How to Work up the Acute Patient By Joe Gilboy PA-C 1984 Duke University PA Program 1985 ER Residency program USC/LAC

Transcription

1 How to Work up the Acute Patient By Joe Gilboy PA-C 1984 Duke University PA Program 1985 ER Residency program USC/LAC What can I do? Look at the vital signs Fix what you can in front of you Low oxygen=apply oxygen Bleeding=direct pressure Low Blood pressure= Fluid bolus High fever= Tylenol or Motrin Nobody knows what really going on in the beginning we need to hunt Make sure to put out the smoke then we can look for the fire Give everybody the benefit of a doubt Assume nothing We are hunters we love data

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3 We are hunting for Zebras not Horses Case #1 35yo female with acute upper abdominal for 3 days which is getting worse. Patient has vomiting and a low grade temperature. Past medical history positive for high cholesterol currently on no medications Vital Signs: Temp=99.8 Pulse=95 Resp=18 BP=135/90 Physical Exam: Tenderness RUQ no rebound No CVA tenderness

4 What would you like to do? IV Normal Saline IV Dilaudid for pain IV Zofran for nausea Morphine would be a possible bad medication to use because if this problem has to do with with gallbladder it may cause an increase in pain What would you like to order? CBC CMP Lipase Abdominal Ultrasound Urinalysis and HCG Need to r/o gallstones, pancreatitis WBC=22,000 10% Bands Electrolytes=WNL Lipase=1200 UA=WNL Ultrasound: thicken gallbladder wall positive Murphy s sign on ultrasound

5 What s your diagnosis? 1. Biliary Stone 2. Hepatitis 3. Peptic Ulcer Disease 4. Cholecystitis What would you like to treat it with? 1. IV Rocephin 2. IV Vancomycin 3. IV Zosyn 4. IV Flagyl Case #2 52yo male with chest pain and SOB x 2 days Pulse oxy=98% HR=85 BP 180/100 Temp=98.9 h/o HTN, smoking and type 2 DM Physical Exam= WNL

6 What would you like to do? EKG monitor IV access Nasal Oxygen EKG What labs would you like to order?? Troponin I CXR CBC, CMP, BNP Need to r/o cardiac involvement and possible pneumonia Need to consider D-Dimer to r/o PE this may also get you in trouble Lab results: EKG=NSR rate of 85 CBC=WNL CMP=WNL Troponin I <.04 BNP=85 D-Dimer= 0.35 CXR= normal CXR Currently patient is asymptomatic

7 What would you like to do? 1. Discharge Home 2. Admit for stress test 3. Send to pulmonologist 4. Send home with Xanax Treadmill test positive at 3 minutes CP in lest than 1 minute taken to cath lab 90% occlusion of right coronary artery Cath Lab for stent Case #3 84yo male with h/o dizziness off and on for 3 days -SOB -CP h/o HTN and DM h/o atrial fibrillation BP 160/100 Pulse oxy=98% Pulse=95 to 100 Current meds: Coumadin, atenolol, metformin, Antivert

8 What would you like to do? Monitor heart rate Pulse Oxy Oxygen IV fluids We could give something for the dizziness (Antivert, Ativan, Benadryl) Physical Exam: Essentially normal Eyes: no lateral or vertical nystagmus Neuro Exam: AxOx4 Motor 4/5 Right=left Sensory 4/5 right=left Gait: small amount of instability is noted What would you like to order??? EKG CBC CMP Troponin I INR MRI (Never ever accept dizziness in the elderly)

9 Lab Results EKG= Atrial fib at CBC= WNL CMP= WNL Troponin I= >0.4 INR= 2.5 MRI= Small lacunar infract Admit to neuro unit outside the tpa window Case #4 37yo female with vaginal bleeding x 2 weeks feeling lightheaded and weak. Patient passed out at home this am No medical problems G1 P1 No BCPs Vital Signs BP 90/60 Temp=37.1 Pulse=125 Pulse Oxy=97% Unable to get orthostatic BPs Exam: Pale appearing female Pale lower inner eyelids Patient is in too much discomfort to get pelvic exam

10 What would you like to do? IV fluids EKG monitor CBC CMP UA Type and Cross for PRBCs???? Dopamine Drip (to increase BP) Beta HCG Pelvic Ultrasound Lab results Hct=18.1 Hgb=6.0 Plt 125K UCG=negative Pelvic Ultrasound=large amount of clots in the uterus along with a large mount of dense pelvic free fluid Diagnosis 1. Ruptured ectopic pregnancy 2. Fibroids 3. Ruptured Hemorrhagic Ovarian Cyst 4. Retained products

