Week 1- Exertional Dyspnoea

Question 1

19-year-old woman living in a remote community has had to drop out of the local basketball team and now
presents with exertional dyspnoea.
Take a patient history

HPC:

• Increasing exertional dyspnea, palpitations and fatigue
• Large indigenous family, 1 of 7 children, remote, 17 people in the home
• Usual gastroenteritis, resp, ear and skin infections, fever and arthritis at 9 (missed schooling)
• Tall and skinny, enjoys sports
• 6 months of short-winded, worsening over last few weeks after about 15 mins of exercise–> heart pounding, arms and legs were ‘heavy’
• Prolonged cough of 30 mins, no wheeze and no blood
• Implanon capsule 3 months, no fever/chills, no weight loss
• Smokes 5 ‘sticks’ a day, occasional marijuana use
• Brother on monthly injections, mother has heart problems

Answer 1

HPC:

• How long have you been short of breath for
• Did it come on quickly/what were you doing?
• Character- tightness, pain, difficult to get a satisfying breath
• Alleviating factors
• Have you experienced this before
• Severity of the SOB
• Associated symptoms- fever, wheeze
• Effect on lifestyle

SXR:

• Chest pain, palpitations, orthopnea/PND
• Painful or stiff joints, rashes
• headaches, weaknesses/jerky movements

PMHx:

• Childhood infections- ie. ear, skin, throat (ARF)
• Previous rheumatic fever
• Any history of lung/heart problems
• Obs/gyn- possibly preg, heavy menstrual (anemia)

PSHx:
-Any past surgeries

Medications- any regular meds
Allergies- agent and reaction
Immunisations- fluvax, pneumoccocal

FHx:
-Family history of any heart or lung problems

SHx:

• Background
• Occupation
• Education
• Religion
• Living arrangements ie. overcrowding, remote
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity- tolerance to exercise (how much can you do before becoming SOB)

Systems:

• General; weight loss, fever, chills, night sweats
• CVS; palpitations, chest pain, orthopnea, PND
• RS: dyspnoea, cough, sputum, wheeze
• GI: vomiting, diarrhoea, constipation, abdo pain, dysphagia
• UG: dysuria, polyuria, nocturia, urgency, incontinence
• CNS: headaches, nausea, trouble with hearing/vision
• ENDO: heat/cold intolerance, swelling in neck/throat, polydipsia/polyuria
• HAEM: easy bruising, lumps in axilla/neck/groin
• MSK: painful or stiff joints, muscle aches, rash

Question 2

Perform a physical exam on this patient

Answer 2

General Inspection→

• Cachectic→ CF, Lung cancer
• Posture→ marfaans syndrome (rare in females), kyphosis
• Alert and orientated→ altered in IE
• Any obvious scars indicative of previous cardiac surgery (can also be done in inspection of chest but good to comment)
• Any obvious deformities (can also be done in inspection of chest but good to comment)
• any pacemakers, defibs (can also be done in inspection of chest but good to comment)

Vital signs→

• Temp→ raised in IE, ARF
• Pulse→ regular, irregular, regularly irregular→ AF
• BP→ hypotensive in anaemia
• RR→ may be elevated if breathless at rest
• BMI/BSL

Hand inspection→
-Nails→ splinter haemorrhage (IE), cap refill (anaemia), clubbing (IE), pallor (anaemia)
-Hands→ temp (cool in cardiac failure), janeways lesions (lesions on palms/pulps of fingers in IE), oslers nodes (nodules on fingers in IE), palmar crease pallor (anaemia)
Arms→ oedema (CF), needle track marks (IE

Face inspection→
Eyes→ conjunctival pallor (anaemia), roth spots (IE)
Face→ malar flushing (if in cardiac failure, blood pressure back flow into face to cause flushing)
Mouth→ dentition (IE), mucosal petechiae (IE), cyanosis

Neck inspection→
JVP→ elevated (above 3cm in LV failure or valve dysfunction)
Carotid→ murmur radiates to carotid in aortic stenosis

Chest inspection→
Apex beat→ may be displaced in cardiomegaly (due to LV hypertrophy), tapping qualities (present with a murmur)
Auscultation→ loud S1 with pansystolic murmur heard over apex (found in RHD)

Back inspection–>

• Inspection- scars, deformity, erythema
• Palpation for sacral oedema
• Percuss lung bases for dullness- heart failure
• Auscultation- bibasal crackles and wheeze throughout lung fields (pulm oedema)

Abdominal inspection:
Liver→ hepatomegaly (in cardiac failure)
Spleen→ splenomegaly (in IE)
Masses, pulsations
Leg exam:
Oedema→ in CF- backflow
CRT, clubbing, splinter haemorrhages, peripheral pulses
Resp exam:
Chest→ crackles (CF), wheeze (asthma)
Neuro exam:
Sydenham chorea
Cranial nerve functions/motor sensory test

Question 3

What is your provisional and differential diagnosis

Answer 3

Provisional diagnosis; RHD
DDX: 
-Endocarditis
-Viral myocarditis
-Cardiomyopathy
-Anaemia
-Congenital defects
-Asthma

Question 4

What investigations would you like to carry out on the patient

Answer 4

• FBC→ checking WBC levels (high in IE), Hb (may be low in anaemia), can check for ASO and anti-dnase (may be high in indigenous people who have already been exposed), ESR, CRP
• U&E→ alterations can cause palpitation, assess renal function
• ECG→ afib→ will have no pwaves→ may have Pmitrale
• CXR→ cardiomegaly (LV hypertrophy)
• Echocardiogram→ transthoracic (TTE-first choice for RHD), transoesophageal (TOE→ only in IE) → echo can also give ejection fraction
• Urine dipstick- beta-HCG

Question 5

What treatment would the patient require

Answer 5

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