1. 4MB Clinical Problem-Solving Dr. Gerard Flaherty Dept. of Medicine

2. 68-yr old ♂ Presenting Complaint: Shortness of Breath

3. History of Presenting Complaint Acute or chronic? Severity? Exercise tolerance? Orthopnoea? Paroxysmal nocturnal dyspnoea? Diurnal variation? Cough…productive? Fever? Chest pain? Haemoptysis? Swollen legs? Weight loss? Back pain? PR bleeding? Occupational history

4. New York Heart Association Classification of Dyspnoea Grade 1No dyspnoea Grade 2Dyspnoea on moderate exertion Grade 3Dyspnoea on mild exertion Grade 4Dyspnoea at rest

5. Physical Examination Heart rate Rhythm Pulse volume Pulse character Raised JVP +ve Pemberton’s sign Cyanosis Clubbing Hyperinflated chest Chest expansion Percussion note Breath sounds Bronchial breathing Crackles Wheeze Pleural rub Peak flow Sputum pot Murmurs (AS, MS, TR) Loud P2? Pale mucous membranes

6. Congestive cardiac failure

7. Pneumothorax

8. Superior Vena Cava Obstruction

9. Investigations Pulse oximetry Chest radiograph Arterial blood gas Electrocardiogram Echocardiogram Full blood count D-Dimers V-Q scan Pulmonary function tests High resolution CT Thorax Sputum culture/cytology/AFB Pleural aspirate ESR/HLA-B27 (?Ankylosing spondylitis) Anti-AchR antibodies

10. Pericardial Effusion

11. Differential Diagnosis Cardiac Left ventricular failure Pulmonary oedema Dilated cardiomyopathy Mitral valve disease Aortic stenosis Arrhythmias Pericardial effusion Respiratory Pulmonary embolism Pulmonary fibrosis Lung tumour Pneumonia Pneumothorax Pleural effusion Asthma COPD Bronchiectasis Lung collapse Primary Pulmonary Hyprtension Metabolic Metabolic acidosis Anaemia Thyrotoxicosis Psychogenic hyperventilation Neuromuscular Kyphoscoliosis Ankylosing spondylitis Muscular dystrophy Poliomyelitis Myasthenia gravis Guillain-Barré syndrome

12. Right Middle Lobe Pneumonia

13. Lung Abscesses

14. Clinical Indicators of Severe Community-acquired Pneumonia 1. Age >60 2. RR >30/min 3. Diastolic BP <60 4. Atrial fibrillation 5. Confusion 6. Immunosuppression 7. Raised urea 8. Leukopenia or severe leukocytosis 9. Hypoalbuminaemia 10. PaO 2 <8kPa

15. Causes of Haemoptysis Pneumonia Bronchiectasis Lung Abscess Tuberculosis Aspergilloma Pulmonary embolus Bronchogenic carcinoma Goodpasture’s syndrome Pulmonary contusion A-V malformation Hereditary haemorrhagic telangiectasia Bleeding disorder Epistaxis Mitral stenosis

16. Pleural Effusions Transudate Protein <30 g/l Cardiac failure Constrictive pericarditis Hypoalbuminaemia Meig’s syndrome SVC obstruction Hypothyroidism Liver failure Exudate Pneumonia Bronchogenic carcinoma Pulmonary infarct Rheumatoid/SLE Dressler’s syndrome Sarcoidosis Renal failure Acute pancreatitis Subphrenic abscess Oesophageal rupture

17. Pulmonary Function Tests Obstructive defect FEV 1   FVC  FEV 1 /FVC <70% RV  TLC  KCO (CO transfer factor)  Restrictive defect FEV 1  FVC   FEV 1 /FVC >80% RV  TLC  KCO 

18. Emphysema

19. Pulmonary Fibrosis

20. Back pain, shortness of breath, sore eyes…give the diagnosis.