4/6/2017

1

PITFALLS IN PRIMARY CARE, HOW TO AVOIDJan Yager DNP, RN, FNP-C, PMHNP2017 Teaching DayTroy Hilton Garden

I HAVE NOTHING TO DISCLOSE

Profession Experience ***Presently employed• Wynantskill Primary Care-Family Medicine• Hometown Health Center- Family Medicine• Southwest Community Health Center- Pediatrics• Sunny view – Physiatrist Group*******************• Loyola – Acute Detox• Southern Vermont Medial Center-Urgent Care• Samaritan Outpatient Behavioral Health Care ***************

LEARNING OBJECTIVES

• 1. Utilize cutting edge contemporary guidelines and standard of care for screening in primary care, and across disciplines.

• 2. Demonstrate competency and knowledge of the principal of screening: what factors must be present for a condition to qualify for population base screening

• 3. Consider clinical and legal aspects of interventions to reduce the potential for prescription opiate abuse and inadvertent overdose

• 4. Incorporate recent evidence regarding pharmacology, dietary and other interventions to prevent serious illness into daily clinical practice

• 5. Develop and Utilize tools and check list and integrate into medical records in order to maximize prevention intervention in primary care

4/6/2017

2

TALKING THE TALK

• Effective communication improve patient satisfaction, and prevents litigation• Make a no interruption rule “interruptions occur only when there is an

emergency” • PIT FALL happens when the provider is frequently interrupted causing an

cognitive disturbance in the providers though progress• What are simple things you can do that could significantly reduce frequent

misinterpretations or misconceptions?

TALKING THE TALK

• Pitfall: Failure to understand why the patient came in for?• Ask: • What made you come in today?• What can I do for you that would be beneficial for you today?• Is there something happening at work, home or social life?• Is there anything else I can help you with today?

TALKING THE TALK

• Pitfall: Failure to give proper instructions when to follow up, and what to look out for

• Every patient should get a set of warning signs when to return for their medical condition if not improved by, or if additional signs develop, potential diagnosis, and plans for follow up.

• Discharge should be written out, handed to the patient in simple language. Have the patient recite the discharge instructions to you, and clarify any misconceptions the patients may have.

4/6/2017

3

INTERACTIVE CASE STUDY

• Discuss the facts of the selected nurse practitioner claims• Provide participants the interactive opportunity to discuss the claim• Resolution:

• Consider whether negligence has occurred –indemnity payment• Expense cost• Interactive poll @• Create awareness of indemnity and expenses made for selected nurse

practitioner claims• Provide recommendations to support nurse practitioners in managing

professional liability risks

CASE PRESENTATION 1

• This case study involves a nurse practitioner as an owner and treating practitioner in a family medical office setting.

• The family nurse practitioner was the primary care provider of a 67 year old male patient for various conditions including diabetes, Chrohn’s disease and hypertension

• He had a 50 year history of smoking ( one to two packs per day) and for the past 40 years he admitted to being a “heavy beer drinker”

• The NP was his primary care provider for the past 5 years after he was discharged from his previous medical provider due to non-compliance with his chronic illnesses and abusive statements to the former provider’s office staff

• The patient claimed that he had issues affording medications and this was the reason for his non-compliance, but offered no explanation for his abusive behavior.

CASE STUDY 1• The 57 year old male patient had health insurance, he afford his medications

and be consistent with his medical during the first three years under the NPs care.

• At one point he has a pulmonary embolism diagnosis and was placed on a blood thinner. The NP monitored his monthly INR levels for a few months until the patient stopped coming into the office despite the NP’s office phone calls to advise the patient that monthly INR levels were necessary to monitor warfarin dosage.

• The last 2 years, he missed most of his scheduled appointments and when his medications required prior approval, he would call the NP and demand refills from the staff without an appointment.

• He was argumentative and even threatened to bring lawsuit against the staff if they failed to refill his medication or tried to contact him about missed appointments

4/6/2017

4

CASE PRESENTATION 1

• One evening the patient was seen in an emergency department (ED) complaining of tingling in his left arm and weakness in his left leg.

• The patient’s initial test, including the laboratory, electrocardiogram, chest x-ray, computerized tomography (CT) of the brain were essentially normal.

• The emergency room provider discharged the patient home and instructed him to take a baby aspirin a day, and follow up with his primary, return to the emergency room with any concerns and scheduled an outpatient magnetic resources imaging of the brain.

