Floor Calls
Bonnie K. Dwyer, MD
Maternal Fetal Medicine
Palo Alto Medical Foundation
4/8/2015
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Introduction
Words of Wisdom
All of the answers lie in the
Differential Diagnosis
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Topics
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•
•
•
•
General Principles
Fever- Intra Partum, Post Partum, General
Low Urine Output
Shortness of Breath
Chest Pain
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General Principles
• Does the patient need to be seen?
– What are the patient’s vitals?
– Is there an abnormal vital sign?
– Is the patient symptomatic?
• Does the patient need to be seen NOW?
• Decide if you need help.
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General Principles
• RUN vs. WALK
– Run for any unstable vital sign
– Go immediately for SOB /Chest Pain/Altered
Mental Status
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General Principles
• While running or walking
– Think about the differential diagnosis
– Think about what more information you will
need to diagnose the problem
– Decide on a plan of action
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General Principles
• Be systematic in your thinking
• Divide every problem into the following
categories:
– Differential diagnosis
– Diagnostic plan
– Treatment plan
• Have a memorized or “Rote” diagnostic plan for
each problem– you may later adjust it according
to circumstance
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Fever
The definition and management of fever
is different depending on the setting
Intra-partum
Post-Partum
General
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Fever: Intrapartum
• Definition- Temperature ≥ 38
• Differential diagnosis
– Chorioamnionitis
– Exertional temperature elevation =
“dehydration”
– “Anesthesia related fever” = “dehydration”
– Previously existing disease
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Fever: Intrapartum
Diagnostic Plan
• Physical exam
– Exertional temperature elevation/ “anesthesia related
fever”- includes only low grade temperatures,
ie T< 38.0 (F100.4)
– Research definition of “chorio” includes maternal
fever and one more sign/symptom including maternal
tachycardia (>100 bpm), fetal tachycardia, foul
smelling lochia, or tender uterus
– Clinical definition, “chorio” is T ≥ 38.0 (F100.4)
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Fever: Intrapartum
Treatment
• Diagnosis determines treatment
– Exertional temperature elevation“Bolus”
– Chorioamnionitis Ampicillin/Gentamicin
during labor
• PCN allergic-->Kefzol
• If PCN anaphylaxis-->clinda/erythro if known GBS
sensitivities available. Vanco if unknown.
• If C/S is performed, add anaerobic coverage. Generally
continued for 48 hours post-op.
• Studies have shown that a single dose of antibiotic post
vaginal delivery is as good as 24 hour doses.
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Fever: Post Partum
• Whole different world!
• Definition
– Temperature greater than 38.5 X1, or
– Temperature greater than 38.0 X2 after the
first 24 hours post partum
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Fever: Post Partum
Diagnosis
• Differential Diagnosis (head to toe)
– Mastitis
– Atelectasis/Pneumonia—aspiration or hospital
acquired
– Endometritis
– Pyelonephritis
– Cellulitis/Wound Abscess
– Vaginal hematoma/abscess
– DVT/other thrombosis (septic pelvic
thrombophlebitis)
– Drugs and other usual suspects
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Fever: Post Partum
Diagnosis
• Endometritis– Uterine tenderness, foul smelling lochia
– Absence of other obvious source
– Know your bugs- On Creogs
• Polymicrobial
• 80% involve anaerobic organisms—peptostreptococci,
bacteroides, etc.
• Gram neg rods (E.coli), Gram pos cocci (GBS), etc.
• Late endometritis—that is two weeks out may involve
chlamydia—so add doxy to this regimen
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Fever: Post Partum
Diagnostic Plan
•
•
•
•
•
•
Physical Exam
+/- U/A, Ucx
+/- CBC
+/- Blood cultures X2
+/- CXR
+/- stool culture
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Fever: Post Partum
Treatment
• Diagnosis determines treatment type and
length
• If you start ABX before you send your
cultures, you may be sorry
• Assume endometritis if no other obvious
source on exam
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Fever: Post Partum
Treatment
• Endometritis
– This is the only bacterial infection that I know of for
which you stop ABX when pt. is afebrile!!
