Flashcards in ILA 5: Shortness of breath Deck (11)
You are the Foundation doctor in Medicine for the day. You are asked to review a 28 year old man in Resus who has come in via the paramedics with sudden onset of dyspnoea.
What is your differential diagnosis?
- Respiratory: Asthma acute exacerbation (unlikely in 28 year old), pneumothorax, pneumonia, PE, lobar collapse, inhaled foreign body
- Cardiac: acute heart failure, MI (unlikely in 28 yr old), arrhythmia (e.g SVT)
- Other: anaphylaxis
Patient is responsive but unable to give history due to severe SOB. His ABC is as follows:
Airway- patent, no stridor, but unable to speak in full sentences.
Breathing – RR 40/min, accessory muscle use, tracheal tug, bronchial breathing right upper zone, no wheeze, dull to percussion right upper zone. Rest of the chest sounds normal. SaO2 = 89%
Circulation – HR = 123bpm, BP = 89/40, CRT = 4 sec, sweaty, clammy and flushed, cool peripheries.
a) What are you concerned about and what practical measures can you take?
b) What investigations would you like to do?
a) Low SpO2:
Signs of shock:
a) Shock is defined as a state of cellular and tissue hypoxia due to reduced oxygen delivery, increased demand or inadequate oxygen utilization. It is usually due to circulatory failure and hypotension.
b) Distributive, hypovolaemic, cardiogenic, obstructive
a) What types of oxygen mask do you know?
b) What type of oxygen mask is a non-rebreathe mask?
c) What percentage oxygen are you delivering to a patient if you give 15l/min oxygen via a non-rebreathe mask with a reservoir bag?
His eyes open to voice, he is obeying commands and he is managing occasional incoherent words. What is his GCS?
Paramedics tell you that he has had a dry cough for 1 week and has had right sided chest pain worse on inspiration. He has recently returned from a holiday clubbing in Ibiza. He flew back into the country two weeks ago. He smokes about 10/day.
No family contactable at this stage. GP surgery closed.
a) Pneumonia (poss. atypical), lobar collapse, acute exacerbation of asthma, pneumothorax, PE
- CXR: shows right upper zone consolidation, no pneumothorax, no pleural effusions, no alveolar oedema, no Kerley-B lines
- ECG: hows a sinus tachycardia, normal axis, no ST changes
- ABG (on 15l/min Oxygen):
pH 7.33, PaO2 7.9, PaCO2 3.72, HCO3- 18.0, BE -5, Lactate 3
- Describe the findings for each investigation.
a) Possible R-sided lobar collapse and/or pneumonia. Rules out heart failure or pneumothorax.
b) Likely non-cardiac
c) Hypoxia without hypercapnia (T1RF) even in spite of 15L oxygen, metabolic acidosis with high lactate (?sepsis)
The rest of the blood results arrive:
- FBC: Hb 128, WCC 21 (Neutrophils 17), Platelets 157
- Clotting: APPT 50.6 secs, PT 16 secs, Fibrinogen 8.3
- UEs: Na 124, K 4.1, Urea 15.1, Creatinine 250
a) What are the abnormalities in the blood results?
b) What is the likely diagnosis?
d) What further investigations / procedures would you like to do?
a) - FBC: leukocytosis (neutrophilia)
- Clotting: raised APTT/PT and low fibrinogen
- UEs: hyponatraemic, ?AKI
b) Sepsis secondary to legionella pneumonia, causing DIC and hyponatraemia
c) ABx: macrolide +/- cipro
d) Sputum culture and L. pneumophila urinary antigen test. Notify PHE?
When you return to the patient to take blood cultures you reassess his response to treatment.
He is still short of breath. Respiratory rate 40/min with SpO2 91% on 15L of O2 via mask with reservoir.
Despite fluid bolus he remains tachycardic and hypotensive.
a) What treatment should you give?
b) How can you escalate oxygen therapy?
c) What should you do if no response to fluid?
d) Where should this patient be managed?
The patient is admitted to HDU / ITU and after invasive monitoring is sited is started on an infusion of Noradrenaline to achieve a mean arterial blood pressure of 65 mmHg.
a) What is Mean Arterial Blood Pressure?