8/25/20151 Floor Calls Bonnie K. Dwyer, MD Maternal Fetal Medicine Palo Alto Medical Foundation.

04/19/23 1

Floor CallsBonnie K. Dwyer, MD

Maternal Fetal Medicine

Palo Alto Medical Foundation

04/19/23 2

IntroductionWords of Wisdom

All of the answers lie in the

Differential Diagnosis

04/19/23 3

Topics

• General Principles• Fever- Intra Partum, Post Partum, General

• Low Urine Output

• Shortness of Breath

• Chest Pain

04/19/23 4

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.

04/19/23 5

General Principles

• RUN vs. WALK– Run for any unstable vital sign– Go immediately for SOB /Chest Pain/Altered

Mental Status

04/19/23 6

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

04/19/23 7

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

04/19/23 8

Fever

The definition and management of fever is different depending on the setting

Intra-partumPost-Partum

General

04/19/23 9

Fever: Intrapartum

• Definition- Temperature ≥ 38

• Differential diagnosis– Chorioamnionitis– Exertional temperature elevation =

“dehydration”– “Anesthesia related fever” = “dehydration”– Previously existing disease

04/19/23 10

Fever: IntrapartumDiagnostic 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)

04/19/23 11

Fever: IntrapartumTreatment

• 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.

04/19/23 12

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

04/19/23 13

Fever: Post PartumDiagnosis

• 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

04/19/23 14

Fever: Post PartumDiagnosis

• 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

04/19/23 15

Fever: Post PartumDiagnostic Plan

• Physical Exam

• +/- U/A, Ucx

• +/- CBC

• +/- Blood cultures X2

• +/- CXR

• +/- stool culture

04/19/23 16

Fever: Post PartumTreatment

• 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

04/19/23 17


• 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!!)

04/19/23 18

Fever: Post PartumEndometritis

• 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!

04/19/23 19


• 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!!!!

04/19/23 20


• 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

04/19/23 21

Fever: General

• Rote– Physical Exam– Blood culture X2– U/A, Ucx– +/- CXR– +/- stool cultures, ie C.diff

04/19/23 22

Fever: GeneralDifferent World!

• Definition- Temperature >38.5 (101.5)• Differential Diagnosis

– Infection– Drug– Thrombus- DVT-upper or lower extremity/PE– Atelectasis– Cancer– Inflammatory disease/Vasculitis/Other

04/19/23 23

Fever: GeneralDiagnostic Plan

Individualize according to the patient. Think through anatomically:

– 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

04/19/23 24

Fever: GeneralDiagnostic 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

04/19/23 25

Fever: GeneralTreatment Plan

• Diagnosis determines treatment type, dose, and duration.

• Empiric treatment only if patient is septic or in danger of sepsis or life threatening complication.

04/19/23 26

Fever: GeneralTreatment 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

04/19/23 27

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

04/19/23 28

Low Urine OutputDefinition

• 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

04/19/23 29

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

04/19/23 30

Low Urine OutputDiagnostic 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

04/19/23 31

Low Urine OutputDiagnostic 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

04/19/23 32

Low Urine OutputTreatment

• 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

04/19/23 33


• “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

04/19/23 34


• 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

04/19/23 35


• ATN can either be oliguric (no pee) or non-oliguric (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 7-21 days, but may be months. A pt. may need dialysis for this time.

04/19/23 36


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

04/19/23 37


• 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

04/19/23 38

Shortness of Breath

Differential Diagnosis:• LOW O2 SAT

– Hypoxemia

• Normal O2 SAT– Airway obstruction– Irritation of the pleura/lung parenchyma– Metabolic- Acidosis, Sepsis– Cardiac Ischemia equivalent– Anemia– Anxiety

04/19/23 39

Shortness of BreathDifferential Diagnosis

• Hypoxemia• Pulmonary edema- cardiogenic, non-cardiogenic

• Pneumonia

• Pulmonary embolism

• Atelectasis

• Pleural Effusion

• Pneumothorax

• Large Airway Obstruction

• Reactive Airway Disease/ COPD

• Restrictive Pulmonary Disease

04/19/23 40

SOB: Diagnostic PlanRote

• Current Vital signs, including a

ROOM AIR SAT

• Evaluate the patient immediately

04/19/23 41

Diagnostic Rote Plan

• Physical Exam- SICK vs. NOT SICK– Is the pt. in distress? – Diaphoretic? Tachypneic?– Altered Mental Status?– Cardiac exam- Tachycardic? Neck Veins?– Lung exam- Crackles? Wheeze?– Abdomen- Pain?– Extremities- Symmetric? DVT?

04/19/23 42


• 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

04/19/23 43


• 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

04/19/23 44


• EKG– Rate– Rhythm– Evidence of ischemia– Evidence of cardiac strain- via hypertrophy

and axis– Evidence of PE

04/19/23 45

SOB: Diagnostic PlanRoteABG

• 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

04/19/23 46

SOB: Diagnostic PlanExtras

• 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

04/19/23 47

SOB: Treatment

• Diagnosis Determines Treatment1. Supportive Care- know code status

-hypoxemia- give O2, Keep Sat >92%

-Ventilatory failure- BIPAP, intubation/ ventilator, narcan

-Airway protection- Intubation

2. Treat underlying cause

04/19/23 48

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 rhythm- convert

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

04/19/23 49


• Pneumonia- Supportive care and ABX• Inpt.- 10- 14 day course of ABX, generally empiric

treatment. – Community Acquired-

1. cefotaxime/ cetriaxone/unasyn AND macrolide (azithro/clarithro/erythro) OR

2. Fluoroquinolones (moxi, gemi, levofloxicin)– ICU-

1. beta lactam AND azithro 2. Beta lactam AND fluoroquinolone3. Aztreonam AND fluoroquinolone

– Aspiration- Zosyn (Clinda OK for outpt. Aspiration)

04/19/23 50


• 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

04/19/23 51


• 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!!!

04/19/23 52


• 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

04/19/23 53


• 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

04/19/23 54


• 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

04/19/23 55

Chest PainDifferential 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

04/19/23 56

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!!

04/19/23 57

Chest Pain: RoteDiagnostic Plan

• Everybody gets an

EKG

And

Usually a CXR

04/19/23 58


• 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?

04/19/23 59


• 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?

04/19/23 60


• 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.

04/19/23 61


• Heart exam- Pain=Pressure=Discomfort– 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?

04/19/23 62


• 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

04/19/23 63

Chest Pain:Diagnostic Plan

• Use what you have learned in your evaluation- even if you are still waiting for studies.

• Identify the organ system involved- Cardiac/ Pulmonary/ GI/ Musculoskeletal/ other

• This will help determine treatment

04/19/23 64

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.

04/19/23 65

Chest Pain:Treatment

• Diagnosis Determines Treatment

• Treatment Includes:– Treating Underlying Disease– Giving analgesics

04/19/23 66

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.

04/19/23 67

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 15-

30%)– Consider transfusion if Hct<30– Bring HR and BP to normal range

04/19/23 68

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.

04/19/23 69

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

04/19/23 70

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

04/19/23 71

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

04/19/23 72

Floor Calls

THE END

04/19/23 73

8/25/20151 Floor Calls Bonnie K. Dwyer, MD Maternal Fetal Medicine Palo Alto Medical Foundation.

Documents

Transcript of 8/25/20151 Floor Calls Bonnie K. Dwyer, MD Maternal Fetal Medicine Palo Alto Medical Foundation.