Student case #2

[GreatChecko]

I want a BNP too

It was equivocal IIRC

[gbrothers98]

hmmmm.....this certainly is an interesting case!

 

 

Simple bedside blood glucose?

Endocrine tests? (PTH, T3, TSH, T4, cortisol, vitamin D, other endocrine tests?)

 

 

I'm starting to reach here...

CMP is normal which includes her normal glucose.

A point to make here is that in the ED, you can do 2 types of testing. 

One the usual send to the lab, wait for radiology to fit you in type testing.

The other is bedside testing. 

Which you want to do at the bedside while examining the patient and getting a history.

So something like complete vital signs, bedside glucose, EKG, portable CXR, bedside ultrasound. All of that can drive decision making and treatment rather quickly.

As for the endocrine tests, yes, you are reaching.....into the IM clinic where mental masturbation is your purview. But not here in this setting nor with this case.

What are you trying to find with those tests? Does it fit your Ddx? Do you think the testing that has been done now is adequate?

GB PA-C

[gbrothers98]

Are you able to do bedside ultrasound? Haven't read much about its use in dx heart failure, but do know that in the right hands (ie not mine) the heart is able to be well visualized. 

This is an excellent idea and a worthwhile bedside test to pursue. Kudos to you. While you consider your hands not to be the right ones, they can. Bedside ultrasound is not difficult and is like any other technical skill, just got to do it with proper feedback and instruction and you can become competent.

Unfortunately for this case, I did not have either the skills yet (case is several years old) nor the u/s machine. I do now and I would not hesitate to put the probe on this dypneic patient.

Any takers on what I would be looking for if I could ultrasound this patient?

GB PA-C

[gbrothers98]

Going to summarize this case so far:

60 something yr old female.

Usually in good health, no meds, doesnt see a dr, smokes tobacco.

Several days worsening DOE, cant make it across her apt without significant SOB, witness noted cyanosis.

No cp, no cough, no nv, no bleeding or bruising, no blood in stool. Mild dyspnea at rest.

On exam afebrile, tachy, resp rate a bit fast, pulse ox 90% RA.

PE nonfocal other than pale and tachy. Mentating well, not overly uncomfortable sitting on gurney.

EKG sinus tach with st changes.

Labs inc cbc, cmp, trop, bnp, ddimer (no one has still given me their rationale for ordering this), portable CXR all within nl ranges.

ABG slight hypoxia, dont remember the #, sorry.

Anything anyone wants to do for this patient now? Treatment? Any physical exam maneuvers or observations?

GB PA-C

[SERENITY NOW]

interesting case.  seems odd that this came out of nowhere for her.  did anything noteworthy happen to her in the month prior? 

My ddx at this point would be COPD, PE, valvular heart dz, cardiac tamponade, neuromuscular disorder, anxiety. 

 

does she look like a COPDer?  barrel chest?  distant lung sounds?   Could do spirometry if readily available or a peak flow to see if obstructed.  I don't think it would hurt to start some albuterol / duonebs to see if there is any response to that. 

 

I'd ask about any DVT/PE risk factors, but with acute onset dyspnea, tachycardia/pnea, hypoxia, age over 50 and nothing else obvious to explain her sx, I am getting the CT-A. 

 

did her heart sound distant?  neck veins/JVD? how are her distal pulses?  blood pressure while breathing deeply?

you said she had these sx for 5 days before coming in?  hmmm, could have had MI with trops that peaked and left by 5 days.  But no pain/pressure anywhere at anytime?

 

As for the bedside ultrasound... could check for a valvular disease, heart wall motion abnormalities, or the cardiac tamponade that you made sure was on the differential. 

[REMPAC]

Echo.....TR Jet?, IVC collapse?, RV diastolic collapse?

[gbrothers98]

Sorry, can only get an echo at my place on tuesdays, it was not tuesday when I saw her.

 

interesting case.  seems odd that this came out of nowhere for her.  did anything noteworthy happen to her in the month prior? 

