Your SlideShare is downloading. ×
Case Presentation Aaron Sibley PGY 3 Emergency Medicine
Objectives: <ul><li>Learn two “take-home” messages. </li></ul><ul><li>Help us all look as smart as Rob 2  . </li></ul><ul>...
“Take-home” Messages: <ul><li>“Not all that wheezes is asthma” holds for young to middle aged adults too. </li></ul><ul><l...
Case: <ul><li>The setting: RAH (newer and better smelling ‘B’ side), Friday night, working with “The Sos”. </li></ul><ul><...
Case con’t 2: <ul><li>As you arrive at the bedside, the nurse says that the patient has a history of asthma, that he drove...
Case con’t 3: <ul><li>A: talking in rapid sentences, no stridor.  </li></ul><ul><li>B: RR 23, sats 98% 10L nonrebreather, ...
Case con’t 4: <ul><li>The nurse is at the bedside waiting for direction, R2: Do you take a more compete Hx first then deci...
Treatment/Investigations: <ul><li>R3:  What tx, what tests/investigations? </li></ul><ul><li>Answer: Tx: 3 back-to-back ma...
History: <ul><li>Pt describes 20 year hx of asthma, dx’d by family doc. </li></ul><ul><li>Last 3 months getting worse, ver...
History: <ul><li>Questions? </li></ul><ul><li>No fever, + dry cough, very wheezy last 3 days. </li></ul><ul><li>No CP/HTN/...
Results: labs/investigations: <ul><li>Please describe this  CXR , what potential complication if Asthma are we worried abo...
CXR: Back
ABG: <ul><li>7.22/79/88/30.9 </li></ul><ul><li>Acidosis, respiratory (acute roughly 10/1 compensation. Chronic 10/3.5) </l...
Summary of Pt: <ul><li>44 year old male, 20 yr hx of asthma,35 pk year smoker, increased SOB in exertion last month, 3 day...
Why not Asthma?: <ul><li>1) Hypoxia </li></ul><ul><li>2) CO2 level </li></ul><ul><li>3) Heavy smoker </li></ul>
Asthma Differential Diagnosis: <ul><li>R2: What is the Dif Dx of Acute Asthma exacerbation? </li></ul><ul><li>COPD </li></...
What Cognitive Errors? <ul><li>Anyone: Name 3 cognitive errors that were made in this case? </li></ul><ul><li>1) Diagnosis...
Course in Hospital: <ul><li>ICU consulted in case pt progressed to Intubation {art line placed for repeat gases q 2h while...
Pulmonary Function Tests: Back FEV1 1.51L (36% pred) FVC 3.4L (65% pred) FEV1/FVC (44%) 1. FEV1>=70% predicted : Mild 2. F...
Questions?
“Take-home” messages: <ul><li>“Not all that wheezes is asthma” holds for young to middle aged adults too. </li></ul><ul><l...
Upcoming SlideShare
Loading in...5
×

Case Presentation (Resp Distress C O P Datypical)

6,157

Published on

Case Presentation (Resp Distress C O P Datypical)

1 Comment
2 Likes
Statistics
Notes
  • lots more @ http://NurseReview.org
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
6,157
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
0
Comments
1
Likes
2
Embeds 0
No embeds

No notes for slide

Transcript of "Case Presentation (Resp Distress C O P Datypical)"

