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MedicalCareer版 - i kinda wonder what you all think about this case?
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话题: case话题: patient话题: she话题: ct
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1 (共1页)
L****n
发帖数: 12932
p******e
发帖数: 12
2
Communication and Documentation - always keep these two things in mind.
I feel this case is especially interesting and alarming for diagnosticians
like pathologists and radiologists.

【在 L****n 的大作中提到】
: http://www.msnbc.msn.com/id/30999530/
L****n
发帖数: 12932
3

Documentation is of course critical. however, at the center of this
malpractice suit is WHO is to blame for her amputation, which is a result of
a septic shock.
from what i read, she had a spiking fever of 106 before she decided to go to
ER. the infection is there to begin with. Prompt treatment could have a
better outcome, but not necessarily. I for one think the jury is correct,
and the judge is ridiculous in tossing out the verdict.

【在 p******e 的大作中提到】
: Communication and Documentation - always keep these two things in mind.
: I feel this case is especially interesting and alarming for diagnosticians
: like pathologists and radiologists.

D*********r
发帖数: 371
4
Brief summary:
Female patient went to ER because of sharp back pain and high fever of 106
degrees. She had a history of kidney stone and claimed that she told the
nurse about it.
Dr. Kocik, the ER attending, insisted that she told Dr. Strong over the
phone that the patient likely had a kidney stone. Dr. Strong works for a
firm contracted by Lisa Strong's insurance company to make medical decisions
if her personal doctor isn't available or chooses not to make the call.
However, Dr. Kocik never wr

【在 L****n 的大作中提到】
:
: Documentation is of course critical. however, at the center of this
: malpractice suit is WHO is to blame for her amputation, which is a result of
: a septic shock.
: from what i read, she had a spiking fever of 106 before she decided to go to
: ER. the infection is there to begin with. Prompt treatment could have a
: better outcome, but not necessarily. I for one think the jury is correct,
: and the judge is ridiculous in tossing out the verdict.

a**e
发帖数: 5094
5
agree with you.
现在考虑要不要去加拿大practice,美国lawsuit太烦了

of
to

【在 L****n 的大作中提到】
:
: Documentation is of course critical. however, at the center of this
: malpractice suit is WHO is to blame for her amputation, which is a result of
: a septic shock.
: from what i read, she had a spiking fever of 106 before she decided to go to
: ER. the infection is there to begin with. Prompt treatment could have a
: better outcome, but not necessarily. I for one think the jury is correct,
: and the judge is ridiculous in tossing out the verdict.

n*******c
发帖数: 501
6
I don't get it. Did she delay being given antibiotics? I am not sure if
removing the stone is indicated if presumably there was no renal impairment
due to obstruction. Also would it make any difference to remove the stone
earlier? Anyway I don't think mentioning the kidney stone is the critical
point but mentioning septic shock obviously is and this would definitely
prompt Dr Strong to come to hospital and examine the patient.
Sometimes it is hard to establish the direct link between malpractice
n*******c
发帖数: 501
7
I see. Thank you.
But then the whole of this is totally not predictable or preventable. How
come they blame the kidney stone and what's the point of the urology chief's
comment regarding prompt treatment of kidney stone.I think if she was given
antibiotics on time and got appropriate observation then nothing else
should be blamed.
h******c
发帖数: 10
8
The sepsis caused by urinary obstruction is a surgical emergency, and the
definitive treatment is release the obstruction ASAP. IV antibiotics alone
is ineffective most of time.
L****n
发帖数: 12932
9

first of all, thanks for your valuable insight.
i agree, the treatment option is release of pressure. The patient is usually
very sick and not able to tolerate open surgery. Pylonephrocentesis under
CT by a radiologist is the best choice if the service is available. I had
handle a patient just like this before and it was one of the most difficult
case i had, anesthesia wise.
coming back to the topic of malpractice. be it sepsis or side effect of
vasoconstrictor, the bad outcome is not cause by

【在 h******c 的大作中提到】
: The sepsis caused by urinary obstruction is a surgical emergency, and the
: definitive treatment is release the obstruction ASAP. IV antibiotics alone
: is ineffective most of time.