CASE PRESENTATION 1• The patient called the NP’s office the next morning to inform her of his ED visit, and

that he had an MRI of the brain scheduled for the following day.• He schedule an appointment with the NP after the MRI to discuss the findings.• The radiologist called the NP’s office with the results to report the patients results.• The radiologist testified that the conveyed the MRI findings with a sense of urgency

and faxed the results soon after his phone call to the NP’s office. He communicated that critical medical treatment was needed such as starting the patient on a blood thinner and having a MRA of the carotids. His medical opinion was that the patient was suffering from small strokes and that he possibly had a blood clot in the right carotid artery.

• The NP disputed the radiologist’s testimony of how the test results were reported to her and stated that she was only told to schedule an MRA and start him on a blood thinner.

CASE PRESENTATION 1

• Upon speaking to the radiologist regarding the results, the NP instructed her staff to call the patient to determine which pharmacy he wanted the blood thinner sent, and schedule a stat MRA.

• Three hours later the patient was on his way home from picking up his prescription when he suffered a massive ischemic stroke and was involved in a motor vehicle accident.

4/6/2017

5

CASE PRESENTATION 1

• The patient was admitted to the hospital for a stroke care, later transported to a trauma center where a CT scan of the brain noted his stroke had progressed.

• His internal carotid artery was 80 % partially occluded causing him to need a right hemicraniectomy.

• Four weeks after suffering from the massive strokes, the patient was discharged to a skilled nursing facility to work on speech, mobility, use of extremities, motor function skills, ect.

• unable to ambulate or care for himself, but is able to communicate and is somewhat able to participate in his care.

• Several health care providers, including the NP and ER provider were sued one year after the patient’s massive stroke.

CASE PRESENTATION 1

• Allegations• Failure to advise the patient of an urgent medical condition• Failure to adequate medical records• Failure to timely address an emergent condition

CASE MANAGEMENT 1• Test your liability IQ!........................Using your smart phone to answer the following

questions

• Do you believe the nurse practitioner was negligent?• Do you believe any other practitioner was negligent?• Do you believe that an indemnity and expense payment was made on behalf of the

nurse practitioner?• If so, how much?

4/6/2017

6

NUISANCE SIDE EFFECTS

• If we tell our patients the following five things when starting a new medication, we can significantly reduce this.

• Most side effects of the medications are “ Nuisance side effect” rather than “medically serious side effects.” They are definitely bothersome and we will do something about them, but it is important for you to know that these nuisance side effects of the medications the you are taking.

• Most side effects occur during the first 30 days, while the medications may be taken for many months or years. If we can work together to get through the first 30 days, very few new side effects are likely to come up.

• Most of these side effects diminished within a few days or weeks. • For many side effects, there is something we can do to reduce the side effect• If any symptoms occur that you thing may be a side effect of the medication,

don’t stop the medication. Call me and we’ll decide together what should be done.

NUISANCE SIDE EFFECTS

• TO MAKE IT EASIER TO REMEMBER THE 5 THINGS TO SAY ARE:• 1. NUISANCE• 2. FIRST 30 DAYS• 3. TEND TO DIMINISH• 4. DON’T STOP THE MEDICATION• 5. CALL ME AND WE’LL DECIDE TOGETHER WHAT TO DO

NUISANCE SIDE EFFECTS ANTIDOTE • Nausea• 1. Patients with GERD, you can treat with a PPI until the nausea subside ( be mindful

Omeprazole increases the levels of Escitalopram and Citalopram).• 2. Check hepatic function test, and serum amylase if the nausea, vomiting or

abdominal pain doesn’t subside consider pancreatitis or drug induced hepatitis.• 3. Any medication can cause nausea, and should be given with food if the nausea

occurs. • 4. Split the dose in half• 5. If the patient is prone to nausea, take a spoonful of peanut butter before the

medication. The peanut butter is high in fat content, coats the stomach and reduces stomach irritation.

• 6. Switch to a sustained released preparation.• 7. Ask the patient to take some form of ginger to calm the nausea.

