Pneumonia v PE

[flyingsquirrel]

A friend of mine went to an urgent care center with a two day history of left sided pleuritic chest pain, wheezing,mild SOB, and fever.

 

HR 110

RR 26

BP 104/60

T 102

LS rales bilaterally in the bases, wheezing in the left base

 

She was hoping for a quick pneumonia workup, abx, steroids, and bronchodilators. She ended up being sent to the ED for a PE workup (which was negative).

 

Am I missing something here? She doesn't smoke, doesn't take birth control, and hasn't been immobile (unless you count sitting in class for 10 hours/day). There is nothing in her history or physical that would suggest a PE as a likely diagnosis to me (unless you take the chest pain and HR completley out of context).

[jen0508]

Tachycardia, SOB, and CP all suggest PE. and yea sitting in class 10 hours would be a risk factor, i was taught any immobilization over 4 hours. her fever suggests pneumonia (though people with PE can have low grade fever). pneumonia definitely the most likely cause, but in emergency medicine you always have to rule out the worst. CYA (cover your a**).

[chiaroscuro27]

PE should always be a consideration in patients with complaints like this. It should always be in the back of your head; it's when it's not on your differential that you'll get burned.

 

Also, PE will kill you pretty quick if it's not ruled out, and if it makes your differential it MUST be ruled out. Most UC's don't have the capacity to do this, so my guess is they sent her to the ED for that reason. You're right, she may not have the common risk factors for developing PE, but there may be some family history that you don't know about. And look at the presentation and vitals. I'd be concerned about a PE, too. Thank goodness the workup was negative.

[Just Steve]

Frustrated rant, please skip if not in the mood to deal with student whining...

 

So every chest pain gets a cath, every headache gets a CT... when does it stop? I am just a student so yes, I am blinded by my ignorance but can't hoofbeats really be horses? A student just got smacked with a 4 figure ER bill for something that can be diagnosed based primarily on history alone.

 

Were there E to A changes? Any changes on percussion? There are easily four or five exams that can be done with bare hands and a stethoscope. I am just so utterly frustrated with the CYA mentality that leads to "paralysis by analysis". We all hate the rising cost of health care but we allow it to perpetuate based out of fear of lawsuits. If we can't diagnose pneumonia without a full PE work up then what the hell are we doing calling ourselves providers instead of "referral specialists"?

 

Yes, I know there is a large number of people reading this post will shake their head and say "that boy is gonna get burned" or "he's gonna kill someone someday". And we all know one critical mistake can wipe out YEARS of good health care decisions. To that, I have no response, no reply.

 

I vote with the above patient that if it walks like a duck, quacks like a duck, looks like a duck, call it a duck. Give the patient the appropriate treatment for pneumonia and have her follow up in 48 hours, sooner if symptoms worsen.

 

I'll now get off my soap box and crawl back into my lowly student role. Thank you for your patience.

[cinntsp]

We all hate the rising cost of health care but we allow it to perpetuate based out of fear of lawsuits.

 

The real problem is the ease at which malpractice lawsuits can be brought against providers. Cost the patient an extra $2k or put yourself at great risk for a massive lawsuit or worse. That's a big decision to make. Serious policy change needs to be made to where malpractice suits can only be brought in true cases of malpractice. I get that Mrs. Smith is really upset by the loss of her husband due to an honest mistake, but does that mean the rest of the country should suffer? Medicine(and its practitioners) are not perfect and there needs to be allowance for that.

[chiaroscuro27]

I'm inclined to agree with you, JustSteve. When does it stop? If we claim to care about the rising costs of healthcare in this country, and if PAs are meant to stifle those costs, why are we falling for the same "CYA" bait?

 

The answer, sadly, is medical-legal issues.

 

Think about it...put your trust in egophony and whispered pectoriloquy (which aren't sensitive) and treat empirically, or make the wrong diagnosis, potentially kill a patient, and lose your license and your livelihood. The choice is too easy.