– Most will stop ABX when a pt. has been afebrile for
24-48 hours. If the pt. is s/p C/S—usually 48 hours.
– Traditional antibiotics are “Triples,” but other broad
spectrum antibiotics have been shown to be just as
efficacious
-Amp/Gent/Clinda—daily or thrice daily dosing
-Clinda/Gent alone – recommended by ACOG
-Zosyn, Unasyn, Cefotetan, Augmetin (po!!)
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Fever: Post Partum
Endometritis
• Blood cultures are done in a patient with
endometritis to direct care if the patient NOT
responding.
• 10-20% of endometritis will have positive blood
cultures.
• 10-20% of endometritis will be secondary to
inadequately covered enterococcus.
• Although most cultures reveal a single organism,
the infection is STILL polymicrobial!
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Fever: Post Partum
Treatment
• Pyelonephritis
– Traditional treatment is Amp/gent, new studies show
Cephalosporins also OK—Kefzol and Ceftriaxone are
fine.
– When afebrile X 24 hours, change to po’s, need 14 day
course
(if pt. not breast feeding, fluroquinolones ok, then only need 7 days)
(+ blood cultures help with diagnosis, but do not alter treatment)
NO MACRODANTIN for PYELO!!!!
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Fever: Post Partum
Treatment
• Mastitis- Typically T≥38.3 with systemic symptoms
– Dicloxicillin or Keflex (traditional)—both OK for breast feeding
and cover staph and strep. (Nafcillin or Kefzol if IV ABX
needed.)
– New emphasis to cover MRSA if recent hospitalization, consider
clindamycin 300 mg qid
– 10-14 day course
– Breast feeding or pumping hastens recovery.
– NSAIDS
– Abscesses must be drained and can be diagnosed by ultrasound
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Fever: General
• Rote
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–
–
–
–
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Physical Exam
Blood culture X2
U/A, Ucx
+/- CXR
+/- stool cultures, ie C.diff
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Fever: General
Different World!
• Definition- Temperature >38.5 (101.5)
• Differential Diagnosis
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–
–
–
–
–
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Infection
Drug
Thrombus- DVT-upper or lower extremity/PE
Atelectasis
Cancer
Inflammatory disease/Vasculitis/Other
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Fever: General
Diagnostic Plan
Individualize according to the patient.
Think through anatomically:
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–
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Head: Sinusitis, Meningitis, otitis/pharyngitis
Heart: Endocarditis
Lungs: Pneumonia, pleural effusion
Chest: Line infection
Abdomen- abscess, pyelonephritis, biliary, infectious diarrhea,
spontaneous or secondary bacterial peritonitis
– Pelvis- PID/TOA, abscess
– Back- Decubitus ulcers, rectal abscess
– Extremities- cellulitis, septic thrombus, line infection, osteomyelitis
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Fever: General
Diagnostic Plan
• If the patient is immunocompromised, expand
your differential diagnosis
• If no obvious source of bacterial infection, think
about viral causes of fever and the rest of the
differential diagnosis
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Fever: General
Treatment Plan
• Diagnosis determines treatment type,
dose, and duration.
• Empiric treatment only if patient is septic
or in danger of sepsis or life threatening
complication.
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Fever: General
Treatment Plan
• Broad spectrum antibiotics
– Know what category of bug each antibiotic covers, ie gram
positive, negative, anaerobic, atypicals
– Neutropenia: Each institution has its own hierarchy of Broad
spectrum coverage.
