🤔 MEDIUM

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!

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Approach to the Patient with Breathlessness - Part One

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Question 1

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?
A
Acute coronary syndrome
B
Acute pulmonary oedema
C
Cardiac arrhythmia
D
Community pneumonia
E
Pulmonary embolism
Question 1 Explanation: 
Any suspicion of PE should undergo a modified Well’s score (defeats internist gestalt on peer-reviewed literature). A score of greater than four indicates a high risk for PE and CTPA is indicated as the definitive first line investigation to confirm. Should the score be lower than four, a D-Dimer (fibrin degradation product) should be commenced ± a PERC (pulmonary embolism rule-out criteria). The memorisation of these scales is NOT the idea at medical school, rather they are designed to be cognitive adjuncts, removing the work of having to remember core things. So learn what the results mean, and when they should be undertaken.
Question 2

Stem 2 of 4

Given your first answer choice, what is the most common symptom associated with this patient (NICE, 2021)?
A
Dyspnoea
B
Palpable-replicated chest pain
C
Pleuritic chest pain
D
Tachycardia
E
Tachypnoea
Question 2 Explanation: 
Any acutely breathless patient should be ?PE as a major ddx. All of the above are common presentations of PE, however acute dyspnoea (DIB) is associated with PE the most often (aside from DIB, the rest score no higher than 30% of incidence, however DIB gets 50%). 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. Thanks to BMJ Best Practice for the reference.
Question 3

Stem 3 of 4

Which of the following would NOT suggest a CTPA should be your first line, or indeed definitive, investigation?
A
Stable, Well’s score 5
B
Unstable, Well’s score 6
C
Well’s score 2, D-Dimer positive
D
Well’s score 5, 4 years old
E
Well’s score 6, pregnant
Question 3 Explanation: 
A pulmonary embolism is a medical emergency oftentimes, with upward of 30-50% mortality, often out-of-hospital. Although a CT pulmonary angiogram contains a high dose of radiation (to put this into perspective, it is 10-12mSV of radiation which is equivalent to four years of “natural” background exposure to the normal environment on earth), it is a vital and definitive test in many cohorts. You will visualise the thrombus directly occluding the pulmonary system. PE should be contraindicated, unless less radiating means are not optional, in young adults and those who have low Well’s scores.
Question 4

Stem 4 of 4

The 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?
A
Alteplase
B
Clopidogrel
C
Dalteparin
D
Rivaroxiban
E
Unfractionated heparin
Question 4 Explanation: 
It is recommended that UFH is the first line for the ?PE patient. This should further include thrombolysis therapy with alteplase. UFH is an antithrombin III activator, ensuring lysis of factors Xa and IIa to “bust the clot”. Further, alteplase is a tissue plasminogen activator, converting the zymogen into plasmin to break down fibrin and form fibrin degradation products (of which one is the infamous D-Dimer). It is classic practice in the UK for UFH to be stopped after 24 hours and the patient placed on long-term OAC (usually a DOAC).
Question 5

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.
A
Bronchodilators mostly agonise beta-2 adrenoceptors
B
SABA is often given as aerosolised powder or nebuliser
C
SABA duration is <5 hours
D
Formoterol duration is <12 hours
E
There are no licenced medications to reduce COPD progression
Question 6

Stem 2 of 4

Which are the top causes of this patient’s presentation generally?
A
Haemophilus influenzae
B
Moraxella catarrhalis
C
Mycoplasma pneumoniae
D
Staphylococcus aureus
E
Streptococcus pneumoniae
Question 6 Explanation: 
HI, MC, SP are the top three bacterial causes of acute exacerbation of COPD. MP is also a cause, but atypical. Do not forget the respiratory viruses that can also cause problems here (eg rhinovirus, RSV etc).
Question 7