 

I'm weeks into my new job in the ED, and I can't tell you how many times I hear the term "medical-legal" being tossed around. I've seen cardiac workups on frequent flyers, and I've seen drug seekers admitted. Last week, the frequent flyer who always used chest pain to get her fix actually had an acute MI and had to be transferred out to a larger facility. It does happen, and the thought of missing it is scary.

 

I agree, if it walks like a duck and quacks like a duck, it most likely is a duck. However, if the history and physical exam and your intuition are pointing you in another direction, it is worth checking out.

[Just Steve]

It was a rant and I can appreciate doing thorough medicine. There are MANY aspects of the OP's description that are missing from our limited picture. General patient affect for one.. I've been hospitalized for pneumonia...there is no doubt you are sick as a dog and feel wretched. We don't know the patient's O2 saturations, their general color or other components of their story (URI sx? Cough? Chest pain? Family hx? social hx? Their age? I know she is a student but one of my classmates is 56)

 

The sitting in class for 10 hours is a large variant from being bed ridden for 10 hours or being trapped in economy section on a plane. Breaks are given, lunch is taken, healthy, non sedated, non altered people wiggle and move unless otherwise impinged (back to the airliner)

 

However... it's all moot. I am sure she is doing better and we will all find our own ways of practicing medicine based on many factors, our own personal style being just ONE of those factors (others may include your SP's desires, the medical legal world, your nagging mother's voice in your head telling you how her Aunt Sally died from an ingrown toenail...)

 

Thanks for letting me vent.

[rev ronin]

Were there E to A changes? Any changes on percussion? There are easily four or five exams that can be done with bare hands and a stethoscope.

 

Can those tests that rule in pneumonia also rule *out* PE? No? Then spiral CT it is...

 

I agree it costs society more in the long term to do so many tests... but consider a game theoretic approach: the provider has nothing to gain by skipping the test, and much to lose. When it boils down to that, there's no way it's going to change until the risk/reward ratio *for the provider* changes. Alternatively, if a provider can both recommend a workup and then allow a patient to AMA it based on *the patient's* comfort level, that might work... but again, with lawyers involved, how much weight does an AMA refusal actually hold?

[EMEDPA]

a cxr showing an infiltrate and an elevated wbc would havew been enough for me to call this pneumonia. most urgent care ctrs can do this.

[Guest]

Maybe people shouldn't go to ED for stupid stuff like abdominal pain or headache, or even worse "pinky pain" or "not feeling well" when they haven't even tried OTC meds. Everyone who's worked in ED knows how many wasteful tests are done. It's all to rule out EMERGENT stuff. It's called ER for a reason. And yes, providers cover their asses by ordering unnecessary tests, but what do you expect in a country when people can sue you because coffee is too hot? Don't go to ER if you don't want a high bill. Make an appt with a doc or go to urgent care.

[True Anomaly]

As a teaching point, flyingsquirrel, I Have two words: PERC and WELLS. Learn them. Love them.

 

(And yes, I'm familiar with the studies that say PERC may not be all it's cracked up to be)

 

That being said....just because someone was referred to the ED for certain tests doesn't mean we're obligated to do them. The ED should be doing their own assessments and treatments, not just because someone is delivered on a percieved "silver platter"

[Just Steve]

Can those tests that rule in pneumonia also rule *out* PE? No? Then spiral CT it is...

 

I agree it costs society more in the long term to do so many tests... but consider a game theoretic approach: the provider has nothing to gain by skipping the test, and much to lose. When it boils down to that, there's no way it's going to change until the risk/reward ratio *for the provider* changes. Alternatively, if a provider can both recommend a workup and then allow a patient to AMA it based on *the patient's* comfort level, that might work... but again, with lawyers involved, how much weight does an AMA refusal actually hold?

 

Nothing to gain? How about sleeping better at night knowing that a patient wasn't possibly put into dire financial hardships due to the high cost of an unneeded procedure? Or perhaps some small comfort may come knowing that a patient wasn't exposed to an ungodly amount of radiation for no real reason other than a provider doesn't feel comfortable making a diagnosis base without the crutch of the most advanced technology?

