11 February 2012

Infectious Disease, week #1

For my last clinical (in-hospital) month of medical school, I have registered for an infectious diseases consult month. First I will describe what a consult service is, after that we get to the cases I saw during the first week.

Consult Service (n) - a group of physicians called by the treating doctors to answer a specific diagnostic or treatment question because of their subject-specific expertise.

It's not really different from consulting in business. You are posed a specific conundrum, you gather data, make recommendations, but have no power or authority to directly enact your plan. From a logistics standpoint, your workflow is also opposite

to a primary team. You see all your new patients in the morning and round in the afternoon.

Day #1:
A person who had altered mental status and shingles. New lesions were appearing and the primary team was worried the shingles was spreading and had become systemic (usually it's limited to a small part of the body). I decided no (lab testing confirmed), however the change in mental status made the idea of it causing an infection in her head possible. We couldn't confirm because the shingles was covering the part of the body we would use to do a lumbar puncture.

A person was admitted to the hospital three times in two months for headache, nausea and vomiting. All tests looking for infection in the head were negative each time. We were asked to weigh in on the likelihood this was a chronic infection we simply couldn't detect in the lab. While those infections exist, it was more likely this represented a manifestation of her not-fully diagnosed auto-immune disorder. Steroids, not antibiotics, were more likely to be helpful.

Day #2:
A person who was taking immunosuppressive therapy who now had bacteria in the blood. Initially appeared to be a standard line infection (bacteria grow on an IV or central line), however turned in to a septic thrombophlebitis (blood clot with bacteria in it) with an abscess. Despite being surgically drained, the person continued to have bacteria in the blood. More to come.
Day #3:
A person on chemotherapy with a chronic cough who had his sputum cultured one month ago. It just turned positive for mycobacterium gordonae; contaminant or infection to be treated? I decided contaminant and we did not treat.

Day #4:
A person with two recent hospitalizations for pneumonia who now is found to have growths (vegetations) on one of their heart valves and on a lead of their pacemaker. No detectable bacteria in the blood. I decide to cover with antibiotics and have the pacemaker removed. Also talk to the surgeons about whether they need to operate on the valve, given how big the vegetations are. I don't think it was pneumonia, I think the person is sending bits of clot into their lungs.

Day #5:
No new patients, just followed up on existing ones.

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