ED training Respiratory/ patient with dyspnea Part 2 Dr Jaycen Cruickshank September 2012

Respiratory - dyspnea Learning objectives The 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… Emergency Department HMO education series 2012

What is the differential diagnosis? Most likely PE Pneumonia Less likely Pneumothorax Arrhythmia AMI Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 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 Pulmonary embolism is the most likely diagnosis – sudden onset, no cause found yet Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 What can you see? Pulmonary embolism Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 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 Emergency Department HMO education series 2012

Differential diagnosis Chronic obstructive pulmonary disease (COPD) with acute infective exacerbation CCF with acute exacerbation Anaemia Less likely Neuromuscular conditions Anxiety Emergency Department HMO education series 2012

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 Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 CXR Hyperinflated chest in keeping with COPD Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 Diagnosis Infective exacerbation of COPD with acute respiratory failure Treatment Bronchodilators, controlled oxygen, corticosteroids, antibiotics, Non Invasive Ventilation (NIV) Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 What if this was the CXR? Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 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 Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 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 These are essentially a group of physical signs consistent with cardiac failure. You would also look for mitral regurgitation, and also tricuspid regurgitation if you wanted to look for right heart failure ( murmur louder in inspiration, in tricuspid area, pulsatile liver, cannon waves on JVP, tender liver, swelling of ankles, ascites) Emergency Department HMO education series 2012

ECG – what is your diagnosis? Rapid Atrial Fibrillation

Emergency Department HMO education series 2012 Cardiac failure Pacemaker Enlarged heart Bilateral pleural effusions Upper lobe vessels Alveolar opacity in the bases Emergency Department HMO education series 2012

Emergency Department HMO education series 2012 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 Emergency Department HMO education series 2012

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) Emergency Department HMO education series 2012

Image gallery – e.g radiology First slide with image /question

Image gallery – e.g radiology First slide with image /question Large right sided pneumothorax

Image gallery – e.g radiology First slide with image /question Moderate sized left pneumothorax

Image gallery – e.g radiology First slide with image /question

Image gallery – e.g radiology First 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 jaycenc@bhs.org.au Part 3 of this talk goes on to discuss these cases…

Emergency Department HMO education series 2012 Excellent website http://lifeinthefastlane.com/2009/11/a-classic-respiratory-case/ Emergency Department HMO education series 2012