– Chronic illness or hospitalization: Add coverage for resistant
gram positives with Vanco
– If pt. in danger of dying or has a nosocomial infection, consider
“double coverage” of gram negatives, specifically pseudomonas
– Traditional Pseudomonal ABXs include: Gent/Tobra, Ceftaz,
Cefepime, Zosyn/Timentin, Cipro, Imipenem/Meropenem,
Aztreonam
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Low Urine Output
Low urine output is not the problem, it
signifies a problem
Your goal is not to make
the patient pee, but to figure out why
she is not peeing
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Low Urine Output
Definition
• Low Urine Output– Less than 0.5cc/kg/hr (30-40cc/hr in a typical
woman)
• Oliguria- 400-500 cc/day
• Anuria- Less than 50cc/day
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Low Urine Output
• Differential Diagnosis
– Intravascularly dry• True hypovolemia: intravascular depletion
• Hypervolemia with intravascular depletion: 3rd spacing or
low albumin states
• “Intravascularly Dry”: low cardiac output, or low SVR (the
kidney thinks the body is intravascularly dry)
– Acute kidney injury (Acute renal failure)
– Obstruction/Mechanical problem-outlet obstruction, ie
FOLEY BLOCKADE, or hole in the bladder
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Low Urine Output
Diagnostic Plan: Rote
• On the phone- rule out easy things first
– Does the pt. have a foley
• If yes—flush foley
• If no- Place foley and call me with the output
• Determine volume status
– Vital signs- HR, BP, O2 sat
– Physicial exam- mucous membranes, neck
veins, lungs, extremities
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Low Urine Output
Diagnostic Plan- Extras
Still can’t figure out volume status?
Here are some tools:
– Blood- BUN/Cr, Na+, HCO3
– Urine – sp. Gravitiy, urine Na+, urine
creatinine (calculate your FeNa!!!)
– CVP if you have a central line in place
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Low Urine Output
Treatment
• Intravasculary Dry: True Hypovolemia,
including 3rd spacing and low albumin states
– Give volume
• NS or LR
• Hesban or albumin
– Avoid nephrotoxins, specifically NSAIDS, ACEI’s,
contrast dye
– Follow volume status on exam, O2 sat, I’s/O’s, daily
wt.s very closely
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Low Urine Output
Treatment
• “Intravascularly Dry”- CHF, Cirrhosis,
sepsis
– Treatment is illness and circumstance specific
– You have to make the kidney see more
perfusion– ie increase cardiac output, increase
SVR, and/or increase intravascular volume
– Avoid Nephrotoxins as above
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Low Urine Output
Treatment
• Acute Kidney Injury (Acute renal failure)
– Pre-renal azotemia- see Intravascularly dry above
– Intra renal- in the hospital usually ATN
• ATN– If secondary to pre-renal azotemia- fluid may help some,
but beware of fluid overload
– Avoid nephrotoxins- NSAIDS, ACEI’s, contrast dye,
Aminoglycosides, Ampho B, Vanco
• Interstitial Nephritis- avoid nephrotoxins- NSAIDS,
PCN/Cephalosporins
• Glomerulonephritis/Vascular lesion—much less common
“hospital acquired problem”
– Post-renal (ureteral/bladder/urethral obstruction)- see next
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Low Urine Output
Treatment
• ATN can either be oliguric (no pee) or nonoliguric (yes pee)
– Lasix can convert oliguric to non-oliguric but will not
change the renal prognosis
– Lasix will only help you control volume
status/electrolytes, NOT IMPROVE RENAL
FUNCTION
– ATN is managed supportively. Typical duration is 721 days, but may be months. A pt. may need dialysis
for this time.
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Low Urine Output
Treatment
Again !!!!
• Lasix is used to treat symptoms of volume
overload– not low urine output
• Remember, low urine output is not your
problem, it is what is causing the low urine
output that is your problem
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Low Urine Output
Treatment
• Obstruction/Mechanical
-You can treat this by removing or circumventing
the obstruction
- After an obstruction is fixed, a pt. can develop
“post-obstruction diuresis” which is an
inappropriate diuresis– causing a pt. to become
intravascularly dry if not monitored appropriately
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Shortness of Breath
Differential Diagnosis:
• LOW O2 SAT
– Hypoxemia
• Normal O2 SAT
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–
–
–
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Airway obstruction
Irritation of the pleura/lung parenchyma
Metabolic- Acidosis, Sepsis
Cardiac Ischemia equivalent
Anemia
Anxiety
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Shortness of Breath
Differential Diagnosis
• Hypoxemia
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•
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•
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•
•
•
•
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Pulmonary edema- cardiogenic, non-cardiogenic
Pneumonia
Pulmonary embolism
Atelectasis
Pleural Effusion
Pneumothorax
Large Airway Obstruction
Reactive Airway Disease/ COPD
Restrictive Pulmonary Disease
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SOB: Diagnostic Plan
Rote
• Current Vital signs, including a
ROOM AIR SAT
• Evaluate the patient immediately
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Diagnostic Rote Plan
• Physical Exam- SICK vs. NOT SICK
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Is the pt. in distress?
