Milwaukie Family Medicine 2020

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  Acute Pancreatitis: Case Report and the Importance of Early Prediction of Severity

  Christelle Serra-Van Brunt

  INTRODUCTION: Acute Pancreatitis (AP) was the third most common GI diagnosis in 2012, resulting in approximately 275,000 admissions and costing about $2.6 billion. It remains a disease characterized by significant morbidity and mortality, and to this day, there is not a medication to treat it. Most care is supportive. Establishing the severity of the disease accurately is important in order to triage patients to the correct level of care to decrease rate of complications, mortality, and potentially shorten duration of stay.

  CASE REVIEW: 30yo male with history of alcohol use/abuse, with prior episode of pancreatitis 5mo earlier, presented to the Emergency Department with sudden onset of epigastric pain radiating to the back, nausea, vomiting. Patient’s last drink was 4 days prior, admitting to binging over the weekend. Initial VS: HR in 110s-120s, RR 20. BP 162/105. Initial remarkable labs: WBC 18.3, Na 133, K 3.0, CO2 15, AG 25,BG 149 lipase 2610. On physical exam, patient was uncomfortable with a diffusely tender abdomen. He appeared hypovolemic. He received 2L NS in ED. Patient was admitted to the medical floor and started on 250mL/hrof LR, given Dilaudidfor pain control and placed NPO. 8 hours after admit, patient acutely decompensated. Repeat VS BP 92/60, HR 159, RR 25. Abdomen was taught on exam. Patient was was transferred to the ICU for further management. Repeat labs now showing H&H 21&61, K 5.6, CO2 9, AG 21, Cr 1.35, CA 6.5, Mag 1.6, lactate 8.9. Patient was started on a bicarbonate drip, received calcium gluconate and 10 units of NPH, and D50 injection. A Foley catheter was inserted with an estimated bladder pressure of 12. Despite measures, patient’s acidosis and renal failure worsened and 3 hours later, patient was transferred to PPMC ICU for further management.

  DISCUSSION: Most authors of past and current guidelines recommend physicians to predict the severity of AP early on to guide the triage of patients. A multitude of predictive models have been developed to predict the severity of AP based upon clinical, laboratory, and radiologic risk factors, various severity grading systems, and serum markers {2] Some of these can be performed on admission to assist in triage of patients, while others can only be obtained after the first 48 to 72 hours or later. However these predictive models have low specificity, which, when coupled with the low prevalence of severe AP, results in low positive predictive values. •A CRP level above 150mg/L at 48 hours is associated with severe pancreatitis with an 80% sensitivity. •A BUN level of 20mg/dLon admission is also associated with an increased risk of death, as is an increase in BUN at 24hrs. •Ranson’scriteria and Apache II scores are 2 scoring tools frequently used in inpatient medicine. •Whilst an Apache II score has a median sensitivity of 100% and can be used on admission and repeated daily, a Ranson‘sscore > 2 has a sensitivity and a specificity in the 80s, and has to be calculated at 48hours. •An Apache II score > 8 and up-trending scores suggest a severe episode5 •Other scoring systems include SIRS, BISAP, CTSI.

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  Diabetes Education with a Teaching Kitchen Intervention Can Improve Hemoglobin A1c for Type 2 Diabetics Compared to Traditional Diabetes Education

  Jill Christensen, Heidi Davis, Charlotte Navarre, Hsin-Fang Li, Kathy Schwab, Richard O'Neil, and Justin Ferley

  Authors
  Jill Christensen MD MPH Providence Milwaukie Hospital
  Heidi Davis MSW Providence Milwaukie Hospital
  Charlotte Navarre RN Providence Milwaukie Hospital
  Hsin-Fang Li PHD Providence Medical Data Research Center
  Kathy Schwab MPH RDN Providence Health Education
  Richard O’Neil MBA Providence Planning Analyst

  Title Diabetes Education with a Teaching Kitchen Intervention Can Improve Hemoglobin A1c for Type 2 Diabetics Compared to Traditional Diabetes Education

  Purpose The Providence Milwaukie Community Teaching Kitchen offers health-focused, budget friendly cooking classes for patients. In 2019, we piloted diabetes education classes with an added hands-on culinary session. This study compares the change in hemoglobin A1c for patients who participated in the pilot with those in the standard curriculum and those referred to diabetes education but did not enroll.

