A 78-year-old male with a history of chronic comorbidities that include hyperten

Question

A 78-year-old male with a history of chronic comorbidities that include hypertension, diabetes, hyperlipidemia, and coronary artery disease presents with a warm, swollen, tender, left arm. He saw his primary care physician 2 days ago, at which time he was prescribed oral penicillin.

Upon being triaged at the emergency department, he is found to be febrile with a temperature of 103 degrees. His right arm has an 8 cm x 12 cm area of erythema and sclerosis, which is tender to the touch. There is moderate weeping of serosanguinous fluid from the posterior aspect of the arm.

The patient is admitted with a diagnosis of severe sepsis and immediately started on intravenous Flucloxacillin 2g IV QDS + Clindamycin 1.2g IV QDS + Gentamicin 7mg/kg IV. He also requires intravenous cyclo-oxygenase-2 with oxycodone.

On the third day of being of hospitalized, the patient's health plan utilization management nurse stops by to check on him. She asks how he is feeling and he tells her he is feeling better than the past few days. Upon check up, he is afebrile, and the sepsis area has decreased by 40%. However, he is still not able to tolerate a diet other than clear liquids, and is ambulating with assistance.

The patient’s PPO health plan notifies the hospital that effective this day, the health plan has determined that further inpatient care is no longer medically necessary and, as such, payment for services beyond this day will be denied.

The patient’s attending physician calls the health plan medical director to advocate for his patient. He explains that the the patient requires further hospitalization because this is the first day he has shown some improvement but he is not fully recovered. The physician explains to the medical director that the patient lives alone which would make it difficult for him to care for himself because he is not able to ambulate without assistance. The medical director responds that based on the information collected during rounding by the utilization management nurse, the patient is stable and ready to be discharged; he may be followed up as an outpatient. The call ends without any resolution.

Questions:

What are some relevant facts and what you consider to be the most important issue. Also, Outline 2-3 possible alternatives.

Explanation / Answer

Sepsis is a medical emergency and if goes untreated may become fatal. It is a 3 stage syndrom which initiates with sepsis, progrssing to severe sepsis, and then finaly to septic shock. Basically, sepsis is an immune response to bacterial infection that gets into the blood causing injury to its own tissues and organs.

In this case the diagnosis is of severe sepsis. The patient is old and started to respond on the third day. Also, the patient lives alone which would make it difficult for him to care for himself because he is not able to ambulate without assistance. As a part of the treatment he is receiving  intravenous Flucloxacillin 2g IV QDS + Clindamycin 1.2g IV QDS + Gentamicin 7mg/kg IV apart from intravenous cyclo-oxygenase-2 with oxycodone. Now, it is not possible to administer all these at home especially when he is alone. All these facts must be considered.

Possible alternatives can be as follows

1. The best alternative would be to convince the medical director and the utilization management nurse so that an extension of 7 days can be taken, so that patient recovers at least 75% -80% so that he can move without any assistance and the frequencey of drug administration gets reduced before he reaches home.

2. To appoint a nurse or may be two who can take care of that man at home coupled with the visit of a physician every day to check his condition if the medical director remains fixated on his point .

Related Questions

Navigate

• Browse (All)
• Browse A
• Subjects

Integrity-first tutoring: explanations and feedback only — we do not complete graded work. Learn more.