The Breathless patient Flashcards
A patient who stops for breath after walking about 100 metres or after a few minutes on level ground is demonstrating which Grade on the MRC dyspnoea scale?
4
What score is used to assess a patient with suspected PE?
Well’s score
Score more than 4 points → PE is likely → immediate CTPA (if CPTA is not available immediately →treat with LMWH or fondaparinux until CTPA)
What’s long-term management of PE
Warfarin or IVC filter
What to do for people with 4 points or less on Well’s score?
PE is unlikely → perform D-dimmer
- if D - dimmer is positive → immediate CPTA ( fondaparinux or LMWH if a delay in performing CPTA)#
- if D-dimmer negative → think of diagnosis different to PE
What drugs may worsen heart failure? (3)
Drugs to stop or reduce in a suspected HF:
- NSAIDs
- beta-blockers (e.g. Bisoprolol)
- calcium channel blockers (e.g. diltiazem)
What’s initial management of a suspected HF? (symptomatic) - before HF is confirmed
Initial management is with a loop diuretic. For example:
- Furosemide 20-40 mg daily.
- Bumetanide 0.5-1.0 mg daily.
- Torasemide 5-10 mg daily
What to prescribe (apart from loop diuretics earlier, when suspected) for a confirmed HF (2)
- B-blocker that is licensed for HF
- ACE-inhibitor
Prescribe one drug at a time
_____________________________
- ACE-inhibitor first if a patient has diabetes or signs of fluid overload
- Beta-blocker first if a patient has an angina
What to start first in the treatment of HF: a beta-blocker or ACE-inhibitor?
- ACE-inhibitor first if a patient has diabetes or signs of fluid overload
- Beta-blocker first if a patient has an angina
New York Heart Association HF scale
When to refer a patient with HF to cardiology?
If the person is still symptomatic (New York Heart Association classification II-IV) despite optimal treatment with an ACE-inhibitor (or AIIRA) and beta-blocker
What else to consider in the management of HF (apart from loop diuretics, ACE-inhibitor and beta-blocker)? (6)
- Antiplatelets if ischaemic heart disease
- Statins if high cholesterol
- Annual flu vaccination
- One-off pneumococcal vaccination
- Exercise program referral
- Screening for depression and anxiety
True or False
Spirometry or peak flow diary once a child is old enough to cooperate with the test can exclude a diagnosis of asthma in a symptomatic child
False
In a child <5 years old, we can diagnose asthma based on history and examination findings
Asthma in a child <5 years old
Levels of probability and initial management
Based on symptoms:
- Highly probable → we give a trial of treatment for 2-3 months and then review
- Low probability →further investigation and/or referral
- Immediate probability → trial of treatment (continue if symptoms improve); watchful waiting, spirometry and reversibility
Symptoms that may be suggestive of asthma diagnosis
- Wheeze, cough, difficulty breathing, chest tightness together with a personal or family history of atopy
- Symptoms are frequent, worse in the night/early morning and with exercise
5 steps in adult asthma management
Step 1: short-acting beta2-agonist e.g. salbutamol (SABA)
Step 2: inhaled corticosteroid e.g. beclometasone (Clenil) 200-800 micrograms/day (usual dose 400 micrograms/day).
*alternatives if steroid not tolerated: leukotriene receptor antagonist or chromone (block mast-cell degranulation).
Step 3: long-acting beta2-agonist (LABA)
If poor control on of beclometasone 800micrograms/day and LABA, add in leukotriene receptor antagonist or modified release theophylline before moving to step 4
Step 4: either increase ICS to the maximum dose (2000 micrograms/day beclometasone (Clenil)) or start a fourth drug that the person is not already using, such as a leukotriene receptor antagonist, modified release theophylline, or an oral modified-release beta2-agonist.
Step 5: Refer to a specialist in respiratory medicine.
Signs of poor asthmatic control
- having symptoms three times weekly or more
- awakening with symptoms one night weekly or more
- having an exacerbation in the past 2 years
- using inhaled beta2-agonist three times weekly or more
If control poor move to next step
Components of CRB-65 score
- Confusion (new disorientation in person, place, or time)
- Raised respiratory rate (30 breaths per minute or more)
- Low blood pressure (diastolic 60 mmHg or less, or systolic less than 90 mmHg)
- Age 65 years or more
Management of CAP in regards to CRB-65
Score of 3 or more → arrange urgent admission to hospital
Score of 2 → hospital admission is usually advised. Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days
Score of 0 or 1 → treatment at home may be appropriate with amoxicillin 500 mg TDS for 5 days OR doxycycline 200mg OD on day 1 then 100mg OD for a total of 5 days
Score of 1 → consider dual therapy as per Score of 2.
*Smokers over 60 years old need a chest Xray to exclude lung cancer
Treatment of CAP scored as CRB-65 of 2
Score of 2 → hospital admission is usually advised
Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days
Treatment of pneumonia in CRB-65 score 0 and 1
Score of 0 → treatment at home may be appropriate:
with amoxicillin 500 mg TDS for 5 days OR doxycycline 200mg OD on day 1 then 100mg OD for a total of 5 days
Score of 1 → consider dual therapy (like in score2):
Treat with amoxicillin 500 mg TDS and clarithromycin 500 mg BD for 7-10 days, or monotherapy with doxycycline for 7-10 days
What Peak Expiratory Flow results are typical of asthma?
Diurnal variability of peak expiratory flow rate (PEFR) greater than 20% for at least three days in a week for two weeks
What condition is characterised by a tapping apex beat?
Mitral stenosis
What condition is characterised by a pansystolic murmur at the apex?
Mitral regurgitation
Causes of ‘high - output’ heart failure
Anything that increases demand on cardiac output
Examples:
Anaemia, pregnancy, hyperthyroidism, Paget’s disease of bone, arteriovenous malformations
*if the underlying cause is treated → HF resolves
