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“ I Can ’ t Breathe! ”

Introduction to Clinical Medicine II January 3, 2013 Andrew M. Luks, MD Associate Professor Division of Pulmonary and Critical Care Medicine. “ I Can ’ t Breathe! ”. Go to www.rwpoll.com and enter the following number: ______. This Talk Will Employ Audience Response. 1.

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“ I Can ’ t Breathe! ”

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  1. Introduction to Clinical Medicine II January 3, 2013 Andrew M. Luks, MD Associate Professor Division of Pulmonary and Critical Care Medicine “I Can’t Breathe!”

  2. Go to www.rwpoll.com and enter the following number: ______ This Talk Will Employ Audience Response 1 Press “Join Session” 2 Press “Continue” (do not sign in) 3

  3. ICM II: Shortness of Breath DISCLOSURE STATEMENT Aside from the fact that he really enjoys clinical medicine, Dr. Luks has no commercial, non-commercial, or institutional financial interests or personal financial relationships to disclose regarding the material presented in this lecture. rwpoll.com Session ID: _____

  4. The Objectives For Today’s Lecture Review how to gather historical information from a patient with acute dyspnea Review how the physical exam can help narrow your differential diagnosis Put these concepts together in the context of actual patient scenarios

  5. What Do You Know Already? Heart failure Asthma Diaphragmatic paralysis Arteriovenous malformation Morbid obesity A patient presents complaining of dyspnea that is worse when standing compared to lying down. Which of the following diagnoses could cause this? rwpoll.com Session ID: ______

  6. Let’s Start By Defining The Clinical Entity Acute Dyspnea: Shortness of breath that develops over a period of minutes to a few days

  7. Patients Will Use Many Phrases For Dyspnea “Hard to breathe” “Can’t get enough air” “I’m really winded” “My chest feels tight” Patients often have trouble being more specific; Cultural and language differences also play a role

  8. ? What is the differential diagnosis for a patient presenting with acute dyspnea?

  9. The Differential Diagnosis For Acute Dyspnea

  10. History

  11. An Approach To The History C O Characterize Onset A L Aggravating Location R D Relieving Duration T Treatments These elements define the patient’s problem and are the starting point for your written or oral assessment S Severity

  12. Rapidity of Onset Matters Which items in this list can cause sudden onset of dyspnea (versus over hours to days)?

  13. The Narrower Differential Of Sudden Onset Dyspnea * Onset can be rapid in flash pulmonary edema, slower in other cases ** Onset will be rapid with an airway foreign body

  14. Orthopnea Platypnea Important Aggravating / Relieving Factors What is the differential for these symptoms?

  15. Differential Diagnoses ForOrthopnea and Platypnea Orthopnea Heart Failure Diaphragmatic Paralysis Asthma Obesity Platypnea Intrapulmonary shunt (e.g., AVM) Intracardiac shunt Hepatopulmonary syndrome

  16. Treatments That Patients May Have Tried Inhalers Antibiotics Oral corticosteroids Increased diuretic dose Increased supplemental oxygen

  17. Assessing The Severity Of Dyspnea Exit “Can you walk from “X” to the door?”

  18. Other Questions To Assess Severity “How do you feel sitting here at rest?” “What activities were you able to do today?” “Did you walk in from your car?”

  19. Important Associated Symptoms

  20. Risk Factor And Exposure History Is Key Examples of Pulmonary Embolism Risk Factors Immobility Hypercoagulability Recent pelvic or lower extremity surgery or trauma Pregnancy Examples of Other Important Exposures Toxic exposure at work Smoke inhalation Submersion incident Large dust exposure

  21. Case Number 1 60 year-old man with a 50 pack-year history of smoking presented to the ER with a 2-3 day history of dyspnea, left upper quadrant abdominal and left lower chest pain. He reported cough productive of yellow sputum, increased relative to his baseline but denied fevers, hemoptysis or lower extremity edema. His other history is noteworthy for hypertension and drinking a six-pack of beer per day.

  22. What Is The Leading Item On Your Differential For Patient #1 • COPD Exacerbation • Pneumonia • Large pleural effusion • Pulmonary edema • Myocardial infarction

  23. Case Number 2 63 year-old man with a history of asthma was brought in by the medics after developing marked dyspnea at the grocery store. He reported 3-4 days of worsening dyspnea that was not improved with his albuterol inhaler. He denied fevers, chest pain or hemoptysis but reported orthopnea and a cough with occasional pink-tinged whitish sputum. He has used tobacco for over 40 years.