  Methods This retrospective analysis compared change in hemoglobin A1c for all patients referred to diabetes education in the Providence Northern Oregon region in 2019. Patients referred to diabetes education but not enrolled were considered a control group. To balance patient characteristics (e.g. age, gender, and pre-A1c score), two-to-one propensity score matching method was used to identify two matched controls for each enrollee. Change in hemoglobin A1c from baseline to 3-6 months were compared among matched comparison groups.

  Results 13,582 patients were identified including 19 patients enrolled in diabetes education plus kitchen class, 640 patients in traditional diabetes education, and 12,923 patients referred but did not enroll. After matching, 1,318 matched patients were selected from the non-enrollees as the control group. The change in hemoglobin A1c was -0.49, -0.81, and -0.95 for the control group, diabetes education group, and diabetes education group with kitchen classes, respectively. Compared to the control group, both diabetes education groups had a greater reduction in hemoglobin A1c (difference of 0.32, 95% Confidence Interval [CI]=0.17, 0.48 for the diabetes education group; difference of 0.46, 95% CI=-0.28, 1.19) for the diabetes plus kitchen class group). Even though the diabetes education plus kitchen intervention had the largest reduction in hemoglobin A1c, the sample was small with large variation.

  Conclusions Integrating a teaching kitchen component into the traditional diabetes education curriculum is a promising approach that can further improve initial biometric outcomes. Future studies are warranted to demonstrate clinical effectiveness of this enhanced intervention.

  Financial Support Health Share Oregon Coordinated Care Organization

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  Increasing Vaccination Rates of Children up to 24 months old at PMG Milwaukie Family Medicine

  Justin Ferley, Rachel Jackson, Aubrey Miller, Sebastian Reeve, Christelle Serra-Van Brunt, Jamie Skreen, Jeffrey Sun, John Yates, and Daniel Ruegg

  Increasing Vaccination Rates of children up to 24 months old at PMG Milwaukie Family Medicine

  Authors: Justin Ferley DO; Rachel Jackson MD; Aubrey Miller MD; Sebastian Reeve MD; Christelle Serra Van-Brunt DO; Jamie Skreen DO; Jeffrey Sun DO; John Yates MD; Daniel Ruegg MD

  Introduction: Each year in the US, 42000 adults and 300 children die of vaccine preventable diseases. Yet across the country, clinics – including ours – fall short of the CDC Healthy People 2020 goals of pediatric vaccination rates. This resident-led quality improvement (QI) project aimed to improve our clinic vaccination rates in the under 24mo population.

  Methods: We identified 3 opportunities for vaccinating children under our clinic current processes: well child visits, medical assistants’ vaccinations visits, and acute care visits. Using a multidisciplinary approach comprising residents, MAs, clinical care coordinators and our nursing quality supervisor, we analyzed our current vaccinations processes and our iterative plan-do-study- cycles (PDSA) included: PDSA #1: standardize our work flow for vaccine reconciliation. PDSA #2: sending personal reminder lebers to patients and overall improving our vaccine recall/ reminder system. PDSA #3: Minimizing provider variation for vaccines given at the 12-18mo WCC.

  Results: We saw an improvement in our vaccinations rates after personalized reminder letters were sent out, outlining that we do not have a reliable vaccine schedule reminder system. We also noted that different providers created different vaccinations schedules in order to prevent giving 5 vaccines at the same $me – with no system in place to follow on missed vaccination, thus creating missed opportunities and suggesting that we need to implement a clinic-wide vaccine schedule.

  Conclusion: Our last PDSA cycle was interrupted by current CIVD-19 pandemic. We have however found valuable data to help improve our clinic’s vaccination rates, and plan to continue this project over the next 2 years.

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  Miliary TB disease with TB meningitis

  Jamie Skreen

  Context/background: Miliary tuberculosis is a condition that is fatal if not diagnosed and can present in the outpatient setting with vague symptoms that resemble a viral illness, therefore, can be easily missed. Recognition of this disease as a differential is important in the primary care setting, especially when caring for immigrant and International patient populations.

