# 內科值班04

## Sepsis 敗血症
### 定義：**感染** + **Organ Dysfunction** **(SOFA≥2)**, not SIRS now

重點：內科急症，如果懷疑，盡早使用廣效抗生素

前言：當一個病人(1)發燒 或(2)有既存感染+臨床(vital signs, UOP, GCS)有變化，都要評估有無sepsis的可能性

### **懷疑sepsis先算qSOFA (≥兩項):**
1. 意識 GCS<15
2. 血壓 SBP≤100
3. 呼吸 RR≥22

### **如果qSOFA≥兩項，進入Hour-1 Bundle流程**

**1. 抽血:**
* CBC/DC, BCS, ABG(?), **Lactate, 兩套B/C**, U/A, U/C, S/C, CXR

**2. 廣效抗生素(一小時內給，依腎功能調整劑量):**
* 本院首選tazocin，已經在用的話升階meropenem
* 懷疑MRSA感染再加Vancomycin or teicoplanin (腎功能差選teico，前三天都不用腎調)
* 感染科會診單可暫存，先把醫囑開出去，病歷後面再慢慢打

**3. 點滴(血壓掉 或 lactate>4):**
* 先給N/S 500ml (病房有可以直接給)，再給L/R (優於N/S)
* 總量30ml/kg in 3hr，但如果給到要喘起來還是問一下二線比較好 (eg. 年紀大或有HF)
* Vital signs不穩的話要放Foley，記I/O，Hold 血壓藥

**4. 醫囑(抽血、抗生素、點滴)先開完，接下來好好survey，找infection focus**
* Hx (Underlying dz, Associated s/s) + PE (from head to toe) + Lab (eg. 之前的Culture, CXR)
* Sourse control (跟二線或原主治討論), eg. 切CT排除IAI, APN+水腎放 PCN, calculous cholecystitis 做 ERCP, abscess 做 aspiration 或 drainage...

**5. 升壓劑 (1st line: levophed)**: **通知二線，狀況不穩定且需要下ICU**
* 使用時機: 輸液無法維持MAP≥65 (CRT>2s, UOP<0.5ml/kg/hr, AMS 也要懷疑shock)
* 確認DNR status，有沒有拒升壓藥

[Duty note]

I was called for ___. 
___-year-old ___ with underlying ___, admitted for ___.
The patient developed ___ at ___, accompanied by ___, ___

Vital Signs:
GCS:
PE: 
UOP:
Lab:
Previous culture and abx:
CXR:

# Fever/Hypotension/Dyspnea with qSOFA(___/3), 
favor sepsis with response to fluid resuscitation/
impending septic shock refractory to fluid resuscitation, 
septic workup showed ___,  
infection focus: peumonia, UTI, IAI, catheter-related infection, soft tissue infection...
- empirical ___ was administered, pending for culture and ID consultation
- fluid resuscitation to keep MAP≥65, transfer to ICU if unstable hemodynamic status / 
  for refracotry to keep MAP≥65 after fluid resuscitation, transfer to ICU for unstable hemodynamic status
- consider sourse control with___
- DNR status:___

**施老大:** 值班懷疑sepsis，抽完血抗生素早點上，水給夠，剩下的交給大人處理

**SOFA (影響重要器官)** 用計算機算，但在ICU比病房實用
1. **心** BP (MAP or 升壓劑使用)
1. **肺** PaO2/FiO2
1. **腦** GCS
1. **肝** T-bili
1. **腎** Cr and UOP
1. **血** PLT

### **Septic shock**
**定義:** sepsis + 需vessopressor維持MAP≥65 + Serum lactate >2 mmol/L

## Pneumonia
**定義:**
* Pneumonia: s/s (fever, cough, purulent sputum, dyspnea) + new infiltrate on CXR/CT
* CAP (醫院外感染)/ HAP (住院後≥48hr)/ VAP (插管後≥48hr)
* Lung empyema: pus 積在 pleural space
* Lung abscess: 肺實質壞死 + cavitation
* Aspiration pneumonitis: 吸入胃內容物後的急性肺損傷，細菌感染可在24-72hr後發生

**Hx:** Fever, cough, purulent sputum, dyspnea, aspiration, TOCC(住院/安養機構), COVID (確診/疫苗)
**PE:** Vital signs, SpO2, chest exam, extra-pulmonary signs?

