1. ED training Respiratory/ patient with dyspnea Part 2
Dr Jaycen Cruickshank
September 2012

2. Respiratory - dyspnea Learning objectives
The respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the principles of diagnostic reasoning. lmportant physical findings that help discriminate different causes of dyspnoea will be discussed along with appropriate initial investigations.
Learning objectives
Be able to describe the differences and similarities in the medical history, physical examination and investigations of common or life threatening causes of dyspnoea.
To manage asthma and pneumonia using best practice guidelines
To be able to use the Wells score & PERC rule in diagnosis of PE
Pre reading
Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK : John Wiley & Sons, 2011.  Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis.
Other learning resources
Relevant clinical clinical guidelines at Ballarat Health Services:
Refer to ED lecture series and self directed workbooks

3. Emergency Department HMO education series 2012
Case C Female in her 60’s
Sudden onset SOB (present now for 1 hour, quite severe) Right sided pleuritic chest pain
Mild fever
Right total knee replacement 3 days ago, persistent leg swelling since then
Non smoker
No previous cardio/respiratory disease
No injury
In the pre reading cases we had young patients with sudden or gradual onset of dyspnea.
The differential diagnosis is different in older patients.
The differential diagnosis is also different in patients with known respiratory illness, with an exacerbation…
Emergency Department HMO education series 2012

4. What is the differential diagnosis?
Most likely PE
Pneumonia
Less likely
Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series 2012

5. Emergency Department HMO education series 2012
On examination & tests
Not too unwell but clear evidence of tachypnoea and some  WOB
RR 24, T 37.6, HR 110, BP 110/70
Sats 93% RA
Chest clear with normal percussion and normal breath sounds
Most likely diagnosis?
CXR normal
ABG pH 7.5/CO2 30mmHg/p02 62mmHg on RA
What test(s) will you perform
Pulmonary embolism is the most likely diagnosis – sudden onset, no cause found yet
Emergency Department HMO education series 2012

6. Emergency Department HMO education series 2012
What can you see?
Pulmonary embolism
Emergency Department HMO education series 2012

7. Emergency Department HMO education series 2012
Case D Woman in 60’s
Progressive SOB over 6 months, worse over 24 hours
Chronic cough
Usually with white sputum
now worse with change in sputum amount and colour
Associated fever
Some orthopnoea
Heavy smoker (35 pack years)
How does this change your thinking compared to the first 3 cases?
Age
Pre existing diseases
Slow onset
Emergency Department HMO education series 2012

8. Differential diagnosis
Chronic obstructive pulmonary disease (COPD) with acute infective exacerbation
CCF with acute exacerbation
Anaemia
Less likely
Neuromuscular conditions
Anxiety
Emergency Department HMO education series 2012

9. Exam & investigations…
Unwell, RR 26, T 37.8, HR 90 SR, BP 140/80
Sat’s 88% RA
Evidence of  work of breathing and use of accessory muscles (which are these?)
Signs of hyperinflation
Barrel chest,  chest expansion, hyper-resonant percussion
Prolonged expiration with wheeze
ABG pH 7.28/pCO2 60/pO2 55/HCO3 26
What do these show?
Acute Type II respiratory failure
CXR
Emergency Department HMO education series 2012

10. Emergency Department HMO education series 2012
CXR
Hyperinflated chest in keeping with COPD
Emergency Department HMO education series 2012

11. Emergency Department HMO education series 2012
Diagnosis
Infective exacerbation of COPD with acute respiratory failure
Treatment
Bronchodilators, controlled oxygen, corticosteroids, antibiotics, Non Invasive Ventilation (NIV)
Emergency Department HMO education series 2012

12. Emergency Department HMO education series 2012
What if this was the CXR?
Emergency Department HMO education series 2012

13. Emergency Department HMO education series 2012
Case E Male in 60’s, with progressive SOB over 6 months, worse over 24 hours
Further history
Orthopnoea, Paroxysmal nocturnal dyspnoea (PND), SOA. All present to a minor degree over the 6 months but worse for 24 hours
Palpitations (last 24 hours)
Previous AMI 4 years ago, pace maker
Ex-smoker, Hypertension (HT), diabetes
How does this change your diagnostic reasoning compared to the last case?
Quite a few clues point to cardiac….
Heart Failure
Arrhythmia
Acute myocardial infarct/angina
COPD
Anaemia
Emergency Department HMO education series 2012

14. Emergency Department HMO education series 2012
Examination
Unwell looking with increased work of breathing
RR 26, afeb, HR Irreg 130, BP 100/70
Sat 90% RA
JVP 5cm
SOA ++
Displaced apex beat, no cardiac murmurs, 3rd heart sound present
Normal chest expansion but stony dull percussion in the bases (R>L), bilateral inspiratory crepitations just above the dull areas
These are essentially a group of physical signs consistent with cardiac failure. You would also look for mitral regurgitation, and also tricuspid regurgitation if you wanted to look for right heart failure ( murmur louder in inspiration, in tricuspid area, pulsatile liver, cannon waves on JVP, tender liver, swelling of ankles, ascites)
Emergency Department HMO education series 2012

15. ECG – what is your diagnosis?
Rapid Atrial Fibrillation

16. Emergency Department HMO education series 2012
Cardiac failure
Pacemaker
Enlarged heart
Bilateral pleural effusions
Upper lobe vessels
Alveolar opacity in the bases
Emergency Department HMO education series 2012

17. Emergency Department HMO education series 2012
Case E Diagnosis
Long standing heart failure with an acute exacerbation due to new onset rapid AF
Treatment of AF, & heart failure
Antithrombotic strategy
Then rate control
Perhaps rhythm control
See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Emergency Department HMO education series 2012

18. What else should I ask? Travel history…
Other important symptoms of respiratory disease
Cough
Acute
Chronic
Haemoptysis (cancer, TB, other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Emergency Department HMO education series 2012

19. Image gallery – e.g radiology First slide with image /question

20. Image gallery – e.g radiology First slide with image /question
Large right sided pneumothorax

21. Image gallery – e.g radiology First slide with image /question
Moderate sized left pneumothorax

22. Image gallery – e.g radiology First slide with image /question

23. Image gallery – e.g radiology First slide with image /question

24. Summary of learning
Diagnosis of the breathless patient requires you to look for clues…
The time course of the illness
Associated symptoms
Known diseases, or risk factors for disease
Wells score for PE… in more detail in another talk…
Treatment of illnesses supported by evidence for pneumonia, asthma, PE, AF etc
Interpretation of radiology best done with the clinical picture, so write good notes re clinical context and help the radiologist provide you with a report.
Your info + their expertise is a powerful tool.

25. Further cases
We are looking for clinical cases that can be de identified and used for learning
So, add those cases to your watchlist in BOSSNET,
This is a good way to discuss a clinical case with your supervisor at end of term appraisal, show off your good clinical notes
Write up 3-5 slides re the case history and them to
Part 3 of this talk goes on to discuss these cases…

26. Emergency Department HMO education series 2012
Excellent website
Emergency Department HMO education series 2012