  Case Description: A previously healthy 35 yo female from Vietnam whom presented initially to the ER for headache and fever for the past 2 weeks. She was diagnosed with acute viral syndrome given her symptoms, normal labs, and head CT, and discharged home. A few days later, she presented to an urgent care because she began having blurry vision, nausea, vomiting, lethargy and had incoherent speech. She did not have any URI symptoms, cough or hemoptysis. At the urgent care, she was noted to have some neck stiffness, fatigue, unsteady gait, and fever to 103F. They had her return to the emergency room for further workup. In the ED, she had an LP that revealed lymphocytic-predominant pleiocytosis, elevated protein, and low glucose. ID was consulted, from LP alone, differential included early viral meningitis vs bacterial (pyogenic vs AFB vs other atypical pathogens such as Listeria, Brucella, Syphilis) vs Cryptococcus. She was started on CTX, vancomycin, and acyclovir while workup was pending. She had a CXR to look for evidence of prior TB, which resulted in ”diffuse pulmonary nodularity.” Differential included respiratory bronchiolitis, miliary tuberculosis and other fungal infections, hypersensitivity pneumonitis and viral infection. After CXR, she was placed on airborne precautions and in a reverse flow room given possibility of TB. Because she had neurological symptoms, she received a brain MRI, which showed ”small ring-enhancing lesions in the left frontal cortex and right frontal cortex.” The following day, CSF resulted was positive for TB by PCR, confirming the diagnosis. Treatment with rifampin, isoniazid, pyrazinamide, ethambutol (“RIPE”) was immediately started. Contacted by the county health department and they stated that even though there was a diagnosis, a sputum sample was needed to determine level of contagiousness. She was unable to produce sputum, even with induction (she had no cough), therefore she had bronchoalveolar lavage for sputum culture, resulted in 3+ (moderate) Mycobacterium tuberculosis. She continued the RIPE regimen and was discharged from the hospital the following day.

  Discussion: Although miliary TB is a rare form of TB (2% of TB cases), when missed it can be fatal, as mortality rate is between 15 to 30%. One of the main causes for high mortality includes late detection of disease caused by non-specific symptoms. Recognition of this disease as a differential is important in the primary care setting and when caring for international patient populations.

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  Necrotizing Fasciitis – Time is of the Essence

  Jeffrey Sun and Edward Kim

  Necrotizing fasciitis (NF) is a life threatening rapidly progressive soft tissue infection that carries a high mortality rate. There are approximately 500-1,500 cases per year in the United States with a mortality rate of up to 18-20%. Without surgical intervention, the mortality rate is near 100%. NF can be characterized by tissue involvement, polymicrobial or monomicrobial etiology, or site of infection. The most common risk factor includes diabetes (reported in up to 60% of cases), IV drug use history, malnutrition, and chronic alcohol abuse. In about 50% of group A streptococcus cases, there is an associated streptococcal toxic shock syndrome with multiorgan system failure. Early recognition and prompt surgical intervention is key in improving mortality and amputation rates.

  We present a case of a 64-year old male with history of severe malnutrition, chronic bilateral deep vein thromboses on apixaban, and chronic pancytopenia who presented with rapidly worsening right leg pain. He was afebrile on arrival with a blood pressure of 70/40 mmHg and heart rate of 90 bpm. Clinically he appeared cachetic and chronically ill with appreciable anasarca. His right lower extremity exhibited significant pitting edema with multiple hemorrhagic and flaccid bullae, areas of open weeping wounds with surrounding erythema, and severe tenderness to palpation. Initial labs showed leukopenia to 1.5k, thrombocytopenia to 107k, lactate of 3.2, procalcitonin of 152, and CRP of 21.9. 3-view X-ray of his right ankle showed diffuse soft tissue swelling without findings concerning for osteomyelitis or acute osseous abnormality. He had poor response to IV fluids and was found to be in septic shock. The physical exam findings and evidence of systemic involvement prompted a high suspicion for necrotizing fasciitis. He was started on broad spectrum antibiotics and eventually needed the support of multiple pressors. Urgent surgical consultation was obtained and transferred to a larger multispecialty hospital center. The patient hesitated about proceeding with surgery but ultimately decided to proceed after 24 hours when he then underwent debridement of his entire right leg. He ended up on three pressors and continuous renal replacement therapy for two weeks. He eventually needed a tracheostomy and transferred to a long term acute care facility only to be readmitted two weeks later for worsening infection. He was found to be bacteremic with streptococcus pneumoniae and underwent a right leg above-the-knee amputation. He ultimately succumbed to his infection and died approximately 3 weeks after readmission.