Diaphoretic? Tachypneic?
Altered Mental Status?
Cardiac exam- Tachycardic? Neck Veins?
Lung exam- Crackles? Wheeze?
Abdomen- Pain?
Extremities- Symmetric? DVT?
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SOB: Diagnostic Plan
Rote
• If the pt. is sick- by virtue of vital signs or
physical exam
– CXR
– EKG
– Room Air ABG—if pt. too hypoxic to take off
oxygen, an ABG on O2 is still useful to
evaluate ventilation
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SOB: Diagnostic Plan
Rote
• CXR
– Pulmonary infiltrates- Water, pus, or blood
(pulmonary edema, pneumonia, diffuse alveolar
hemorrhage)
– Low lung volumes- poor breath, atelectasis, pleural
effusion, pneumothorax
– Large lung volumes COPD
– Normal lung fields think PE
– Heart size
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SOB: Diagnostic Plan
Rote
• EKG
–
–
–
–
Rate
Rhythm
Evidence of ischemia
Evidence of cardiac strain- via hypertrophy
and axis
– Evidence of PE
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SOB: Diagnostic Plan
Rote
ABG
• Two components of respiratory distress
– Oxygenation- Calculate the Aa gradient (on room air)
– Ventilation- What is the pCO2?
• If the pCO2 is low (<40)– this is appropriate for someone
who is hypoxic and trying to compensate with respiratory rate
• If the pCO2 is normal or high (near 40 or above)– Is normal appropriate?—if the pt. appears to be working hard
to breathe, a nl or elevated pCO2 may represent resp. failure
– This may be secondary to chronic pCO2 retention from COPD
You can check the HCO3-, if elevated you’re OK
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SOB: Diagnostic Plan
Extras
• After the CXR, EKG, and ABG– you still
may not know
• For example:
- Is the pulmonary edema cardiogenic or
non-cardiogenic?
- Is it a PE?
• Consider other diagnostic tools, such as
ECHO, V/Q scan, or CT angiogram
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SOB: Treatment
•
Diagnosis Determines Treatment
1. Supportive Care- know code status
-hypoxemia- give O2, Keep Sat >92%
-Ventilatory failure- BIPAP, intubation/
ventilator, narcan
-Airway protection- Intubation
2. Treat underlying cause
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SOB: Treat Underlying Cause
• Pulmonary edema- may need ECHO or SWAN to
distinguish. These have different treatments and different
prognoses.
– Cardiogenic- Diurese, if pt. not in Sinus rhythmconvert or slow to nl rate
• Ask yourself, why she decompensated
• If pt. on Mg++--Turn off the Mg++, give Ca gluconcate
• ?MI, arrythmia, fluid overload, valvular lesion, peripartum
cardiomyopathy
– Non-Cardiogenic- Diuresis may help
• Otherwise known as acute lung injury (ALI) or ARDS–
depending on extent
• Treat underlying cause/Treatment primarily supportive
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SOB: Treat Underlying Cause
• Pneumonia- Supportive care and ABX
• Inpt.- 10- 14 day course of ABX, generally empiric
treatment.
