A patient is admitted to a busy emergency department with symptoms the doctor assumes is pneumonia. With the integration of DynaMed and the hospital's EMR system, the doctor is triggered to look for other symptoms and the underlying reason why the patient is feeling the way he does. DynaMed successfully guides the doctor in the right direction at the point-of-care, and the patient is correctly diagnosed with the early stages of sarcoidosis.
In busy clinical environments, treating the patient at the point-of-care is critical to the patient’s recovery. Making sure that the patient is provided the accurate diagnosis from the start is even more essential.
This case study highlights a 48 year-old male who entered the emergency room at Norman Regional Health System in Norman, Oklahoma, with shortness of breath, dyspnea on exertion, fever and cough. The patient reveals that he currently smokes a pack of cigarettes every day, and has a 25-year pack history. The emergency physician places the initial orders in Provider Order Management—the patient is admitted to the hospital under the initial admission diagnosis of pneumonia.
A busy emergency room doctor calls the patient’s primary physician to establish initial inpatient care, providing the following information:
48 year-old male patient presents with five days of fever and cough; chest x-ray shows pneumonia and I’m putting him in to you on the pneumonia care map.
The patient’s primary physician presents to the hospital for the admission. The analyses of the data shows PNA community acquired, but underlying this condition, the physician believes there is a reason that his 48 year-old patient is getting an upperlobe pneumonia. Reading the data, the differential diagnosis is forming—TB, HIV, aspergillosis, histoplasmosis, COPD, asthma, sarcoidosis or possibly cancer. The physician is familiar with how to diagnose/treat asthma, HIV, TB and COPD—he will follow up with the lab, order a PPD, chest CT, treat the patient with broad spectrum antibiotics, place the patient in isolation, check for HIV and do a sputum culture.
However, he has not recently thought about aspergillosis, histoplasmosis and sarcoidosis, and wonders if he has missed something regarding the early warning signs of ARDS. He questions if there is a need to run any specialized studies first line or if he should wait. He also wonders if he should be treating the patient with high-dose IV steroids—which could help or hurt depending on the diagnosis.
With many possibilities, from the original thought of pneumonia, the physician needs to find the correct diagnosis in a short amount of time.
To answer his questions and gain insight into the diagnoses that he is less familiar with, the physician accesses DynaMed at the point-of-care from the EMR and initially searches “vital signs, respiratory rate.” COPD yields a top result; he first checks to see if there are any new drugs available that he should be aware of. He then does a search for aspergillosis and for histoplasmosis—results determine that those diagnoses are a low likelihood for the patient as the patient does little gardening or hiking, and the initial tests cover this spectrum of diagnosis.
The physician then performs a search for sarcoidosis. While quickly scanning the evidence in DynaMed, he notes that the patient is African American, in his forties and has a family history of severe lung disease.
He also notes that the CXR had a lot of mediastinal haziness; this information leads him to believe that a diagnosis of sarcoidosis is a strong possibility.
Reviewing the evidence, the physician determines that an alpha-1 antitrypsin will help differentiate early onset COPD, and in quickly scanning the sarcoidosis information, finds that an ACE level may help diagnose sarcoidosis. He also determines that a bronchoscopy is needed, and decides to consult the pulmonologist right away instead of later.
Benefits & Results
With the help of DynaMed, the physician receives the test results at the point-of-care—alpha-1 antitrypsin is negative, as are the fungal tests, PPD (TB) and HIV. However, ACE level is positive. Sarcoidosis is the most-likely underlying issue threatening the patient’s life. Referring to DynaMed for further testing options, the physician recommends a biopsy of a mediastinal lymph node, which confirms his diagnosis. High-dose steroids are used to treat the patient.
Through DynaMed, the physician has positively diagnosed the patient—as early as possible—with sarcoidosis. ARDS is narrowly avoided. The CT chest image reveals a large necrotic mass in the left anterior mediastinum and bilateral hilar lymphadenopathy, and the biopsy from the lymph nodes shows multiple non-caseating granulomas with multinucleated giant cells and histiocytes.
Upon diagnosis, the physician accesses Patient Education Reference Center (PERC) and prints evidence-based handouts regarding PNA and sarcoidosis for the patient and his family five days prior to discharge. These educational materials provide the patient and the family with tangible information to help demystify what just happened; the family had no idea that his symptoms were so serious— they assumed he had a bad cold and would leave the hospital with an antibiotic.
Dr. Yeaman puts it best when he describes: “When you can look another person in the eye and they thank you for saving their life, and you know you went the extra mile and did something right—that you utilized every tool at your disposal—that is a great feeling; second to none. The best part is you know that you didn’t get lucky, you applied the best science available. No longer should evidence and the EMR exist on separate islands of care. Technology allows us to bring them together and provide the highest-level quality of care for each patient, which leads to the ultimate finish line—improved outcomes.”