Shortness of Breath in the ER
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1 Shortness of Breath in the ER October 27 th,2017 Stéphane Léveillé CD Physician Assistant ER & OR Kirkland & District Hospital
2 Disclosure I attest that my presentation will provide a balanced view of therapeutic options and will be entirely free of promotional bias. that neither I nor my spouse has a current financial relationship with the grantor and/or any commercial interest(s) that may have a direct interest in the subject matter of the CPD program.
3 Overview Different Cases of Shortness of Breath seen in the Emergency Shortness of Breath 1. Determine the severity of the Shortness of breath, 2. Distinguish the source (Cause) of the shortness of breath, 3. Understand the evidence for various treatments for acute shortness of breath, 4. Don t judge a books by it s cover Elderlies are more fragile Not because they are young means they are healthy.
4 Overview
5 Case Study 03 March 78 year old female, Healthy, Triage: Presents to the Emergency department with the primary complaint of cough X 3 weeks, clear mucous expectorant, increase Shortness of Breath with exertion, not sleeping well, sore back from coughing. Tried Benelyn syrup yesterday with no relief. Past Medical History: Hypothyroidism Allergies: Sulfa Surgical Tape Vitals: Blood pressure 181/103, Pulse 91, Temperature 35.3, Respiratory Rate 20 Oxygen saturation 95% room air Repeat vitals: BP 161/86, P 80, O2 sat 96% room air
6 Case Study Assessment: 78 year old female, cough X 3 weeks, began with chest cold and head aches, mild fever resolved, light cough present, had sinus congestion resolved, ribs sore with cough, denies Chest pain. Exam: Well, Blood pressure up slightly, No respiratory distress chest good no wheezing, no crackles, congested Cardio Vascular System Normal, no murmurs Plan: Biaxin 500mg BID X 7 days, Return if not resolving Discharge Diagnosis: Upper Respiratory Infection (URI)
7 Case Study Returned 28 March 78 year old female, seen in ER March 3 rd Triage: Complaining of Short of Breath for a few weeks but today feeling much worse, was on antibiotic for chest infection, finished on March 10 th, was Prescribed a new puffer last week but not helping. Past Medical History: Hypothyroidism Allergies: Sulfa Surgical Tape Vitals: BP 191/116, P 138, T35.8, RR 30, O2 sat 94%
8 Case Study Assessment: 78 year old female presented to Emergency Department with a main complaint of Shortness of Breath for the past few weeks but has been getting some back discomfort since yesterday. This morning when she was walking out to the vehicle she had some increase shortness of breath and decide to come to the Emergency Department. The patient was put on antibiotic March 3 rd and had taken all of the antibiotics. Also, the patient is on a puffer but states that it does not appear to be helping her at this time. Past Medical History: Hypothyroidism HTN Past Surgical History: Uterine Prolapse, Cystocele Vaginal Hysterectomy Left Mastectomy (Carcinoma) Left Breast biopsy (no malignancy) Family History: Father died of lung cancer Brother died of Leukemia
9 Social History: Live at home with husband Retire Secretary Non smoker Alcohol Has a glass of wine at supper with her meal Exam: Ear, nose and throat Normal Heart Irregular heart rhythm, no murmurs heard Respiratory good air entry left lung field - decrease air entry right lung field - No wheezing or crackles heard No pitting edema lower limbs Investigation: Chest Xray Blood work: CBC, Lytes, BUN, Cr, BS, Trop, LFT s, INR, PTT, Ca++, Mg+, Phosphate Electrocardiogram
10 Electrocardiogram
11 Chest X-Ray
12 Chest X-Ray
13 Laboratory Investigations Hematology WBC 8.8 RBC 4.62 Hgb 140 Plt Count 348 Chemistry Na 129 K+ 4.5 Cl 95 Urea 5.9 GFR 89 Cr 57 Glu 7.1 Ca Phos 1.22 Mg GGT 118 AST 37 ALT 43 Alk Phos 144 Trop 0.01 Coagulation INR 1.1 aptt 28
14 WHAT S NEXT
15 What is next: 1. New onset Atrial Fibrillation 2. Pleural effusion right lung 3. Blood work is Normal with mild elevation in the liver function test GGT 118 Alk Phos 144 Plan: Intravenous Catheter Medication: Metoprolol 5mg IV Furosemide 20mg IV Investigation: Computed Tomography (CT) Scan of chest Admit to Hospital
16 C.T Scan Look at the CT Scan here.
17 Chest Tube
18 Lateral view
19 Admission to Hospital Put on Beta blocker (Bisoprolol), Levonox. Current medication: Coversyl, Synthroid Transferred to Sudbury to see Specialist 5 April Thoracic surgeon - Repeat CT: Chest, Abdomen and Pelvic - Bronchoscope - Thoracoscope - Biopsy Oncology consult - Metastatic Adenocarcinoma (Ovarian)
20 Conclusion Case Study 78 year old female Metastatic Adenocarcinoma (Ovarian) Treatment : Palliative systemic treatment with Chemo therapy.