  1. 1. Case Presentation Aaron Sibley PGY 3 Emergency Medicine
  2. 2. Objectives: <ul><li>Learn two “take-home” messages. </li></ul><ul><li>Help us all look as smart as Rob 2 . </li></ul><ul><li>Have fun with an interesting case. </li></ul>
  3. 3. “Take-home” Messages: <ul><li>“Not all that wheezes is asthma” holds for young to middle aged adults too. </li></ul><ul><li>COPD can occur in young to middle aged adults. </li></ul><ul><li>Bonus: Recognize potential cognitive errors early and avoid. </li></ul>
  4. 4. Case: <ul><li>The setting: RAH (newer and better smelling ‘B’ side), Friday night, working with “The Sos”. </li></ul><ul><li>From the desk: a forty something, tall, thin Black male, tripod in bed, diaphoretic, rapid laboured breathing-nurse at side. </li></ul><ul><li>R1: a) Sick or not sick? b) Initial actions? </li></ul><ul><li>Answers: a) Sick. b) ABCs/IV O 2 monitor. </li></ul>
  5. 5. Case con’t 2: <ul><li>As you arrive at the bedside, the nurse says that the patient has a history of asthma, that he drove himself to the ED, and that his sats were 70% at triage. </li></ul><ul><li>You ask the patient “Do you have asthma, does this feel like your asthma, what brought it on?”. </li></ul><ul><li>The patient states that he has had asthma for 20 years, this is the worst time, and that he got a cold from his 2 daughters 3 days ago and has been getting wheezier and more SOB since. </li></ul>
  6. 6. Case con’t 3: <ul><li>A: talking in rapid sentences, no stridor. </li></ul><ul><li>B: RR 23, sats 98% 10L nonrebreather, breath sounds- increased exp phase (R1 what is normal ratio of insp to exp?) and wheezes throughout, + accessory muscle use, trachea midline, no sub cut emphysema. </li></ul><ul><li>C: P 70, BP 138/93, PPP. </li></ul><ul><li>D: GCS 15, pupils PERL x2. </li></ul><ul><li>E: Temp 36.4 Celsius. </li></ul>
  7. 7. Case con’t 4: <ul><li>The nurse is at the bedside waiting for direction, R2: Do you take a more compete Hx first then decide on tx/investigations, or do you make decisions now with little info? </li></ul><ul><li>Answer: Get things started early with sick patients, don’t worry about over investigating, tx takes time to initiate and you can cancel when more info available. </li></ul>
  8. 8. Treatment/Investigations: <ul><li>R3: What tx, what tests/investigations? </li></ul><ul><li>Answer: Tx: 3 back-to-back masks (Ventolin 5mg/Atrovent 500ug), IV steroids (125mg Methylprednisilone), MgSO 4 (2g over 20 mins) Inv/tests: CBC,Lytes, BUN/Cr, CXR (portable), EKG, ABG, peak flow. </li></ul>
  9. 9. History: <ul><li>Pt describes 20 year hx of asthma, dx’d by family doc. </li></ul><ul><li>Last 3 months getting worse, very SOB walking up 1 flight stairs, emptying ventolin puffer q 1wk. </li></ul><ul><li>Caught URI from daughters 3 days ago, since getting +++ SOB, 50 puffs ventolin/day- put off coming in until couldn’t breathe. </li></ul>
  10. 10. History: <ul><li>Questions? </li></ul><ul><li>No fever, + dry cough, very wheezy last 3 days. </li></ul><ul><li>No CP/HTN/heart troubles, mild HA, no PE risk factors. </li></ul><ul><li>Meds: ventolin prn, Allergies: none (no environmental). </li></ul><ul><li>PMed Hx: Cocaine use 10 years ago, 35 pk year hx, no ICU/intubations, no ED visits. </li></ul><ul><li>Vocation: DJ, singer. </li></ul><ul><li>Fam Hx: father died from emphysema in 40s. </li></ul>
  11. 11. Results: labs/investigations: <ul><li>Please describe this CXR , what potential complication if Asthma are we worried about? </li></ul><ul><li>Answer: Large volumes, flat diaphragms, no focal pathology. Pneumothorax. </li></ul><ul><li>Please explain this ABG ? The patient did not respond well to initial tx, what treatment might this prompt you to start/think about? </li></ul><ul><li>Answer: ?Acute on chronic resp acidosis. Bipap (pt tolerated full face well and started to feel better in mins). </li></ul>
  12. 12. CXR: Back
  13. 13. ABG: <ul><li>7.22/79/88/30.9 </li></ul><ul><li>Acidosis, respiratory (acute roughly 10/1 compensation. Chronic 10/3.5) </li></ul><ul><li>Expected comp is increase in bicarb 3.9 if acute 10.5 if chronic </li></ul>Back
  14. 14. Summary of Pt: <ul><li>44 year old male, 20 yr hx of asthma,35 pk year smoker, increased SOB in exertion last month, 3 day hx URTI and severe SOB, on exam hypoxic but normal LOC, CXR shows hyperinflation, Blood gas resp acidosis (acute on chronic), minimal response to bronchodilators/Mg/steroids, significant improvement with Bipap. </li></ul><ul><li>R4: Is this asthma? Why or why not? </li></ul>
  15. 15. Why not Asthma?: <ul><li>1) Hypoxia </li></ul><ul><li>2) CO2 level </li></ul><ul><li>3) Heavy smoker </li></ul>
  16. 16. Asthma Differential Diagnosis: <ul><li>R2: What is the Dif Dx of Acute Asthma exacerbation? </li></ul><ul><li>COPD </li></ul><ul><li>Anaphylaxis </li></ul><ul><li>Foreign Body Aspiration </li></ul><ul><li>IV Drug induced (Talc lung), non IV (ACE) </li></ul><ul><li>Cardiac Asthma </li></ul><ul><li>Vocal cord paralysis </li></ul><ul><li>Pulmonary embolis </li></ul>
  17. 17. What Cognitive Errors? <ul><li>Anyone: Name 3 cognitive errors that were made in this case? </li></ul><ul><li>1) Diagnosis momentum </li></ul><ul><li>2) Symptom cueing </li></ul><ul><li>3) Anchoring </li></ul>
  18. 18. Course in Hospital: <ul><li>ICU consulted in case pt progressed to Intubation {art line placed for repeat gases q 2h while on Bipap (full face)} </li></ul><ul><li>ICU suggests COPD…..what test did ICU ask to be ordered? </li></ul><ul><li>Based on mild improvements in gases (pH and CO 2 ), Pulmonary also consulted. Pt started on Levofloxacin, remained on Bipap 3 days on Pulm ward. </li></ul><ul><li>PFTs showed severe obstructive lung disease. CT Chest mod. centrilobular emphysema. </li></ul><ul><li>Pt D/C’d home in stable condition (ABG 7.43/55/57/30.9), educated about smoking cessation, started on combivent, po steroids. </li></ul>
  19. 19. Pulmonary Function Tests: Back FEV1 1.51L (36% pred) FVC 3.4L (65% pred) FEV1/FVC (44%) 1. FEV1>=70% predicted : Mild 2. FEV1=50-69% predicted : Moderate 3. FEV1<50% predicted : Severe
  20. 20. Questions?
  21. 21. “Take-home” messages: <ul><li>“Not all that wheezes is asthma” holds for young to middle aged adults too. </li></ul><ul><li>COPD can occur in young to middle aged adults. </li></ul><ul><li>Bonus: Recognize potential cognitive errors early and avoid. </li></ul>

×