4/6/2017

7

NUISANCE SIDE EFFECTS ANTIDOTE• Dry Mouth• 1. Avoid: Alcohol –based mouthwash ( Listerine), tobacco in any form, and caffeine. • 2. Increase oral hygiene, brushing, flossing, and dental visits• 3. Rinse mouth out after every meal• 4. Increase saliva production by eating carrots, apples and celery, and by using

sugarless gum.• 5. Sipping small amounts of water.• 6. suck on ice chips• 7 Use a humidifier• 8. Use Biotene (gel, oral rinse, gum, toothpaste) it helps relief dry mouth. Other saliva

substitutes are cellulose gum, Oasis moisture mouth spray, and Xylitol ( Brad names are Spry, Epic, and Pur)

NUISANCE SIDE EFFECTS ANTIDOTE

• Akathisia• It not caused by typical antipsychotics only• http://nei.global/akathisia• Once you complete the article you can click on an additional link to

obtain another CME

DRUG-DRUG INTERACTION• Avoid errors • Malpractice suits regarding drug interactions is sky rocketing.• Many common complaints can occur from drug-drug interactions:

1. fatigue2. confusion3. falls4. excessive drowsiness/ or dizziness5. agitation or anxiety6. depression7. change in bowel patterns, incontinence8. weakness or tremors9. decreased sexual behaviors.

4/6/2017

8

DRUG-DRUG INTERACTIONS

• Drug interaction can occur:

• When medication utilize the same enzyme in the liver for metabolism• If one medication interferes with another medication that is being excreted

through the kidney• If multiple protein bound drugs are given to a patient

DRUG –DRUG INTERACTION

• It is impossible to remember every medications which cytochrome P450 is isoenzyme metabolizes it

• There is a well-established source; The Flockhart table

• http://medicine.iupui.edu/clinpharm/ddis/main-table/

• http://medicine.iupui.edu/clinpharm/ddis/clinical-table/

DRUG-DRUG INTERACTIONS

• The Transformer database you can find information about the isoforms of the Cytochrome P450 enzymes of a drug.

• The Transformer database also allows you to check whether two or more drugs interact with each other.

• http://bioinformatics.charite.de/transformer/index.php?site=home

4/6/2017

9

DRUG-DRUG INTERACTIONS

• For drugs excreted in the kidneyshttp://www.pharmacytimes.com/contributor/shivam-patel-pharmd-candidate/2016/08/medications-requiring-renal-dosage-adjustments

• For highly bound protein drugshttp://redbook.streamliners.co.nz/commonlyuseddrugs.pdf

EVIDENCE BASE

• MD CALC• Mdcalc.com• A website that has numerous tools for clinical decision making, each tool has

gone through a significant amount of time researching, reviewing and validating in clinical practice. The have also included a Pearls and Pitfall content to point out the tools shortcomings.

• Examples: • Canadian c-spine rule• Ottawa ankle rule• Vancouver chest pain rule

4/6/2017

10

EVIDENCE BASED CARE

• Websites:• 1. Society of Gastroenterology Nurse and Associates. INC

https://www.sgna.org/• 2. American Nurses Credentialing Center http://www.nursecredentialing.org/• 3. American Society of Perianesthesia Nurses http://www.aspan.org/• 4. The Joint Commission https://www.jointcommission.org• 5. Department of Health http://health.ny.gov/• 6. American Nursing Association http://www.aorn.org/• 7. Emergency Nursing Association http://www.ena.org

EVIDENCE BASED CARE

8. Association of Women’s Health, Obstetric and Neonatal Nurses http://wwwawhonn.org/9. Sigma Theta Tau International http://www.nursingsociety.org/10. Oncology Nursing Society https://www.ons.org/11. American Association of Critical-Care Nurses http://www.aacn.org/12. The New York State Nurse Practitioner Association Http://www.thenpa.org/13. American Association of Nurse Practitioners http://www.aanp.org/

EVIDENCE BASE CARE• Databases:• 1. Access Medicine• 2. CINAHL• 3. Cochrane Central Register of Controlled Trials• 4. Journal Watch• 5. LexiComp RX• 6. Medline• 7. Micromedex• 8. PubMed• 9.QuantiaMD• 10. Uptodate

4/6/2017

11

EVIDENCE BASE CARE

• Government Sites:• 1. CDC-Central for Disease Control• 2. FDA• 3. Federal Register• 4. National Institute of Health• 5. HealthCare.gov• 6. National Institutes of Health• 7. PubMed• 8. Clinical Trials. gov