My ddx at this point would be COPD, PE, valvular heart dz, cardiac tamponade, neuromuscular disorder, anxiety. 

 

does she look like a COPDer?  barrel chest?  distant lung sounds?   Could do spirometry if readily available or a peak flow to see if obstructed.  I don't think it would hurt to start some albuterol / duonebs to see if there is any response to that. 

 

I'd ask about any DVT/PE risk factors, but with acute onset dyspnea, tachycardia/pnea, hypoxia, age over 50 and nothing else obvious to explain her sx, I am getting the CT-A. 

 

did her heart sound distant?  neck veins/JVD? how are her distal pulses?  blood pressure while breathing deeply?

you said she had these sx for 5 days before coming in?  hmmm, could have had MI with trops that peaked and left by 5 days.  But no pain/pressure anywhere at anytime?

 

As for the bedside ultrasound... could check for a valvular disease, heart wall motion abnormalities, or the cardiac tamponade that you made sure was on the differential. 

I like this thinking.

I did give a neb, didnt do anything. Could have done a peak flow in the department, didnt do it. 

She could have cleared her troponins but that is an imperfect assumption and her ekg showed nothing other than sinus tach. I think if she recently had NSTEMI, she would have some post EKG changes.

 

I wish I had bedside u/s then, would have been interesting to visualize her IVC, her ventricles and also take a look at her deep veins in her legs.

 

You are moving to the CTA and that was the similar thought process I had.

I had posed a question concerning d dimer and pairing it with a thought process.

That should be the Wells criteria. My initial process was that she scored low, only positive was tachycardia. With a neg d dimer, following established guidelines, could determine that she was low risk for PE.

 

The caveat is that you have no alternative diagnosis.

 

One thing that I did in the ED was prove that she got very hypoxic and cyanotic with exertion. Put a pulse ox on her finger and had nursing walk her down the hall from her bed. She dropped her sats to 70% on RA and became profoundly dyspneic. Holy shi&t. We had to put her in a wheelchair to get her back to bed, literally 20 ft away.

That is when I did the CTA of her chest and found her larger bilateral PEs.

 

If you look at the Wells criteria, there is one section, PE is #1 diagnosis or EQUALLY LIKELY. As you rightly pointed out with age, hypoxia, tachycardia and nothing else to explain her symptoms, that despite a neg d dimer, she should get a CTA. That is because when you become moderate risk for PE, you cant rely on d dimer, you have to do imaging.

 

Anyone want to point out lessons learned here?

GB PA-C

[PACdan]

Anyone want to point out lessons learned here?

GB PA-C

 

"When you have eliminated the impossible, whatever remains, however improbable, must be the truth." - Sherlock Holmes

 

​We have been taught recently that with a low Wells' criteria score and a negative D-dimer, you can be very comfortable in ruling out PE/DVT (less than 1% probability).

 

​But, as demonstrated here: There are exceptions to the rule.

[True Anomaly]

Just to also point out that the other major PE decision rule out there, PERC- this patient would've failed it- so can't rule out PE using that either.

[EMEDPA]

Just to also point out that the other major PE decision rule out there, PERC- this patient would've failed it- so can't rule out PE using that either.

I like perc >>>>wells as there are no subjective parts of perc. you can downgrade a high wells score by saying/thinking(at the end of a busy day....) well, it's probably just bronchitis...

PERC would have gotten this pt a chest CT 100% of the time: tachycardia + hypoxia + age>50 = +3.

honestly, since I learned PERC I never use wells. PERC + common sense (long distance travel, hx malignancy, etc) >>>>>wells.

[gbrothers98]

I like perc >>>>wells as there are no subjective parts of perc. you can downgrade a high wells score by saying/thinking(at the end of a busy day....) well, it's probably just bronchitis...

PERC would have gotten this pt a chest CT 100% of the time: tachycardia + hypoxia + age>50 = +3.

honestly, since I learned PERC I never use wells. PERC + common sense (long distance travel, hx malignancy, etc) >>>>>wells.

