1. Floor Calls Bonnie K. Dwyer, MD Maternal Fetal Medicine
Palo Alto Medical Foundation
4/20/2017

2. Introduction Words of Wisdom
All of the answers lie in the
Differential Diagnosis
4/20/2017

3. Topics General Principles Fever- Intra Partum, Post Partum, General
Low Urine Output
Shortness of Breath
Chest Pain
4/20/2017

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.
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5. General Principles RUN vs. WALK Run for any unstable vital sign
Go immediately for SOB /Chest Pain/Altered Mental Status
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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
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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
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8. Fever
The definition and management of fever is different depending on the setting
Intra-partum
Post-Partum
General
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9. Fever: Intrapartum Definition- Temperature ≥ 38 Differential diagnosis
Chorioamnionitis
Exertional temperature elevation = “dehydration”
“Anesthesia related fever” = “dehydration”
Previously existing disease
4/20/2017

10. 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)
4/20/2017

11. 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.
4/20/2017

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
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13. 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
4/20/2017

14. 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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15. Fever: Post Partum Diagnostic Plan
Physical Exam
+/- U/A, Ucx
+/- CBC
+/- Blood cultures X2
+/- CXR
+/- stool culture
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16. 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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17. 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 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!!)
4/20/2017

18. 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!
4/20/2017

19. 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!!!!
4/20/2017

20. 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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21. Fever: General Rote Physical Exam Blood culture X2 U/A, Ucx +/- CXR
+/- stool cultures, ie C.diff
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22. Fever: General Different World!
Definition- Temperature >38.5 (101.5)
Differential Diagnosis
Infection
Drug
Thrombus- DVT-upper or lower extremity/PE
Atelectasis
Cancer
Inflammatory disease/Vasculitis/Other
4/20/2017

23. Fever: General Diagnostic 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
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24. 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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25. 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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26. 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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27. Low Urine Output Your goal is not to make
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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28. Low Urine Output Definition
Less than 0.5cc/kg/hr (30-40cc/hr in a typical woman)
Oliguria cc/day
Anuria- Less than 50cc/day
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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
Chronic renal failure—on HD or PD– obviously also causes low urine output, but this is not your overnight dilemma
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30. 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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31. 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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32. 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
4/20/2017

33. 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
4/20/2017

34. 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
If this is new in the hospital, it is probably something you did!!! Look to see what is new.
4/20/2017

35. Low Urine Output Treatment
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.
I will explain what supportive care means—BP control, volume control, electrolyte control, toxin control
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36. 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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37. 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
4/20/2017

38. Shortness of Breath Differential Diagnosis: LOW O2 SAT Normal O2 SAT
Hypoxemia
Normal O2 SAT
Airway obstruction
Irritation of the pleura/lung parenchyma
Metabolic- Acidosis, Sepsis
Cardiac Ischemia equivalent
Anemia
Anxiety
4/20/2017

39. Shortness of Breath Differential Diagnosis
Hypoxemia
Pulmonary edema- cardiogenic, non-cardiogenic
Pneumonia
Pulmonary embolism
Atelectasis
Pleural Effusion
Pneumothorax
Large Airway Obstruction
Reactive Airway Disease/ COPD
Restrictive Pulmonary Disease
4/20/2017

40. SOB: Diagnostic Plan Rote
Current Vital signs, including a
ROOM AIR SAT
Evaluate the patient immediately
4/20/2017

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?
4/20/2017

42. 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
4/20/2017

43. 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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44. 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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45. 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
4/20/2017

46. 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
4/20/2017

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
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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
4/20/2017

49. SOB: Treat Underlying Cause
Pneumonia- Supportive care and ABX
Inpt 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)
4/20/2017

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— day course
4/20/2017

51. 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!!!
4/20/2017

52. 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
4/20/2017

53. 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
4/20/2017

54. 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 mg qd and then do a rapid taper
****NOT all wheezes are “asthma”—wheeze can be heard with pulmonary edema
4/20/2017

55. Chest Pain 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
4/20/2017

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!!
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57. Chest Pain: Rote Diagnostic Plan
Everybody gets an
EKG
And
Usually a CXR
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58. 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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59. 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?
4/20/2017

60. 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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61. Chest Pain: Rote Diagnostic Plan
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?
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62. 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
4/20/2017

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
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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.
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65. Chest Pain: Treatment Diagnosis Determines Treatment
Treatment Includes:
Treating Underlying Disease
Giving analgesics
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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.
4/20/2017

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
4/20/2017

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.
4/20/2017

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
4/20/2017

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
4/20/2017

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
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72. Floor Calls
THE END
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73. 4/20/2017