1. Problem Solving in Medicine
Dr Sidrah Lodhi
Assistant Professor
North Medical Unit
King Edward Medical University

2. I CANNOT BREATH. I FEEL LIKE I AM GOING TO DIE!
Case 1
I CANNOT BREATH. I FEEL LIKE I AM GOING TO DIE!

3. Case 1
You are working in the ER when 57-year-old Mr M. is brought in with the complaint:
“Doctor, I cannot breath. I feel like I am going to die!”

4. Questions What additional information do you need from the patient?
What specifically do you want to look for on examination?
Is there anything you would like to advise before going on further?
What are your thoughts about a differential diagnosis as you proceed to the patient?

5. Further Evaluation
He is unable answer any questions because of his extreme shortness of breath.
He is sitting leaning forward, supporting his arms on pillow, looking distressed, pale, sweaty and coughing up pinked tinged frothy sputum.
He also has history of myocardial infarction 6 months ago.

6. Examination
BP 90/70, Pulse 120 reg., RR 28, Temp 98.5 ̊F Oxygen saturation 83%. JV P is elevated 12 cm.
Extremities are cool with thready pulses and without edema.
Chest: Crackles to above the scapula.
Cardiac exam: apex diffuse, laterally and inferiorly displaced, distant heart sounds, S3 gallop.
Abdominal exam is normal.

7. Investigations CBC Biochemistry: ABG pH 7.48 p02 54 pCO234 HCO3 24
Hb 12.2g/dL
Hct 38
WBC X 109/L
DLC: Polys:75% Lymphos: 25%
Plt 245 X 109/L
Biochemistry:
Sodium 135mg/dL
Potassium 3.7 mg/dL
Blood Urea 44 mg/dL
Serum Creatinine 1.4 mg/dL
Blood Glucose 116 mg/dL
ABG pH p pCO234 HCO3 24

8. ECG

9. Chest X-ray

11. Diagnosis
Acute Pulmonary Edema

12. Pulmonary Edema
Pulmonary edema means an excess collection of watery fluid in the lungs. The fluid collects in the many air sacs of the lung, making it difficult to breathe.

16. Pulmonary Edema Treatment: Treat the Symptoms
oxygen, medicines to remove the excess fluid from the lungs (diuretics) and other medicines to help the heart work more effectively.
Treat the precipating factors (hypertension, ischemia, arrhythmia, infection, etc)
Treat the underlying cause

17. Causes Heart Failure Lung Fluid overload Capillary
CARDIAC – Due to increased hydrostatic pressure
NON-CARDIAC – Due to increased capillary permeability
Heart Failure
Coronary artery disease
Cardiomyopathy
Valvular disease
Fluid overload
Lung
Smoke inhalation
Near – drowning
Aspiration
ARDS
Capillary
Sepsis
DIC

18. Take Home Message

19. Take Home Message

21. Case 2

22. Case 2
A 32 year old gentleman has presented in the OPD with the following:
“Doctor, I can’t breath properly and I have this pain on breathing!”

23. Questions What additional information do you need from the patient?
What specifically do you want to look for on examination?

24. Further Evaluation Patient has travelled from Australia 3 days back
He was in his office working at his computer when all of a sudden, he had pain in upper part of his chest and he felt that he has difficulty in breathing since then.
He is a smoker but otherwise healthy.

25. Examination BP 120/80, Pulse 120, RR 22, Temperature 98.6 ̊
Oxygen saturation 93% on room air
Chest: Pain in upper part of chest on deep breathing
Cardiac exam: Normal
Abdominal exam is normal.

26. WHAT IS GOING ON? WHAT TO DO NEXT?

27. Investigations
Routine blood work
Arterial blood gases

28. ECG

29. Chest X-Ray

30. Our Thoughts

31. Targeted Testing
D-Dimers
V-Q Scan
CTPA (CT pulmonary angiogram)

32. VQ Scan

33. CTPA- Normal

34. CTPA - Patient

35. Diagnosis
Pulmonary Embolism

36. Treatment Oxygen 100%. Obtain IV access, monitor closely
Pain relief (eg, morphine).
Assess circulation: suspect massive PE if systolic BP is <90 mm Hg
Anticoagulation – No further clots
Unfractionated heparin
Low-molecular-weight heparin
Factor Xa inhibitors
Fondaparinux
Warfarin

37. Treatment Clot removal stategies – Medical – Thrombolysis
Surgical – embolectomy , IVC filters

38. Where Did The Clot Come From?

39. How TO Prevent The Clot? Adequate rest before flight
Wear loose clothing
Good hydration
Avoid alcohol
Get out of your seat and walk every hour
Avoid crossing your legs
In-seat exercises – every 10 min
Lift your toes
Lift your heels
Make toe circles
Slide feet back & forth

40. How TO Prevent The Clot?

41. Why Are We Talking About This?

42. Further Thoughts Lots of people travel…
Why did this particular gentleman have a clot?

43. Risk Factor For Pulmonary Embolism