EVIDENCE BASED CARE

• Drugs• 1. Drug Information Portal

https://druginfo.nlm.nih.gov/drugportal/drugportal.jsp• 2. FDA U.S. Food & Drug Administration

http://www.fda.gov/drugs/default/htm• 3. FDA News http://www.fdanews.com/• 4. Medline Plus http://medlineplus.gov/druginformation.html• 5. Safe Medication http://www.safemedication.com• 6. U.S. Pharmacopeial Convention http://www.ups.org/

EVIDENCE BASE CARE

• Health Literacy1. National Patient Safety Foundations http://npsf.site-

ym.com/default.asp/page=askme32. Health Literacy Universal Precaution Toolkit https://www.ahrq.gove/sites/default/files/wysiwyg/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthliteracytoolkit.pdf

4/6/2017

12

PITFALL

• Failure to ensure patients with eye injuries are treated with the proper antibiotic and follow care ( Seen by an ophthalmologist within 24 hours)

• Corneal abrasions• Corneal Ulcers • Corneal foreign body• Hyphema

PITFALL

• Presentation • Eye pain• Gritty• Foreign body sensation• Impaired visual acuity • Acute monocular vision loss ( RED FLAG) refer to the ER, not urgent care.

Possible causes central retinal artery occlusion, central retinal vein occlusion, acute angle glaucoma, or retinal detachment, or central nervous process ( CVA/TIA), or MS.

PITFALL

Throat Not indiscriminate use of antibiotics for acute pharyngitis

Key facts virus counts for the majority of pharyngitis. Group A strep occurs 10% of the time . Overuse of antibiotics puts the patient at risk for superinfection, such as Candida and Clostridium. Corticosteroids improve severe throat pain in Group A Streptococcal pharyngitis

The center criteria constitutes a clinical decision rule with the diagnosis of Streptococcal Pharyngitis: the four criteria are tonsillar excavate, swollen tender anterior cervical nodes, absence of cough, and a fever ( current or a history of). The present of all four criteria confers a risk of group A streptococcus pharyngitis of 56%

4/6/2017

13

PITFALL

• Ear• Not instructing the patient to keep the ear canal free of water or debre

PITFALL• Lip• Failure to appropriate repair of a oral laceration

• Refer to plastics surgery immediately. Failure to align the vermillion border as little as 1 millimeter can result in a cosmetically noticeable scar. Lacerations greater than 2 cm or interfere with mastication should be sutured

• Key fact: Antibiotics are controversial with lacerations. Lacerations caused by animal bites and grossly contaminated are at a higher risk of infection, prophylaxis antibiotics are recommended. Pride is beneficial. Upon discharge the patient should be instructed to complete a salt water rinse ,after eating and to keep the wound dry, a wound care check should be done by a health care provider within 48 hours. Non absorbable sutures should be removed in 7-10 days.

PITFALL

• Nose• Failure to appropriately control epistaxis

• Key fact: frequent occurs in the winter months due to the low humidity level, digital trauma, chemical irritants and infections. Bleeds are from two primary locations anterior bleeds ( occur in the Kiesslebach’s plexus and are often amend to pressure) and posterior bleeds ( are from the sphenopalatine artery), and are more serious.

4/6/2017

14

PITFALL

• Over-reliance on a negative urinalysis to rule out renal colic• 3-5% will experience urinary stones in their lifetime. 50% will have a

recurrence within the next 10 years, peak incidence is between the age of 35-50/ m/f ratio is 3:1, symptoms are flank pain with radiation to the groin, visible distress, urinary frequency, occasionally with hematuria, CT scan is the preferred method for diagnosing. Some acute care providers continue to use a negative UA for hematuria as a screening tool to rule out renal colic ( this can lead to a misdiagnosis that could put the patient at risk for Kidney stones, urinary obstruction, hydronephrosis, renal failure, and renal capsule rupture).

PITFALL

• Failure to add medical explosive therapy to the outpatient treatment of kidney stones.

• Meaning failure to add medications that relaxes the ureteral smooth muscle and facilitate stone passage. A-blockers ( tamsuloosin, terazosin and doxazosin), calcium channel blockers (CCB) (Nifedipine) inhibit the contraction of the ureteral smooth muscle that causes ureteral spasms, and other pain. Other agents include non steroidal anti-inflammatories, and corticosteroids (13).

• Patient who had nephrolithiasis had a 65 % spontaneous stone passage with the use of medical explosive therapy (14).

