Sarah. 58 year old factory worker

Transcription

1 Sarah 58 year old factory worker

2 Presentation 58 year old factory worker who presents to your office with progressive dyspnea over 6 months Background history of treated breast cancer and risk factors for cardiovascular disease. Preliminary findings and observations as in your package What is your Differential Diagnosis for this presentation?

3 Presentation 58 year old factory worker who presents to your office with progressive dyspnea over 6 months Background history of treated breast cancer and risk factors for cardiovascular disease. Preliminary findings and observations as in your package What is your Differential Diagnosis for this presentation?

4 Dyspnea Impaired Oxygen Intake Poor Oxygen Uptake High Altitude Upper Airway Bronchial Alveoli Malfunction of Thorax Impaired Hgb Deficiency Obstruction Infection Pulmonary Edema Respiratory Muscle Paralysis Heart Failure Anemia Infection Asthma Emphysema Thoracic Deformities Shunts CO Toxicity Inflammation Foreign Body Pulmonary Fibrosis PA Stenosis Methemoglobinemia Trauma Bronchiectasis Cystic Fibrosis Pulmonary Infarction Sulfemoglobinemia Allergies Infection (Pneumonia) Emboli Cyanide Infiltration (Cancer) Cobalt Differential Diagnosis Dyspnea Compression Pneumothorax Hydrothorax Abdominal Distension

5 Assessment Given the Differential Diagnosis you have developed: What key questions do you wish to ask? What are the key physical examination features you wish to explore?

6 Directed Clinical Assessment Upper Airway Obstruction History Trouble getting breath in Better in cold air Inspiratory stridor Pharyngeal edema Physical Infection Asthma Heart failure Pulmonary Embolism Pulmonary malignancy Anemia Fever Productive cough Pleuritic chest pain Prior history On medications Can t get air out Known cardiac disease Progressive onset Orthopnea PND Prior history Coagulopathy Pleuritic chest pain Known history Recent chemo or radiotherapy Known history Recent blood loss Nutritional history Appears septic Signs of consolidation Wheezes Pulmonary rales Edema Jugular venous distension Cardiomegaly Gallop rhythm Pulmonary hypertension Ascites, organomegaly Deep Vein thrombosis Nodes Pleural or pericardial effusions Consolidation in lung fields Pallour (nail beds, mucosa, skin creases) Jaundice

7 Sarah s History Exertional dyspnea orthopnea sleeping upright Weight loss over last 3 months 20 pounds Increasing peripheral edema and abdominal bloating Lightheaded when getting up quickly almost passed out yesterday

8 Sarah s Physical HR 110 ( seems to come and go when she breaths in ); RR 28; BP 100/60 with pulsus paradoxus of 18 mmhg Lung fields clear Pitting edema to knees bilaterally JVP at angle of jaw with patient sitting upright Cardiac apex not palpable Heart sounds difficult to hear but no murmurs, no extra sounds noted

9 Diagnosis Given the clinical history and physical findings you have elicited, what diagnostic testing do you wish to carry out?

10 CBC Electrolytes, BUN, Creatinine Cardiac enzymes Chest X-Ray EKG Treadmill Stress Test Blood gases CT chest CT head CT angiogram Ventilation-Perfusion scan Carotid Dopplers Leg Dopplers Echocardiogram Cardiac Catheterization Other

11 CBC +3 Electrolytes, BUN, Creatinine +2 Cardiac enzymes +1 Chest X-Ray +2 EKG +5 Treadmill Stress Test +2 Blood gases 0 CT chest +3 CT head -2 CT angiogram +2 Ventilation-Perfusion scan +2 Carotid Dopplers -3 Leg Dopplers +1 Echocardiogram +5 Cardiac Catheterization 0 Other

12 CBC Hgb 100 Electrolytes, BUN, Creatinine Cr 115 Cardiac enzymes normal Chest X-Ray completed EKG completed Treadmill Stress Test Unable to complete Blood gases Hypoxia CT chest couldn t be done CT head Scheduled CT angiogram scheduled Ventilation-Perfusion scan completed Carotid Dopplers scheduled Leg Dopplers scheduled Echocardiogram completed Cardiac Catheterization delayed Other

13 Sarah s Chest X-ray

14 Sarah s EKG

15 Sarah s CT Scan

16 Dyspnea in female 55 y/o Normal CT Lung metastases

17 Sarah s V/Q Scan

18 Sarah s Echocardiogram

19 Sarah s Echo

20 Sarah s Echo

21 Hgb = 100 WBC = 13,000 Plts = 130,000 Na + = 136 K+ = 3.2 Cl- = 120 Cr = 115 Ca ++ normal Mg Chest X-Ray Marked enlargement of cardiac silhouette No evidence of pulmonary infiltrate or congestion Normal vascular pattern Consider pericardial effusion CT Chest Multiple pulmonary masses consistent with metastases Large pericardial effusion noted Ventilation-Perfusion Scan Normal No evidence of pulmonary emboli Echocardiogram Normal left and right ventricular systolic function Normal valvular morphology with no significant stenosis or regurgitation by Doppler Large circumferential pericardial effusion with diastolic compression of right atrium and right ventricle Doppler evidence of marked respiratory variation in transvalvular flow velocity, consistent with elevated intrapericardial pressure

22 Management What initial treatment would you suggest for Sarah? What will be the key components of her long term management?

23 Pericardiocentesis

24 Sarah s Treatment Plan Pericardiocentesis of 1.2 litres of fluid + drain rapid relief Close follow-up for reaccumulation Fluid cytology reveals malignant cells. Chemotherapy Social and family assistance