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Floor Calls

Floor Calls. Bonnie K. Dwyer, MD Maternal Fetal Medicine Palo Alto Medical Foundation. Introduction Words of Wisdom. All of the answers lie in the Differential Diagnosis. Topics. General Principles Fever- Intra Partum, Post Partum, General Low Urine Output Shortness of Breath

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Floor Calls

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  1. Floor Calls Bonnie K. Dwyer, MD Maternal Fetal Medicine Palo Alto Medical Foundation

  2. IntroductionWords of Wisdom All of the answers lie in the Differential Diagnosis

  3. Topics • General Principles • Fever- Intra Partum, Post Partum, General • Low Urine Output • Shortness of Breath • Chest Pain

  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.

  5. General Principles • RUN vs. WALK • Run for any unstable vital sign • Go immediately for SOB /Chest Pain/Altered Mental Status

  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

  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

  8. Fever The definition and management of fever is different depending on the setting Intra-partum Post-Partum General

  9. Fever: Intrapartum • Definition- Temperature ≥ 38 • Differential diagnosis • Chorioamnionitis • Exertional temperature elevation = “dehydration” • “Anesthesia related fever” = “dehydration” • Previously existing disease

  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)

  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.

  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

  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

  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

  15. Fever: Post PartumDiagnostic Plan • Physical Exam • +/- U/A, Ucx • +/- CBC • +/- Blood cultures X2 • +/- CXR • +/- stool culture

  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

  17. Fever: Post PartumTreatment • 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!!)

  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!

  19. Fever: Post PartumTreatment • 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!!!!

  20. Fever: Post PartumTreatment • 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

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

  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

  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

  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

  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.

  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

  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

  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

  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

  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

  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

  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

  33. Low Urine OutputTreatment • “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

  34. Low Urine OutputTreatment • 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

  35. Low Urine OutputTreatment • 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.

  36. Low Urine OutputTreatment 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

  37. Low Urine OutputTreatment • 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

  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

  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

  40. SOB: Diagnostic PlanRote • Current Vital signs, including a ROOM AIR SAT • Evaluate the patient immediately

  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?

  42. SOB: Diagnostic PlanRote • 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

  43. SOB: Diagnostic PlanRote • 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

  44. SOB: Diagnostic PlanRote • EKG • Rate • Rhythm • Evidence of ischemia • Evidence of cardiac strain- via hypertrophy and axis • Evidence of PE

  45. SOB: Diagnostic PlanRote 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

  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

  47. SOB: Treatment • Diagnosis Determines Treatment • Supportive Care- know code status -hypoxemia- give O2, Keep Sat >92% -Ventilatory failure- BIPAP, intubation/ ventilator, narcan -Airway protection- Intubation 2. Treat underlying cause

  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

  49. SOB: Treat Underlying Cause • Pneumonia- Supportive care and ABX • Inpt.- 10- 14 day course of ABX, generally empiric treatment. • Community Acquired- • cefotaxime/ cetriaxone/unasyn AND macrolide (azithro/clarithro/erythro) OR • Fluoroquinolones (moxi, gemi, levofloxicin) • ICU- • beta lactam AND azithro • Beta lactam AND fluoroquinolone • Aztreonam AND fluoroquinolone • Aspiration- Zosyn (Clinda OK for outpt. Aspiration)

  50. 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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