  This case highlights the importance of both early clinical recognition and surgical intervention of necrotizing fasciitis due to its extremely high morbidity and mortality rate. Despite concerted efforts to get this patient into surgery, even a few hours of delay worsened the already poor prognosis. Especially as primary care physicians, prompt recognition and decisive action to get the patient appropriate care is crucial to improving overall outcomes. In addition, having clear goals of care discussions between PCPs and their patients who are most at risk for hospitalizations can aid in making difficult time sensitive medical decisions.

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  Project Nurture: An Educational Model for Substance Use Disorder Treatment During & After Pregnancy: Saving lives, saving money, saving families, and training future doctors

  Roxanne Thomas, Brenda Brischetto, Josh Reagan, and Daniel Ruegg

  BACKGROUND: • 25% of women presenting for prenatal care are using substances. • Substance Use Disorders (SUDs) in pregnancy are associated with preterm birth, intrauterine growth restriction, placental abruption, increased risk of C-section. • Infants exposed to in utero illicit substances have higher likelihood of being small for gestational age, experiencing a neonatal opioid withdrawal syndrome that requires prolonged NICU hospitalization, and are at higher risk of developmental delay. • Societal costs of SUDs in pregnancy include worsening mental illness, increased utilization of the foster care system, early death secondary to overdose, and associated financial burdens. • The nature of SUDs, and how they are perceived by society, has made it difficult for pregnant women to receive appropriate care. • Pregnant women suffering from addiction often feel they cannot trust the medical system and fear the potential loss of their infants. • There is considerable variation in the way that pregnant women with chemical dependency are treated, and most models have not been adequately studied. • Project Nurture is a novel treatment model combining prenatal care, primary care, and addiction treatment with a multidisciplinary team • Housed within Providence Milwaukie Family Medicine Residency, Project Nurture has also provided doctors in training with valuable experience caring for women and babies affected by SUDs, including: • Training in Medication Assisted Therapy • Education and experience on managing high risk pregnancy care for patients with SUDs • Caring for newborns with Neonatal Opioid Withdrawal Syndrome, both in and out of the NICU • Participating in an innovative primary care model • Pediatric primary care for infants with utero drug exposures • Managing buprenorphine induction during pregnancy • Continuity delivery experiences • Developing knowledge of community resources available to patients with SUDs

  OBJECTIVES: • Assess resident interest, experience, and goals related to addiction care for pregnant women and families • Examine common primary care outcomes for women and families involved in the Project Nurture program

  METHODS: 1. Pregnancy-related outcomes, social measures, and primary care outcomes were tracked for 3 years for all participating Project Nurture patients and their infants. 2. Current and former residents of Providence Milwaukie Family Medicine were surveyed on their training experience and translation to independent primary care practice. 3. Data was compiled and analyzed for review and exploration of outcomes and trends.

  RESULTS: • 84% of surveyed residents indicated an interest in addiction medicine prior to entering the program. • The majority of current residents indicate that they will feel comfortable managing infants with Neonatal Opioid Withdrawal Syndrome in their future practice. • The majority of current residents indicate that they will feel comfortable addressing addiction with pregnant patients in their future practice.

  • 87% of Project Nurture patients obtained long-acting contraception (Nexplanon, intrauterine device, tubal ligation). • 80% of infants born to Project Nurture were completely up to date on their recommended vaccinations. • 77% of Project Nurture patients had successfully obtained long-term custody of their infants. • 88% of Project Nurture patients were up to date on well woman care such as cervical cancer screening.

  CONCLUSIONS: • Incoming residents value addiction medicine training. • Residents recognize importance of managing addiction in their future practice. • Project Nurture and other MAT models of care provide valuable training experiences. • Residents plan to care for patients and families suffering from addiction. • Resident training experiences have provided a foundation for providing addiction care in future practice.

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  Quality Improvement: Improving Depression Screening Rates at PMG Southeast Family Medicine Clinic

  Elizabeth Deyo, Edward Kim, Tyler Nelson, Roxanne Thomas, Jemie Walrod, Nicholas Wolfgang, and Ben Pederson

  Introduction: Major depressive disorder is one of the most common mental health problems encountered by primary care providers in the U.S. For people age 12 and older, prevalence is estimated at eight percent. The economic cost of depression has been estimated at $210.5 billion per year, attributed to both costs to the work place and medical costs. People who experience depression are at greater risk for suicide, an otherwise preventable death if depression can be recognized and adequately treated. For these reasons, depression screening has become an essential function within primary care practices both within Providence and nation-wide.

