Hypoxia and Dyspnea

1. Hypoxia and Dyspnea Intern Bootcamp Lecture Series Anne Huml July 15th and July 17th, 2008

3. Differential Diagnosis-context is inpatient with shortness of breath or change in pulse ox. Pulmonary Pathology Pulmonary edema Pneumonia COPD/Asthma OSA Pulmonary embolism Pneumothorax Plueral effusion Etc, etc�. Extra-pulmonary Insult CNS (hemorrhage, ischemia, drugs, tumor) Cardiac (MI, arrythmia, HF, pericardial process) Abdominal (ascites, hernia) Hematologic (anemia, sickle cell disease) Renal (acidemia) Psychiatric (anxiety)

4. Determining the Cause Before entering the patient�s floor/room While at the bedside Diagnostic tools/interpretation

5. The Signout What is the patient admitted for? What are the co-morbidities? Pertinent medications? Pertinent lab values?

6. At the Bedside Review flow sheet-ask the RN/assistant for stat vital signs Review recently given medications Take a very focused history Examine the patient Provide immediate supportive measures

7. Diagnostic Interventions Think back to the differential: PULMONARY VS. EXTRAPULMONARY CXR? is it the lungs? ECG? is it the heart? ABG? what is the imbalance? LABS?r/o other causes.

8. The Next Step Intensification of oxygen delivery Medications-IV, PO, inhaled Intervention Further imaging Transfer Call for reinforcement F/U important studies Documentation

9. Case #1 75 yo male with history of a fib, CAD with ICM and OA presented to UH with a 1 day h/o hematemesis. He underwent EGD on arrival to UH which revealed a peptic ulcer with a clot. His H/H was 7 and 23 respectively and the Cherniak team had ordered 2 units of PRBC to be infused during the evening. At 11 pm, the RN on Lk 50 pages to report that the patients pulse ox is 89% on 2L NC. On review of the RECS information, you note that the patient�s EF on a TTE done 1 year ago is 40%. His coumadin and ibuprofen are on hold as well as the remainder of his home PO regimen as he is NPO. He is receiving IV PPI as well as IVF and the plan is to check serial h/h after transfusion and advance the diet if his HCT stabilizes and there is no further evidence for bleeding.

10. On arrival at the bedside VS stat: afeb, HR 99, R 23, BP 155/90 (baseline was 130/80) and he is 89% on 2L�which responded to increased of 35% VM at 92% Exam: pt. using some intercostal muscles for respiration, diffuse crackles bilaterally.

11. CXR

12. What is your impression? What can you expect to learn from any additional data obtained? What is the next step?

13. Case #2 A 93 yo female with h/o recent CVA resulting in PEG tube placement and chronic foley due to neurogenic bladder presented to the hospital from her NH where she is undergoing rehab with altered mental status. She is on the Carpenter medicine service being treated with IV antibiotics while cultures are pending. Her MS had improved after IVF administered and IV antibiotics commenced. At 9 PM on hospital day #3, you are notified by the RN on Lk 65 that the patient is requiring 6L oxygen by NC to maintain sats at 90% and her temp at 8 PM was 38.5. On your way from T3 to examine the pt, you review her signout. You note that she has just been transitioned to oral bactrim for her UTI and the social worker is planning on d/c in the morning to Judson Park nursing home. She underwent modified barium swallow that morning.

14. On arrival at the bedside, no repeat vital signs are available. You step into the room to exam the patient and note that she is extremely somnolent, difficult to arouse and A&O x2. What do you do next?

15. CXR

16. What is your interpretation? What is the next step?

17. Case #3 A 56 yo female with history of breast cancer is admitted to T6 with newly diagnosed brain mets. She is awaiting surgical intervention for brain lesion by neurosurgery. You are on the Ratnoff team and called by the T6 nurse that the patient�s HR is increased to 122-130 and that her oxygen requirements have increased over the past 4 hours. On review of your signout, you note that her brain surgery is scheduled for 2 days from today. She has been started on high dose steroids and today, she was given PRN ativan for anxiety due to her upcoming surgery. She is also on tamoxifen, SQ heparin and a PPI.

18. As you approach her room, you note that her stat VS are: afeb, HR 129, BP 134/88, R 19. You enter the room and observe a slightly distressed female. Upon questioning, she states that she is anxious about her surgery. Her breathing feels somewhat different than earlier in the day, and it hurts to take a deep breath. She states, �perhaps, I am just anxious�.

19. CXR

20. You increase supplemental oxygen and obtain ABG to confirm hypoxia as well as ECG due to tachycardia. What is your biggest concern? What is the appropriate course of action? What do you anticipate the findings of subsequent studies to be?

21. Case #4 A 77 yo male is admitted to the hospital by a private doctor to the Hellerstein service for work-up of palpitaions/syncope. On hospital day #2, no underlying etiology of his symptoms have surfaced. Since he was admitted on a Friday night, he is awaiting a TTE on Monday morning, then d/c is planned. You are called by the T5 nurse for a HR 130 and a new oxygen requirement of 2L NC.

22. As you approach the room, the patient is undergoing a 12 lead ECG and the telemetry strip is thrown over the chart box at the door. You note that his BP is 110/70, HR 150 and SpO2 on 2L NC is 95%. Pt. states that he is feeling OK, some fluttering in chest. On exam, he is irreg/irreg.

23. ECG

24. CXR

25. What is next step in management? What do you think other studies will show?

26. Case #5 79 yo male with h/o tobacco abuse who has not seen a doctor in over 15 years presented to the hospital with a cellulitis of his LE. He initially had a leukocytosis and was being given morphine for pain control. You are called by the Lk 20 RN that the patient is not arousable. He was visited by his girlfriend approx. 4 hrs ago and at that time, she requested that he have his IV morphine. The nurse went to hang his PM dose of vancomycin and found him to be extremely lethargic.

27. On your way to Lk 20, you furiously shuffle through your pockets for the Wearn signout. You note that the patient is on IV antibiotics, a nicotine patch and newly initiated HCTZ for hypertension. He has an order for PRN albuterol. On arrival, the patient is difficult to arouse, afeb, oxygen sats on RA are 88%, his BP is stable. Lungs with diminished breath sounds bilaterally.

28. Last CXR

29. You obtain an ABG and note that his pCO2 is high and his pO2 is marginal. What is the next step? What are your options for reducing pCO2? Why did his pCO2 climb?

30. References Braunwald, et al. Harrison�s Principles of Internal Medicine. New York, McGraw-Hill, 2001. Dr. Chandrasekhar�s online chest x ray atlas: www.meddean.luc.edu/lumen/MedEd/medicine/pulmonar/cxr/atlas/cxratlas_f.htm - 2k -