Stem 3 of 4

What is the most important treatment recommendation to improve quality of life in this patient?
A
Administer PDE inhibitor roflumilast
B
Escalate to oral corticosteroids
C
P38 mitogen-activated protein inhibitor
D
Provide anti-HDAC therapy
E
Stop smoking service referral
Question 7 Explanation: 
Stopping smoking is the best thing a patient can do to improve outcomes. There are, however, no licenced therapies in the UK currently to improve progression of COPD or halt the destructive inflammation. It seems that COPD is more resistant to steroid therapy than asthma - with complex epigenetic theories postulated as causes.
Question 8

Stem 4 of 4

The patient is stabilised and is screened for a vitamin deficiency. Which is most important in this demography?
A
Vitamin A
B
Vitamin B1
C
Vitamin B9
D
Vitamin C
E
Vitamin D
Question 8 Explanation: 
All patients needing hospitalisation following acute COPD exacerbation should be screened for vitamin D deficiency. Data suggest that supplementation of vitamin D for those deficiency reduces severity and frequency of exacerbations. This has led to calls for shielding persons during the 2019-21 COVID19 pandemic to take vitamin D supplementation (though data for this specific use-case is lacking, it isn’t anticipated to cause harm). 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.
Question 9

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?
A
S1
B
S2
C
S3
D
S4
E
S5
Question 9 Explanation: 
S3, heard after S2, is representative of an overfilled heart from dilation (representing a major Framingham criteria for heart failure).
Question 10

Stem 2 of 4

The patient requires a full screening. Which of the following investigations would NOT be considered a first-line to order?
A
Blood glucose
B
BNP
C
BUN
D
Cardiac MRI
E
Creatinine
F
CXR
G
ECG
H
Electrolytes
I
FBC
J
LFT
K
TFT
L
TTE
M
VO2 max test
N
Walking test
Question 10 Explanation: 
First line labs for heart failure are so high-yield I use SHERBET to remember them: Sugar (BCG), haem (FBC, haematemics), ECG, Echo, RFT, BNP, Electrolytes (Ca, Mg), effusion (CXR), TFT.
Question 11

Stem 3 of 4

Which of the following is false about the investigation B-type natriuretic peptide?
A
<100ng/L rules out decompensated HF
B
Associated with asthma
C
Associated with COPD
D
Associated with left ventricular hypertrophy
E
Associated with pulmonary embolism
Question 12

Stem 4 of 4

The patient is started on captopril with significant lifestyle modifications. A second drug is added. Which of the list is most appropriate?
A
Carvedilol
B
Chlorothiazide
C
Furosemide
D
Hydralazine
E
Isosorbide dinitrate
Question 12 Explanation: 
Carvedilol is the first line beta-blocker, with proven superiority to metoprolol (though the jury is still out in studies as to whether it is superior to other cardioselective beta blockers). It is widely known that ACEi ± BB combo reduces morbidity and mortality uniquely in heart failure. Loop diuretics would be indicated in patients with fluid retention history, combined with ACEi and a beta blocker. A second line consideration could be a thiazide as listed above. If a patient is intolerant of ACEi and ARB, a combination of both hydralazine and ISDN can be administered to improve mortality - but this is getting into the weeds, and far too down-the-line for our patient here.
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There are 12 questions to complete.

References

 

  1. AAFP – Approach to Dyspnoea – https://www.aafp.org/afp/2020/0501/p542.html
  2. BMJ Best Practice – https://bestpractice.bmj.com
  3. Crash Course Respiratory Medicine – Elsevier
  4. 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.
  5. 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.
  6. NICE CKS – Breathlessness – https://cks.nice.org.uk/topics/breathlessness/
  7. Oxford Handbook of Clinical Medicine – OUP
  8. Radiology Info – https://www.radiologyinfo.org/en/pdf/safety-xray.pdf
  9. Rang, H., Ritter, J., Flower, R., Henderson, G. and Dale, M., 2016. Rang and Dale’s pharmacology. [Edinburgh etc.]: Elsevier, Churchill Livingstone.

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