Breathlessness, as defined by NICE, is “a subjective, distressing sensation of awareness of difficulty in breathing”. It is often divided, based on presentation, as acute, subacute or chronic.
It can also be divided, based on the system affected, into cardiac or noncardiac breathlessness.
Have a go at three more patient cases – good luck!
Reviewed by: awaiting review
Approach to the Patient with Breathlessness - Part One
Stem 1 of 4
A 52YOM presents to ED with acute shortness of breath. History is notable for “nearly blacking out Doctor” when the breathlessness commenced (20 minutes ago), recent discharge for elective surgery, and sharp inhalation-exacerbated chest pain. Ignoring the Oxford comma, of which there is an excellent Vampire Weekend song, he is pyrexic and tachycardic with normal blood pressure and PaO2 saturations.
Which is the best-matched differential in this patient?
Acute coronary syndrome
Acute pulmonary oedema
Stem 2 of 4Given your first answer choice, what is the most common symptom associated with this patient (NICE, 2021)?
Palpable-replicated chest pain
Pleuritic chest pain
Stem 3 of 4Which of the following would NOT suggest a CTPA should be your first line, or indeed definitive, investigation?
Stable, Well’s score 5
Unstable, Well’s score 6
Well’s score 2, D-Dimer positive
Well’s score 5, 4 years old
Well’s score 6, pregnant
Stem 4 of 4The patient undergoes CT pulmonary angiogram (CTPA) and a pulmonary embolism is confirmed. Two medications are started. Which are the more likely DUAL medications at this stage?
Stem 1 of 4
A 62YOF patient presents to ED with acute coughing, productive of green sputum, pyrexia and worsening difficulty in breathing subacutely. With a past diagnosis of COPD, she has been using her SABA and ICS inhalers, to decreasing effect, since the fever began four days earlier.
Which of the following is true of COPD medication? Select all that may apply.
Bronchodilators mostly agonise beta-2 adrenoceptors
SABA is often given as aerosolised powder or nebuliser
SABA duration is <5 hours
Formoterol duration is <12 hours
There are no licenced medications to reduce COPD progression
Stem 2 of 4Which are the top causes of this patient’s presentation generally?
Stem 3 of 4What is the most important treatment recommendation to improve quality of life in this patient?
Administer PDE inhibitor roflumilast
Escalate to oral corticosteroids
P38 mitogen-activated protein inhibitor
Provide anti-HDAC therapy
Stop smoking service referral
Stem 4 of 4The patient is stabilised and is screened for a vitamin deficiency. Which is most important in this demography?
Stem 1 of 4
A patient, with long-standing struggle to control primary hypertension and hyperlipidaemia, presents to the GP frustrated about having trouble sleeping. She has increased the number of pillows used because lying flat is “really making it hard to get my breath!”. There is an additional heart sound heard on auscultation, with changes to the lung bases from the norm.
Which added heart sound is more likely?
Stem 2 of 4The patient requires a full screening. Which of the following investigations would NOT be considered a first-line to order?
VO2 max test
Stem 3 of 4Which of the following is false about the investigation B-type natriuretic peptide?
<100ng/L rules out decompensated HF
Associated with asthma
Associated with COPD
Associated with left ventricular hypertrophy
Associated with pulmonary embolism
Stem 4 of 4The patient is started on captopril with significant lifestyle modifications. A second drug is added. Which of the list is most appropriate?
- AAFP – Approach to Dyspnoea – https://www.aafp.org/afp/2020/0501/p542.html
- BMJ Best Practice – https://bestpractice.bmj.com
- Crash Course Respiratory Medicine – Elsevier
- Jolliffe DA, Greenberg L, Hooper RL, et al Vitamin D to prevent exacerbations of COPD: systematic review and meta-analysis of individual participant data from randomised controlled trials Thorax 2019;74:337-345.
- Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020 Jan 21;41(4):543-603.
- NICE CKS – Breathlessness – https://cks.nice.org.uk/topics/breathlessness/
- Oxford Handbook of Clinical Medicine – OUP
- Radiology Info – https://www.radiologyinfo.org/en/pdf/safety-xray.pdf
- Rang, H., Ritter, J., Flower, R., Henderson, G. and Dale, M., 2016. Rang and Dale’s pharmacology. [Edinburgh etc.]: Elsevier, Churchill Livingstone.