PITFALL

• Failure to recognize and appropriately treat complicated urinary tract infections.

• Complications can include urosepsis, acute renal failure, emphysematous pyelonephritis (EP) and perinephric abscesses (PA). Any patients with risk factors should be treated as if they had a complicated UTI (Risk factors include diabetics (DM), male gender, children, elderly, recent hospitalization, indwelling catheter, nephrostomy, stents or renal insufficiency). EP and PA are usually seen in diabetic patients exclusively and carries a 25% mortality (broad spectrum antibiotics )need to be heavily concentrated in the urine and renal parenchyma) to be given after an urine culture is obtained)(15).

4/6/2017

15

PITFALL

• Failure to accurately diagnosis and manage acute scrotal pain• All scrotal pain should be treated as testicular torsion until ruled out by a Doppler

ultrasound and/ or urological consult. Physical exam findings with acute scrotal pain is often misleading. The Prehn’s sign commonly used for differing and epididymitis ( by elevating the inflamed testicle the pain was relieved) is not specific. Other signs that suggest torsion are displacement of the epididymis format usual posterior position, and high position of the affected testis (16)

• If epididymitis is the diagnosis, empiric treatment is recommended by the CDC, before lab test are available in patients 18-35 years of age, N. gonorrhea and C. trachoma is suspected. Patients over 35 years of age Escherichia Coli accounts for the majority of the case. Appropriate antibiotics should be chosen as well as adjunctive therapy including bedrest with scrotal elevation, and analgesics (18).

PITFALL

• Failure to suspect pregnancy• Although patient may report she is not pregnant providers should

maintain a fair amount of skepticism. Given some patient are a poor historian, and the potential for missed diagnosis of pregnancy, it is recommended a laboratory of urine or serum HCG be preformed to determine the diagnosis of pregnancy for women with abdominal /pelvic pain who are within childbearing years (20).

PITFALL• Failure to treat asymptomatic bacteriuria in pregnancy

• The pregnancy population desires special consideration for the treatment of asymptomatic bacteria due to:

• Hormone change causes the ureter and the bladder to relax, leading to stagnation of the urine flow in the urinary tract.

• Ureteral compression and obstruction by the gravid uterus causes further slowing of the urine flow.

• Glucose in the urine serves as a medium growth for bacteria.• There is also an increased risk for preterm labor, which may result in a low

birth weight fetus.• Ampicillin is resistant to e coli, which makes the penicillin's obsolete.

Cephalosporin's and Nitrofurantoin are the most common used (21).

4/6/2017

16

PITFALL

• Failure to consider ovarian torsion in females who present with acute lower abdominal pain

• Classic presentations is with abrupt onset, unilateral lower abdominal pain that radiates to the flank and groin area and progressively gets worse over several hours. However in a retrospective study analysis patient with confirmed ovarian torsion, their physical exam where highly variable and may have been misleading. One third of the patients in the study only had mild tenderness, while another third had no pain during the pelvic exam. Fifty three present had a known diagnosis of a mass or a cyst (22).

• Patient with lower abdominal pain that is progressive should have a sonogram and a OBGYN consult (22).

PITFALL

• Failure to diagnose and treat pelvic inflammatory disease (PID) due to lack of symptoms.

• The prevalence of PID is down since the 1980 due to heighten awareness in the general population and increase in free STD clinics.

• However there is a high misdiagnosis of PID and lead to complications such as ovarian cyst, ectopic pregnancies, and infertility.

• Classic diagnosis for PID is pelvic pain, vaginal discharge, and fever ( not frequently found). The patient presentations can mimic other diagnosis such appendicitis, or an urinary tract infection.

• In 2010 the CDC recognized the difficulty in making diagnosis of PID. The CDC created a criteria for PID (23).

PITFALL

• Failure to diagnose a posterior shoulder dislocation• A missed diagnosis can result in degenerative changes in the joint,

avascular necrosis and disability. Seventy nine percent of providers miss the diagnosis on initial examinations. The inability to externally rotate the humerus or supinate the palm suggest a posterior dislocation.

• Axillary view should be ordered for all patients with potential shoulder injuries or humeral injuries as it is the most sensitive means for identifying posterior shoulder dislocation.

• If a posterior dislocation is diagnosed, an orthopedic referral is required, and a transfer to the emergency room is warranted (24,25).

