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The Breathless Patient – A clinical approach

The Breathless Patient – A clinical approach. Graeme Mattison FY1 Transplant Surgery. Contents. History Examination CXR Interpretation Cases & Questions. Surgical Sieve: Breathlessness. Cardiovascular. Respiratory. Haematological (anaemia). (Misc). Causes of Breathlessness.

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The Breathless Patient – A clinical approach

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  1. The Breathless Patient – A clinical approach Graeme Mattison FY1 Transplant Surgery

  2. Contents • History • Examination • CXR Interpretation • Cases & Questions

  3. Surgical Sieve: Breathlessness Cardiovascular Respiratory Haematological (anaemia) (Misc)

  4. Causes of Breathlessness • Cardiovascular • Congestive Cardiac Failure • Acute LVF • Aortic Stenosis • Mitral Regurgitation • (Cor Pulmonale) • Respiratory • COPD • Lung Fibrosis • Asthma • Pneumonia • Lung Cancer • Pneumothorax • Sarcoidosis • TB

  5. History Taking • Introduce yourself + ask for permission to take a history. Always start with an open question! • E.g. “I understand you’ve been feeling breathless, could you tell me more about that please?” • Let the patient do the work! • Not “So you’re breathless. Any chest pain? Any fevers? Any palpitations? Any cough?” etc etc

  6. Questions to Ask Cardiovascular Respiratory • Chest Pain • SOCRATES • Cough/Sputum • Palpitations • Ankle Swelling • Exercise Tolerance • Blackouts • Cough/Sputum • Fever + Travel Hx • Pleuritic Chest Pain

  7. Common Medications on the ward Cardiovascular Respiratory • Beta-blockers • Bisoprolol (and other “lol”s) • ACE inhibitors • Ramipril (and other “pril”s) • Ca-channel blockers • Amlodipine, nifedipine, verapamil • Diuretics • Furosemide • Bendroflumethiazide • Short-acting Beta-agonists • Salbutamol, terbutaline • Combination Inhalers • Seretide • Salmeterol + Fluticasone • Spiriva • Formoterol + Budesonide • Steroids • Prednisolone

  8. To Finish Up Your History • Past Medical History • Drugs and Allergies • Family History • Social History • Smoking • Alcohol • Occupation • ICE • “What worries you most about your breathing?” • “Is there anything you feel the hospital could be doing for you that they currrently aren’t?” • ...now move onto examination!

  9. First and Foremost... • WIPE! • W – wash your hands (obviously) • I – introduce yourself if not done already • P – permission & position • 45o for a cardio/respiratory exam...comment on this! • E - explanation • Don’t describe EVERYTHING you are going to do...! • A concise description will suffice

  10. INSPECT! • Be really particular about this...stand at the end of the bed and say “From the end of the bed I can notice...” • Oxygen – if patient has oxygen attached, measure the volume going through/the Venturi mask concentration • Inhalers – which ones are they? • Salbutamol • Beclomethasone • Seretide • Symbicort (white) • Sputum Pot – if there is one, offer to look in it • Respiratory Rate – approx...are they comfortable? • Now is a good time to ask the patient if they are comfortable and if you can start the examination • (Bonus points for patient relationship)

  11. General Examination • Hands: • Finger Clubbing? • Tar Staining? • Tremor? (Think salbutamol) • Peripheral Cyanosis? • CO2 retention flap? (Asterixis) • Q1. What are the respiratory causes of finger clubbing? • Carcinoma of the bronchus • Chronic Suppurative Lung Disease • Cystic Fibrosis, Bronchiectasis, Empyema, Lung Abscess • Idiopathic Pulmonary Fibrosis • Congenital Cyanotic Heart Disease (Think SOB)

  12. General Examination: • Pulse: • Bounding may suggest chronic CO2 retention • Collapsing pulse seen in AR, slow-rising pulse in AS • Blood Pressure • Eyes: • Conjunctival Pallor • Xanthelasma • Oral mucosa • Central cyanosis • JVP • Think corpulmonale/congestive cardiac failure/SVC obstruction • Lymph Node Examination: • Offer both cervical AND axillary!

  13. Now onto the actual chest... • INSPECT! • Scars: • Thoracotomy, median sternotomy • Swellings: • Hyperexpansion of the chest wall, lymphadenopathy (esp Virchow’s Node) • Deformities: • Pectus Excavatum • Pectus Carinatum

  14. Palpation • FIVE things in palpation: • Trachea • AWAY from TENSION pneumothorax/ LARGE pleural effusion • TOWARDS lung collapse • Chest Expansion • Equal on both sides? • Good volume expansion? • Apex Beat • Determine position – where is it anatomically? • Palpable Thrills • Tactile Vocal Fremitus

  15. Apex Beat • Located at the 5th intercostal space, on the mid-clavicular line • Usually just below the left nipple in men • Consent when examining women! • Displaced in: • 1) LVH • 2) COPD • 3) Dextrocardia (!)

  16. Percussion • Compare right to left, and remember... • DULL – consolidation • STONY DULL – effusion • Stony dull is like percussing a table or something really thick

  17. Auscultation: Cardiovascular

  18. Auscultation: Respiratory • Listen to: • Apices • Upper Zone • Middle Zone • Lower Zone • Infra-axillary Zone • When listening to the back, get patient to cross arms to prevent blocking of air sounds by scapulae • Sounds of the Chest: • Crackles – Consolidation (infection/malignancy) • Expiratory wheeze – Obstructive Airways Disease • Fine inspiratory crackles – Pulmonary Fibrosis • Coarse crackles – Bronchiectasis • Absent/severely reduced – Pleural Effusion • There are others but unless you’re a respiratory SpR don’t bother with them!

  19. To complete my assessment I would... • 1) Inspect the lower limbs • 2) Ask to see a recent ECG • 3) Ask to see a recent peak flow chart • 4) Inspect a recent CXR • 5) Thank the patient for letting me examine them!

  20. And now a practical demonstration!

  21. Chest X-Ray Interpretation

  22. Chest X-Ray Interpretation • Where to begin...? • If you like acronyms, try CIRPA • C: Complete: is the entire field visible? • I: Idenitification: Who’s CXR is it?? Do we have the right person? • R: Rotation: is the CXR well-rotated? • P: Penetration: is it a well penetrated CXR? • A: Any technical concerns? (E.g. Wrong way round!)

  23. Then it’s a simple case of ABC! (and d and e...) • ABCDE • Airway • Tracheal deviation – tension pneumothorax/large pleural effusion • Obstruction • Breathing • Lung fields – increased shadowing, masses • Apices – anything in there? Think TB/Pancoast tumour • Hyperinflated chest? (Should see 6 anterior + 10 posterior ribs) • Costophrenic angles - ?effusions

  24. Now CD and E • Circulation • Heart - ?cardiomegaly (NB AP film can be misleading!) • Diaphragm • Right side higher than left • Look UNDER the diaphragm too - ?bowel obstruction, ?perforation, ?hiatus hernia • Everything else • Fractures (NB rib fractures can cause SOB!) • Soft tissue swelling/subcutaneous emphysema

  25. Thank you for listening! • Try to do one of the following: • Go to AM1/AM2 • FY1s there are great (Aliya/Sanna/Caroline) • Shadow a Dr Hardy ward round • 2) Practice exams in pairs or groups of 3 • Go through cases afterwards + give feedback Any questions, feel free to contact me: g.mattison@doctors.org.uk

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