  24. What Is The Leading Item On Your Differential For Patient #2 • Asthma Exacerbation • Pneumonia • Whole lung collapse • Pulmonary edema • Pulmonary embolism

  25. Case Number 3 56 year-old man documented COPD presents to the ER with increasing dyspnea. He had been feeling poor for about a week and not getting around as much as normal. He has dyspnea at exertion at baseline but had a sudden, significant increase in symptoms earlier in the day. He has left-sided pleuritic chest pain but denies, fever, cough or sputum production.

  26. What Is The Leading Item On Your Differential For Patient #3 • COPD Exacerbation • Pneumonia • Pneumothorax • Myocardial infarction • Pulmonary embolism

  27. Examination

  28. Don’t Forget To Use These Tools Visual cues inform you about the severity of the problem and whether you need to start managing the issue while you are still sorting out the diagnosis.

  29. Get A Look At The Pulse Oximeter And Other Vitals Severe abnormalities will lead you to manage the the patient while you pursue a diagnosis

  30. You Will Gather A Lot By Listening* As Well “Your… patient… may…be speaking… like… this… trying to… catch… their breath… in between words…” “Or… they may be speaking in complete sentences without having to pause to catch their breath.” * Without your stethoscope

  31. The Components Of A Complete Lung Exam Percussion Auscultation Tactile Fremitus Voice Sounds

  32. Prolonged Expiration? Crackles, Wheezes? Vesicular or Bronchial? The Components Of A Complete Lung Exam Percussion Auscultation Tactile Fremitus Voice Sounds

  33. The Components Of A Complete Lung Exam Percussion Auscultation Egophany? Tactile Fremitus Bronchophony? Voice Sounds Whispered Pectoriloquy?

  34. What Do You Expect To Find: Pneumothorax Percussion: Tactile Fremitus: Auscultation: Other:

  35. What Do You Expect To Find: Pleural Effusion Percussion: Tactile Fremitus: Auscultation: Other:

  36. What Do You Expect To Find: Large Pneumonia Percussion: Tactile Fremitus: Auscultation: Other:

  37. What Do You Expect To Find: COPD Exacerbation Percussion: Tactile Fremitus: Auscultation: Other:

  38. What Do You Expect To Find: Pulmonary Embolism Percussion: Chest CT Tactile Fremitus: PE Auscultation: Other:

  39. What Do You Do Once The Exam Is Completed EKG CXR Other laboratory studies

  40. Let’s Go Back To The Patient Cases

  41. Synopsis: 60 year-old man with a 2-3 day history of dyspnea, chest pain and cough productive of yellow sputum. Back To Case Number 1 • His Exam: • Appearance: moderate respiratory distress • Percussion: dull at the left base • Auscultation: bronchial breath sounds at left base. Prolonged expiratory phase • Other: Increased tactile fremitus on the left

  42. Now What Is The Leading Item On Your Differential For Patient #1 • COPD Exacerbation • Pneumonia • Large pleural effusion • Pulmonary edema • Myocardial infarction

  43. Case Number 1 Synopsis: 60 year-old man with a 2-3 day history of dyspnea, chest pain and cough productive of yellow sputum. The Patient’s Imaging (not shown so as not to spoil the surprise (and learning) The Diagnosis:

  44. Synopsis: 63 year-old man with asthma and marked increase in dyspnea not responsive to inhaled albuterol. Back To Case Number 2 • His Exam: • Appearance: severe respiratory distress • Percussion: resonant throughout • Auscultation: crackles in bilateral lung fields, mildly prolonged expiratory phase, no wheezes • Other: no egophany

  45. Now What Is The Leading Item On Your Differential For Patient #2 • Asthma Exacerbation • Pneumonia • Whole lung collapse • Pulmonary edema • Pulmonary embolism

  46. Case Number 2 Synopsis: 63 year-old man with asthma and a marked increase in dyspnea not responsive to inhaled albuterol. The Patient’s Imaging (not shown so as not to spoil the surprise (and learning) The Diagnosis:

  47. Synopsis: 56 year-old man with COPD and a sudden increase in dyspnea after a week of feeling poor. Back To Case Number 3 • His Exam: • Appearance: Tachypneic but unlabored. • Percussion: hyper-resonant throughout • Auscultation: diminished breath sounds in all lung fields. Prolonged expiratory phase • Other: No egophany

  48. Now What Is The Leading Item On Your Differential For Patient #3 • COPD Exacerbation • Pneumonia • Pneumothorax • Myocardial infarction • Pulmonary embolism

  49. Case Number 3 Synopsis: 56 year-old man with COPD and a sudden increase in dyspnea after a week of feeling poor. The Patient’s Imaging (not shown so as not to spoil the surprise (and learning) The Diagnosis:

  50. The Take-HomeMessages

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