11 Now what?? Transfuse with blood IV fluids and dopamine OB-GYN consult ASAP Final outcome: ruptured ovarian hemorrhagic cyst that was removed and ovarian vessels were tied off Case #5 43yo female with an acute headache x 3 days with nausea and vomiting BP 190/105 HR=105 Temp=98.6 Exam: WNL No other medical problems Patient tried Advil at home with no relief What would you like to do? IV pain meds for headache Zofran for nausea Clonidine or hydralazine for HTN

12 What would you like to order? CBC CMP CT Scan of brain Need to r/o other causes for headache other HTN Results WBC=9k Hct=37.1 Hgb=12.9 Plt=270K CMP=WNL Creatine=1.1 GFR=55 CT Scan= negative What next?? 1. Chest CT Scan hour creatine clearance 3. Renal Ultrasound 4. Send home Decrease flow to both kidneys Final outcome= renal artery stenosis

13 Case #6 65yo female with abdominal pain x 2 days Positive for fever and chills and diarhea h/o HTN, DM, CAD No recent antibiotics or foreign travel Temp=39.7 Pulse=135 BP=135/96 Pulse oxy=98% Physical exam: tenderness in the suprapubic area What would you like to order?? CBC CMP UA Lactic Acid Blood Cultures Stool cultures Need to r/o colitis or possible abdominal infection or abscess if tenderness is present Which imaging would you like to order? 1. Abdominal ultrasound 2. HIDA Scan 3. KUB 4. Abdominal pelvic CT scan

14 Results WBC=29k 35% Bands Lactic Acid=3.0 CMP= WNL UA= WNL Stools=normal CT Scan=Acute Sigmoid Diverticulitis with abscess and perforation IV Levaquin and Flagyl and admission on sepsis protocol Case #7 7yo female patient with h/o asthma comes in c/o SOB and wheezing F/C x 2 days Currently on albuterol Temp=38.7 Pulse=113 Pulse Oxy=93% Exam= Inspiratory and expiratory wheezes What would you like to give and what would you like to order?? Albuterol nebulizing treatment Need to order CXR to r/o pneumonia as a cause of her fever Can we give steroids??

15 Anything else you would like to order?? 1. CBC 2. CMP 3. Mono Spot 4. UA Results CXR= no pneumonia UA= WBC>100phf Bacteria=moderate Nitrite=positive Treatment: Bactrim can consider shot of Rocephin before discharge Always remember urine in any child with a fever Case #8 37yo female comes in c/o right upper back pain for 2 days no h/o trauma and it hurts to take a deep breath. Recently got over a URI Positive smoking history Current meds: BCPs Vitals: Pulse=95 Temp=37.1 BP=145/90 Pulse Oxy=95% Physical Exam: WNL

16 Which of the following labs would you order? 1. EKG 2. Troponin I 3. D-Dimer 4. All are correct Results CBC=WNL CMP=WNL EKG=NSR at 90 Troponin I=WNL CXR=WNL D-Dimer=2.1 Radiology Results CTA Chest Right upper lobe pulmonary embolism IV heparin and admission

17 Case #9 54yo female brought in by paramedics from the courthouse where she just found out her son is going to jail for life for murder. Patient c/o SOB and numbness in hands and feet with carpal-pedal spasm noted. Past medical history=negative Current medication=nothing Vital signs: BP=135/80 Temp=37.1 Pulse=115 Pulse oxy=98% What would you like to do? IV fluids Ativan 1mg IVP What would you like to do next? 1. EKG and troponin I 2. CBC and CMP 3. UA and pregnancy test 4. Nothing

18 Results EKG=slight ST elevation inferior leads rate=115 Troponin I= 2.1 CBC WBC=12K Hct=38.1 Hgb=12.3 Plt=320K CMP=WNL DX Acute Coronary Syndrome IV Lopressor IV Lisinopril Cath Lab Broken Heart Syndrome Case #10 75yo male currently on Coumadin for atrial fibrillation comes in c/o blood in stools for 2 days now with dizziness and SOB Vitals: BP=90/60 Pulse=145 Resp=26 Temp=37.6 Pulse Oxy=91%

19 What would you like to do?? IV fluids=ringers lactate (to expand volume) Dopamine Drip (to elevate BP) Nasal oxygen (to help increase oxygen saturation) Transfuse PRBCs (O-) Vitamin K (reverse Coumadin) Lab work CBC, CMP, PT/PTT, INR, type and cross Hct=19 Hgb=6.3 Plt=150K INR=3.0 Creatine=4.0 GFR=30 Imaging Ultrasound Abdominal/Pelvic CT Scan CTA of the abdomen Tagged RBC Scan Final Dx: diverticular bleed

20 We are hunting for Zebras not Horses

21 This is where the next picture was shot from in space from the Voyager 1 February 14, 1990

22 This speck is home Think about it