n*******c
发帖数: 501
10
Thanks again.
Fever and back pain should prompt consideration of pyelonephritis. I think a non-contrast CT would be necessary in this case then. Or IVP? which i think they did within 16 hours.
I have had a case in which a female presented with RUQ pain and adm with acute
cholecystitis but she turned out to be pyelonephritis as we examined her. She then developed E Coli sepsis and was treated with antibiotics. She did not have stone shown on the subsequent CT scan though. But the CT was done 48 h
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c*****0
发帖数: 9
11
For the patients with acute pyelonephritis, without response to the
antibiotics after 3 days of treatment. CT or U/S need to be done to look for
any obstruction even without history of stone.
For this case, release the obstruction and drainage is the fundamental for
the successful treatment of sepsis from pyelonephritis. If the septic shock
can be early recovered then the vessel constrictors could be avoid or can be
withdrawal earlier. The related side effects will be reduced.
Did the vasssconst
a**e
发帖数: 5094
12
pressors are given through central line.

for
shock
be

【在 c*****0 的大作中提到】
: For the patients with acute pyelonephritis, without response to the
: antibiotics after 3 days of treatment. CT or U/S need to be done to look for
: any obstruction even without history of stone.
: For this case, release the obstruction and drainage is the fundamental for
: the successful treatment of sepsis from pyelonephritis. If the septic shock
: can be early recovered then the vessel constrictors could be avoid or can be
: withdrawal earlier. The related side effects will be reduced.
: Did the vasssconst

c*****0
发帖数: 9
13
Thanks.
For a septic shock itself, the , most common consequence is acute renal
failure from acute renal necrosis, ARDS and DIC. All these did not happen to
this patient. Without prompt release of obstruction from kidney stone would
be the first to be blamed for this case. The other thing we need to careful
think about is the risk-benefit of maintaining the optimal level of the Bp
for a shock patient (temporally) and the dosage of epi.( the lowest accepted
level?)
I agree with happydoc, the ambu

【在 a**e 的大作中提到】
: pressors are given through central line.
:
: for
: shock
: be

y******a
发帖数: 590
14
They (Dr.Kocik and Dr.Strong) definitely made a huge mistake in diagnosis.
Otherwise if pt was treated with nephrostomy tube and obstruction relieved,
plus IV antibiotics, pressor is not necessary in her case. I also wondered
how much fluid they gave before they started pt on pressor, without large
amount of fluid, vasopressor will cause more damage than its benefit.
Another issue is the communication with patient. pt should be informed the
side effect of vasopressors, and proper documentati
y******a
发帖数: 590
15
a pt with fever, back pain or abd pain, positive UA, pyelo should always be
one of the ddx. either renal sono or CT A/P should be done, esp. if pt is
hemodynamically unstable. All tests can be done within a few hours. Image
test is not necessary for diagnosis or treatment for pyelo, but if pt is
critical or there is no improvement after treatment started 24-48 hr, or pt
has a lot of co-morbidities, imaging should be done immediately. My 2 cents
.

a non-contrast CT would be necessary in

【在 n*******c 的大作中提到】
: Thanks again.
: Fever and back pain should prompt consideration of pyelonephritis. I think a non-contrast CT would be necessary in this case then. Or IVP? which i think they did within 16 hours.
: I have had a case in which a female presented with RUQ pain and adm with acute
: cholecystitis but she turned out to be pyelonephritis as we examined her. She then developed E Coli sepsis and was treated with antibiotics. She did not have stone shown on the subsequent CT scan though. But the CT was done 48 h

n*******c
发帖数: 501
16
Thanks all the input and I learned a lot from the discussion.
In this case the stone was removed 16 hours after the patient presented but
still not early enough to save her from sepsis shock. I may consider earlier
imaging r/o of obstruction for pyelo given the outcome could be so bad as
shown in this case.
L****n
发帖数: 12932
17
Everyone can learn alot from the case, hopefully resulting better patient
care down the road.
but the fact remains: septic shock patient had a death rate of 50%. the mere
fact that she survived this indicated that she is the lucky one. The
malpractice suit is nothing more than a witch hunt that's trying to extort
the system, IMHO. if i scrutinize anyone patient's chart long enough, i can
find things that may be done better in the rear view mirror, and potentially
could have an impact on the outc
W******g
发帖数: 143
18
the main reason of this case i think is miscommunication. GOOD POST
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