 

I get it, we're all scared about "oohhh they may sue us". No one wants to go through that but the horror stories of providers losing their careers are more of urban myth and stories unsubstantiated in fact. We are all super worked up about it but at the same time, we all know that if we educate our patients, do proper follow up care, ARE NICE to our patients, trust in the skills that you have learned as a care provider (small pitch for direct patient care experience BEFORE PA school), you can rest easy knowing you are doing a good job. If you run every possible pneumonia patient through a CT, what does that say about your exam skills? Are we letting machines do the medicine for us?

 

Why didn't that patient get worked up for congestive heart failure? Flash pulmonary edema? Allergic reaction? Liver failure? Renal failure? Or every other anomaly that can cause shortness of breath, tachycardia, with abnormal lung sounds? Where does it stop? Who decides where it gets to stop? At what point do we look at our practice and say "ya know, that was a bit overkill"?

 

But this is just one person's opinion. Thanks EMEDPA for showing there is some basic clinical skills out there still alive.

[Just Steve]

As a teaching point, flyingsquirrel, I Have two words: PERC and WELLS. Learn them. Love them.

 

(And yes, I'm familiar with the studies that say PERC may not be all it's cracked up to be)

 

That being said....just because someone was referred to the ED for certain tests doesn't mean we're obligated to do them. The ED should be doing their own assessments and treatments, not just because someone is delivered on a percieved "silver platter"

 

I just looked up PERC and WELLS...both have the criteria for HR > 100 bpm... if I suspect dehydration is the cause of the increased heart rate and treat them with a 500cc bolus to which they respond with a decrease in HR, can I exclude it from the criteria? In other words, I ran the patient through both of the criterias.. I don't know what her room air saturations were so I fudged and said they were above 94%. Her only outstanding mark was for heart rate. I am wondering if I can fix that within a reasonable amount of time, say perhaps < 60 minutes, can I give her a perfect score of 0? I realize there are some adventitious lung sounds but I am really doubting fluid overload is the cause of them. Even so, 500cc's in a young, active person who has been sick for a couple of days, who walked in under their own power, isn't going to push them over the edge into acute failure.

 

Thanks for the teaching points

[Acebecker]

I have to agree with Emed that an infiltrate and leukocytosis would be enough to call PNA. But we are playing armchair quarterback here - there was something in the H&P that made the clinician think PE strongly enough that he/she couldn't write it off and be done with it. There is a lot to be said for being able to live with yourself based on how you care for your patients, and I don't fault the clinician for wanting to r/o PE. However, have we forgotten about the d-dimer? If your clinical suspicion is low and you order the dimer with it coming out negative, then you can rest easily knowing you have made a good, inexpensive, effort to r/o the scary thing, the life-threatening thing. And, if it comes back positive, then you can go down the road to CTA of the chest. D-dimer is something that, at least in our UC, is a stat lab and done within an hour. Some places, maybe not an option. At any rate, that's my $.02.

 

Andrew

[flyingsquirrel]

I just looked up PERC and WELLS...both have the criteria for HR > 100 bpm... if I suspect dehydration is the cause of the increased heart rate and treat them with a 500cc bolus to which they respond with a decrease in HR, can I exclude it from the criteria?

 

Don't forget about fever as a cause for tachycardia as well. (Room air SpO2 was 97%, no hx DVT or PE.)

 

I'm semi-familiar with PERC and Well's, which was part of my confusion with this case. The only criteria met for PERC was HR, and for Well's there is the HR and "alternative diagnosis is less likely than PE" which is what I thought wouldn't apply. Thanks everyone for the input.

[andersenpa]

Can those tests that rule in pneumonia also rule *out* PE? No? Then spiral CT it is...

 

I agree it costs society more in the long term to do so many tests... but consider a game theoretic approach: the provider has nothing to gain by skipping the test, and much to lose. When it boils down to that, there's no way it's going to change until the risk/reward ratio *for the provider* changes. Alternatively, if a provider can both recommend a workup and then allow a patient to AMA it based on *the patient's* comfort level, that might work... but again, with lawyers involved, how much weight does an AMA refusal actually hold?

