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OSCE Acute > Approach to Acute SOB > Flashcards

Approach to Acute SOB Flashcards

1
Q

Life threatening differentials

A
  1. PE
  2. Pneumothorax
  3. Asthma / COPD
  4. Pneumonia
  5. Acute LVF
  6. ACS
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2
Q

Focussed hx

A

Explore

  • When did it start?
  • How did it come on?
  • Exercise tolerance - current vs normal
  • Orthopnoea, PND

Systems review

  • general - fever
  • chest - chest pain, wheeze, cough, sputum, leg swelling

PMH

  • Happened before
  • Other medical conditions
  • Asthma / COPD - baseline and severity (home nebs/O2), exacerbation hx and how mx, normal peak flow
  • recent surgery

DH + Allergies - incl inhaler compliance

SH - smoking, alcohol, long-haul travel

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3
Q

Focussed exam

A 
Tracheal deviation and JVP 
Inspect chest
Expansion, apex, heaves
Percuss
Auscultate heart and lungs 
Legs - swelling, tender, oedema 
Peak flow if asthmatic
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4
Q

Investigations

A

Bloods

  • FBC, U&E, CRP
  • D-dimer (if Wells score low)
  • BNP
  • Blood cultures
  • ABG

Orifice
- sputum culture

X-ray / imaging

  • CXR
  • CTPA

ECG

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5
Q

Pulmonary embolism

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • pleuritic chest pain
  • haemoptysis and SOB
  • RF - long haul flight, surgery, immobility

Exam

  • Tachycardia, raised JVP, RV heave
  • Tachypnoea, clear chest / pleural rub
  • Calves - DVT
  • Massive PE - SBP<90, pulseless, persistent bradycardia

Ix findings

  • D-dimer raised - if Wells score low
  • CTPA (diagnostic)
  • ECG - tachy, RV strain (t wave inversion in right chest and inferior leads), RBBB, RAD, S1Q3T3 (rare)
  • ABG - hypoxaemia and hypocapnia
  • CXR - may show wedge opacity, effusion

Mx

  • treatment-dose anticoagulation
  • thrombolysis if massive PE
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6
Q

Pneumonia

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • fever
  • SOB
  • Productive cough
  • Pleuritic chest pain
  • Confusion

Exam

  • Tachypnoea, cyanosis
  • Coarse creps, bronchial breathing
  • dullness to percussion
  • increased vocal resonance

Ix

  • CXR (diagnostic) - consolidation, air bronchogram
  • Raised CRP
  • Cause - sputum and blood culture, mycoplasma serology, urinary pneumococcal and legionella antigens

Mx

  • O2
  • Abx
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7
Q

Pneumothorax

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • Sudden onset pleuritic chest pain
  • SOB if large enough
  • RF - Marfans, COPD/asthma

Exam

  • Reduced chest expansion
  • Absent breath sounds
  • Hyperresonance
  • Tension - tracheal deviation, hypotension, raised JVP, resp distress

Ix
- CXR (diagnostic) - air in pleural space

Primary Mx

  • <2cm - CXR monitoring
  • > 2cm or Sx - aspirate

Secondary

  • <1cm - observe for 24 hours + high flow oxygen
  • 1-2cm - aspirate
  • 2cm - chest drain
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8
Q

Asthma exacerbation

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx
- SOB, wheeze, known asthmatic

Exam

  • Tachypnoea, wheeze, use of accessory muscles
  • reduced air entry and PEFR

Ix - clinical dx

  • CXR - exclude infection and pneumothorax
  • ABG - usually normal PaO2 and low PaCO2 (hyperventilation) - severe if hypoxia and hypercapnic
  • Blood and sputum cultures if ?infection

Mx

  • salbutamol and ipratropium nebs
  • steroids
  • magnesium IV
  • abx if infection
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9
Q

COPD exacerbation

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx
- SOB, wheeze, change in sputum, known COPD/lifelong smoker

Exam
- tachypnoea, reduced air entry, wheeze, accessory muscles

Ix

  • CXR (exclude infection and pneumothorax)
  • ABG (hypoxaemia and hypercapnia)

Mx

  • salbutamol and ipratropium nebs
  • steroids
  • abx
  • BiPAP if required
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10
Q

Other resp differentials

A 
Extrinsic allergic alveolitis
Laryngitis
Bronchitis
Pneumonitis
Bronchiectasis
LRTI 
Pleural effusion
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11
Q

ACS

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • crushing central chest pain
  • radiates to left arm or neck
  • nausea, SOB, sweaty
  • CVD RF

Exam

  • sweaty, SOB, pain
  • signs of HF, Brady or tachy

Ix

  • ECG - ST elevation, new LBBB, inverted T waves, Q waves
  • Troponin - increased (normal in UAP)
  • CXR - normal / signs of heart failure
  • Coronary angiography

Mx - MONA

  • Morphine
  • Oxygen
  • Nitrates
  • Anti-platelets
  • PCI
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12
Q

Acute LVF

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • SOB, orthopnoea, PND
  • pink frothy sputum
  • peripheral oedema
  • cardiac hx

Exam

  • tachycardia, tachypnoea
  • raised JVP
  • fine bibasal creps
  • S3
  • peripheral oedema

Ix

  • CXR (A-E)
  • ECHO (diagnostic)
  • BNP
  • ECG - look for MI

Mx - POD MAN

  • Position sitting up
  • Oxygen
  • Diuretics
  • Morphine
  • Antiemetic
  • Nitrate infusion
  • CPAP if required
  • treat cause
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13
Q

Other cardiac differentials

A 
Cardiomyopathy 
Myocarditis 
Acute valvular disease
Pericardial effusion 
Pulmonary hypertension
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14
Q

Hyperventilation of anxiety

  • hx
  • exam findings
  • ix findings
  • mx
A

Hx

  • tight chest pain, SOB, sweating, dizzy, palpitations, feeling of impending doom
  • anxious personality / other sx of GAD
  • recurrent episodes triggered by stimulus

Exam
- usually normal, hyperventilation

Ix - diagnosis of exclusion

  • ECG and troponin - exclude MI
  • D-dimer - exclude PE
  • CXR - exclude infection
  • ABG - resp alkalosis

Mx

  • reassurance
  • CBT
  • SSRI
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15
Q

Other differentials

A 
DKA
Overdose
Metabolic acidosis 
Sepsis
Foreign body 
Anaphylaxis 
Anaemia
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OSCE Acute (21 decks)

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