Improving patients’ experience in hospitals necessitates the improvement of service quality. Using mystery patients as a tool for assessing and improving patients’ experience is praised for its comprehensiveness. However, such programs are costly, difficult to design and may cause unintended negative consequences if poorly implemented. Following an Action Research theoretical framework, the aim of this study is to utilize the Mystery Patient (MP) for engaging the patient in co-creating valuable non-clinical services and producing guidance about future managerial interventions. This was operationalized at the Outpatient Clinics at a large Academic Hospital in the Middle East region whereby 18 Mystery Patients conducted 66 visits to clinics and filled out 159 questionnaires. The results indicated higher scores on hard criteria or skills (technical), such as personal image and professionalism, and lower scores on soft criteria (interpersonal), including “compassion” and “courtesy”. The data also demonstrated how the MP tool could provide targeted information that can point to future interventions at any one of the patient experience core pillars, namely: process, setting, and employees. This paves the way for another cycle of spiral learning, and consequently, a continuous process of organizational learning and development around service provision. The MP tool can play the role of the catalyst that accelerates the value co-creation process of patient experience by directing management to necessary interventions at the three pillars of patient experience: employees, processes, and setting.
Diabetes mellitus type 3c (DM3c) is an uncommon cause of diabetes due to pancreatic pathology. Its prevalence reaches about 5-10% among all diabetics in the Western world, largely due to chronic pancreatitis. DM3c occurs due to the destruction of the endocrine islet cells. Glucagon and insulin levels are both decreased due to the destruction of alpha and beta cells, respectively. This makes the development of diabetic ketoacidosis (DKA) a rare process in patients with DM3c because of the destruction of glucagon, which facilitates ketone production. We report a case of DM3c presenting with DKA. The patient presented with a history of chronic pancreatitis and was on pancreatic enzyme replacement therapy. Prior records revealed that HbA1c levels were normal. Prior computed tomography evidence revealed diffuse pancreatic calcifications. The patient was admitted for DKA, presenting with hyperglycemia, blood glucose of 703 mg/dL, bicarbonate of 16 mmol/L, ketones in the urine and acetone in the blood. The patient’s anion gap corrected for albumin was 27. The patient was admitted to the medical intensive care unit where he was treated with intravenous (IV) insulin and IV hydration. Once the anion gap closed, the patient was transitioned to long-acting insulin. HbA1c level on admission was elevated, autoimmune causes of diabetes were sent and were negative, ruling out late onset type 1 diabetes. This shows that although it is a rare phenomenon, diabetics with DM3c can present in DKA.
A 21-year-old African-American male presented to the emergency room with a sudden diffuse onset abdominal pain of one day duration. CT findings revealed mild telescoping of loops of small bowel and mesenteric fat in the left mid abdomen with no apparent masses. The patient underwent an exploratory laparoscopy revealing intussusception of the mid jejunum. As a fair amount of distention compromised safe navigation of the bowel, laparoscopic resection was not warranted at this time. Open approach allowed for segmental resection of the affected segment of the small bowel. This was followed by primary anastomosis. Pathological findings revealed focal reactive lymphoid hyperplasia with marked congestion in the lamina propria of the jejunum. The patient had an unremarkable postoperative period and recovered with no further complications.
Aortitis is an inflammation of the aorta that is linked to large vessel vasculitis and other rheumatologic cases. Less often, an infectious etiology of aortitis is diagnosed. Aortitis is associated with high mortality and morbidity and requires a high index of suspicion. Here we present a rare case of aortitis secondary to Salmonella Septicemia treated with six weeks of antibiotics in the hospital without and remained asymptomatic and inflammatory markers normalized at 2 weeks follow up (ESR, CRP, and WBCs).
INTRODUCTION: Strongyloides stercoralis is an intestinal roundworm that infect humans through contact with soil that is contaminated with free-living larvae. The larvae penetrate the skin and migrate through the body to the small intestine to lay their eggs. It is associated with immigrant populations from tropical regions such as Southeast Asia and the south pacific. Strongyloidiasis is often mild or asymptomatic in over 50%-60% of cases, but may present with cutaneous and gastrointestinal symptoms like abdominal pain, bloating and diarrhea. The rise in blood eosinophils count could be the only finding. Strongyloides is able to re-infect the host through the wall of gastrointestinal tract, a process described as autoinfection. This is why it may be detected decades after original exposure. CASE DESCRIPTION/METHODS: We encounter a 64-year old Hispanic male with PMH of Multiple Myeloma, who was admitted to our hospital due to fatigue and spiking fever. Patient was recently diagnosed with Multiple Myeloma and was on Bortezomib, Cyclophosphamide and Dexamethasone for the last 22 days. During the presentation, maculopapular rash was noted on his right inner thigh that later on got more diffused and affected the bilateral thigh and right forearm. Laboratory results shows Leukocyte 6.8 thousand/uL, hemoglobin 7.3 g/dL, platelet 35 thousand/uL, eosinophil 34 cells/uL, and plasma cell 2 cells. Patient had Tmax of 103 and empiric antibiotic was started. All blood cultures, urine cultures and chest X-ray was negative for any source. His liver enzymes and direct bilirubin trended up without any sign of cholecystitis on ultrasound and Cholescintigraphy scan. During the hospital course, the rash got more characteristic of reticulated purpuric patches. EBV, HSV, Varicella, Spotted fever, Typhus fever, ANA, IGG and hepatitis panel back negative. Due to reticular rash development, suspicion of Strongyloidiasis increased and IGG antibody came back positive. Patient started on Stromectol 15 mg for 2 doses and the rash resolved following the second dose of the medication. DISCUSSION: Strongyloides stercoralis is a challenging diagnosis in immunocompromised patients. It is important to screen for helminth diseases in patients with high blood eosinophils count, especially before starting chemotherapy.
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