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Amir Sam DPD 2018 > DPD2 - SOB > Flashcards

DPD2 - SOB Flashcards

Resp: Causes of SOB

1
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. What is the most likely diagnosis?

  1. Pneumothorax
  2. PE
  3. Airway disease
  4. Pneumonia
  5. Pulmonary oedema
  6. Interstitial lung disease
  7. Pleural effusion
  8. Anaemia
  9. Thyrotoxicosis
  10. Nerve/muscle disease
A

Pneumothorax
Sudden onset so you want to exclude PE or pneumothorax. There are no RFs for PE.
COPD is a risk factor for secondary pneumothorax - bullous bursts.

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2
Q

What are the risk factors for PE?

A

Signs of DVT
Previous DVT/PE
Immobility, surgery, malignancy

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3
Q

What framework can you use to classify DDx of SOB?

A

Onset:
Seconds
Minutes/hours
Days/weeks

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4
Q

What are the DDx for SOB that came on in seconds?

A

Pneumothorax
Pulmonary embolism
Foreign body
Anxiety

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5
Q

What are the DDx for SOB that came on in minutes/hours?

A 
Airways (inflammation/obstruction) e.g. Asthma, COPD
Chest infection (pus)
Acute heart failure (fluid)
Pulmonary haemorrhage (blood)
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6
Q

What are the DDx for SOB that came on in days/weeks?

A

Any of DDx for seconds/days if chronic/not resolving
Interstitial lung disease (pulmonary fibrosis)
Malignancy/large pleural effusion
Neuromuscular
Anaemia/thyrotoxicosis

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7
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. A diagnosis of a R pneumothorax is made and patient is started on oxygen. What is the next most appropriate step in his management?

  1. Chest drain insertion
  2. Chest USS
  3. CPAP
  4. Observation
  5. Pleural aspiration
A

Chest drain insertion

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8
Q

What are the two types of pneumothorax?

A

Primary - in patients who do not have lung disease

Secondary - in patients with lung disease e.g. COPD

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9
Q

What is the Tx for a primary pneumothorax?

A

If < 2 cm, reassure + discharge, repeat CXR

If > 2 cm/SOB, aspiration. If fails: chest drain

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10
Q

What is the Tx for a secondary pneumothorax?

A

If < 2 cm, aspiration

If > 2 cm, chest drain in 2nd ICS + MCL using a 3-4 cm 16 French gauge needle

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11
Q

A 60 y/o ma presents w/ sudden onset SOB + no cough, sputum or haemoptysis. PMHx: COPD + DHx: symbicort & tiotropium. HR: 110 bpm. O/E: raised JVP, decreased breath sounds, scattered wheeze & creps (R), peripheral oedema + sats 80% on air. Ix: FBC: Hb 85, WCC 12, Plt 300. A diagnosis of a R pneumothorax is made and patient is started on oxygen. A chest drain is performed. What medication should you prescribe?

A

Analgesia e.g. 2% lidocaine

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12
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. What is the most likely diagnosis?

A 
Pulmonary Embolism (PE) 
Acute onset + Hx of DVT + raised JVP
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13
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What would her ECG show?

A

S1, Q3, T3

Potentially right axis deviation + RBBB (indicates right heart strain)

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14
Q

What is a quick way of determining if there is axis deviation looking at an ECG?

A
  1. Is lead I or lead II overall negative? If yes, then there is axis deviation
  2. Is aVL overall positive? If yes, Left axis deviation. If no, right axis deviation
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15
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 120/80 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What is the next most appropriate step of her management?

  1. LMWH
  2. BiPAP
  3. Warfarin
  4. Thrombolysis
  5. Furosemide
A

LMWH administered when PE is suspected. CTPA to confirm diagnosis and then warfarin started. However, LMWH must still be continued for a few days as warfarin has a paradoxical procoagulant effect (inhibits protein C&S)

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16
Q

A 47 y/o woman presents w/ acute SOB + pleuritic chest pain. PMHx: DVT. O/E: O2 saturation 78% on air; HR 110; BP 90/60 mmHg; raised JVP; vesicular BS. A diagnosis of PE is made. She is started on high flow oxygen and CXR does not show pneumothorax. What is the next most appropriate step of her management?

