4MB Clinical Problem-Solving

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4MB Clinical Problem-Solving

• Dr. Gerard Flaherty
• Dept. of Medicine

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68-yr old ? Presenting Complaint Shortness of
Breath
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History of Presenting Complaint

• Acute or chronic?
• Severity?
• Exercise tolerance?
• Orthopnoea?
• Paroxysmal nocturnal dyspnoea?
• Diurnal variation?
• Coughproductive?

• Fever?
• Chest pain?
• Haemoptysis?
• Swollen legs?
• Weight loss?
• Back pain?
• PR bleeding?
• Occupational history

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New York Heart Association Classification of
Dyspnoea

• Grade 1 No dyspnoea
• Grade 2 Dyspnoea on moderate exertion
• Grade 3 Dyspnoea on mild exertion
• Grade 4 Dyspnoea at rest

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Physical Examination

• Heart rate
• Rhythm
• Pulse volume
• Pulse character
• Raised JVP
• ve Pembertons 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

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Congestive cardiac failure
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Pneumothorax
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Superior Vena Cava Obstruction
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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

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Pericardial Effusion
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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

• Metabolic
• Metabolic acidosis
• Anaemia
• Thyrotoxicosis
• Psychogenic hyperventilation
• Neuromuscular
• Kyphoscoliosis
• Ankylosing spondylitis
• Muscular dystrophy
• Poliomyelitis
• Myasthenia gravis
• Guillain-Barré syndrome

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Right Middle Lobe Pneumonia
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Lung Abscesses
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Clinical Indicators of Severe Community-acquired
Pneumonia

1. Age gt60
2. RR gt30/min
3. Diastolic BP lt60
4. Atrial fibrillation
5. Confusion
6. Immunosuppression
7. Raised urea
8. Leukopenia or severe leukocytosis
9. Hypoalbuminaemia
10. PaO2 lt8kPa

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Causes of Haemoptysis

• Pneumonia
• Bronchiectasis
• Lung Abscess
• Tuberculosis
• Aspergilloma
• Pulmonary embolus
• Bronchogenic carcinoma

• Goodpastures syndrome
• Pulmonary contusion
• A-V malformation
• Hereditary haemorrhagic telangiectasia
• Bleeding disorder
• Epistaxis
• Mitral stenosis

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Pleural Effusions

• Transudate
• Protein lt30 g/l
• Cardiac failure
• Constrictive pericarditis
• Hypoalbuminaemia
• Meigs syndrome
• SVC obstruction
• Hypothyroidism
• Liver failure

• Exudate
• Pneumonia
• Bronchogenic carcinoma
• Pulmonary infarct
• Rheumatoid/SLE
• Dresslers syndrome
• Sarcoidosis
• Renal failure
• Acute pancreatitis
• Subphrenic abscess
• Oesophageal rupture

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Pulmonary Function Tests

• Obstructive defect
• FEV1 ? ?
• FVC ?
• FEV1/FVC lt70
• RV ?
• TLC ?
• KCO (CO transfer factor) ?

• Restrictive defect
• FEV1 ?
• FVC ? ?
• FEV1/FVC gt80
• RV ?
• TLC ?
• KCO ?

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Emphysema
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Pulmonary Fibrosis
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Back pain, shortness of breath, sore eyesgive
the diagnosis.