ED training
Respiratory/
patient with dyspnea Part 2
Dr Jaycen Cruickshank
September 2012
Respiratory - dyspnea
Learning objectives
The respiratory session will examine contrasting clinical cases of dyspnoea that will illustrate the
principles of diagnostic reasoning. lmportant physical findings that help discriminate different
causes of dyspnoea will be discussed along with appropriate initial investigations.
Learning objectives
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Be able to describe the differences and similarities in the medical history, physical examination
and investigations of common or life threatening causes of dyspnoea.
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To manage asthma and pneumonia using best practice guidelines
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To be able to use the Wells score & PERC rule in diagnosis of PE
Pre reading
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Hughes T & Cruickshank J. Adult Emergency Medicine at a Glance. Chichester, West Sussex, UK
: John Wiley & Sons, 2011. Chapter 36 Shortness of breath. Chapter 7 Blood gas analysis.
Other learning resources
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Relevant clinical clinical guidelines at Ballarat Health Services:
Refer to ED lecture series and self directed
workbooks
Case C Female in her 60’s
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Sudden onset SOB (present
now for 1 hour, quite
severe) Right sided pleuritic
chest pain
Mild fever
Right total knee
replacement 3 days ago,
persistent leg swelling since
then
Non smoker
No previous
cardio/respiratory disease
No injury
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In the pre reading cases we
had young patients with
sudden or gradual onset of
dyspnea.
The differential diagnosis is
different in older patients.
The differential diagnosis is
also different in patients
with known respiratory
illness, with an
exacerbation…
Emergency Department HMO education series
2012
What is the differential
diagnosis?
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Most likely
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PE
Pneumonia
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Less likely
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Pneumothorax
Arrhythmia
AMI
Emergency Department HMO education series
2012
On examination & tests
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Not too unwell but clear
evidence of tachypnoea
and some  WOB
RR 24, T 37.6, HR 110, BP
110/70
Sats 93% RA
Chest clear with normal
percussion and normal
breath sounds
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CXR normal
ABG pH 7.5/CO2
30mmHg/p02 62mmHg on
RA
What test(s) will you
perform
Most likely diagnosis?
Emergency Department HMO education series
2012
What can you see?
Emergency Department HMO education series
2012
Case D Woman in 60’s
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Progressive SOB over 6
months, worse over 24
hours
Chronic cough
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Usually with white sputum
now worse with change in
sputum amount and colour
Associated fever
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How does this change your
thinking compared to the
first 3 cases?
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Age
Pre existing diseases
Slow onset
Some orthopnoea
Heavy smoker (35 pack
years)
Emergency Department HMO education series
2012
Differential diagnosis
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Chronic obstructive
pulmonary disease
(COPD) with acute
infective exacerbation
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Less likely
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CCF with acute
exacerbation
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Anaemia
Neuromuscular
conditions
Anxiety
Emergency Department HMO education series
2012
Exam & investigations…
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Unwell, RR 26, T 37.8, HR
90 SR, BP 140/80
Sat’s 88% RA
Evidence of  work of
breathing and use of
accessory muscles (which
are these?)
Signs of hyperinflation
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ABG pH 7.28/pCO2 60/pO2
55/HCO3 26
What do these show?
Acute Type II respiratory
failure
CXR
Barrel chest,  chest
expansion, hyper-resonant
percussion
Prolonged expiration with
wheeze
Emergency Department HMO education series
2012
CXR
Emergency Department HMO education series
2012
Diagnosis
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Infective exacerbation of COPD with acute
respiratory failure
Treatment
Bronchodilators, controlled oxygen,
corticosteroids, antibiotics, Non Invasive
Ventilation (NIV)
Emergency Department HMO education series
2012
What if this was the CXR?
Emergency Department HMO education series
2012
Case E Male in 60’s, with progressive SOB
over 6 months, worse over 24 hours
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Further history
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Orthopnoea, Paroxysmal
nocturnal dyspnoea
(PND), SOA. All present
to a minor degree over
the 6 months but worse
for 24 hours
Palpitations (last 24
hours)
Previous AMI 4 years
ago, pace maker
Ex-smoker, Hypertension
(HT), diabetes
How does this change
your diagnostic
reasoning compared to
the last case?
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Quite a few clues point to
cardiac….
 Heart Failure
 Arrhythmia
 Acute myocardial
infarct/angina
 COPD
 Anaemia
Emergency Department HMO education series
2012
Examination
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Unwell looking with increased work of breathing
RR 26, afeb, HR Irreg 130, BP 100/70
Sat 90% RA
JVP 5cm
SOA ++
Displaced apex beat, no cardiac murmurs, 3rd heart
sound present
Normal chest expansion but stony dull percussion in
the bases (R>L), bilateral inspiratory crepitations
just above the dull areas
Emergency Department HMO education series
2012
ECG – what is your diagnosis?
Cardiac failure
Emergency Department HMO education series
2012
Case E Diagnosis
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Long standing heart failure with an acute
exacerbation due to new onset rapid AF
Treatment of AF, & heart failure
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Antithrombotic strategy
Then rate control
Perhaps rhythm control
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See review article re AF treatment
To be published early 2013 Australian Rural Doctor
Emergency Department HMO education series
2012
What else should I ask?
Travel history…
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Other important symptoms of respiratory
disease
Cough
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Acute
Chronic
Haemoptysis (cancer, TB, other infections)
Chest Pain
Daytime sleepiness (obstructive sleep apnea)
Emergency Department HMO education series
2012
Image gallery – e.g radiology
First slide with image /question
Image gallery – e.g radiology
First slide with image /question
Image gallery – e.g radiology
First slide with image /question
Image gallery – e.g radiology
First slide with image /question
Image gallery – e.g radiology
First slide with image /question
Summary of learning
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Diagnosis of the breathless patient requires you to
look for clues…
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The time course of the illness
Associated symptoms
Known diseases, or risk factors for disease
Wells score for PE… in more detail in another talk…
Treatment of illnesses supported by evidence for
pneumonia, asthma, PE, AF etc
Interpretation of radiology best done with the clinical
picture, so write good notes re clinical context and
help the radiologist provide you with a report.
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Your info + their expertise is a powerful tool.
Further cases
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We are looking for clinical cases that can be de
identified and used for learning
So, add those cases to your watchlist in BOSSNET,
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This is a good way to discuss a clinical case with your
supervisor at end of term appraisal, show off your good
clinical notes
Write up 3-5 slides re the case history and email them to
jaycenc@bhs.org.au
Part 3 of this talk goes on to discuss these cases…
Excellent website
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http://lifeinthefastlane.com/2009/11/a-classicrespiratory-case/
Emergency Department HMO education series
2012