Problem Solving in Medicine Dr Sidrah Lodhi Assistant Professor North Medical Unit King Edward Medical University

I CANNOT BREATH. I FEEL LIKE I AM GOING TO DIE! Case 1 I CANNOT BREATH. I FEEL LIKE I AM GOING TO DIE!

Case 1 You are working in the ER when 57-year-old Mr M. is brought in with the complaint: “Doctor, I cannot breath. I feel like I am going to die!”

Questions What additional information do you need from the patient? What specifically do you want to look for on examination? Is there anything you would like to advise before going on further? What are your thoughts about a differential diagnosis as you proceed to the patient?

Further Evaluation He is unable answer any questions because of his extreme shortness of breath. He is sitting leaning forward, supporting his arms on pillow, looking distressed, pale, sweaty and coughing up pinked tinged frothy sputum. He also has history of myocardial infarction 6 months ago.

Examination BP 90/70, Pulse 120 reg., RR 28, Temp 98.5 ̊F Oxygen saturation 83%. JV P is elevated 12 cm. Extremities are cool with thready pulses and without edema. Chest: Crackles to above the scapula. Cardiac exam: apex diffuse, laterally and inferiorly displaced, distant heart sounds, S3 gallop. Abdominal exam is normal.

Investigations CBC Biochemistry: ABG pH 7.48 p02 54 pCO234 HCO3 24 Hb 12.2g/dL Hct 38 WBC 10.9 X 109/L DLC: Polys:75% Lymphos: 25% Plt 245 X 109/L Biochemistry: Sodium 135mg/dL Potassium 3.7 mg/dL Blood Urea 44 mg/dL Serum Creatinine 1.4 mg/dL Blood Glucose 116 mg/dL ABG pH 7.48 p02 54 pCO234 HCO3 24

ECG

Chest X-ray

Diagnosis Acute Pulmonary Edema

Pulmonary Edema Pulmonary edema means an excess collection of watery fluid in the lungs. The fluid collects in the many air sacs of the lung, making it difficult to breathe.

Pulmonary Edema Treatment: Treat the Symptoms oxygen, medicines to remove the excess fluid from the lungs (diuretics) and other medicines to help the heart work more effectively. Treat the precipating factors (hypertension, ischemia, arrhythmia, infection, etc) Treat the underlying cause

Causes Heart Failure Lung Fluid overload Capillary CARDIAC – Due to increased hydrostatic pressure NON-CARDIAC – Due to increased capillary permeability Heart Failure Coronary artery disease Cardiomyopathy Valvular disease Fluid overload Lung Smoke inhalation Near – drowning Aspiration ARDS Capillary Sepsis DIC

Take Home Message

Take Home Message

Case 2

Case 2 A 32 year old gentleman has presented in the OPD with the following: “Doctor, I can’t breath properly and I have this pain on breathing!”

Questions What additional information do you need from the patient? What specifically do you want to look for on examination?

Further Evaluation Patient has travelled from Australia 3 days back He was in his office working at his computer when all of a sudden, he had pain in upper part of his chest and he felt that he has difficulty in breathing since then. He is a smoker but otherwise healthy.

Examination BP 120/80, Pulse 120, RR 22, Temperature 98.6 ̊ Oxygen saturation 93% on room air Chest: Pain in upper part of chest on deep breathing Cardiac exam: Normal Abdominal exam is normal.

WHAT IS GOING ON? WHAT TO DO NEXT?

Investigations Routine blood work Arterial blood gases

ECG

Chest X-Ray

Our Thoughts

Targeted Testing D-Dimers V-Q Scan CTPA (CT pulmonary angiogram)

VQ Scan

CTPA- Normal

CTPA - Patient

Diagnosis Pulmonary Embolism

Treatment Oxygen 100%. Obtain IV access, monitor closely Pain relief (eg, morphine). Assess circulation: suspect massive PE if systolic BP is <90 mm Hg Anticoagulation – No further clots Unfractionated heparin Low-molecular-weight heparin Factor Xa inhibitors Fondaparinux Warfarin

Treatment Clot removal stategies – Medical – Thrombolysis Surgical – embolectomy , IVC filters

Where Did The Clot Come From?

How TO Prevent The Clot? Adequate rest before flight Wear loose clothing Good hydration Avoid alcohol Get out of your seat and walk every hour Avoid crossing your legs In-seat exercises – every 10 min Lift your toes Lift your heels Make toe circles Slide feet back & forth

How TO Prevent The Clot?

Why Are We Talking About This?

Further Thoughts Lots of people travel… Why did this particular gentleman have a clot?

Risk Factor For Pulmonary Embolism