**Lab:**
* **必做:**
CBC/DC, BCS (±lactate), 兩套B/C (before abx!), ±ABG
CXR (PA+LAT)
Sputum culture (Gram stain & Aerobic, Legionella/S. Pneumo urine Ag, ±AFB ± Mycobact.)
* **考慮:**
COVID PCR, Influenza Ag
Pneumonia panel? (high risk of aspiration, refractory to tx?)
Chest CT (懷疑細菌性肺炎以外的診斷, eg. fungal/viral/chemical/PE/CHF/ARDS/DAH/ILD, 懷疑ILD要做HRCT)
BAL (懷疑VAP或Atypical pneumonia)
PCT (<0.25可停abx, 免疫不全跟CKD不適用, 偽陽: CPR, shock, burns, surgery)

**Severity (qSOFA, CURB65, PSI)**
* CURB-65: confusion, BUN>20, RR>30, BP<90/60, Age>65 (>2: admit, >3: ICU)
* PSI(按計算機): age, sex, 住機構, 共病, vital signs, AMS, lab (pH, BUN, Na, Glu, Hct, PaO2, pleural effusion)

**Management**
* Sepsis → Early Abx ; Cover pathogen accordingly
* **CAP (5-7d) → IV Augmentin + 3d of Oral Azithromycin** ± Vanco if MRSA carrier
(Tazocin + azithromycin if recent Hx of PsA肺炎, 住院, iv abx)
* **HAP (7d) → Tazocin + 3d of Azithromycin** ± Vanco if MRSA carrier
* If severe → Tazocin + Ciproxin/Levofloxicin/Amikacin + Vanco
* Consider PJP/Flu/Fungus/Autoimmune/Tumor/Treat-relate?

## Urinary tract infection
* Voiding U/C >10^5
* Upper or lower; complicated or uncomplicated?
* 排除其他疾病 (pyuria ≠ UTI): eg. Appen? Psoas abscess?

**Dx**
* Hx: LUTs?, fever, rigors, malaise, back pain, GI s/s (if APN)
* PE: Vitals, CV angle knocking, DRE if man
* Labs: CBC,B/C,UA,U/C, ± Echo: hydronephrosis? Stone? BPH?
* WBC太低的病人不會有pyuria，U/C 記得直接留
* CT A/P: severely illness, obstruction, persisted sx after 48-72hr of appropriate abx

**Management**
- Hydration
- 如果有Foley，拔掉或重放
- 沒症狀的話只有孕婦、腎移植跟做泌尿科procedure前要治療 (狀況差或意識不清除外)
- 經驗性抗生素 (記得留U/C, B/C，記得看之前culture結果，記得腎調)
- 下泌尿道症狀 (simple or uncomplicated): **Cefazolin or cefuroxime**
- 發燒冷顫、後腰痛或男生DRE有壓痛 (upper or complicated): **Ceftriaxone**
- 懷疑院內感染: **Ceftazidime** (+pseudo)
- Critical illness: **Tazocin** (+enterococcus)
- If sepsis + hydronephrosis → consider PCN (跟二線討論)

## Skin and soft tissue infection
* Carbuncle (毛囊), erysipelas (真皮), cellulitis (皮下組織)
* **急症要開刀: Necrotizing fasciitis, Fournier gangrene, Ludwig angina**

