Differential Diagnosis - Acute Chest pain- Respiratory

Question 1

Pulmonary Embolism - Classical History

Answer 1

• Sharp and pleuritic in nature;
• shortness of breath;
• Haemoptysis may occur if pulmonary infarction develops;
• massive PE results in syncope;

1. risk factors:
2. history of immobilisation, orthopaedic procedures,
3. oral contraceptive use,
4. previous PE, hypercoagulable states,
5. or recent travel over long distances;
6. unilateral swollen lower leg that is red and painful suggests DVT;

Question 2

Pulmonary Embolism - Classic History?

Answer 2

• tachycardia,
• loud P2,
• right-sided S4 gallop,
• jugular venous distention,
• fever,
• right ventricular lift;
• massive PE may cause hypotension

Question 3

Pulmonary Embolism - Investigations?

Answer 3

• ECG: sinus tachycardia; presence of S1, Q3, and T3 More
• D-dimer: non-specific if positive; PE excluded if result negative in patients with low probability of having a PE
• CXR: decreased perfusion in a segment of pulmonary vasculature (Westermark sign); presence of pleural effusion
• CT pulmonary angiography:identification of thrombus in the pulmonary circulation

Question 4

Pulmonary Embolism - Treatment?

Answer 4

• Treatment dose LWMH
• Thrombolysis if massive PE

Question 5

Pneumonia - Classical History?

Answer 5

• productive or dry cough,
• fever,
• pleuritic pain associated with shortness of breath;
• may have rigors,
• myalgias, and arthralgias;
• recent history of travel or infectious exposures

Question 6

Pneumonia - Classic Examination?

Answer 6

• decreased breath sounds,
• rales,
• wheezing,
• bronchial breath sounds,
• dullness to percussion,
• increased tactile fremitus observed with severe consolidation

Question 7

Pneumonia - Investigations?

Answer 7

• CXR: pulmonary infiltration, air bronchograms, and pleural effusion
• WBC count: elevated with left shift (increased neutrophil count)
• sputum culture: may reveal culprit organisms, but not sensitive or specific
• blood culture: may reveal culprit organisms, but not sensitive or specific

Question 8

Pneumonia - Treatment?

Answer 8

• Antbiotics

Question 9

Pneumathorax - Classical History?

Answer 9

• acute, pleuritic chest pain,
• shortness of breath;
• primary spontaneous between ages 20 and 40 years;
• secondary spontaneous in patients with COPD;
• traumatic due to acute trauma or iatrogenic;
• shock may occur if rapidly increasing (tension pneumothorax)

Question 10

Pneumathorax - Classical Examination?

Answer 10

• Ipsilateral
• absent breath sounds,
• increased resonance to percussion; (hyperresonance)
• jugular venous distention,
• trachea deviation,
• hypotension if tension pneumothorax (due to compromise of the great vessels)
• reduced chest expansion

Question 11

Pneumathorax - Investigation?

Answer 11

• CXR

Question 12

Pneumathorax - Treatment?

Answer 12

Primary

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

Secondary

• <1cm observe for 24hrs
• 1-2cm aspirate
• >2cm or Sx chest drain

Question 13

Pleurisy - Classic History?

Answer 13

• prodrome of viral illness
• (myalgias, malaise, rhinorrhoea, cough, nasal congestion, low-grade temperatures);
• sick contacts

Question 14

Pleurisy - Classic Examination Findings?

Answer 14

• pleural friction rub with or without low-grade fever;
• sometimes reproducible tenderness to palpation of chest when perichondritis or pleurodynia accompanies pleuritis

Question 15

Pleurisy - Investigations?

Answer 15

• CXR: usually normal but can uncommonly have effusion
• FBC: normal, or leukocytosis with lymphocytic predominance

Question 16

Pleurisy - Treatment?

Answer 16

• NSAIDS
• Treat Cause
• Treat complications, effusion, pneumathorax