 

So.....what happens to the young student who get's their spiral CT....and then develops contrast nephropathy and gets admitted for ARF? Or simply gets an unnecessary radiation exposure?

Another "low probability" event which could happen for a test without a hard indication.

We don't have the patient's chart, but the pretest probability should drive this. Nonspecific factors like tachycardia should not be something to hang a diagnosis on.

 

If anyone has been involved in a medicolegal care review or trial, there are many factors which determine the liability of the clinician. Being familiar with the formal recommendations (eg ACCP) and following them shows the clinician was reasonable, prudent, and within the standard. Paranoid fear of being sued leads to unnecessary expense and patient risk exposure.

 

The provider has MUCH to gain by not ordering a test....or another way of saying it, greater risk to avoid.

[andersenpa]

- there was something in the H&P that made the clinician think PE strongly enough that he/she couldn't write it off and be done with it.

 

Yeah, and that was "this pt might have a PE"......

[bgdog]

d-dimer, baby. thats the ticket. the research is pretty powerful.

 

not so fast nurse MAC, it depends on the pt and it depends on the test.

 

from Up To Date:

 

D-dimer assays for the diagnosis of PE have been extensively studied. They are best characterized as having good sensitivity and negative predictive value, but poor specificity and positive predictive value.

 

Sensitivity — D-dimer levels are abnormal in approximately 95 percent of all patients with PE when measured by ELISA, quantitative rapid ELISA, or semi-quantitative rapid ELISA [32]. This falls to approximately 90 percent when measured by qualitative rapid ELISA or quantitative latex agglutination, 86 percent when measured by semi-quantitative latex agglutination, and 82 percent when measured by erythrocyte agglutination [32]. Among patients who have subsegmental PE, D-dimer levels are abnormal in only 50 percent when measured by quantitative latex agglutination [33].

 

Specificity — D-dimer levels are normal in only 40 to 68 percent of patients without PE, regardless of the assay used [32]. This is a consequence of abnormal D-dimer levels being common among hospitalized patients, especially those with malignancy or recent surgery (table 3) [34-36]. The specificity decreases even further in the setting of severe renal dysfunction (ie, GFR <60 mL/min) [37] and/or increased patient age [38].

 

Negative predictive value — The ability of a normal or negative D-dimer assay to exclude acute PE depends on both the type of D-dimer assay and the clinical pretest probability that a patient has acute PE [39]. The data that follows assumes a pretest probability assessed using the modified Wells criteria (table 4)(calculator 1):

 

 

• Quantitative rapid ELISA – Among patients who have a normal D-dimer level and either a low, moderate, or high pretest probability of having an acute PE, the posttest probability is 0.5 to 2, 5 to 6, or 19 to 28 percent, respectively, when measured by quantitative rapid ELISA [32,40,41].
  
• Semi-quantitative latex agglutination – Among patients who have a normal D-dimer level and either a low, moderate, or high pretest probability of having an acute PE, the posttest probability is 0.7 to 3, 7 to 8, or 24 to 36 percent, respectively, when measured by semi-quantitative latex agglutination [32,40,41].
  
• Erythrocyte agglutination assay – Among patients who have a negative D-dimer level and either a low, moderate, or high pretest probability of having an acute PE, the posttest probability is 1 to 5, 13 to 14, or 45 to 65 percent, respectively, when measured by erythrocyte agglutination [32,40,41]. Similarly, other studies have found acute PE in only about 1 percent of patients with a low pretest probability of acute PE and a negative erythrocyte agglutination assay [42,43].
  

With respect to recurrent PE, a normal D-dimer measured by quantitative rapid ELISA appears to exclude it in patients with prior venous thrombosis or PE [44]. However, few patients with prior events have a normal D-dimer level, limiting the assay's usefulness.

