October 27 Shortness of Breath in the ER - CAPA - … · Overview •Different Cases of Shortness...

Shortness of Breath in the ER

October 27th,2017

Stéphane Léveillé CD

Physician Assistant ER & OR

Kirkland & District Hospital

• Disclosure • I attest that my presentation will provide a balanced view of

therapeutic options and will be entirely free of promotional bias.

• that neither I nor my spouse has a current financial relationship with the grantor and/or any commercial interest(s) that may have a direct interest in the subject matter of the CPD program.

Overview • Different Cases of Shortness of Breath seen in

the Emergency

• Shortness of Breath 1. Determine the severity of the Shortness of breath,

2. Distinguish the source (Cause) of the shortness of breath,

3. Understand the evidence for various treatments for acute

shortness of breath,

4. Don’t judge a books by it’s cover

• Elderlies are more fragile

• Not because they are young means they are healthy.

Overview

Case Study 03 March

78 year old female, Healthy,

Triage: Presents to the Emergency department with the primary complaint of cough X 3 weeks, clear mucous expectorant, increase Shortness of Breath with exertion, not sleeping well, sore back from coughing. Tried Benelyn syrup yesterday with no relief.

Past Medical History:

• Hypothyroidism

Allergies:

• Sulfa

• Surgical Tape

Vitals: Blood pressure 181/103, Pulse 91, Temperature 35.3, Respiratory Rate 20

Oxygen saturation 95% room air

Repeat vitals: BP 161/86, P 80, O2 sat 96% room air

Case Study

Assessment: 78 year old female, cough X 3 weeks, began with chest cold and head aches, mild fever – resolved, light cough present, had sinus congestion – resolved, ribs sore with cough, denies Chest pain.

Exam: Well, Blood pressure up slightly,

No respiratory distress

chest good – no wheezing, no crackles, congested

Cardio Vascular System – Normal, no murmurs

Plan: Biaxin 500mg BID X 7 days, Return if not resolving

Discharge Diagnosis: Upper Respiratory Infection (URI)

Case Study Returned 28 March

78 year old female, seen in ER March 3rd

Triage: Complaining of Short of Breath for a few weeks but today feeling much

worse, was on antibiotic for chest infection, finished on March 10th, was

Prescribed a new puffer last week but not helping.


• Hypothyroidism

Allergies:

• Sulfa

• Surgical Tape

Vitals: BP 191/116, P 138, T35.8, RR 30, O2 sat 94%

Case Study Assessment: 78 year old female presented to Emergency Department with a main complaint of Shortness of Breath for the past few weeks but has been getting some back discomfort since yesterday. This morning when she was walking out to the vehicle she had some increase shortness of breath and decide to come to the Emergency Department. The patient was put on antibiotic March 3rd and had taken all of the antibiotics. Also, the patient is on a puffer but states that it does not appear to be helping her at this time.


• Hypothyroidism

• HTN

Past Surgical History:

• 2014 -Uterine Prolapse, Cystocele

• 2014 -Vaginal Hysterectomy

• 2001 - Left Mastectomy (Carcinoma)

• 2000 - Left Breast biopsy (no malignancy)

Family History:

• Father died of lung cancer

• Brother died of Leukemia

Social History: Live at home with husband

Retire Secretary

Non smoker

Alcohol – Has a glass of wine at supper with her meal

Exam: Ear, nose and throat – Normal

Heart – Irregular heart rhythm, no murmurs heard

Respiratory – good air entry left lung field

- decrease air entry right lung field

- No wheezing or crackles heard

No pitting edema lower limbs

Investigation: Chest Xray

Blood work: CBC, Lytes, BUN, Cr, BS, Trop, LFT’s, INR, PTT, Ca++,

Mg+, Phosphate

Electrocardiogram

Electrocardiogram

Chest X-Ray

Laboratory Investigations

Hematology

WBC 8.8 RBC 4.62 Hgb 140 Plt Count 348

Chemistry

Na 129 K+ 4.5 Cl 95 Urea 5.9

GFR 89 Cr 57 Glu 7.1 Ca+ 2.26

Phos 1.22 Mg+ 0.75 GGT 118 AST 37

ALT 43 Alk Phos 144 Trop 0.01

Coagulation

INR 1.1 aPTT 28

WHAT’S NEXT

What is next:

1. New onset Atrial Fibrillation

2. Pleural effusion right lung

3. Blood work is Normal with mild elevation in the liver function test

GGT 118 Alk Phos 144

Plan:

Intravenous

Catheter

Medication: Metoprolol 5mg IV

Furosemide 20mg IV

Investigation: Computed Tomography (CT) Scan of chest

Admit to Hospital

C.T Scan

Look at the CT Scan here…….

Chest Tube

Lateral view

Admission to Hospital

Put on Beta blocker (Bisoprolol),

Levonox.

Current medication: Coversyl, Synthroid

Transferred to Sudbury to see Specialist 5 April

Thoracic surgeon - Repeat CT: Chest, Abdomen and Pelvic

- Bronchoscope

- Thoracoscope

- Biopsy

Oncology consult - Metastatic Adenocarcinoma (Ovarian)

Conclusion Case Study

78 year old female

Metastatic Adenocarcinoma (Ovarian)

Treatment : Palliative systemic treatment with Chemo therapy.