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  Sola Dosis Facit Venenum: Understanding Severity of TCA Intoxication

  Sean Brachvogel, Justin Osborn, and Tanya Page

  The Dose Makes the Poison, or does it? Judicious Management of TCA Intoxication.

  Author(s): Sean Brachvogel, MD, MPH; Justin Osborn, MD; Tanya Page, MD

  Context/background: Tricyclic antidepressants (TCAs) have been mostly supplanted by SSRIs in the treatment of depression, however they remain a mainstay of chronic pain management.¹ Untreated suicide attempts with a TCAs carry a 70% fatality rate, which drops dramatically to 3% with hospitalization.² As such, maintaining healthcare provider recognition and management of TCA toxicity is of lifesaving importance.

  Objective: Here we describe a case report in which alcohol ingestion masked the severity of an accidental TCA overdose, and we reflect on a common diagnostic approach.

  Case Report: Our discussion begins with a 68-year-old Caucasian female with a history of COPD, diverticulitis, HLD, HTN, and chronic pain who presents with 80 minutes of altered mental status after consuming alcohol and her regularly prescribed amitriptyline. Her EKG demonstrated QRS widening and her serum alcohol level was 217. She was diagnosed with TCA overdose and alcohol intoxication and was treated with a sodium bicarbonate drip. Management of her TCA intoxication was clouded by a background of significant alcohol intoxication, and an amitriptyline and nortriptyline levels were collected to elucidate the severity of the TCA overdose. After eight hours of bicarbonate infusion her QRS narrowed and her condition stabilized.

  Conclusions: TCA therapy is common and TCA overdose is both especially dangerous and treatable. In our case, collecting amitriptyline and nortriptyline levels did not aid in our diagnosis or treatment. We conclude that EKGs are the superlative diagnostic modality when evaluating suspected TCA overdoses.

  References:

  1. Meloy, Patrick, et al. “Tricyclic Antidepressant Overdose.” UC Irvine Journal of Teaching in Emergency Medicine, 2019, escholarship.org/content/qt196242gj/qt196242gj.pdf?t=pwuyer.
  2. Tsai, Vivian, and David Vaerrier. “Tricyclic Antidepressant Toxicity.” Practice Essentials, Pathophysiology, Epidemiology, 17 Mar. 2020, emedicine.medscape.com/article/819204-overview#a6.

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  Sweets Syndrome: A Case Report

  Michael Waddick and Elizabeth Deyo

  Title: Add Sweet’s Syndrome to your dermatologic differential

  Authors: Dr. Elizabeth Deyo, Dr. Mike Waddick

  Context: Sweet’s Syndrome, an uncommon acute painful inflammatory rash, can be easily misdiagnosed. Early recognition and treatment can speed clinical recovery for patients with this difficult condition.

  Objective: Here we describe an interesting case report of Sweet’s Syndrome in one of our patients in order to help providers remember this diagnosis on their dermatologic differential diagnosis.

  Case report synopsis: Our 44 year old male HIV positive patient with type 2 diabetes mellitus presents with athralgias, chills, malaise and a plaque-like rash on the back of his neck, head and right wrist. Course: Lab work-up with blood culture, crp, cbc, cmp, HIV viral load, RPR, and biopsy were performed. The biopsy confirmed neutrophilic dermatosis consistent with Sweet’s Syndrome. The patient was started on treatment after biopsy results returned. The patient had rapid improvement with treatment.

  Treatment: Prednisone 30mg daily for 7 days, then tapered over 5 weeks.

  Conclusion: Sweet’s Syndrome, an acute febrile neutrophilic dermatosis, is an uncommon inflammatory skin condition characterized by the abrupt onset of painful erythematous papules, plaques or nodules and systemic symptoms. The disease is classified into classical (idiopathic), malignancy-associated and drug-induced Sweet’s Syndrome. While uncommon, primary care physicians should be familiar with the clinical presentation, diagnosis and initial management of this disease; and add it to their differential diagnosis when faced with acute painful rashes as described above. Key points include the diagnostic criteria, clinical appearance, and initial treatment of Sweet’s Syndrome.