SOB

Question 1

How is PE diagnosed?

Answer 1

-Immediate admission is required if patient is showing signs of haemodynamic instability (hypotension, shock, collapse) OR if pregnant / given birth in last 6 weeks
-Wells score estimates probability of PE
-Score >4 = PE likely

Question 2

What should be done for patients with a likely PE?

Answer 2

-If score >4 –> hospital admission –> immediate CTPA
-If score <4 –> D-dimer test
-Positive D-dimer –> CTPA
-Negative D-dimer –> consider alternative diagnosis
-ABG (but only abnormal in 80%)
-CXR and ECG to exclude other diagnoses
-VQ / perfusion scan if patient is pregnant
-Echo for those with hypotension (‘massive PE)
-Further investigations to exclude cancer in >40s eg CT TAP
NB if CTPA cannot be carried out immediately give LMWH

Question 3

How is a PE managed?

Answer 3

-Apixaban / rivaroxaban
-If not suitable, give LMWH followed by edoxaban / dabigatran after 5 days // vit K antagonist
-Mechanical options include: IVC filter, thrombolysis

Question 4

What ECG findings are common in PEs?

Answer 4

-Sinus tachy (most common)
-RBBB
-AF
-S1Q3T3 - deep S wave in lead 1, a q wave in lead 3, and a deep T wave in lead 3

Question 5

How does a COPD exacerbation present?

Answer 5

-Acute dyspnoea
-Wheeze
-Crackles and wheeze on auscultation
-Increased work of breathing ie use of accessory muscles, pursed lip breathing, intercostal recession
-Productive cough
-Cyanosis
-Confusion

Question 6

How are COPD exacerbations classified?

Answer 6

-Mild = FEV1 >80% predicted
-Moderate = FEV1 50-80%
-Severe = FEV1 30-50%
-Very severe = FEV1 <30%

Question 7

How would you investigate a COPD exacerbation?

Answer 7

-PEFR
-CXR (expect to see hyperinflation, consolidation, RVH)
-ABG (expect to see respiratory acidosis due to T2RF)
-FBC, U+Es
-ECG (RVH due to right heart strain)
-Sputum cultures
-Blood cultures if pyrexic

Question 8

How would you manage a patient with a COPD exacerbation?

Answer 8

COSICAARRR
-Controlled Oxygen
-Salbutamol (5mg nebuliser)
-Ipratropium (bronchodilator, 0.5mg nebuliser)
-Corticosteroids - prednisolone 30mg PO / hydrocortisone 100mg IV
-Antibiotics
-Aminophylline (consider)
-Radiography CXR
-Respiratory support (BiPAP if high CO2 and persistent respiratory acidosis >1hr after treatment starting)
-Refer

Question 9

What examination findings would you expect in a patient with pulmonary oedema?

Answer 9

-Often severe dyspnoea and distress
RESP
-Tachypnoeic, tachycardic
-May be cyanosed / unable to talk if severe
-Fine inspiratory creps / wheeze on auscultation
CARDIO
-Evidence of decreased cardiac output (sweaty, cool peripheries, pale)
-Raised JVP
-Heart murmurs on auscultation

Question 10

What are the typical features and causes of cardiogenic pulmonary oedema?

Answer 10

FEATURES:
-LHF results in increased LV end-diastolic pressure –> increased pulmonary capillary pressure –> fluid collects in extravascular pulmonary tissues
CAUSES:
-An acute complication of: MI, IHD
-An exacerbation of: pre-existing CVD eg HTN, aortic/mitral valve disease
-Other causes: arrhythmias, failed prosthetic valves, VSD, cardiomyopathy, negatively inotropic drugs, acute myocarditis

Question 11

What are the features and causes of non-cardiogenic pulmonary oedema?

Answer 11

FEATURES:
-May occur in absence of increased pulmonary pressure
-Can be due to:
–Increased capillary permeability
–Decreased plasma oncotic pressure
–Increased lymphatic pressure
CAUSES:
-ARDS
-Intracranial causes
-IV fluid overload
-Hypoalbuminaemia
-Toxins
-Smoke inhalation
-Near drowning
-High altitude sickness

Question 12

What investigations should you order for someone presenting with pulmonary oedema?

Answer 12

Commence treatment before completing investigations
-Cardiac monitor
-SpO2
-ECG (check for LAD, LVH, LBBB, recent/current MI)
-Bloods (U+Es, glucose, troponin, ABG if sats<94)
-CXR (A-F)

Question 13

How would you manage a patient with pulmonary oedema?

Answer 13

-High flow oxygen
-GTN if BP<90
-IV furosemide 50mg
-Morphine if required
-?Catheter to monitor output
-?ICU if in cardiogenic shock

Question 14

What features would you expect to note in varying severities of an acute asthma exacerbation?

Answer 14

MODERATE = PEFR 50-75% predicted, speech normal
SEVERE = PEFR 33-50% predicted, can’t complete sentences, RR>25, HR>110
LIFE-THREATENING = PEFR<33%, sats <92, silent chest, cyanosis, bradycardia

Question 15

What drug treatment should be commenced for an asthma exacerbation?

Answer 15

-Salbutamol 5mg nebs with o2
-Ipratropium 500mcg nebs with o2
-Steroids either:
–IV hydrocortisone 200mg
–Oral prednisolone 40mg
-Magnesium sulphate 2g IV (senior)

Question 16

What other non-pharmacological management should be done for asthma exacerbations?

Answer 16

-Positioning (sit up)
-Give high flow O2 15L via reservoir mask
-FBC, U+Es, glucose, CRP
-Check trachea and chest for signs of pneumothorax
-Consider blood cultures if ?sepsis
-ABG