How to Work up the Acute Patient. Polling Instructions. CAPA Conference What can I do?
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1 How to Work up the Acute Patient By Joe Gilboy PA-C 1984 Duke University PA Program 1985 ER Residency program USC/LAC Polling Instructions To Use the CAPA Events App: Open the CAPA App, go to Agenda and find this session. Click on the session and go to the tab for Polls. Answer each polling question when instructed. For Text Polling from Your Phone: You will be provided the Question ID on upcoming poll slides. Text the Question ID to and you will be given the opportunity to provide your answer. 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 1
2 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 2
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 3
4 Vital Signs: Temp=99.8 Pulse=95 Resp=18 BP=135/90 Physical Exam: Tenderness RUQ no rebound No CVA tenderness 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 4
5 WBC=22,000 10% Bands Electrolytes=WNL Lipase=1200 UA=WNL Ultrasound: thicken gallbladder wall positive Murphy s sign on ultrasound Q1: What s your diagnosis? 1. Biliary Stone 2. Hepatitis 3. Peptic Ulcer Disease 4. Cholecystitis Take the poll in the CAPA App or text to What would you like to treat it with? IV Rocephin IV Vancomycin IV Zosyn IV Flagyl 5
6 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 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 6
7 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 Q2: What would you like to do? 1. Discharge Home 2. Admit for stress test 3. Send to pulmonologist 4. Send home with Xanax Take the poll in the CAPA App or text to Treadmill test positive at 3 minutes CP in lest than 1 minute taken to cath lab 90% occlusion of right coronary artery 7
8 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 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 8
9 What would you like to order??? EKG CBC CMP Troponin I INR MRI (Never ever accept dizziness in the elderly) 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 9
10 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 What would you like to do? IV fluids EKG monitor CBC CMP UA Type and Cross for PRBCs???? 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 10
11 Q3: Diagnosis 1. Ruptured ectopic pregnancy 2. Fibroids 3. Ruptured Hemorrhagic Ovarian Cyst 4. Retained products Take the poll in the CAPA App or text to Now what?? Transfuse with blood IV fluids 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 11
12 What would you like to do? IV pain meds for headache Zofran for nausea Clonidine or hydralazine for HTN CBC What would you like to order? 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 12
13 Q4: 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 Take the poll in the CAPA App or text to Case #6 65yo female with diarrhea x 2 days Positive for fever and chills h/o HTN, DM, CAD No recent antibiotics or foreign travel Temp=38.1 Pulse=89 BP=135/96 Pulse oxy=98% Physical exam: tenderness in the suprapubic area What would you like to order?? CBC CMP UA Stool for cultures, WBCs and O&P Need to r/o infectious forms of diarrhea (shigella, salmonella, C. Diff, etc.) Need to r/o colitis or possible abdominal abscess if tenderness is present 13
14 Q5: Which imaging would you like to order? 1. Abdominal ultrasound 2. HIDA Scan 3. KUB 4. Abdominal pelvic CT scan Take the poll in the CAPA App or text to Results WBC=22k 15% Bands CMP= WNL UA= WNL CT Scan=Acute Sigmoid Diverticulitis IV Levaquin and Flagyl and admission 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 14
15 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?? Q6: Anything else you would like to order?? 1. CBC 2. CMP 3. Mono Spot 4. UA Take the poll in the CAPA App or text to 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 15
16 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 Q7: Which of the following labs would you order? 1. EKG 2. Troponin I 3. D-Dimer 4. All are correct Take the poll in the CAPA App or text to Results CBC=WNL CMP=WNL EKG=NSR at 90 Troponin I=WNL CXR=WNL D-Dimer=2.1 16
17 Radiology Results CTA Chest Right upper lobe pulmonary embolism IV heparin and admission 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 17
18 Q8: What would you like to do next? 1. EKG and troponin I 2. CBC and CMP 3. UA and pregnancy test 4. Nothing Take the poll in the CAPA App or text to 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 18
19 19
20 We are hunting for Zebras not Horses 20
21 This is where the next picture was shot from in space from the Voyager 1 February 14, 1990 This speck is home Think about it 21
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