Conclusion — Taken together, the evidence indicates that a D-dimer level <500 ng/mL by quantitative ELISA or semi-quantitative latex agglutination is sufficient to exclude PE in patients with a low or moderate pretest probability of PE. A negative D-dimer by erythrocyte agglutination is only sufficient to exclude PE in patients with a low pretest probability of PE.

[True Anomaly]

I just looked up PERC and WELLS...both have the criteria for HR > 100 bpm... if I suspect dehydration is the cause of the increased heart rate and treat them with a 500cc bolus to which they respond with a decrease in HR, can I exclude it from the criteria? In other words, I ran the patient through both of the criterias.. I don't know what her room air saturations were so I fudged and said they were above 94%. Her only outstanding mark was for heart rate. I am wondering if I can fix that within a reasonable amount of time, say perhaps < 60 minutes, can I give her a perfect score of 0? I realize there are some adventitious lung sounds but I am really doubting fluid overload is the cause of them. Even so, 500cc's in a young, active person who has been sick for a couple of days, who walked in under their own power, isn't going to push them over the edge into acute failure.

 

Thanks for the teaching points

 

I'm not immediately familiar with the specific parameters of the initial PERC study- that if the patient's tachycardia was felt to be more due to dehydration/fluid loss by other means (fever/infection, etc), would they try to correct the tachycardia and then include them in the study, or just exclude them outright- that being said, I would think that clinical judgement alone would be enough to say "Clearly I considered other causes of tachycardia, addressed them, they were corrected- therefore my likelihood of PE diminishes further".

 

Plus....it would help to actually treat their fever with an antipyretic, then see if that alone will correct the tachycardia.

[Guest hubbardtim48]

Good point. Love the nurseMAC also :)

[EMEDPA]

a note on d-dimer: sensitivity decreases with time. we have had cases of folks with b/l PE's(big ones) with 2 weeks of chest pain and nl d-dimers. it peaks and then decreases even if the clot persists...

[True Anomaly]

So.....what happens to the young student who get's their spiral CT....and then develops contrast nephropathy and gets admitted for ARF? Or simply gets an unnecessary radiation exposure?

Another "low probability" event which could happen for a test without a hard indication.

We don't have the patient's chart, but the pretest probability should drive this. Nonspecific factors like tachycardia should not be something to hang a diagnosis on.

 

If anyone has been involved in a medicolegal care review or trial, there are many factors which determine the liability of the clinician. Being familiar with the formal recommendations (eg ACCP) and following them shows the clinician was reasonable, prudent, and within the standard. Paranoid fear of being sued leads to unnecessary expense and patient risk exposure.

 

The provider has MUCH to gain by not ordering a test....or another way of saying it, greater risk to avoid.

 

Thank you....you said it better than I was going to. There is so much stock put into "what if I don't order the right tests and catch everything?" without considering that in some cases, you're better able to be defended legally when you don't order more tests. A perfectly healthy 18 y/o with potentially two obvious sources of tachycardia- fever/infection and fluid loss due to such- no one's gonna bat an eye at your clinical gestalt being "The pretest probability of this patient having a PE is so low that they are essentially NO RISK". Key words being "pretest probability".

 

If you're going to try to cover your *** legally by making someone go somewhere for another workup "Just because they might" even without any solid clinical data to support it, then know that there's the potential for it to bite you in the *** legally as well by ordering a test you should have just left alone.

[True Anomaly]

a note on d-dimer: sensitivity decreases with time. we have had cases of folks with b/l PE's(big ones) with 2 weeks of chest pain and nl d-dimers. it peaks and then decreases even if the clot persists...

 

From what I understand, it's about a week on average.

[Guest hubbardtim48]

That is what I was just taught, 5-7 days. This professor was a med. tech. longer than I have been alive so I believe her when she said she has seen it happen many times. :)

[rev ronin]

The provider has MUCH to gain by not ordering a test....or another way of saying it, greater risk to avoid.

 

No, the *patient* avoids risk by not having an unneeded test run. The provider's risk for being "prudent" and "ordering a gold standard test" is going to be far, far less than the provider's risk for *not* ordering such a test. Don't confuse the patient's best interest with the provider's--they're not the same.