ED training Respiratory/ patient with dyspnea Part 2

ED trainingRespiratory/ patient with dyspnea Part 2

Dr Jaycen Cruickshank

September 2012

Respiratory - dyspneaLearning objectivesThe respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the

principles of diagnostic reasoning. lmportant physical findings that help discriminate different causes of dyspnoea will be discussed along with appropriate initial investigations.

Learning objectives Be able to describe the differences and similarities in the medical history, physical examination

and investigations of common or life threatening causes of dyspnoea. To manage asthma and pneumonia using best practice guidelines To be able to use the Wells score & PERC rule in diagnosis of PE

Pre reading Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex,

UK : John Wiley & Sons, 2011. Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis.

Other learning resources Relevant clinical clinical guidelines at Ballarat Health Services:

Refer to ED lecture series and self directed workbooks

Emergency Department HMO education series 2012

Case C Female in her 60’s Sudden onset SOB (present

now for 1 hour, quite severe) Right sided pleuritic chest pain

Mild fever Right total knee

replacement 3 days ago, persistent leg swelling since then

Non smoker No previous

cardio/respiratory disease No injury

In the pre reading cases we had young patients with sudden or gradual onset of dyspnea.

The differential diagnosis is different in older patients.

The differential diagnosis is also different in patients with known respiratory illness, with an exacerbation…


What is the differential diagnosis?

Most likely PE Pneumonia

Less likely Pneumothorax Arrhythmia AMI


On examination & tests

Not too unwell but clear evidence of tachypnoea and some WOB

RR 24, T 37.6, HR 110, BP 110/70

Sats 93% RA Chest clear with normal

percussion and normal breath sounds

Most likely diagnosis?

CXR normal ABG pH 7.5/CO2

30mmHg/p02 62mmHg on RA

What test(s) will you perform


What can you see?


Case D Woman in 60’s

Progressive SOB over 6 months, worse over 24 hours

Chronic cough Usually with white sputum now worse with change in

sputum amount and colour Associated fever

Some orthopnoea Heavy smoker (35 pack

years)

How does this change your thinking compared to the first 3 cases? Age Pre existing diseases Slow onset


Differential diagnosis

Chronic obstructive pulmonary disease (COPD) with acute infective exacerbation

CCF with acute exacerbation

Anaemia

Less likely

Neuromuscular conditions

Anxiety


Exam & investigations… Unwell, RR 26, T 37.8, HR

90 SR, BP 140/80 Sat’s 88% RA Evidence of work of

breathing and use of accessory muscles (which are these?)

Signs of hyperinflation Barrel chest, chest

expansion, hyper-resonant percussion

Prolonged expiration with wheeze

ABG pH 7.28/pCO2 60/pO2 55/HCO3 26

What do these show? Acute Type II respiratory

failure CXR


CXR


Diagnosis

Infective exacerbation of COPD with acute respiratory failure

Treatment Bronchodilators, controlled oxygen,

corticosteroids, antibiotics, Non Invasive Ventilation (NIV)


What if this was the CXR?


Case E Male in 60’s, with progressive SOB over 6 months, worse over 24 hours

Further history Orthopnoea, Paroxysmal

nocturnal dyspnoea (PND), SOA. All present to a minor degree over the 6 months but worse for 24 hours

Palpitations (last 24 hours)

Previous AMI 4 years ago, pace maker

Ex-smoker, Hypertension (HT), diabetes

How does this change your diagnostic reasoning compared to the last case? Quite a few clues point to

cardiac…. Heart Failure Arrhythmia Acute myocardial

infarct/angina COPD Anaemia


Examination

Unwell looking with increased work of breathing RR 26, afeb, HR Irreg 130, BP 100/70 Sat 90% RA JVP 5cm SOA ++ Displaced apex beat, no cardiac murmurs, 3rd heart

sound present Normal chest expansion but stony dull percussion in

the bases (R>L), bilateral inspiratory crepitations just above the dull areas

ECG – what is your diagnosis?


Cardiac failure


Case E Diagnosis

Long standing heart failure with an acute exacerbation due to new onset rapid AF

Treatment of AF, & heart failure Antithrombotic strategy Then rate control Perhaps rhythm control

See review article re AF treatment To be published early 2013 Australian Rural Doctor


What else should I ask?Travel history…

Other important symptoms of respiratory disease

Cough Acute Chronic

Haemoptysis (cancer, TB, other infections) Chest Pain Daytime sleepiness (obstructive sleep apnea)

Image gallery – e.g radiologyFirst slide with image /question

Summary of learning Diagnosis of the breathless patient requires you to

look for clues… The time course of the illness Associated symptoms Known diseases, or risk factors for disease Wells score for PE… in more detail in another talk…

Treatment of illnesses supported by evidence for pneumonia, asthma, PE, AF etc

Interpretation of radiology best done with the clinical picture, so write good notes re clinical context and help the radiologist provide you with a report. Your info + their expertise is a powerful tool.

Further cases

We are looking for clinical cases that can be de identified and used for learning

So, add those cases to your watchlist in BOSSNET, This is a good way to discuss a clinical case with your

supervisor at end of term appraisal, show off your good clinical notes

Write up 3-5 slides re the case history and email them to [email protected]

Part 3 of this talk goes on to discuss these cases…


Excellent website

http://lifeinthefastlane.com/2009/11/a-classic-respiratory-case/

ED training Respiratory/ patient with dyspnea Part 2

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