PROBLEM BASED LEARNING RESPIRATORY MEDICINE ACUTE SHORTNESS OF BREATH Dr. Lalitha Pereirasamy

CASE SCENARIO 1 A 22 year old man develops acute shortness of breath while watching television at home. The shortness of breath is associated with sharp pain over his left hemithorax and over the left shoulder. He was well prior to this. He had URTI and fever 1 week ago but recovered.

Examination of the hands, head and neck is unremarkable. Physical Examination In the emergency room, his vital signs were : RR = 28/min, PR = 110/min, BP = 130/80, T = 370C, O2 sats : 92% (on room air). Examination of the hands, head and neck is unremarkable. The trachea is central. There is reduced tactile fremitus, hyper- resonant percussion note, and reduced vesicular breath sounds over the left hemithorax. Auscultation of the precordium is normal.

QUESTIONS 1. What are your differential diagnosis based on the history alone? 2. What questions would you like to ask to clarify the differentials? 3. What is the final diagnosis? 4. Explain the pathophysiology of the examination findings? 5. What investigation is required to confirm the diagnosis? 6. What is the management?

The shortness of breath came on suddenly and spontaneously 3 days ago. CASE SCENARIO 2 A 50 year old lady presents with a 3 day history of shortness of breath. The shortness of breath came on suddenly and spontaneously 3 days ago. It is associated with a sharp stabbing pain over her right posterior chest. She also describes a one day history of coughing up small specs of bright red blood. She doesn’t have any sputum production and has no fever. She was feeling reasonably well prior to the onset of these symptoms.

She had a right mastectomy 6 months ago for breast cancer. She is currently undergoing chemotherapy and appears to be tolerating the treatment well. She has NO other significant past medical history.

On examination in the ER, her vital signs are: RR = 24/min, PR = 110/min, BP = 100/70 mmHg, T = 370C, O2 sats = 90%. There is no visible JVP. S1 S2. No murmurs. Normal tactile fremitus. Percussion note is resonant throughout both lung fields. Auscultation reveals normal intensity vesicular breath sounds bilaterally with occasional crepitations on the right. There is a pleural rub over the right lower zone posteriorly

QUESTIONS 1. What are the differential diagnoses based on the history? 2. What further questions would like to ask? 3. Describe the expected physical findings for each of the differentials 4. How would you investigate this patient? 5. How would you manage this patient?

CASE SCENARIO 3 35 year old lady presents to the emergency department with 4 day history of increasing SOB, associated with wheeze, chest tightness and a dry cough. She also had sore throat and mild fever on the first day of symptoms, but has now resolved.

Past medical history : Childhood asthma. Only 1 previous admission 5 years ago for acute exacerbation of bronchial asthma. She visits the GP and gets symptomatic therapy on prn basis if she feels wheezy. She is allergic to ibuprofen and diclofenac. She also has allergic rhinitis.

2. What further questions would you like to ask ? 1. What is your diagnosis? 2. What further questions would you like to ask ? 3. What physical signs would suggest a severe asthmatic attack? 4. Outline the management for acute severe asthma.

The patient is discharged home after several days of hospitalization. She returns to your clinic 6 weeks later.

QUESTION 5. How do you assess outpatient asthma control? 6. Outline the management of bronchial asthma in an outpatient setting.

Case History 68 year old, Chinese Man Chief complaint : Sudden worsening of SOB ( on day of admission ) Background history: COPD Ischaemic Dilated Cardiomyopathy Chronic Hepatitis B infection with liver cirrhosis

Question What are your differential diagnosis? What further history would you like to ask? What investigations will you order to help confirm diagnosis at this point?

Further history Just got discharged from Cardio ward 2 weeks ago for ACS Has been feeling breathless with reduced effort tolerance since discharge from ward Wheezing More copious sputum production since discharge but whitish phlegm. No fever. Had 1 emergency nebulization 1 week ago Was watching TV, felt breathless suddenly

Physical Examination Reduced breath sounds bilaterally Prolonged expiratory phase noted on left side with end expiratory rhonchi. PR 100bpm Speaks in short phrases.

Question What is your diagnosis now? How would you manage the patient now? How do you calculate pack years of smoking?

Question How do you diagnose and stage COPD? What guidelines are being used in our setting? Outline outpatient management of COPD

Thank you