Week 5- Acute Dyspnoea Flashcards
Chloe is a 17-year-old trainee hairdresser. She presents at the surgery acutely short of breath.
Take a history of this patient.
HPC:
• Woke up 7am couldn’t get her breath (sudden shortness of breath).
• Occasional smoker. Last night party with many smokers, marijuana.
• Smoking 5-10/day - 6 months.
• No SOB 6 months, no wheeze, no fever, no sputum.
• No weight loss, no night sweats (TB, sarcoidosis)
• Asthma as a child, inhaler 2 years ago.
• Sneezes a lot in summer, allergy to dust?
• Dry skin at elbows and on hands.
• Trigger? Could be related to sprays, hair etc.
• Pale, runny nose, slightly red eyes. Looks tired. Speaking in short sentences.
• Audible wheeze (what is the pathogenesis?) and use of accessory muscles of respiration.
• Sitting in tripod position (what is the significance?).
• Widespread inspiratory and expiratory wheeze (which is more typical? What is the significance?).
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, night sweats?
- Recent illness or travel?
PMHx:
• Past history of any asthma, heart or lung problems?
• If have a history of asthma - what are their background symptoms, previous acute episodes and their severity, usual and recent treatment?
PSHx:
• Any past surgeries?
Medications:
• Any regular medications e.g. OCP, bronchodilators, corticosteroids?
Allergies:
• Any allergies?
• Allergy related symptoms? i.e. runny nose, red eyes (hay fever) dry skin (eczema).
• Triggers? i.e. cold air, exercise, emotion, allergens (house dust mite, pollen, fur), infection, smoking, passive smoking, pollution, NSAIDS, beta blockers, pets, work.
Immunisations:
• E.g. Fluvax, pneumococcal?
FHx:
• Family history of any asthma, heart or lung problems?
SHx: • Background? • Occupation? • Education? • Religion? • Living arrangements? • Smoking? • Nutrition? • Alcohol/recreational drugs? • Physical activity? i.e. tolerance to exercise.
Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI
• UG
• CNS - nausea, headaches?
• ENDO
• HAEM
• MSK - painful or stiff joints, muscle aches or rash?
Perform an exam on the patient
- Introduction, explanation, consent, wash hands. Patient properly positioned, seated, chest exposed.
- General inspection: body habitus, dyspnoeic, drowsy/confused, cyanosis, pallor, respiratory distress, use of accessory muscles, wheezing, cough. Ability to speak in full sentences.
- Vital signs:
• HR - tachycardia/bradycardia (life-threatening).
• RR - tachypnoeic.
• BP - hypertensive/hypotensive (life-threatening).
• Temp - may be febrile (infective exacerbation).
• O2 sats
4. Hands/arms: • Cool, dry palms. • Pallor/peripheral cyanosis. • CRT. • CO2 retention flap. • Signs of eczema - dry skin/irritation. • Salbutamol tremor.
- Face:
• Eyes/nose - conjunctival pallor/haemorrhage, nasal polyps/enlarged turbinates, signs of hay fever - red eyes, runny nose.
• Mouth - peripheral/central cyanosis, hydration, oral thrush (corticosteroid use). - Neck:
• Trachea - tracheal tug, tracheal deviation.
• Cervical lymph nodes. - Chest/back:
• Inspection - shape/symmetry (hyper inflated), scarring/deformity, chest expansion.
• Palpation - chest expansion (decreased), tactile fremitus, chest wall tenderness.
• Percussion - hyper-resonance
• Auscultation - bilateral air entry, decreased breath sounds, wheeze, crackles, increased expiratory time. Vocal resonance. - Legs:
• Peripheral cyanosis.
• CRT.
• Peripheral pulses. - CVS:
• JVP, auscultation.
What is your provisional and ddx diagnosis
Provisional diagnosis: acute asthma/mild exacerbation of asthma. • DDx: - LRTI (e.g. CAP). - Anaphylaxis. - PE (smoker, OCP).
What tx does this patient require
Immediate:
• Salbutamol 5mg nebuliser with O2.
• Hydrocortisone 100mg IV or prednisolone 40-50mg PO or both if very ill.
• Start O2 if saturations <92%, aim for 94-98%.
If life-threatening:
• Inform ICU and seniors.
• Give salbutamol nebulisers every 15mins or 10mg continuously per hour. Monitor ECG, watch for arrhythmias.
• Add in ipratropium 0.5mg to nebulisers.
• Give single dose of magnesium sulphate (MgSO4) 1.2-2g IV over 20mins.
If not improving: refer to ICU for consideration of ventilatory support and intensification of medical therapy e.g. aminophylline, IV salbutamol.
If improving within 15-30mins:
• Nebulised salbutamol every 4 hours.
• Prednisolone 40-50mg PO OD for 5-7 days.
• Monitor peak flow and O2 sats, aim for 94-98% with supplemental if needed.
Outline the severity of asthma
Mild/moderate: can walk, speak whole sentences in one breath, O2 sat >94%
Severe: lethargic, unable to complete sentences in one breath due to dyspnoea, O2 sat 90-94%. Obvious respiratory distress. Use of accessory muscles of neck or intercostal muscles or tracheal tug during inspiration or subcostal recession (abdominal breathing). Visibly breathless, increased work of breathing, tachycardia, tachypnoea.
Life-threatening: reduced consciousness or collapse, exhaustion, confusion or coma, cyanosis, O2 sat <90%, poor respiratory effort, soft/absent breath sounds (silent chest), bradycardia or hypotension.
What ix would you perform on this patient
FBC - WCC (infection), Hb (anaemia), eosinophils (asthma). • U+Es, CRP. • Blood/sputum culture - infection. • ABG. • CXR - infection. • PEF - may be too ill. • Spirometry - not in acute attack.