**DX:**
- Hx: TOCC, Pain+progress?, sea/river/cat/dog
- PE: skin erythema (with sharp margin in erysipelas, edema, warmth, petechiae, hemorrhage, superficial bullae, crepitant and gangrenous​)
- **懷疑Necrotizing fasciitis**
- **crepitant 捏氣泡紙的聲音/ bullae/ necrosis or ecchymosis**
- **不成比例的劇烈疼痛/ 對疼痛的感覺減弱/ 快速進展/ 低血壓/ systemic illness**
- **懷疑深部感染：**
- erythema without sharp margins 邊緣不清楚
- edema extends beyond the visible erythema 水腫範圍大於紅斑
- 眼肌麻痺 ophthalomoplagia/ 眼球突出protosis/ 眼球運動疼痛
- 牙關緊閉trismus/ 斜頸/ 聲音低沉不清楚 muffled voice
- 流口水/ 唾液積聚/ 喘鳴/ 吞嚥困難/ 吞嚥痛
- Labs: CBC/CRP, pus culture, B/C; lactate, AST, CK (for deep tissue necrosis); PT/aPTT if surgical indicated; CT if fasciitis

**Management**
* **Consider Necrotizing fasciitis!! → Surgical Debridement (叩二線/外科/放射科)**
→ Cefepime/Tazo ± Vancomycin ± clindamycin ± Doxy
* 特殊情況: 懷疑深部感染/臉部危險三角 (叩二線)
* **Erysipelas: cefazolin or ceftriaxone (出院: Amoxicillin or Cephalexin)**
* **Cellulitis: oxacillin or cefazolin (出院: Dicloxacillin or Cephalexin)**
* Consider MRSA if poor response
* 懷疑abscess -> sono抽吸或引流

感染症抗生素使用可參考:
uCentral>> 醫療專區(contents) >> 3. Infectious Diseases Guidelines (感染症診治及用藥指引)
UpToDate

## Acute heart failure
鑑別診斷: 肺栓塞、氣喘發作、肺炎、ARDS、pericardial tamponade

多因呼吸困難或氧合能力不佳而就醫

找原因:
* 飲食不當或服藥依從性不佳 (40%)
* 心肌缺血/梗塞 (10-15%); myocarditis
* 腎衰竭 (↑ preload)
* 高血壓、AS (↑ left-sided afterload)
* 藥物: βB, CCB, NSAIDs, TZDs, anthracyclines, trastuzumab, EtOH
* 心律不整、瓣膜疾病、Aortic dissection
* COPD、PE、Anemia、壓力、感染、甲狀腺亢進/低下

臨床表現:
* Acute dyspnea, orthopnea, tachypnea, tachycardia, and hypertension
* 低血壓反映疾病較嚴重，需要評估周邊組織及重要器官的灌流 (GCS, UOP, CRT)
* PE: JVE, diffuse rales, wheezing (cardiac asthma), S3/S4, pitting edema
* ECG: ACS, Arrythmia, LVH
* CXR: pulmonary edema, cardiomegaly, pneumonia; CXR正常不能排除ADHF
* Lab: CBC/DC, 肝腎, Na/K/Mg/Cl/HCO3-, Cardiac enzymes, NT-proBNP, thyroid function, lactate if suspect shock, D-dimer if unlikely PE (likely PE 要做CTA)
* 心臟超音波

Management:
* 監測血氧、VS、心律
* 給氧 if SpO2 <90%, 坐直
* Furosemide 40 mg IV，血壓高沒有shock可用NTG
* 找上述原因並治療
* Af with RVR: 藥物降HR, new onset 考慮 Cardioversion (ACLS)
* 已知HF
* HFrEF (LVEF<40%) 合併 cardiogenic shock: 停用長期使用的βB，上強心劑
* HFpEF (LVEF≧50%) 合併 cardiogenic shock: βB + IV fluid + 升壓劑 + 心超 (排除 acute AR/MR)
* LVEF未知但合併cardiogenic shock: 強心劑 +/- 升壓劑 + 心超

HFrEF四支柱: ACEi/ARB/ARNi + βB + MRA + SGLT2i

## COPD AE
特徵: Diffuse wheezing, 桶狀胸, tachypnea, tachycardia, 吸菸 >20 pack years
嚴重: 用呼吸輔助肌、講話零碎/片段、無法躺平、冒汗/躁動、蹺蹺板呼吸、初始治療未能改善。
合併/加重: ACS, ADHF, PE, pneumonia, pneumothorax, sepsis

Hx, PE and Labs
* Infection(sputum↑)? Chest pain? Vital signs, wheezes;
* CBC,BCS,CRP,ABG(CO2); CXR, ± CTPA if PE suspected, influenza?

