponatremia of extreme degree, though not recognized for that.  After some testing, his cortisol was low at 3.1 so they called me.  The original lab looked like there was some other substance restricting plasma volume so I had the residents repeat the serum osmolality which had come down to 290, still inappropriate to the sodium of 129.  Since his glucose, bun and proteins were not high, this is usually from a lipid problem.  Sure enough, the cholesterol was 1208 and ldlc 1098, by far the highest numbers I have ever seen.  I assume the liver dysfunction impairs some of the serum cholesterol disposal enzymes.

Not sure why it took 5 days to figure this out.

Tuesday, July 10, 2018

Unrestrained PRN

Sometimes we get complacent.  A very nice diabetic came to the hospital about 10 days back having been at our other campus not long ago.  He had a foot wound requiring two toe amputations here.  Glucose management at the other hospital seemed more difficult than it was here, with the continuation of insulin dosing proving too much, particularly the nightly basal dose which brought the dawn glucoses too low.  With some minor revisions the glucose control coasted along, his BP remained decent on medicine and his underlying cardiovascular disease mandated high dose atorvastatin which he continued uneventfully.  He always seemed pleasant, never seemed in any distress, a placid and pleasant fellow who never complained, at least not to me.

Ordinarily I take a look at my medicines on daily rounds.  The computer makes this easy by putting an asterisk next to the medicines I ordered.  There were antibiotics and there were analgesics ordered by other people to which I did not pay a lot of attention, his being in the hands of medical and surgical colleagues who do this professionally.

As he prepared for discharge I went over the list and noted a prn q 4h oxycontin order.  When I called up how much he actually took, it turns out that he has been requesting 4 doses a day on roughly a q4h while awake pattern every day for 5 consecutive days.  It seemed like a much larger amount of medicine than I would have anticipated for somebody who never looked uncomfortable at any of my visits.  Needless to say there are questions relating to his medical care and there are better ways to manage ongoing anticipated pain.  Was his pain control adequate or was there incomplete treatment of its source?  Does he really desire euphoria more than analgesia?  Does the prn nature of the order create a conflict between a patient in pain now and a surgical nurse who is otherwise occupied at the time with other patients whose needs are more immediate?

And who should be the one noticing this aberration?  I asked some of the nurses on the ward at the time if they note excessive prn use of opiates as the patients start demanding it of them repetitively.  Generally no, as no single nurse dispenses more than two in any shift and doesn't really come passively on the overall utilization.  I asked the pharmacist.  There really is no automatic mechanism to detect this.  Every day  there is a group meeting to discuss the progress and discharge planning for each patient.  Needless to say, this would not continue past discharge, but it whizzes by the daily sessions.  And then there is the surgical resident.  They look at wounds at the bedside.  Looking at medicines is a distraction from their surgical tasks.

So as we deal professionally with excess opiate utilization as a public health crisis, how much of that was our own creation, initial legitimate prescribing with a blind eye to use that seems excessive.  We have no mechanism to intercept that other than individual diligence in paying attention to medicine orders and administration.  Alas, good systems work better than astute people, and our system here seems absent.

Friday, July 6, 2018

Old Records

Got a semi-urgent consult, a man with a calcium of 11.9.  He was asymptomatic but what made it urgent was the desire to send him to a rehab facility the next day.  Not being otherwise engaged, I went up to see him, having read the current chart from my desk.  As I got to the charting room, some brand new interns, first week, were milling around, already discussing discharges with each other to the neglect of incomplete medical care.  One of them owned up to having been assigned this fellow who just had his hyperparathyroidism confirmed by the lab.  So the questions were obvious to me:  what was his previous calcium?  Did he have urolithiasis?  Did he ever fracture anything?  Why was he on Casoex?  They looked at the lab work, called me, took no relevant history, did not seek out records, and plotted his exit at the earliest possible time.  Not a good way to imprint the expectations of medical care on medical newbies.

I called the young'un over.  We opened the chart from the other campus of our medical center, about a five minute effort.  He had been hospitalized the previous year.  His calcium was consistently 10.6-11.0.  No testing was done, though he did have an abdominal CT which showed no renal stones at the time.  There was a lab result from six months ago, calcium 11.0 so it is clearly rising.  He had a medicine list.  hctz on it, though stopped here.  Also leupron on it so now it is clear why he also took Casodex.  Renal function normal, then and now. 

Haven't even entered this fellow's room and it was clear he had hyperparathyroidism with a rising calcium and he also had prostate carcinoma that was being treated medically.

Interviewing him did not add a whole lot.  He could tell me who was prescribing the prostate treatment.  He did not have stones, moans, groans, or psychic overtones.  He had also not been told of the calcium elevation before.  And his bp was pretty high, presumably some of it from stopping the hctz.

So he would benefit from a parathyroidectomy and from some revisions in his antihypertensives.

And the new trainees need to redirect their focus away from discharge to more thorough care while the patient is their responsibility.