Week 4 - Dyspnoea on exertion and pedal oedema

Question 1

Mr. B.G. Bob, 87 year old retired public servant. ‘I feel rotten and can’t get up a flight of stairs as I feel so puffed and my ankles are swollen’.

Take a history of this patient.

HPC:
• SOB 10 years, getting worse 2 weeks. Cannot do routine work.
• Chronic wet cough, clear-yellow sputum. No change.
• Frequent exacerbations of smoking related COPD (15 y), 3m.
• Coronary stents 6y. BP usually 140/75 mmHg.
• Bilateral ankle swelling, 2 wk - first time.
• Mild R abdominal discomfort.
• Hyperlipidaemia 15y, salt in diet?
• Increase in weight - since prednisolone (COPD).
• Sitting in tripod position, pale, BMI 18, JVP 5cm, apex beat 6th ICSMCL.

Answer 1

HPC:
• Site - swelling.
• Onset - dyspnoea, oedema.
• Alleviating factors.
• Timing - experienced it before, constant or intermittent, worse at a particular time, how long does it last?
• Exacerbating factors.
• Severity.
• Associated symptoms e.g. cough/sputum, wheeze, fever/recent illness, chest pain, palpitations, orthopnoea/PND, weight gain.

PMHx:
• Past medical history of heart/lung problems, hypertension etc.

PSHx:
• Past surgeries?

Medications:
• Regular medications?

Allergies:
• E.g. agent, reaction, treatment.

Immunisations:
• E.g. Fluvax, pneumococcal.

FHx:
• Family history of heart/lung problems, hypertension etc.

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition
• Alcohol/recreational drugs
• Physical activity

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

What is your provisional diagnosis and differential diagnoses?

Answer 2

• Provisional diagnosis: COPD → heart failure.
• DDx:
- Heart failure.
- COPD → cor pulmonale.
- Cirrhosis.
- Malignancy.
- Anaemia.
- Renal failure.
- Hypothyroidism.
- SLE.
- Wegener’s granulomatosis.
- Pneumonia.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: COPD → heart failure (cor pulmonale).
• DDx:
- Heart failure.
- COPD → cor pulmonale.
- Cirrhosis.
- Malignancy.
- Anaemia.
- Renal failure (ESRD).
- Hypothyroidism.
- SLE.
- Wegener’s granulomatosis.
- Pneumonia.

• Valvular disease.
• DVT/PE.
• General inflammatory conditions.
• Thyrotoxicosis.

Question 4

What investigations would you carry out on this patient?

Answer 4

• FBC, U&Es, LFTS, TFTs, BSL
• BNP
• Lipids
• ABG
• Sputum culture.
• ECG
• Echocardiography
• CXR
• Urine dipstick
• Spirometry

Question 5

What treatment does this patient require?

Answer 5

• GTN
• Diuretics
• Fluid restriction
• Review by cardiologists and respiratory physician