Download Case 1 - BHS Education Resource

Case 1
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A 27 yr old woman who is 1 week postpartum presents complaining of chest pain.
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On further questioning pain is pleuritic
Associated with some breathlessness
No sputum, no fever, no trauma
No cardiac risk factors
On examination she is anxious, HR 100, RR
20, SaO2 97
Case 1
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CXR NAD
ECG sinus tachycardia
ABG pH 7.47 O2 80
CO2 35 HCO3 19
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What is your differential
diagnosis?
What is the most likely
diagnosis?
It is the 8am morning
handover, what are you
going to say and what
is your plan
DDX
 PE, pneumothorax, pneumonia,
Most likely – PE
Case 1 8am handover round – Using ISBAR
tool to handover
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Identity – Patient’s name, 27 yo female in Bay 12
Situation – Patient referred by GP, arrived by ambulance, and I think she
needs to have Pulmonary Embolism excluded
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Background – post partum
Assessment – features consistent with PE e.g sinus tachycardia, no
other diseases found, tests including CXR normal
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Request – I would like to organise a CTPA, and when the result is available,
refer to medical registrar if positive. If negative, I think could go home if stable and
pain settles.
I could discuss with the medical team before handing over to the next doctor, but the
CTPA result will define the management.
Case 1
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CT PA
Pulmonary embolism
confirmed
Management
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Referral to medical team
Consider testing for
predisposition to clots
Anticoagulation
Explain to patient
Follow up plan
Case 2
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A 45 yr old man presents with increasing
shortness of breath. He is hypoxic on room
air and unable to lie down. He has a past
history of chronic renal failure (on dialysis),
NIDDM, Hypertension and peripheral
vascular disease.
On examination he has signs of moderate
pulmonary oedema, he is pain free and
normotensive.
Image – describe this CXR
Case 2 questions
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What are the
appropriate initial
investigations
What are the likely
aetiologies of his
oedema
Who do you need to
speak to?
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Tests
Bedside
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Bloods
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What can be done in the
department?
Send these off, when
obtaining IV access
Radiology
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CXR, preferably in the
department
Questions 2
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The ECG shows no acute changes and the
patient is stable with a Sat of 93% on
Oxygen, bedside troponin is normal
What is the most appropriate management
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In emergency
Definitively
Discuss with the unit who looks after him, e.g the
renal unit, because after initial management of
potassium it is likely that urgent dialysis is what is
required.
Case 3
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A 19 yr old presents complaining of severe
shortness of breath after running around the
lake. He has a past history of similar
symptoms but they usually settle
spontaneously. On examination his RR is 30,
he is alert and orientated. Saturation on air
100%
What is the cause of his condition?
What will you look for on history and
examination?
History – sounds like asthma
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respiratory distress
precipitating factors
past asthma indicators
of severity
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life threatening events
ICU/ intubation
oral steroids in last 6/12
medications/smoking
other past history
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In addition to asthma,
what serious causes
should be considered?
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HOCM
Paroxysmal SVT or AF
Pneumothorax (not likely
given recurrent episodes
but always worth
considering)
Examination
Look for…
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Respiratory distress
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speech
use of accessory muscles
chest movement & air entry
wheeze duration and distribution more important
than volume
pneumothorax
signs of hypoxia
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agitation, confusion, cyanosis, coma
Investigations
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Bed side
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CXR only if suspect:
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PEFR
counting test
pneumothorax
pneumonia
severe disease
ABG
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if Sat<92% on RA
Management options
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Airway
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oxygen
BIPAP/CPAP
bronchodilators
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B agonists
anticholinergics
aminophylline
magnesium
ketamine
Management options
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steroids
What would you use in this case?
Mild exercise induced asthma
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B agonists via MDI & spacer
Inhaled or oral steroids
asthma plan and follow up
Where do you find asthma action plans?
What modes of delivery exist for B agonists
and what is their efficacy?
What are the side effects?
B agonists
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MDI & spacer
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droplets in critical size range
cheap
home same as hospital
nebuliser
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delivery depends on
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gas flow
volume
construction & maintenance
temperature
only 55% nebulised, 18% inhaled
B agonists
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intravenous
side effects
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tachycardia
tremor
hypokalaemia
hyperglucaemia
lactic acidosis
Case 4
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A 40 yr old male collapses in his home, he is
a business man and has recently returned
from a overseas business trip
On examination he is now conscious alert
HR 110 RR 20 BP 90/60 SaO2 90
Case 4
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CXR NAD
ECG sinus tachycardia,
RBBB, ST depression
V1, V2
Case 4
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ABG pH 7.35 O2 70
CO2 30 HCO3 17
The patient remains
hypotensive,
tachycardic and unwell
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The most likely
diagnosis is PE
The patient is referred
for a CTPA
What are the possible
outcomes from here?
Case 4
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the patient arrests in
the CT scanner
ECG shows sinus
rhythm pulse remains
non-palpable
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Outcomes of arrest
caused by PE.
http://www.ncbi.nlm.nih.
gov/pubmed/10826469
Case 5
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A patient presents with sudden onset of SOB that
woke him from sleep. He has no chest pain, but is
quite distressed and unable to lie flat and finds the
oxygen mask claustrophobic.
He has a past history of hypertension, smoking, no
history of ischaemic heart disease
O/E moderate to severe pulmonary oedema,
hypoxic on 6lt oxygen, hypertensive, agitated.
