Infectious disease can be almost overwhelming. However, if you look at the fundamental basics, it’s not that hard. You have to know your infectious diseases because PAs and NPs are on the front line of infectious disease and addiction. A lot of us are very ill-prepared for it.
Let’s talk about the common infections in urgent care. When it comes to working up someone for an infectious disease, first and foremost make sure you get a valid temp. That mean rectal temps in kids and demented geriatric patients. If they don’t keep the thermometer probe under their tongue, you get a falsely low temp.
That can burn you because you’ll have a geriatric patient come in from a nursing home short of breath. What are the two most common causes? You’re looking at pneumonia versus failure. If they have a temp of 103 and they’re short of breath, your job is easy. If they’re euthermic, you can think it’s failure. If you squirt a pneumonia patient with Lasix, you dehydrate their pneumonia and increase their mortality.
Secondly, as a hospitalist guy, I see a CBC as an incomplete picture. Don’t call and say, “Hey, I think someone’s infected because their white count is 18,000.” There are three numbers I want: white count, neutrophils and bands. That tells me you’re thinking like an internist and a critical care provider.
A band count is in reference to a left shift. Some people think a high neutrophil count is a left shift, but it’s not. Your normal band should be a couple percent. That’s physiologic. Bands that go into the double digits are as sinister as a positive troponin.
You have someone you think is infected and you say, “I have someone with belly pain and a white count of 12,000.” I’m going to say, “So what?” Then you tell me, “They have 18 bands.” That’s going to make me go, “Wow, okay.” Now you have my attention and I want to know if you got a surgical consult, did a lactate level and scanned them.
My daughter is 15 and she’s having a slumber party. So, I text her, asking her if she wants me to tell ghost stories. You know what she texts back? “SMH.” What does SMH stand for when you’re 15? It stands for “shake my head.”
Do me a favor and take your first three fingers and put them against your throat. These three fingers represent the three germs that live in your throat. We’re also going to use the shorthand “SMH” to remember these germs.
If we’re going to talk about urgent care infections, we have to talk about these germs. These germs are the primary players in upper respiratory infections.
Five Major Body Systems
There are five major body systems we have to think about when looking at an infection: wind, water, brain, belly and skin.
I want to warn you about meningeal signs because I know of two patients that died due to advanced practitioners getting bad advice about potential meningitis. You walk into a room and you have a guy with a fever of 103, headache, neck pain and altered mental status. All of a sudden, it hits you and you go, “I think I’ve got meningitis.”
As soon as you realize this could be bacterial meningitis, you push a button on your stopwatch. How much time do you have to squirt antibiotics? What is the appropriate period of time to wait after a presumptive diagnosis of meningitis? Critical Care Society gives you one hour.
What’s the barrier to squirting with antibiotics right away? You want the LP. What’s the problem? A lot of us don’t do LPs.
Let me tell you about the two fatal meningitis cases I know of. You call the doc, “Sorry to bother you. Listen, I’ve got a guy I think has bacterial meningitis. I’m concerned about it but I don’t do LPs.” Then, the doctor gives you some really bad advice, “Don’t put antibiotics on the board. Ship them over here by ambulance. As soon as they get here, I’ll tap them right away and then put them on antibiotics.” You can’t do that, because you only have one hour. If the patient has serious strep-pneumoniae in their spine, they will die.
If you see a patient you think has bacterial meningitis and you can’t get the LP within an hour, do blood cultures and flood them with antibiotics. Do it before you make the phone call. Don’t let the doc on the other side tell you not to put them on antibiotics. You say, “Oh man, I’m sorry. They just got two grams of ceftriaxone.” In this scenario, the patient may still die, but it’s not on you.
What makes a patient septic? I think the SIRS criteria is a little bit crazy. It’s a little bit abstract. It’s more for researchers. There’s what’s called SOFA scoring, kind of like the NIH stroke scale. It’s very busy and very heavy. It’s probably good if you’re inpatient.
I want to give you a more clinically-applicable tool. It’s called a quick SOFA, and it’s an evidence-based “sniff test.” Use the 3 Bs to determine if your patient is sick: brain (are they altered?), breathing (are they tachypneic?) and blood pressure.
I think the respiratory rate is one of the most important vital signs, but it’s also the most disrespected. No respiratory rate is valid unless you take it yourself. When someone becomes acidotic from sepsis they produce lactic acid. Bicarb drops because it’s trying to buffer the lactic acid. Now there’s too much carbon dioxide relative to the bicarb and they start becoming tachypneic.