Management
* Primary ABC，血氧目標: SpO2: 88-92% or PaO2: 60-70 mmHg
* 評估需不需要插管 (嚴重度及病家意願)，要插或看起來快插->叩二線
* A (Atrovent) + B (Ventolin) INHL Q4HPRN
* Methylprednisolone 60-125 mg IV, Q6H-Q12H，記得驗血糖
* BIPAP if CO2 retention (禁忌: AMS、無法保護airway、high aspiration risk)
* Intubate if AMS, with RSI (eg, etomidate, ketamine, or propofol)
* Abx: Ceftriaxone 2g QD or Tazocin 4.5gm Q6H if cover Peudo

## DVT & PE
### Risk factors
* Virchow’s triad
* Stasis: 臥床少活動, CHF, 三個月內中風過, 坐飛機超過六小時
* 血管內皮受損: trauma, surgery, prior DVT/PE, central line
* Thrombophilia: genetic disorders, 避孕藥, HRT
* Malignancy
* 肥胖、抽菸、急性感染、產後

### DVT
* 小腿或患肢有紅/腫/熱/痛
* Homan’s sign (dorsiflexion 更痛)
### PE
* 喘 (50%), 肋膜性胸痛 (40%), 咳嗽 (20%), 咳血 (10%)
* ↑ RR (>70%), crackles (50%), ↑ HR (30%)
* fever, cyanosis, pleural friction rub, loud P2
* Massive: syncope, HoTN, ↑JVP
* ECG: sinus tachycardia, S1Q3T3 (<10%)
* CXR: 正常 (12%), 肺塌陷, 肋膜積液, Hampton hump (wedge-shaped, pleural-based opacification), Westermark sign (栓塞處distal端的肺紋變少/radiolucency)
* Lab: ABG (hypoxemia, ↑ A-a gradient), D-dimer, ±TnI ±NT-proBNP
* 心超: RV strain, D-shape LV

### **Approach to suspected DVT (Simplified Wells Pretest Probability Scoring of DVT)**


### **Approach to suspected PE (Modified Wells Pretest Probability Scoring for PE)**


### Management
* 穩定 vital signs (O2, IV, vessopressor)
* 不穩定: 轉ICU 打tPA
* 穩定: heparin/LMWH/DOAC/warfarin
* IVC filter if contraindicated to anticoagulants
* Refractory → Catheter(EKOS為導管超音波震波溶栓) or surgical thrombectomy

## Clostridium difficile infection
* Risk factors: 之前抗生素使用, 高強度化療, PPI, GI surgery, HSCT, etc.
* 特徵: ≥3 unformed stools in 24 hours, 連續兩天 (排除ileus)
* 診斷:
* Stool CDI toxin PCR
* 大便未成形才要驗, 太水流不到檢體可用rectal swab
* PCR (+) toxin (-) 不一定要治療
* CBC/DC and BCS if no data, B/C if fever
* CT if megacolon/unstable
* 治療 (依嚴重程度):
* Non-severe (WBC <15K and SCr <1.5 or Cr 上升 <50%)
* Metronidazole 500mg PO/IV TID
* Severe (WBC ≥15K or SCr ≥1.5 or Cr 上升 ≥50%)
* Vancomycin 125mg PO QID
* Fulminant colitis (HoTN, ileus, toxic megacolon, perforation, need colectomuy or ICU)
* Vancomycin 500mg PO/NG/Rectal/colostomy QID + Metronidazole 500mg IV Q8H + surgical consultation

## Acute pancreatitis
Enzymes → autodigestion; Lipase↑ ± Imaging, 排除其他
3rd space fluid; ARDS, hemorrhage, infected pseudocyst

Hx, PE and Labs
* Abd pain(worse when lying), gallstone/alcohol/Drugs?
* SIRS, abd PE; CBC+ B/C(if fever) + Lipase/BUN, CXR ± CT

Management
* BISAP score for prognosis
* NPO + fluid resuscitation +early feeds ; follow up BUN
* ERCP for gallstone pancreatitis (in 24 hours)
* ABx if signs of infection/shock