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Admitted to Hospital
73 year old woman MT, admitted to orthopaedic ward -
Surgery
MT has surgery to repair a fractured neck of femur. -
Post Surgical Review
MT develops respiratory symptoms: cough, shortness of breath and fever and is treated for pneumonia with Tazocin for five days. -
~ 8:30am What Assessment Does MT Require?
- Pulse
- Blood pressure
- Temperature
- Respiratory rate
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~ 9:00am An Infectious Cause of Diarrhoea is Suspected, What Actions Should be Taken?
- Consider patient placement
side room if possible, consult with Infection Control team - Ensure staff and patient use hand hygiene – soap and water in this case as we suspect C difficile
- Ensure gloves and aprons available
- Diagnostic testing – send diarrhoeal stool to lab for C difficile testing (see the C. difficile Adult Treatment of Infection Policy )
- Stop any medication that cause diarrhoea, and if possible stop antibiotics in use
- Consider patient placement
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~ 12 noon Further Diarrhoea
- MT is placed in a side room as she continues to have watery diarrhoea and contact precautions with soap and water, as well as gloves and aprons are made available in the room
i) Vital signs (P, T, BP, RR)
ii) Abdominal examination for any tenderness or distension
iii) Assessment of hydration status -
~ 12:15pm Assessing Severity of Disease
- MT has temp of 38.8C, pulse of 90, BP 110/75, and respiratory rate of 18
- Abdominal exam indicates mild central abdominal tenderness but no distension
- She is mildly dehydrated
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~ 12:30pm What Action Should Be Taken Now?
- IV access for administration of fluids
- Abdominal X ray if needed
- Ensure C difficile sample has been sent
- Seek advice on choice of antibiotics for C difficile
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~ 8:00am Onset of Diarrhoea
- Frequency of stool
Type of stool - Review medications to find any that can cause diarrhoea
- Especially laxative or enema administration
- Frequency of stool
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~ 1:30pm Medical Assessment
- MT is reviewed by the F2 doctor and commenced on IV fluids, an abdominal X ray is arranged and the antibiotics for the previous chest infection (Tazocin) stopped
- He then contacts the Registrar for advice on treatment of probable C difficile
- Registrar shows the F2 the C difficile management algorithm and decides that the patient has non-severe disease and starts treatment with metronidazole orally (400mg TDS)
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C difficile Result
Microbiology contact the medical team to inform that the C difficile test is positive, ensure isolation precautions in place and give clinical advice. -
9:00am Further Clinical Symptons
MT’s diarrhoea reduces in frequency over the next 48 hours, but remains watery, but the abdominal pain increases and there is now distension- Pulse ~ 100, BP~ 100/60, T 37C, RR 24
- WCC = 23; creatinine = 190 (baseline 88); albumin = 16
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9:30am What Steps Should Be Taken Next?
- Refer to C difficile clinical management guidance on Source
- Reassess clinical status – she now has evidence of severe disease
- Call for opinion from infection team, surgical team, gastroenterology team
- Abdominal imaging now essential
CT may now be more useful than a repeat AXR, especially as the patient’s condition suggests a very unwell, unstable patient - Escalation of treatment on advice from infection / GI teams
Surgery may be considered – so contact surgeons early
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12 noon Input from Specialist Teams
- CT abdomen shows colitis but no toxic megacolon or evidence of bowel perforation
- Surgeons and gastroenterology team agree on an initial trial of conservative management and close surgical review
- Infection team recommends IV metronidazole, high dose PO vancomycin, and review next day
- Other additional options are available if required
- Nutrition and hydration support are needed
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 20; creatinine = 170 (baseline 88); albumin = 16
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 18; creatinine = 140 ; albumin = 17
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 14; creatinine = 115; albumin = 18
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 12; creatinine = 112; albumin = 19
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 11; creatinine = 109; albumin = 21
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Daily Obs
- Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
- WCC = 9; creatinine = 105; albumin = 22
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Progress
- MT is able to have treatment rationalised to PO vancomycin and a plan is put in place to complete 14 days therapy
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Progress
- MT makes a good recovery, diarrhoea settles and she is discharged home with follow up in orthopaedics and primary care
- MT makes a good recovery, diarrhoea settles and she is discharged home with follow up in orthopaedics and primary care
