RESP - dyspnoea

Question 1

(5) clinical causes of dyspnoea

Answer 1

•Respiratory
•Cardiac
•Chest wall restriction/muscle weakness
•Metabolic/anaemia
•Psychogenic
–This is a diagnosis of exclusion
–Dyspnoea may be a physical manifestation of stress
–Don’t forget, sick people are often anxious as well

Question 2

What Ix would you do to diagnose a pt with dypsnoea?

Answer 2

–CXR, ECG, ABG’s, basic bloods

–Lung function, CT, VQ, exercise test, echo

Question 3

23 yo male, sudden onset SOB, present for a few hours & now very severe. Previously well, 10 cigarettes/day. L chest pain pleuritic & started with SOB.

DDx?

Answer 3

• Pneumothorax
• Arrhythmia
• Pulmonary Embolism

•Pneumonia, Asthma (less likely), anxiety

Question 4

• Looks unwell, quite distressed with ­ WOB
• RR 26, HR 125 SR, BP 80/60, afeb
• Saturation 93% RA
• Trachea midline
• reduced chest expansion on the left
• Hyperesonant percussion note on the left
• reduced air entry left lung

DDx?

Answer 4

Tension pneumothorax

Pneumothorax

Question 5

23yo male, progressive SOB over 48 hours, now present at rest. Wheeze, dry cough, recent URTI, childhood asthma, hay fever.

O/E:
•RR 24, HR 110 SR, BP 110/70
•Sat 97% RA
•Widespread wheeze (what causes this sound?)

Ix:
•CXR normal
•Peak Flow 300/min (how does this help us?)
•ABG ph 7.5/CO2 30/O2 70/HCO3 23

What do the blood gases show? Dx? Mx?

Answer 5

Resp alkalosis
–Widened Aa gradient
–Gas exchange is NOT normal despite normal saturation on the monitor.

Dx: exacerbation of asthma

Mx: Bronchodilators, corticosteroids, oxygen

Question 6

68yo female, sudden onset SOB (for 1 hour quite severe). R pleuritic chest pain, mild fever, R TKR 3 days ago, persistent leg swelling. non smoker, no previous CV/resp disease, no injury

O/E:
•Not too unwell but clear evidence of tachypnoea and some ­ WOB
•RR 24, T 37.6, HR 110, BP 110/70
•Sats 93% RA
•Chest clear with normal percussion and normal breath sounds

Ix:
•CXR normal
•ABG pH 7.5/CO2 30mmHg/p02 62mmHg on RA
•CTPA pending

DDx?
Rx of most likely diagnosis?

Answer 6

• PE
• Pneumonia
• Pneumothorax
• Arrythmia
• AMI
• Anxiety

Mx: Anticoagulation

Question 7

68 yo female, progressive SOB over 6/12 worse over 24 hours. Chronic cough, usually with white sputum, now worse with change in sputum amount & colour. Fever. Some orthopnoea, heavy smoker of 35pack years.

O/E:
•Unwell, RR 26, T 37.8, HR 90 SR, BP 140/80
•Sat’s 88% RA
•Evidence of ­increased work of breathing and use of accessory muscles (which are these?)
•Signs of hyperinflation
–Barrel chest, reduced chest expansion, hyper-resonant percussion
•Prolonged expiration with wheeze

Ix:
•ABG pH 7.28/pCO2 60/pO2 55/HCO3 26
•What do these show?
•Acute Type II respiratory failure

DDx? Mx?

Answer 7

Dx: Chronic obstructive pulmonary disease (COPD) with acute infective exacerbation

DDx:
•CCF with acute exacerbation
•Anxiety
•Muscle weakness
•Anaemia

Mx: Bronchodilators, controlled oxygen, corticosteroids, antibiotics, Non Invasive Ventilation (NIV)

Question 8

68yo male, progressive SOB over 6/12, worse over 24hours. Orthopnoea, PND, SOA present to a minor degree over 6 months but worse for 24 hours. Palpitations (last 24hours), previous AMI 4 years ago, pace maker. Ex-smoker, HTN, DM.

O/E:
•Unwell looking with increased work of breathing
•RR 26, afeb, HR Irreg 130, BP 100/70
•Sat 90% RA
•JVP 5cm
•SOA ++
•Displaced apex beat, no cardiac murmurs, 3rd heart sound present
•Normal chest expansion but stony dull percussion in the bases (R>L), bilateral inspiratory crepitations just above the dull areas

Ix:
•ECG Rapid AF
•ABG ph 7.43/pCO2 36/PO2 60/HCO3 20
•CXR

DDx? Mx?

Answer 8

Dx: Long standing heart failure with an acute exacerbation due to new onset rapid AF

DDx:
•Arrhythmia
•Acute myocardial infarct/angina
•COPD
•Anaemia

Mx: Digoxin, Beta blocker, diuretic, ACE inhibitor, warfarin, oxygen