21 Any Question
22 Case Study #2 9 June 43 year old Male, otherwise Healthy, Triage: Presents to the Emergency department with the primary complaint of Shortness of breath for the past weeks, no expectorant, increase Shortness of Breath with exertion, not sleeping well. Recently had surgery, right hip replacement on June 6 th, post motorcycle accident. Past Medical History: Healthy Age 4, Broke right Femur, Tibia and Fibula Past Surgical History: 2013 Right Hip replacement 1998 Right shoulder labrum tear, AC tear 1997 Left Knee - Meniscal tear 1994 Right elbow Bursectomy Family History: Father decease age 41 Mining accident
23 Case Study #2 Social History: Married 20 years 3 children at home Smoker 1PK/Day 30 years Alcohol Occasion Drugs - None Medication : Xeralto post operation and Tylenol #3, PRN Allergies: Penicillin Vitals: Blood pressure 107/74, Pulse 63, Temperature 36.6, Respiratory Rate 18 Oxygen saturation 97% room air
24 Case Study #2 Assessment: 43 year old male, complaint increase shortness of breath and chest pain. Describes it as a squeezing pain in the center of the chest. It is non-radiant, not associated with sweating but breathlessness. Denies fever, chills. Pain lasting for hours. Exam: Ear, nose and throat Normal Heart regular heart rhythm, no murmurs heard Respiratory good air entry bilat - No wheezing or crackles heard No pitting edema lower limbs Investigation: Chest Xray Blood work: CBC, Lytes, BUN, Cr, BS, Trop,, INR,D-Dimer
25 Chest X-Ray
26 Laboratory WBC 7.3 RBC 3.43 Hgb 101 Plt Count 147 Na 138 K+ 3.6 Cl 100 Urea 4.5 Cr 78 EGFR 94 Glu 7.8 CK 987 Trop 0.01 INR 1.4 D-Dimer 987
27 Case Study #2 Diagnosed: SOB NYD Plan - Discharged home - Felt unwell for about a week and then the symptoms improved IS THIS IT.NOT
28 Case Study #2 28 July 43 year old Male, otherwise Healthy, Triage: Presents to the Emergency department with the primary complaint of Shortness of breath, increase shortness of breath on exertion. not sleeping well. Denies fever, chills or cough Past Medical History: Healthy Age 4, Broke right Femur, Tibia and Fibula Past Surgical History: 2013 Right Hip replacement 1998 Right shoulder labrum tear, AC tear 1997 Left Knee - Meniscal tear 1994 Right elbow Bursectomy Family History: Father decease age 41 Mining accident uncle on mother s side with Cardiomegaly Unknown Grand Mother (mother s side) sudden death, Cardio infact.
29 Case Study #2 Social History: Married 20 years 3 children at home Smoker 1PK/Day 30 years Alcohol Occasion Drugs - None Medication : Xeralto post operation and Tylenol #3, PRN Allergies: Penicillin Vitals: Blood pressure 110/72, Pulse 72, Temperature 35.6, Respiratory Rate 28 Oxygen saturation 95% room air
30 Case Study #2 Assessment: 43 year old male, complaint increase shortness of breath and shortness of breath on exertion. Describes it as a squeezing in the center of the chest. It is nonradiant, not associated with sweating but breathlessness. Denies fever, chills. Exam: Ear, nose and throat Normal Heart regular heart rhythm, no murmurs heard Respiratory good air entry bilat - No wheezing or crackles heard No pitting edema lower limbs Investigation: Chest Xray Blood work: CBC, Lytes, BUN, Cr, BS, Trop,, INR,D-Dimer
31 Chest X-Ray
32 Laboratory Every test was normal, with the exception of the D-Dimer which was 2160 WHAT NEXT. Computed Tomography Scan (CT) Pulmonary Angio Report: revealed no definite evidence for a pulmonary embolus. There was mediastinal adenopathy. Uncertain significance. No evidence of pleural effusion, pneumothorax or pneumonia.. Cardiac Echo Report: Left ventricle enlargement 72mm and left atrium 54mm Ejection fraction 28
33 Specialist Internal Medicine Consult - Shortness of breath most likely to a viral cardiomyopathy. - Start medication 40mg Furosemide, Digoxin and slow K 2 tabs od. - Urgent referral to Cardiologist Mount Sinai Toronto. Cardiologist Consult - Admit to Intensive Care Unit (1 week). - Testing during admission - Muga Heart scan (multiple-gated acquisition) Nuclear imaging : EF 24% - MRI (Magnetic Resonance Imaging) : Negative, nil acute - Angiogram : Negative - All blood work : Negative
34 Specialist Diagnosis of Congestive Heart Failure Most likely due to virus Cardiologist treatment Furosemide 180mg IV daily Bisoprolol 5mg po daily Digoxin mg po daily Spironolactone 25mg po daily Coversyl 8mg po daily Discharged from Hospital ICD Implantable Cardioverter Defibrillator Furosemide 120mg po daily Bisoprolol 5mg po Bid Digoxin mg po daily Spironolactone 25mg po daily Coversyl 8mg po daily
35 Conclusion Case Study Patient is 5 years post insertion of ICD - Check-up - Having unsustain V.T (no shock) - Mild SOBOE - EF 22% - Continues with daily activities - Cardiologist - Genetic testing done + - Family members tested - Son has the Gene - Sister and her 2 daughters have Gene - At risk for sudden death
36 Conclusion 1. Not all shortness of breath are simple as a common cold 2. Always expect the worst in Shortness of breath 3. Don t treat the age, treat the condition and acuteness 4. Symptoms can be sneaky, be careful, not because they are SOB mean that they have a lung issue, it can also be cardiac.
37 Questions & Discussion
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