Week 4 - Worsening dyspnoea

Question 1

Mr. P.Z. is a 62 year old male. He presents to the Emergency at TTH with worsening shortness of breath.

Take a history of this patient.

HPC:
• Worsening shortness of breath for 2 days and ‘sweating so much’ (suspect fever).
• Previously SOB after exertion, gradually worsening over the years, now SOB at rest (chronic problem).
• Cough usually in the winter if he gets an URTI - cough lingers and can go for months (cough in winter is indicative of chronic bronchitis).
• Sputum chronic clear white but light brown today (rusty sputum).
• L. chest pain worse with breathing today, fever, sweaty.
• Smoked 1 pack/day for 35 years; quit 5 years ago.
• Foreign travel - nil.

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.
• Effect on lifestyle?

• Do you smoke?
• Weight loss, loss of appetite?
• Orthopnoea, PND?
• Haemoptysis, night sweats?
• Recent illness or travel?

PMHx:
• Past history of any heart or lung problems, cancer?

PSHX:
• Any past surgeries?

Medications:
• Any regular medications?

Allergies:
• Agent, reaction, treatment?

Immunisations:
• E.g. Fluvax, pneumococcal?

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

SHx:
• Background?
• Occupation?
• Education?
• Religion?
• Living arrangements?
• 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 - change in bowel habits, heartburn, dysphagia?
• UG -
• CNS - nausea, headaches?
• ENDO -
• HAEM -
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical exam on this patient.

Answer 2

1. Introduction, explanation, consent, wash hands. Patient properly positioned, seated, chest exposed.
2. General inspection: dyspnoeic, use of accessory muscles, pursed lip breathing, tripod position, cyanosis, cough, wheeze, stridor, hoarseness, body habitus (wasting, cachexia). Check patient surroundings (sputum cup, oxygen mask).

3. Vital signs:
• HR - tachycardia
• RR - tachypnoeic.
• BP - normal/hypotensive.
• Temp - febrile.
• O2 sats, BGL, BMI

4. Hands:
   • Warm/cool, dry/sweaty.
   • Pallor, peripheral cyanosis.
   • CRT, clubbing (cancer not COPD).
   • Tar staining of fingers.
   • Palms - wasting of small muscles of hand, finger weakness with abduction.
   • Wrists - flapping tremor, wrist tenderness.
   • Pemberton’s sign - flushing, plethora, cyanosis, inspiratory stridor, elevation of JVP when arms in full abduction for 1 minute.
5. Face:
   • Thick leathery skin.
   • Eyes - sub-conjunctival haemorrhage, Horner’s syndrome (ptosis, miosis, anhydrosis).
   • Nose - discharge, swelling, nasal polyps/enlarged turbinates.
   • Mouth - cyanosis.
6. Neck:
   • Trachea - tracheal tug, tracheal deviation.
   • Cervical/axillary lymph nodes.
7. Chest/back:
   • Inspection - shape/symmetry (barrel shaped - COPD), scarring/deformity, chest expansion (may be reduced bilaterally - hyperinflated chest with reduced expansion).
   • Palpation - chest expansion (reduced bilaterally, Hoover’s sign anteriorly), tactile fremitus (may be increased on affected side), chest wall tenderness (may be pleuritic chest pain).
   • Percussion - hyper-resonance (COPD), dullness to percussion over any masses/affected side.
   • Auscultation - may be bronchial breath sounds, reduced intensity, crackles. Vocal resonance (may be increased on affected side).

8. Legs:
• Temperature.
• Oedema.
• Clubbing.
• CRT.
• Peripheral pulses.

9. CVS:
   • JVP, auscultation.

Question 3

What is your provisional diagnosis and differential diagnoses?

Answer 3

• Provisional diagnosis: infective exacerbation of COPD.
• DDx:
- LRTI i.e. pneumonia.
- COPD.
- CCF.
- Lung cancer.
- Asthma exacerbation.
- TB.

Question 4

What investigations would you carry out on this patient?

Answer 4

• ECG.
• CXR.
• FBC, U+Es, LFT, CRP.
• ABG.
• Blood/sputum culture.
• Urinalysis.

Question 5

What treatment does this patient require?

Answer 5

• The most important aspects of management are oxygenation, fluid balance and antibiotic therapy (treat the chest infection and maintain good hydration).
• Oxygen - aim for ≥94%.
• Start IV fluids.
• Antibiotics - orally if not severe and not vomiting, severe given by IV.
• Simple analgesia may be needed if pain arises e.g. paracetamol 1g/6h.
• Influenza and pneumococcal vaccination.
• Bronchodilators/corticosteroids.

Question 6

Outline CURB-65 and SMART-COP for pneumonia severity.

Answer 6

CURB-65/CORB:
• Confusion.
• Urea >7 mmol/L or O2 sats <90%.
• RR >30 bpm.
• BP <90 mmHg (systolic) or <60 mmHg (diastolic).
• Age >65y.

Total: /5
• 0-1 - outpatient care (low risk - home treatment).
• 2 - short inpatient hospitalisation or closely supervised outpatient treatment (intermediate risk).
• ≥3 - inpatient admission with consideration for ICU admission with score of 4 or 5 (severe - high risk).

• Severe CAP is defined as the presence of at least two of these features (CORB).

SMART-COP:
CAP confirmed on CXR.
• Systolic BP <90 mmHg - 2 points.
• Multilobar CXR involvement - 1 point.
• Albumin <35g/L - 1 point.
• RR ≥25 bpm (≤50y) or ≥30 bpm (>50y) - 1 point.
• Tachycardia ≥125 bpm - 1 point.
• Confusion - 1 point.
• O2 sats ≤93% (≤50y) or ≤90% (>50y) - 2 points.
• pH <7.35 - 2 points

Total: /11

• Severe CAP = a SMART-COP score of 5 or more points.
• Additional severity scores: PSI (pneumonia severity index).