4/6/2017

17

PITFALL

• Failure to consider septic bursitis in a patient with a swollen elbow• Most commonly affects the superficial pre-patellar and olecranon bursa,

non infectious bursitis can be the results of acute or chronic traumata crystal arthopathy, or rheumatoid arthritis.

• Septic bursitis, unlike septic arthritis, does not significantly affect the rage of motion.

• All patients with a possible septic bursitis require re-evaluations by a health care provider within 48-72 hours.

PITFALL

• Failure to recognize a potential scaphoid injury• approximately fifteen percent of patients with a history and examination

concerning for scaphoid fracture and negative imaging with have a fracture on follow up imaging.

• The scaphoid bone acts to block wrist extension, and abuts the distal radius. Due to the anatomical sites the scaphoid in vulnerable in a fall onto an outstretched hand (FOOSH)

• Tenderness is usually found over the anatomic sniff box. The scaphoid is located on the floor of this triangular depression.

PITFALL

• Failure to diagnose a fibular head fracture in a patient presenting with ankle pain.

• Imaging should be obtained using the Ottawa Ankle Rules: inability to bear weight for four steps, tenderness to palpate at posterior edge of the tibia, posterior edge of the fibula, medial malleolus and lateral malleolus

• Providers should palpate the distal head of the fibula.• Maisonneuve’s deformity is a fracture of the distal tibia at the ankle with

extension of injury through the interosseous membrane resulting in a fracture of the proximal third of the fibula

4/6/2017

18

PITFALL

• Failure to identify a Lisfranc Fracture-dislocation on plain imaging of the foot• Up to 19% of patients with a Lisfranc injury will have negative initial

radiographs• Patients with Lisfranc fracture dislocations are at risk for compartment

syndrome

PITFALL

• Missing a growth plate fracture• A child with point tenderness at the growth plate should be splinted and

treated as a fracture , regardless of imaging finding until cleared by a pediatric orthopedic surgeon.

PITFALL

• Failure to recognize a fracture commonly associated with child abuseWhile there is no one fracture type that is truly pathognomonic for

abuse, one must have a high index of suspicion for abuse when a young child presents with a femur or mid shaft humerus fracture.

Child abuse should always be a consideration when a child has a fracture or bruising in an infant. Rib, metaphyseal fracture, midshaft humeral and femur fracture in infant and non-ambulatory toddlers at high risk for abuse.

4/6/2017

19

CASE STUDY 2

• This case involves an employed NP working in an urgent care center where he treated a 58 year old male with a boxer fracture to his right hand

• The NP ordered the medical assistant to apply a temporary gutter splint to the patient’s right hand.

• The patient returned to the center as scheduled and our NP noted in the healthcare record the appearance above the forth and fifth mid-metatarsals area with tenderness and decreased range of motion. Additional x-rays were ordered, which the NP interpreted as revealing a “’complex/oblique fracture with good potion” of the forth and fifth metatarsal.

CASE STUDY 2 • A metal gutter splint was ordered and by the NP, and applied by an MA. The orthopedic

was scheduled to seen an orthopedic surgeon two days later.• Approximately one month later, the patient returned to the urgent care center with a

complaint of decreased movement and swelling of the fingers.• He stated that he was dissatisfied with the orthopedic surgeon, whom he asserted would

not spend any time with him, did not discuss any therapy or follow up treatment and would not return any of his phone calls.

• The NP ordered additional imaging, which revealed a lack of any callus formation. He noted that the patient had considerable edema to his hand and could not fully flex his fingers.

• The NP elected to leave the gutter splint on the patient’s hand and schedule a second opinion with another surgeon. The patient didn’t keep the appointment with the second orthopedic surgeon. He decided to return to the initial orthopedic surgeon despite his satisfaction.

CASE STUDY 2

• Over the next couple of months, the patient’s hand worsened, which the orthopedic surgeon believed this condition suggested Reflex Sympathetic Dystrophy ( RDS)

• The patient remained dissatisfied with the treating orthopedic surgeon and was non-complaint with his appointments and the physical therapy regimes

• One year after his fracture. The patient continued to suffer from temperature intolerance, numbness and tingling and loss of hand grip

4/6/2017

20

CASE STUDY 2

• Allegations• Failure to consult the patient of the risk of being non- complaint with

treatment plans/ regime• Failure to provide appropriate clinical supervision to ancillary medical staff• Failure to keep an adequate medical record• Failure to timely address a patient’s change in condition• Failure to ensure that the patient has kept schedule referrals and

consultations.

