Question

PART 1: Ying’s Illness

Tuesday afternoon, January 8, 2013

Min and Wai were becoming very worried about their family member’s health. “Wai, honey, maybe you should go to Med-Way Drugs to see if they have something besides isatis root that will help Ying’s fever.” Her eldest sister n law, Ying, was sitting in the family room growing more agitated in pain by the minute. She had been this way for a few days. “I am starting to worry because she seems hotter than she was a couple of days ago and she’s complaining about not being able to swallow because of the pain,” Min exclaimed to her husband.

“I don’t want to talk to the pharmacist about any of those ’New World’ drugs, if that is what you are suggesting, Min. I just called my Mom and she said that her herbalist in Beijing always recommends yarrow for a fever. Maybe we can try that instead,” Wai suggested.

“Our neighbor told me that lots of other people on our block are getting sick. She said that during this time of the year, that’s pretty common so I think we need to think about a more aggressive treatment,” Min added.

“Aggressive? These are the strongest herbs that I can find! Let’s give her some hot mint tea as well. That always helped our sore throats as kids,” said Wai, as he started for the door. “In the meantime, I’m going to our herbalist for something more specific for her fever.”

Wednesday morning, January 9, 2013

Ying’s fever had spiked even higher despite the use of a variety of Chinese traditional treatments. Her throat was erythematous and she was refusing to eat. Her brother and sister n law continued to worry about her condition and monitored her progress over the week with continued encouragement for food and fluids as well as the herbal medications Wai was recommended by his local herbalist.

Part II – Admittance

January 11, 2013

Over the next couple of days Ying’s condition exponentially worsened. Wai’s herbalist had run out of options and encouraged them to rush Ying to the Neumann Hospital ER. Both Wai and Min were very worried and anxious, especially Wai, who disliked having to resort to conventional treatments for Ying. But they ultimately decided to go. A senior medical student made the following notes from the initial physical examination and lab tests:

Ying Chen – Initial Report

DOB: 11-16-1966

Gender: Female - Weight: 155.2 lbs. - Height: 64 inches

PHI: 53 yo Chinese female presents to ER with complaints of throat and ears hurting. Patient very agitated and fussy, complaining that she cannot swallow, with persistent cough. Family report onset as 6 days ago with focus on throat only, with persistent and progressive pain every day. Sister n law reports increased sickness around their neighborhood. Pain is described as burning and scratching, difficult to swallow, with nothing alleviating any pain beyond the mint tea family made. Family practice Chinese traditional medicine in the home and this visit marks the first for Ying in a Western institution. Parents came to hospital because they ran out of options.

Allergies: NKDA

Med Hx: Untold herbals, no Rx/OTC; Brother noted to contact local herbalist for list

FH/SH: Nothing disclosed by family (some inherent distrust of Western medicine and slight language barrier); patient lives with brother and sister n law. Patient came to the U.S. 6 months ago. Vaccination history unknown.

Vitals: T 39.9 degrees C, BP 110/71 mmHg, RR 40bpm, Pulse 110bpm

Physical examination:

(+) Drowsiness, agitation, opthorrhea, rhinorrhea, cough

(-) Epiglottitis, flushing, impetigo, circumoral pallor, rash, erysipelas

*Pharyngeal erythema with petechiae and dark white tonsillar exudates, tender, hypertrophied cervical lymph nodes

Initial Laboratory Results:

WBCs: 11,800/uL, Differential: 78% PMNs, 18% bands, 4% monos

Chest X-ray: clear

Urinalysis: hematuria, proteinuria

Throat and blood cultures pending

Plan: Consult Pharmacy for optimal treatment. Ordered Echocardiogram.

Questions

1. Min and Wai are anxious about using conventional medicine. What can be done to assuage their concerns? Is the hospital meeting their needs? Why or why not?

Part III – Progress

January 13, 2013

Before rounding with the care team this morning, you (the nurse on the care team) have a chance to meet with Ying and her family. You decide to look up the progress notes made on her and find the following:

Day 0: Started on empiric therapy of Penicillin VK per pharmacy recommendations. Fever still persists, but less agitation and runniness is noted; improved diet and fluid intake is noted by dietician. Around 2300, Min alerts nurses to a rash on Ying’s trunk; empiric therapy is discontinued.

Day 1: The throat culture on sheep blood agar revealed Streptococcus pyogenes (Streptococci) and Ying was given a diagnosis of streptococcal pharyngitis (strep throat). Blood culture confirms S. pyogenes. Gentamicin is initiated by the resident with renal dosing per pharmacy. ECHO scheduled for next afternoon.

Once Ying was feeling better, Dr. Smith sent for a translator to ensure that her family is accurately translating his messages. He needs to discuss a very serious matter and wants to make sure Ying understands. Now that the diagnosis and treatment for strep throat is almost complete, they need to address a potential heart disease that is associated with Chinese heritage contracting strep throat during the adult stage. An echocardiogram was ordered to see how Ying’s heart is because Dr. Smith is afraid there is an underlying condition that hasn’t been addressed.