– Community Acquired1. cefotaxime/ cetriaxone/unasyn AND macrolide
(azithro/clarithro/erythro) OR
2. Fluoroquinolones (moxi, gemi, levofloxicin)
– ICU1. beta lactam AND azithro
2. Beta lactam AND fluoroquinolone
3. Aztreonam AND fluoroquinolone
– Aspiration- Zosyn (Clinda OK for outpt. Aspiration)
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SOB: Treat Underlying Cause
• Pneumonia
– Outpt. Community Acquired PNA
– OK, if pt. <65, can take Po’s, has nl O2 sat, has
capability of aquiring and taking ABX, has no comorbid
illness, and is not pregnant
– May be bacterial or viral or mycobacterial!
– For bacterial: Azithro/doxy/fluoroquinolone OR
Amoxicillin/Augmentin AND macrolide— 10-14 day
course
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SOB: Treat Underlying Cause
• Pulmonary Embolism- Think PE until proven
otherwise
– Risk Factors- ALL OF YOUR PTs.—any one who is
pregnant, post-op, or has cancer
– Work up may or may not show large Aa gradient,
right axis / S1Q3T3 on EKG– pregnant women are
especially tricky
– D-dimer ELISA is great for screening (great negative
predictive value)—but will not work in pt.s who are
pregnant, post-op, or who have cancer!!!
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SOB: Treat Underlying Cause
• Think PE until proven otherwise– especially with
a negative CXR
– Anticoagulate immediately if suspicion is high enough
to get a definitive study (pretest probability>30%)
– Lovenox 1mg/kg bid is treatment dose
– Use unfractionated Heparin if worried about bleeding,
if pt. has renal disease, or if pt. very obese
– Do not feel bad for anticoagulating or getting a
definitive study if the scan is negative—you still did
the right thing
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SOB: Treat Underlying Cause
• PE– the definitive study
– CT angio vs. V/Q scan- The better test
depends on the radiologist and the institution
– At Stanford they are equally good
– If the pt. has a Cr>1.5, choose V/Q
– If the pt. has underlying lung parenchymal
disease, choose CT angio
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SOB: Treat Underlying Cause
• Asthma
– Identify triggers and remove them
– Albuterol immediately/add atrovent– if severe, may
need epi
– Long acting β-agonist
– Steroid inhaler
– If severe, systemic steroids—Solumedrol or
Prednisone- most start with 30-60 mg qd and then do a
rapid taper
****NOT all wheezes are “asthma”—wheeze can be
heard with pulmonary edema
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Chest Pain
Differential Diagnosis
• Differential Diagnosis
– Cardiac: Cardiac Ischemia/Pericarditis/Aortic
Dissection
– Pulmonary: Pulmonary Embolism/ Pneumonia/
Pulmonary edema/Pleuritis/Pneumothorax
– Musculoskeletal: Muscle spasm/Costochondritis/
Herpes Zoster
– GI: GERD/gastritis/PUD/Esophageal
spasm/Pancreatitis/Biliary Disease
– Pre-eclampsia
– Anxiety—Diagnosis of exclusion
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Chest Pain: Rote
Diagnostic Plan
• Get vital signs from the nurse
• Order an EKG over the phone—STAT
• Think about a relevant DDx on your way!!
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Chest Pain: Rote
Diagnostic Plan
• Everybody gets an
EKG
And
Usually a CXR
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Chest Pain: Rote
Diagnostic Plan
• When you arrive at the scene
Rule out, Rule in:
– You are basically taking a systematic
approach—
• Is it Deadly?—Call for help.
• Is it Sick or Not Sick?
• Is it Cardiac/Pulmonary/GI/other?
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Chest Pain: Rote
Diagnostic Plan
• Get the EKG, ask for the nurse to obtain an old one
• Obtain vitals at bedside
• Physical Exam
– Is the pt. in distress? Diaphoretic? Tachypneic?
– Is the pt.’s pain pleuritic? Reproducible with external pressure or
limb movement?
– Heart exam- rate, rhythm, JVP
– Lungs- decreased breath sounds? Air movement?
– Abdomen- Acute abdomen?
– Extremities- Symmetric?
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Chest Pain: Rote
Diagnostic Plan
• History- As you are performing the exam,
ask questions which relate to what you are
examining.