CASE STUDY 2

• Additional information• The MA was inexperience and new received any formal training on how to

apply splints. She has been employed at the clinic for only a few months.• The urgent care center had a hybrid healthcare information record system

utilizing both paper and electronic records, which made it difficult to follow the patient’s medical care/ plan of care.

CASE STUDY 2

• Test your liability IQ……. Answer the following questions now using your smart phone

• Do you believe that the nurse practitioner was negligent?• Do you believe that any other practitioner or parties were eglegent?• Do you believe that an indemnity payments were made on behalf of the

nurse practitioner• If yes, how much?

4/6/2017

21

PITFALLS

• Failure to appropriately manage zipper injuries• Cut below the trapper skin and pull the teeth apart to release it. • Provide appropriate analgesia when treating patient with a zipper injury• If the skin is trapped in between the teeth, cut the clothing around the

effected area and gently pull the teeth apart. • The most common method involves using wirer cutters to cut the median

bar, separate the anterior and posterior faceplate to release the skin

PITFALL

• Overlooking burns to high risk areas• Silver sulfadiazine should be avoided on the face (due to its bleaching

effects) and in pregnant women and nursing mothers since it may cause kernicterus in infants.

• Bacitracin is an alternative.• Burns around the eyes should be treated with topical ophthalmic

antibiotic ointment

PITFALL• Failure to recognize a rash as a manifestation of a life threatening underlying condition, constituting a

dermatologic emergency• Signs, symptoms, and clinical features suggestive of a dermatologic emergency

• Hypotension• Tackycardia• Hypoxia• Fever >102• Pain is out of proportion to clinical features• Ill appearing• Altered mental status• Dyspnea• Mucosal involvement • Extensive blistering, skin sloughing or desquamation petechiae

4/6/2017

22

PITFALLS

• Misdiagnosis of an aggressive soft tissue infection as cellulitis• Necrotizing fasciitis rapidly spreads along tissue planes without significant

skin surface involvement• Common pathogens group A streptococcus, Staphylococcus aureus,

and clostridium perfringer, and various mixtures of anaerobic organisms.• Clinical signs of necrotizing fasciitis presence of a bullae, ecchymosis,

crepitus, and superficial anesthesia of the skin• Clinical clues that might help you diagnose necrotizing fasciitis early are

the pain is out of proportion to the skin involvement; edema extending past the skin of erythema; and a history of immunosuppression. Patient with these symptoms should be referred to the emergency room to initiate emergent care which requires debridement, and parenteral antibiotics.

PITFALL• Confusion of scabies infestation with bed bug infestation

• Bed bugs are typically wingless, red-brown, blood sucking insects that grow up to 7 mm in length with a life span of 4 months to 1 year. They hide during daylight hours, and emerge for nocturnal feeding. They can anesthetizing the skin which allows them to take blood from the victim without being detected. There bites appear in a group of three, resembling a mosquito bite.

• Scabies is caused by microscopic mites to small to be seen without magnification. They burrow into the superficial layer of the skin, and lay eggs. Scabies spread by direct and prolonged skin to skin contact. Patient exposed to scabies for the first time don’t develop symptoms for 2-6 weeks after infestation. Infested patients are capable of transmitting the mites during asymptomatic period. Patient to prior exposure will develop symptoms 1-4 days post infestation. A rash appears as nonspecific small papules which may be diffused or limited to areas of the body where two layers of skin rub or touch such as fingers, armpits, buttocks. Occasionally, tiny burrows can be visualized as raised lines on the skin surface.

• The purities associated with bed bugs improves with warm water, whereas it intensifies with scabies.

PITFALL

• Failure to identify life threatening headaches• Secondary headaches have serious pathology that require more

complex diagnosis and management

4/6/2017

23

PITFALL• Failure to identify red flags for secondary headaches.