“I ordered an echocardiogram, which is a test to look at Ying’s heart. I’d like to explain why I think this needs to be done.” Min and Wai looked surprised and as the translator finished translating the message to Ying, she began to cry.

In her native language, she asked her family am I going to die?

Min and Wai were very quick to say no and reassure her. They expressed their concern to the doctor as to why he was getting Ying upset. He began to explain.

“When strep throat isn’t caught in time, it can travel to the heart. If this occurs over time and often and isn’t properly handled, it can cause a fatal case of heart disease. The echocardiogram will make sure everything is okay with her heart.” This seemed to put Min and Wai at ease, but Dr. Smith knew this wouldn’t last because there was more to explain.

“There is one more thing to ask your permission,” said Dr. Smith. “I’d like to take a blood sample and see if Ying carries any mutations that are linked to heart disease, specifically rheumatic heart disease.”

At the same time, Min and Wai both asked, “what is that? Is it contagious? Will it kill her?”

At this point, Dr. Smith was not sure if he was explaining this at all correctly as it wasn’t his specialty, and handed them the informed consent and told them to sign it. Min and Wai could see that the doctor wanted to help her, so despite not really understanding what was going on they signed the consent form to have her blood taken and be genetically tested.

Part IV – The Results

January 18, 2013

Ying was still in the hospital receiving her antibiotics when Dr. Smith came in with her genetic testing results. The interpreter was not present in the room but Min and Wai were by her bedside. Dr. Smith looked anxious and unsettled. He began to quickly explain the results.

“I’m afraid my gut feeling was correct. Ying has a genetic mutation that makes her susceptible to rheumatic heart disease. We need to take immediate action to make sure that this condition does not progress and become worse. I’ll be back later today with a treatment plan” and immediately left the room after handing them the folder that contained the results.

Min and Wai together opened the envelope after he left. Ying was wide-eyed and scared as she looked at her family for an explanation.

The three of them looked at each other and looked down at all the numbers and letters on a piece of paper not knowing what to think or where to start.

Part V – Discharge

January 19, 2013

Ying was finishing up her course of antibiotics and her family were aiming for a great prognosis. All vitals had returned to normal and Ying was one blood culture away from being discharged. Min and Wai were now very interested in conventional medicine and had talked to Ying’s nurse and medical student about her disease and the way the medications work. Seeing its effects on Ying had particularly affected Wai, who was steeped in Chinese traditional medicine.

Continuing the discussion on explaining the genetic testing results to Min, Wai, and Ying was never resolved. Dr. Smith was called to several emergent cases in the ED, and Ying was discharged before anyone was able to come back and explain the outcome and treatment plan. Ying is now at high risk for developing rheumatic heart disease in the near future if no preventative action is taken.

Two weeks after discharge: It is your duty to follow up with each patient from the care team and ensure optimal and holistic care. The second-year resident forgot to include follow up points in Ying’s patient record and now he was off on his next rotation. Dr. Smith’s administrative assistant scanned Ying’s genetic testing results into her chart, but he did not document her results or his recommendations for preventative treatment options and follow-up procedures.

Questions

1. How was communication between the provider and the family members?

2. How would you discuss the integration of Western medicine into the family while still honoring the family’s traditional approach to medicine?

3. Was the communication surrounding genetic testing handled appropriately? Why or why not?

4. Were any professional lines blurred or crossed? Why or why not?

5. Were the appropriate steps taken for Ying’s care?

Answer 1

1.there is no effective communication happened between the provider and family members. Only the primary nurse could talk to the family members about patient's disease and how the medicines work. But the nurse couldn't resolve. And also the family didnt receive health education before discharge about the preventive actions.

2. Explain about all the pharmaceutical therapies by western medicine to the family and advice them to go for a combination with traditional medicine.

Provide health education

Explain about disease condition

Explain about the complications and treatment

Explain about all the sideeffects of the treatment

Advise about the preventive methods of complications  

3. Communications surrounding genetic testing not handled appropriately. Why because, the nurse couldn't resolve while explaining genetic test to the patient's family. And physician also were busuwith the patients in Emergency room and there is no effective communication happened. They couldn't explain about the preventive measures, And also the test results not handled property by the physician's assistant and so the doctor also couldn't see ther result at the right time.

4. Professional lines were crossed while handling the test results documentation and discharge education.  

Doctor's assistant / doctor /any health care provider shoul document all the data properly. I this scenario they mishandled the test result.

The nurse must explain to the patient and family all the discharge medications, complications may develop and preventive measures to be taken by the patient.

Resident doctor also forgot to include the follow up points in patient's record.

5. Patient received complete antibiotic course and he returned to the normal vital signs.