Case 5 questions
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What are the appropriate initial investigations
What are the likely causes for his pulmonary
oedema
What are the appropriate emergency
treatments
Case 6
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A 13 yr old with a past history of atopy, presents
with increasing SOB. She has had a URTI for the
last 3/7, and now has 1/7 of increasing SOB not
responding to home therapy. On examination she
has SOB at rest, marked wheeze, she is able to give
a limited history pausing frequently to breathe.
What other information do you require?
What is your assessment?
What is your initial therapy?
Case 6; Moderate asthma
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Further history
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treatment at home?
Normal treatment?
Past history asthma
indicators of severity
PEFR (normal PEFR)
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Who manages the
asthma?
Any asthma education?
Management
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Initial
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therapy B agonists 3
doses over 1/24
oral steroids
reassess
Asthma stickers in our
Emergency Department
what are the indications
for admission?
Moderate asthma admission
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PEFR <75% predicted on arrival
Sat < 92% on air 1/24 post therapy
PEFR < 60% predicted 1/24 post therapy
Case 7
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A 25 yr old with a history of mild asthma
presents from her work place after a minor
fire. She presents now with rapidly increasing
SOB. The ambulance have given her 4x
nebulisers of salbutamol in transit with little
relief. She is tachypneoic, tachycardic, quite
agitated and refuses to lie down to be
examined. She is unable to give any history
due to her dyspnoea
What is her diagnosis?
What further information do you require and
what is your management?
History
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current illness
baseline function important to assess management
& prognosis
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duration symptoms
risk factors
LFT & response to B agonists
maintenance therapy including steriods
normal activity levels
home oxygen
intercurrent illness
Examination
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accessory muscle use
cyanosis
hypoxia
precipitating factors
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infection
bronchospasm
LVF/IHD
sputum retention
what investigations?
Severe Asthma
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PEFR<40%
Sat <92% RA
ABG CO2 important indicator
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normo/hypercarbia indicator of exhaustion
management
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oxygen
continuous B agonist +/- ipratropium
intravenous steriods
monitor
 vitals,Sats,GCS
Severe asthma not responding
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intravenous B agonists
BIPAP/CPAP
?theophylline
Intubation
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Ketamine induction agent of choice
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bronchodilator
doesn’t reduce respiratory drive
Case 8
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A 60 yr old man presents with 1/52 of
increasing SOB. He has had a mild URTI for
10/7. He tells you he has had asthma for
many years, but the puffers don’t seem to
help much. He still smokes 20 cigarettes per
days and becomes annoyed when you
suggest that this will make his asthma worse.
What is his likely diagnosis?
Case 8 Investigations
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Saturation & PEFR
ECG looking for ischaemia
ABG
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useful to identify acute from chronic
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CXR if unwell to identify precipitants
FBE
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CO2  10mmHg - HCO3  1 upto 30mmol acute
CO2  10mmHg - HCO3  4 upto 36mmol chronic
WCC  infection or steroids
polycythaemia indicator of chronic hypoxia
What is your management?
Case 8
COAD management
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largely irreversible disease
small improvements may give significant
symptomatic relief
manage as per asthma
CO2 retainers
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rare loss of hypercapnic drive
low FiO2
NIPSV
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reduced work of breathing
improved V/Q
reduces incidence of intubation
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patients with poor pre-morbid function (FEV1<25%)
<50% weaned within 4 months
Additional therapies
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aminophylline
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theoretically good
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problems
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bronchodilator
respiratory stimulant
improves diaphragmatic function
pro-arrhythmic
no proven benefit over other therapies
what are your admission criteria?
COAD admit or discharge?
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depends on
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pre-existing disease
severity of exacerbation,
hypoxia
reversible precipitants
response to therapy
social & medical
supports
ability to return if
deteriorates
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Medical registrar may
see the patient hours
after you see them, late
at night, condition may
change.
“how far can you walk,
what activities of daily
living can you do/not
do?”
Case 9
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A 57yr old woman presents complaining of
chest pain and shortness of breath she is
currently under going chemotherapy for
breast cancer.
On examination she is febrile 38º , HR 110
RR 24 BP 95/60 SaO2 90
Case 9
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CXR LUL consolidation
ECG sinus tachycardia
ABG pH 7.35 O2 70
CO2 45 HCO3 22
Case 9
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you admit the patient
for treatment of her LUL
pneumonia, she
collapses in the toilet
unconscious
unresponsive
ECG shows sinus
rhythm without palpable
pulse
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This is Pulseless
Electrical Activity/EMD
arrest
Could the presentation
be due to PE?
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Yes
Can PE produce CXR
findings that mimic
pneumonia?
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Yes
Case 10
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A patient presents via ambulance with severe
central chest pain, agitation, SOB and
hypoxia on 10lt oxygen.
Examination reveals a very agitated,
distressed patient. He is hypoxic on high flow
oxygen, hypotensive and tachycardic.
The monitor shows ST elevation in lead 1
Questions
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What are the appropriate initial investigations
What is the likely diagnosis
What are the appropriate emergency
treatments
What is the appropriate disposition and
further management
Image gallery – describe and
give likely diagnosis
Diagnosis?
Diagnosis
Diagnosis
Describe this CXR
Emergency Department HMO education series
2012