• History and physical are the key to understanding who requires aggressive treatment

• Examples causes of secondary headaches:• Subarachnoid hemorrhage

• Meningitis

• Encephalitis

• Cervico cranial artery dissection

• Temporal arteritis

• Acute angle closure glaucoma• Hypertensive emergency

• Carbon monoxide poisoning

• Pseudotumor cerebi

• Cerebral venous and dural sinus thrombosis

• Acute stroke: either hemorrhagic or ischemic

• Mass lesion including tumor abscess, and hematoma

PITFALL

• Historical or physical examination features that may suggest a serious secondary cause of headache

1. Rapid progress to maximal intensity in a matter of seconds be concerned forINTRACRANIAL BLEEDING OR ARTERIAL DISSECTION2. First time or the worst headache of my life be concerned for INTRACRANIAL e OR MASS3. Concomitant infection or immunosuppression be concerned for INTERCRANIAL INFECTION4. Acute visual changes, asymmetric eye findings, or abnormal funduscopic examination be concerned for ACUTE CLOSURE ANGLE GLAUCOMA, INTERCRANIAL MASS, TEMPORAL ARTERITIS, OR CAROTID ARTERY DISSECTION

PITFALL

• Historical or physical examination features that may suggest a serious secondary cause of headache

• 5. Headache spreading to the lower neck be concerned for INTERAL CRANIAL HEMORRHAGE OR INFECTION

• 6. Pain upon palpation to the temporal be concerned for TEMPORAL ARTERITIS

• 7. Similar headaches in other people in close proximity be concerned for CARBON MONOXIDE POISING

• 8. Patient with a history of cancer be concerned for INTERCRAINAL METASTASIS

4/6/2017

24

PITFALL

• Historical or physical examination features that may suggest a serious secondary cause of headache

• 9. Pregnant patient be concerned for PREECLAMPSIA• 10. Head trauma or a patient on Warfarin be concerned for

INTERCRANIAL HEMORRHAGE• 11. Significant hypertension be concerned for INTERCRANIAL

HEMORRHAGE OR HYPERTENSION ENCEPHALOPATHY• 12. Confusion, altered mental status, or focal neurologic deficit be

concerned for INTERNAL CRANIAL MASS, HEMORRHAGE, OR INFECTION

PITFALLS

• Failure to recognize the red flags in the medical history or physical exam that suggest a serious cause of a patient’s back pain

• SUBJECTIVE: less than 18 years of age, greater than 50 years of age, pain lasting more than 6 weeks, history of cancer, fever, night sweats, unexplained weight loss, recent bacterial infection, intravenous drug use, immunocompromised state, major trauma, minor trauma in the elderly, or night pain or pain that increases when supine.

• OBJECTIVE: fever, bowel or bladder incontinence, saddle anesthesia, decreased or absent sphincter tone, or new neurological deficit

PITFALLS

• Pediatric back pain failure to identify red flags• SUBJECTIVE: Prepubertal children, especially younger than 5, functional

disability, duration greater than 4 weeks, recurrent or worsening pain, early morning stiffness, night pain, fever, weight loss, malaise, postural change, kyphosis, scoliosis, limp, or alter gait

• OBJECTIVE: fever, tachycardia, weight loss, bruising, lymphadenopathy, abdominal mass, altered spine, mobility, vertebral/intervertebral tenderness, limp, alter gait, neurological symptoms, bladder or bowel dysfunction.

4/6/2017

25

PITFALLS

• Failure to educate parents about the significance of a fever• The child should be brought to emergency room is they are under 28

days with a fever, look toxic, if the fever doesn't break with an antipyretic

PITFALL

• Not considering foreign body aspiration in a young child with a wheeze • Classic triad is wheeze, cough and decreased breath sounds• Often missed diagnosed for asthma, pneumonia, chocking spell or

respiratory infection• Children between the ages of 1-3 usually have a sudden cough• Most common type of obstruction is food• Inspiratory and forced expiratory chest imaging should be obtained.

PITFALL

• Failure to manage concussions according to guidelines• Utilizing a simple clinical decision rule for minor head injury can

significantly reduced the use of CT scans in children presenting with minor head injuries but does not rule out the possibility of a concussion.

4/6/2017

26

PITFALL

• Failure to appreciate atypical presentation of acute coronary syndrome• The most common “atypical” symptoms of acute coronary syndrome in

the elderly diaphoresis, dyspnea, nausea/vomiting and syncope. Only 35% of patient over 84 years old will have a ST elevation in acute coronary syndrome

PITFALL

• Under appreciating the morbidity and mortality associated with simple falls.• CNS injuries • Rib fractures

PITFALL

• Failure to adequately manage pain• scopeofpain.org

4/6/2017

27

QUESTIONS

• Thank You!!!!!!!!!!!!!!!!!!!!!!!!!!!!