Any

Question

Case Study #2 9 June

43 year old Male, otherwise Healthy,

Triage: Presents to the Emergency department with the primary complaint of Shortness of breath for the past weeks, no expectorant, increase Shortness of Breath with exertion, not sleeping well. Recently had surgery, right hip replacement on June 6th, post motorcycle accident.

Past Medical History: Healthy

Age 4, Broke right Femur, Tibia and Fibula

Past Surgical History: 2013 Right Hip replacement

1998 Right shoulder – labrum tear, AC tear

1997 Left Knee - Meniscal tear

1994 Right elbow – Bursectomy

Family History: Father decease age 41 – Mining accident

Case Study #2 Social History: Married 20 years

3 children at home

Smoker 1PK/Day 30 years

Alcohol – Occasion

Drugs - None

Medication : Xeralto post operation and Tylenol #3, PRN

Allergies: Penicillin



Case Study #2

Assessment: 43 year old male, complaint increase shortness of breath and chest pain. Describes it as a squeezing pain in the center of the chest. It is non-radiant, not associated with sweating but breathlessness. Denies fever, chills. Pain lasting for hours.


Heart – regular heart rhythm, no murmurs heard

Respiratory – good air entry bilat




Blood work: CBC, Lytes, BUN, Cr, BS, Trop,, INR,D-Dimer

Chest X-Ray

Laboratory

WBC 7.3 RBC 3.43 Hgb 101

Plt Count 147 Na 138 K+ 3.6

Cl 100 Urea 4.5 Cr 78 EGFR 94 Glu 7.8 CK 987

Trop 0.01 INR 1.4 D-Dimer 987

Case Study #2

Diagnosed: SOB NYD

Plan - Discharged home

- Felt unwell for about a week and then the symptoms improved

IS THIS IT…………….NOT

Case Study #2 28 July

43 year old Male, otherwise Healthy,

Triage: Presents to the Emergency department with the primary complaint of Shortness of breath, increase shortness of breath on exertion. not sleeping well. Denies fever, chills or cough

Past Medical History: Healthy

Age 4, Broke right Femur, Tibia and Fibula

Past Surgical History: 2013 Right Hip replacement

1998 Right shoulder – labrum tear, AC tear

1997 Left Knee - Meniscal tear

1994 Right elbow – Bursectomy

Family History: Father decease age 41 – Mining accident

uncle on mother’s side with Cardiomegaly Unknown

Grand Mother (mother’s side) sudden death, Cardio infact.

Case Study #2

Social History: Married 20 years

3 children at home

Smoker 1PK/Day 30 years

Alcohol – Occasion

Drugs - None

Medication : Xeralto post operation and Tylenol #3, PRN

Allergies: Penicillin



Case Study #2

Assessment: 43 year old male, complaint increase shortness of breath and shortness of breath on exertion. Describes it as a squeezing in the center of the chest. It is non-radiant, not associated with sweating but breathlessness. Denies fever, chills.


Heart – regular heart rhythm, no murmurs

heard

Respiratory – good air entry bilat




Blood work: CBC, Lytes, BUN, Cr, BS,

Trop,, INR,D-Dimer

Chest X-Ray

Laboratory

Every test was normal, with the exception of the D-Dimer which was 2160

WHAT NEXT ….

Computed Tomography Scan (CT) Pulmonary Angio

Report: revealed no definite evidence for a pulmonary embolus. There was mediastinal adenopathy. Uncertain significance. No evidence of pleural effusion, pneumothorax or pneumonia..

Cardiac Echo

Report: Left ventricle enlargement 72mm and left atrium 54mm

Ejection fraction 28

Specialist Internal Medicine Consult

- Shortness of breath most likely to a viral cardiomyopathy.

- Start medication 40mg Furosemide, Digoxin 3.125 and slow K 2 tabs od.

- Urgent referral to Cardiologist Mount Sinai Toronto.

Cardiologist Consult

- Admit to Intensive Care Unit (1 week).

- Testing during admission

- Muga Heart scan (multiple-gated acquisition) Nuclear imaging : EF 24%

- MRI (Magnetic Resonance Imaging) : Negative, nil acute

- Angiogram : Negative

- All blood work : Negative

Specialist Diagnosis of Congestive Heart Failure – Most likely due to virus

Cardiologist treatment

Furosemide 180mg IV daily

Bisoprolol 5mg po daily

Digoxin 0.625 mg po daily

Spironolactone 25mg po daily

Coversyl 8mg po daily

Discharged from Hospital

ICD – Implantable Cardioverter Defibrillator

Furosemide 120mg po daily

Bisoprolol 5mg po Bid

Digoxin 0.625 mg po daily

Spironolactone 25mg po daily

Coversyl 8mg po daily

Conclusion Case Study

Patient is 5 years post insertion of ICD

- Check-up - Having unsustain V.T (no shock)

- Mild SOBOE

- EF 22%

- Continues with daily activities

- Cardiologist - Genetic testing done +

- Family members tested

- Son has the Gene

- Sister and her 2 daughters have Gene

- At risk for sudden death…

Conclusion

1. Not all shortness of breath are simple as a common cold

2. Always expect the worst in Shortness of breath

3. Don’t treat the age, treat the condition and acuteness

4. Symptoms can be sneaky, be careful, not because they are SOB mean that they have a lung issue, it can also be cardiac.

Questions &

Discussion

October 27 Shortness of Breath in the ER - CAPA - … · Overview •Different Cases of Shortness...

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