Week 1 - Exertional dyspnoea

Question 1

Mrs JM, 19 year old woman living in a remote community who drops out of local basketball team, presents with exertional dyspnoea.

Take a history of this patient.

HPC:
• Increasing exertional dyspnoea, palpitations and fatigue.
• Large indigenous family, 1 of 7 children, remote, 17 people in home.
• Usual gastroenteritis, respiratory, ear and skin infections. Fever and arthritis at 9 yo - off school for a month.
• Tall skinny girl, loves sports.
• 6 months ‘short-winded’, worsening over last few weeks after about 15 mins of game. Heart pounding, arms and legs were ‘too heavy’.
• Prolonged cough ~30 mins, no wheeze, no blood.
• Implanon capsule 3 months. No fever/chills, no weight loss.
• Smokes 5 ‘sticks’ a day, occasional ‘gunja’ (THC).
• Brother on monthly injections. Mother heart problems, takes medication.

Answer 1

HPC:
• How long have you been short of breath?
• Did it come on quickly/what were you doing?
• Character? i.e. tightness, pain, difficult to get a satisfying breath.
• Alleviating factors?
• Experienced it before? How long does it usually last?
• Exacerbating factors?
• Severity?
• Associated symptoms? i.e. fever, wheeze, cough/sputum, chest pain, palpitations.
• Effect on lifestyle?

• Recent illness, fever?
• Chest pain, palpitations, orthopnoea/PND?
• Painful or stiff joints, rashes?
• Headaches, weakness/jerky movements?

PMHx:
• Childhood infections? i.e. skin, ear, throat infections.
• Previous rheumatic fever.
• Any history of heart or lung problems?
• Obs/gyn.

PSHx:
• Any past surgeries?

Medications:
• Any regular medications? i.e. injections.

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

FHx:
• Family history of any heart or lung problems?

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements? i.e. overcrowding, remote.
• Smoking?
• Nutrition?
• Alcohol/recreational drugs?
• Physical activity? i.e. tolerance to exercise (how much can you do before SOB stops you or slows you down?)

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands. Patient 45˚, chest exposed.
2. General inspection: alertness/consciousness, unwell/distressed, anxious, dyspnoeic, pallor, bruising, fatigue/lethargy, rashes, habitus (e.g. tall, skinny).

3. Vitals signs:
• HR - tachycardic (rate, rhythm, volume).
• RR - tachypnoeic.
• BP
• Temp - may be febrile.
• O2 sats, BSL, BMI.

4. Hands/arms:
• Warm/cool, dry/sweaty.
• Peripheral cyanosis, pallor.
• CRT, clubbing.
• Splinter haemorrhages, Osler's nodes, Janeway's lesions.
• Koilonychia.
• Rashes.
• Arthralgia (swollen, red, tender).
• Subcutaneous nodules.
• Track marks and petechial haemorrhages.

5. Face:
   • Eyes - conjunctival pallor/haemorrhage (Roth’s spots), scleral jaundice.
   • Malar flush.
   • Mouth - peripheral/central cyanosis, mucosal petechiae, dental hygiene (e.g. caries).
6. Neck:
   • Carotids - volume/character.
   • JVP (may be raised).
7. Praecordium:
   • Inspection - scars, abnormal pulsations, pacemaker, prominent veins.
   • Palpation - apex beat, heaves, thrills.
   • Auscultation - heart sounds (murmurs).
8. Back:
   • Inspection - scars, deformity, erythema marginatum.
   • Palpation - sacral oedema.
   • Percuss - lung bases for dullness (heart failure).
   • Auscultation - lung bases (bibasal crackles), crackles and wheeze throughout lung fields (pulmonary oedema).
9. Abdomen:
   • Inspection - masses/pulsations.
   • Palpation - hepatosplenomegaly (heart failure, anaemia, endocarditis).

10. Legs:
• Subcutaneous nodules.
• Peripheral cyanosis.
• Oedema.
• CRT, clubbing.
• Splinter haemorrhages.
• Peripheral pulses.

11. NEURO
    • Sydenham chorea.
    • Motor/sensory test.
    • Cranial nerves.

Question 3

What is your provisional and differential diagnosis?

Answer 3

• Provisional diagnosis: RHD.
• DDx:
- Bacterial endocarditis.
- Viral myocarditis.
- Cardiomyopathy (dilated/hypertrophic).
- Asthma.
- Anaemia.

Question 4

What investigations would you carry out on this patient?

Answer 4

• ECG.
• CXR - cardiomegaly, enlarged LA.
• Echocardiogram - diagnostic.
• FBC - Hb (anaemia), WCC (infection)
• U+Es - renal function.
• ESR.
• ASO.
• Anti-DNAse B - more sensitive for group A strep, antibody titers stay elevated for longer.
• Urine dipstick - beta-HCG.

Question 5

What treatment does this patient require?

Answer 5

• Treat AF
• Antibiotics (penicillin) to prevent further recurrences.
• Consider anti-coagulant e.g warfarin.
• Address dental issues.
• Referral to cardiologist.
• Multidisciplinary care.
• Social support - TAIHS.
• Discuss implanon/pregnancy.
• Regular follow-up.