  1. LMWH
  2. BiPAP
  3. Warfarin
  4. Thrombolysis
  5. Furosemide
A

Thrombolysis

Patient is not haemodynamically stable

17
Q

What is the Tx of PE if patient is haemodynamically stable?

A
  1. LMWH
  2. CTPA to confirm PE
  3. Continue LMWH + warfarin for a few days
  4. Just warfarin when INR optimal
18
Q

What is the Tx of PE if patient is haemodynamically unstable?

A

Thrombolysis

19
Q

What is the CXR sign seen in PE?

A

Westermark sign = hypovolaemia leading to vessel collapse distal to PE
CXR shows slightly darker area + CTPA shows clot and no filling after clot

20
Q

What is FEV1?

A

Forced expiratory volume in 1 second

21
Q

What is FVC?

A

Forced vital capacity - deep breath in until cannot inhale more, then exhale until cannot anymore

22
Q

What does a FEV1/FVC ratio > 70% mean?

A

Restrictive lung disease e.g. fibrosis

23
Q

What does a FEV1/FVC ratio < 70% mean?

A

Obstructive lung disease e.g. COPD or asthma

24
Q

A 50 y/o female presents w/ progressive (chronic) SOB, dry cough, clubbing, FEV1/FVC ratio >70%. CXR shows reticular shadowing. What is the most likely diagnosis?

A

Pulmonary fibrosis due to FEV1/FVC ratio and clubbing w/ dry cough. Remember COPD does not cause clubbing

25
Q

Does COPD cause clubbing?

A

NO

26
Q

What are the DDx of restrictive lung conditions (pulmonary fibrosis)?

A

Idiopathic fibrosing alveolitis
Connective tissue disease e.g. SLE, RA, Scleroderma
Drugs e.g. methotrexate, nitrofurantoin
Asbestosis (ship builders) = pulmonary fibrosis due to asbestos N.B. this is different to asbestosis plaques which are due to asbestos exposure

27
Q

A 50y/o female presents w/ chronic SOB, sputum, no clubbing + FEV1/FVC ratio < 70%. Considering the most likely diagnosis, what would her CXR show?

A 
Hyperinflated lungs (>7 anterior ribs)
Flattened diaphragm
28
Q

A 50y/o female presents w/ chronic SOB, sputum, no clubbing + FEV1/FVC ratio < 70%. CXR shows hyperinflated lungs (> 7 anterior ribs) + flattened diaphragm. What is the most likely diagnosis?

A

COPD

29
Q

A pt presents with cough, sputum, weight loss and night sweats. Considering the most likely diagnosis, what would their CXR show?

A

Area of shadowing in L/R upper zone

30
Q

A pt presents with cough, sputum, weight loss and night sweats. CXR shows area of shadowing in R upper zone. What is the most likely Dx?

A

Pulmonary TB

31
Q

70 y/o man w/ SOB and keeps pigeons. Considering the most likely diagnosis, what would his CXR show?

A

Bilateral reticulonodular shadowing

32
Q

70 y/o man w/ SOB and keeps pigeons. CXR shows bilateral reticulonodular shadowing. What is the most likely Dx?

A

Extrinsic allergic alveolitis

33
Q

What does a homogenous white shadow on a CXR indicate?

A

Fluid
Effusion
Collapse
(Look at trachea - Effusion pushes trachea away due to increased pressure; collapse pulls trachea towards)

34
Q

What do reticulonodular shadowing (lines + dots) indicate on a CXR?

A

Fibrosis e.g. allergic alveolitis

35
Q

What does fluffy alveolar shadowing (interstitial) indicate on CXR?

A

Fluid (pulmonary oedema) - bat wing appearance
Pus (pneumonia)
Blood (pulmonary haemorrhage)

36
Q

What does a mass/cavitation on a CXR indicate?

A

Infection e.g. TB
Inflammation e.g. sarcoidosis
Malignancy e.g. lymphoma

37
Q

What does a globular heart on CXR indicate?

A

Pericardial effusion

Amir Sam DPD 2018 (8 decks)

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