This is an interesting take on wells and perc. More and more I tend to rely upon gestalt (common sense) and use wells/perc/ddimer to flesh out the rest.

 

I actually attended a lecture Kline, the author of PERC, gave several years ago, soon after he published.

He was very clear that PERC has its limitations. He also repeated several times that PERC was to be used in essentially the low risk population to reduce imaging AND avoid testing because the risk was so low, <1-2%.

He never outlined using PERC to determine whom got imaged though. If a pt didnt PERC, then there needed to be further eval. He did not list that a certain # of positives would lead to imaging. He outlined then that using Wells and d dimer were needed.

He also focused quite a bit on gestalt, which is basically putting together the whole picture and using that to determine if you were going to PERC a patient or not.

He gave a great example of a 40 y/o female with respirophasic CP & dyspnea, pulse ox 96%, pulse 90, recent cross country trip driving for several days. This pt passes PERC. She could still have a PE which is where gestalt comes in to play.

 

I have seen other evaluation schemes that rely on the following:

1. Gestalt -if you hear the story and the first thing you intuitively think of is PE, then image, dont cloud the picture with PERC, Wells, d dimer, et al. Heuristic thinking at it's peak, something those with experience should not discount.

2. Wells score first- if zero or low, 1 or less then use PERC, if PERC zero, then you are done.

3. If Wells score low or zero, but cant pass PERC, get d dimer. If neg d dimer, then done.

4. Otherwise you are imaging.

 

What I invariably see repeatedly is one of 2 things. Get a neg d dimer and use that solely to state risk of PE is low despite Wells being moderate to high, PERC not passing or gestalt still high ie the case I presented.

Next is the abnormal d dimer. If your process of thinking led you to get the d dimer, then that process should still be valid. Sure you can explain away an abnormal d dimer but essentially you are also throwing out your entire rationale in getting it in the first place. 

 

The case that I presented illustrates the serpentine thinking that needs to happen with a more complicate pt where the low hanging fruit doesnt produce an answer. I used wells to determine she was low risk but could not pass PERC. So I got a d dimer which was neg. Could have stopped there. Except you cant blame bronchitis for a pulse ox of 70 and DOE so severe the pt could not walk back to her bed. Working within the limitations of my practice setting, understanding the Ddx and what needs to be done to definitively say a patient is not suffering from a condition, I had to rework my entire thought process to find an answer that truly made sense.

 

GB PA-C

[SERENITY NOW]

Yes I heard the same thing as Gbrothers with regards to PERC.  Gestault first.  Medium or high risk from gestualt get CT.  Low risk use PERC rule to determine if you should get DDimer or not.  Positive d-dimer gets CT scan, negative is ruled out.  But this patient was medium risk at the get go AND didn't have anything else to explain so deserved to get CT in the end. 

 

Great case - thanks for taking time to do it Gbrothers! 

[EMEDPA]

another caveat for d-dimer(have posted this here before). it is only accurate for acute clot. if a pt has had 2 weeks of pleuritic CP from a PE that hasn't killed him yet the d-dimer may have already peaked and returned to baseline. we had a case of a guy with 2 weeks of CP, a neg dimer, 2 neg trops, a neg treadmill, and a CTA+ for 2 giant PEs found 24 hrs after admission to our obs unit.

agree with George and JGStangl that gut feeling trumps any test.  let me revise my prior statement GUT>Perc>wells. I still think the subjective component of wells can lead folks astray, that's why I don't use it. a novice to the process could come up with some differential in their head that they feel is more likely than PE and use that as a reason to not continue pursuing PE. if you have gotten as far as thinking about PE and apply Perc in the right population(folks who don't go straight to scanner due to common sense), you will find the vast majority of PEs.

my d-dimer use has gone way down. I use it mostly for the young woman with pleuritic CP who is on BC who I don't think has a PE by hx and has bc as the only worrisome feature of hx and PE.. bc + tachy  or bc+hypoxia goes to scan without getting a dimer if they don't have any other obvious cause like pneumonia, etc.