Common Acute Presentations - SOB

Question 1

What are the 6 life threatening differentials

What are the other possible differentials

Answer 1

LIFETHREATENING

• PE
• Pneumothorax
• Asthma/COPD exacerbation
• Acute HF
• ACS

Others
Resp - pneumonia
Psych - anxiety related hyperventilation

Question 2

Key questions in focused history

• PC
• Systems review
• PMHx, DHx, allergies
• SHx

Answer 2

PC

• when did it start, speed of onset
• worsening?
• worse on physical exertion
• orthopnea? PND?

Systems

• fever => infection?
• cardioresp - chest pain, cough, wheeze, leg swelling

PMHx, DHx, allergies

• past episodes like this
• other medical conditions - asthma, COPD and management? cancer?
• recent surgery?

SHx

• smoker, alcohol
• recent flights

Question 3

Key parts of the focused examination

Answer 3

HR, RR

Tracheal deviation, JVP
Heaves, thrills
Inspect, palpate, percuss, ausculate chest and heart
Leg edema

Question 4

Key investigations you want to ask for

Answer 4

Bloods

• FBC, U&E, CRP
• DD - exclude PE if Wells score low
• BNP - HF?
• TnT - ACS
• cultures - if infection?
• ABG

Orifice
-Sputum culture

Xray, imaging

• Echo - ACS
• CXR
• CTPA if PE suspected (but do CXR first to rule out other causes)

ECG

Special tests
-Peak flow, spirometry`

Question 5

PE

• core features + risk factors
• exam findings
• investigation findings
• management

Answer 5

Core - pleuritic pain, haemoptysis, SOB
Risk factors - long haul flight, recent surgery/chemo, past DVT

Exam findings

• high HR, pleural rub
• DVT
• low BP, HR, pulseless, => massive PE

Wells score for PE
3 - clinical presentation
3 - most likely differential
1.5 - high HR
1.5 - past DVT, PE
1.5 - immobiliation for 3 days/surgery past month
1 - haemoptysis
1 - malignancy treatment in last 6 months

Initial investigations - DD if Wells score low => +ve
Definitive investigation - CTPA
Others
-ABG - T1RF
-ECG 
-CXR

Management - DOAC
-massive => thrombolysis

Question 6

DVT

• core features + risk factors
• exam findings
• investigation findings
• management

Answer 6

Core features

• unilateral localised throbbing pain, worse on movement
• calf swelling, tender
• skin changes, edema, red, warm
• vein distension

Risk factors - Wells Score 
A -
-alternate veins (superficial collaterals)
B 
-bedridden 3days+ in 1month/big surgery in 3months
C 
-cancer in 6months
D - DVT
-unlikely -2
-past DVT
-deep local vein tender
E - edema
-entire leg swollen
-3cm calf size difference
-edema in leg
F 
-fixity - paralysis, paresis, plaster immobilisation

2+ => leg US within 4hrs
-if not, DD + DOAC until leg US 
U2 => DD results within 4hrs + DOAC
- +ve => treat as WS 2+
- -ve => stop DOAC

Management - DOAC

• 3months if linked to transient risk factor
• 6months if no risk factor found