• These questions are ROTE and memorized.
They do not have long answers.
• Just interrupt the patient
• If the pt. cannot answer– don’t waste time
here.
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Chest Pain: Rote
Diagnostic Plan
• Heart exam- Pain=Pressure=Discomfort
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–
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Have you ever had anything like this before?
CADRFs
What were you doing when it started?
Does it radiate to the arm, back, or neck?
Is it assoc. with Nausea/ Diaphoresis/
SOB/palpitations?
How long has it been present?
Does it come and go, or is it constant?
Out of 10, how bad is it?
Does it get worse with a deep breath?
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Chest Pain: Rote
Diagnostic Plan
• EKG- Obtain this as soon as possible, keep
asking for it/help obtain it
• You need an old EKG. Just make a rule—ALL
PATIENTS OVER 50 OR WITH HISTORY OF
DIABETES OR CARDIAC DISEASE GET A
BASELINE EKG ON ADMISSION– or you will
be sorry when she develops Chest Pain.
• Strongly consider CXR
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Chest Pain:
Diagnostic Plan
• Use what you have learned in your
evaluation- even if you are still waiting for
studies.
• Identify the organ system involvedCardiac/ Pulmonary/ GI/ Musculoskeletal/
other
• This will help determine treatment
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Chest Pain:
Treatment
• Deadly?—Call for help- more Nurses,
Senior Resident, Medicine, Cardiology, or
Code?
• Sick, Not Sick?-- Determine level of care.
• Organ system?— Hedge your bets, begin
to treat while you are figuring it out.
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Chest Pain:
Treatment
• Diagnosis Determines Treatment
• Treatment Includes:
– Treating Underlying Disease
– Giving analgesics
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Chest Pain:
Treatment
• Think of BAD things first.
• Consider treating these empirically, if they are
low risk interventions.
– Give O2
– Consider ASA– if no contraindications, will decrease
mortality by 23-50%, if unstable angina or true MI-pt.s may chew it.
– Consider Maalox/Nitroglycerin—for diagnosis/
treatment.
– Turn off the Mg++ if it is on.
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Chest Pain:
Cardiac Ischemia
• Treatment– Oxygen
– Morphine for pain
– Nitroglycerin for pain- SL/paste/drip- typically 0.4 mg SL given
q 5 min. X3, then another route should be used—hold for
SBP<100—obtain post pain EKG
– ASA to decrease risk of MI
– Try to decrease myocardial work/increase O2 delivery
– Consider beta blockade (with MI, decreases mortality by 1530%)
– Consider transfusion if Hct<30
– Bring HR and BP to normal range
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Chest Pain:
Cardiac Ischemia
• Call Cards to help decide- +/- Lovenox,
IIb/IIIa inhibitor, Cath lab, or
TPA/thrombolysis– these are EKG
dependent
• “Time is Myocardium!”
• Aortic Dissection is a contraindication to
heparinization, etc.
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Chest Pain:
Pleuritic
• Treat underlying cause- ie. ABX, lasix, chest
tube etc.
• If you suspect PE >30% pre-test probability give
lovenox—rule out aortic dissection first.
• Treat with analgesics
– Narcotics are good for air hunger—but careful if
worried about drive to breathe
– NSAIDs are good for pleurisy—careful if concerned
about bleeding
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Chest Pain:
GI
• GERD/PUD—Maaolx good for acute
discomfort, consider Pepcid, PPI
– May need additional outpatient diagnostic and
treatment follow up
• GI disaster- perforated viscous, ischemic
bowel, pancreatitis—individualize
treatment
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Chest Pain:
Other
• Musculoskeletal- NSAIDs
• Pre-eclampsia- True Abd. Pain implies
severe disease and end organ
complications
• Anxiety- Reassurance, consider Benzo.
– This is a true diagnosis of exclusion
– If panic attacks– pt. may need outpt. diagnosis
and treatment—SSRIs generally used
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Floor Calls
THE END
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