64 year old man with 5 days of breathlessness

adam presented an interesting case of a man with a 90 pack-year history of smoking and a short history of breathlessness


we discussed the most likely causes, namely LVF [secondary to something], COPD and pneumonia


as there was little evidence for these conditions, we pursued other diagnoses, eg PE, anaemia [secondary to something] and cancer


we discussed the distinction between massive and peripheral PE, including examination & ECG features of right heart strain


here is the classical SI QIII TIII, taken from ABC of clinical electrocardiography, which is a useful resource [we should have mentioned AF as a common ECG presentation of PE]

he also briefly mentioned hypercoaguability, something worth knowing about

adam it would be good if you could upload an anonymous image of his acute ECG & the most relevant CTPA image [with arrows if possible]


homework generated included:


- causes of breathlessness [kumar & clark, harrisons, cecils, cheese & onion, medicine at a glance and beck et al were mentioned as things to read - paul dilworth's lecture is also a possibility - eric beck is a PDS tutor at the whitt & basically invented the MRCP - very good clinician, co-author diana holdright is one of your cardiology consultants]
- causes of metabolic acidosis
- wells score (or geneva score) for DVT/PE


most important, it is vital to follow this chap up to see what happens to him - this is the only way to get a full picture of what is going on

breathlessness in a 72 year old man

saaid presented a case of an elderly gentleman [did we get his ethnicity? - see previous post] with a short-ish history of breathless, and a significant history of past PEs


we reviewed the aetiology of SOB, dividing them into hyper-acute, acute and chronic causes


an systematic division (cardiac, respiratory, chest wall, neurological, haematological etc) was also noted


we noted that diagnosis of PE is best based on a formal scoring system, eg wells & geneva, and that clinical features of PE & alternative diagnoses are part of the score [there are data showing the appropriate use of scoring leads to fewer repeat events, eg roy et al 2006]

this gentleman had emboli confirmed on CTPA


we briefly discussed investigation, in particular examination, CXR & ECG findings. we did not look at D-dimers or VQ scans - he was severely hypoxic but not retaining C02


we briefly discussed LMWH, warfarin, thrombolysis & embolectomy as therapies

[as an aside this gentleman had a troponin of 0.2 - is this significant?]

i mentioned the algorithm in davidson's 21e as being useful


as lessons, we raised the following issues, amongst others:


- presenting patients/summarising patients
- ABGs
- causes SOB
- NYHA classes
- investigation PE


as action points, we endeavored to:


- list causes aortic regurg
- find out how not to kill patients presenting with a sickle chest crisis
- improve our skills in ABG interpretation by finding a good learning resource & looking at patients' results
- find out if there is a NICE guideline on PE (i don't think so - the is a BTS guideline)
- review Dr Dilworth's lecture on SOB
- read various bits of Kumar & Clark, Baliga [not only is he a professor in ohio, he also has an MBA!] 
- review Medicine at a Glance
- see more patients with PE
- follow up our patient