CASE 3

Reyes, Carmen; Reyes, Jenilene; Reyes, Lourdes; Rivera, Laila; Rivere, Djeaune; Robosa, Dean Antonio; Rodas, Francis; Rodriquez, Reine; Rogelio, Graciella; Roque, Marianne; Ruanto, Maria Theresa

OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 2

OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 3

CASE PRESENTATION

R.F. 24 y/o Female

CHIEF COMPLAINT: Shortness of breath

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HISTORY OF PRESENT ILLNESS

1 month PTA •Patient started having episodes of shortness of breath•No consult was done nor medications taken

2 weeks PTA•Increasing shortness of breath•Difficulty climbing 2 flights of stairs•Consult: given vitamins

1 day PTA •No improvement•Progressive shortness of breath when walking a short distance

ADMISSION5

REVIEW OF SYSTEMS

Poor appetite No headache/blurring of vision No cough/colds Occasional chest pain No abdominal pain/no vomiting No joint pains

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PAST MEDICAL HISTORY

No previous hospitalizations (+) episodes of sore throat and fever as a

child No hypertension No diabetes No surgeries

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FAMILY HISTORY

(-) Heart disease (-) Diabetes (-) Asthma/Allergies

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PERSONAL/SOCIAL HISTORY

Non-smoker Non-alcoholic beverage drinker

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PHYSICAL EXAMINATION FINDINGS

Conscious, coherent, ambulatory BP: 120/80 HR: 70 bpm RR: 20’s Warm moist skin ,no dermatoses

HEART: apex beat 5th LICS, MCL(+) accentuated S1(+) diastolic murmur

LUNGS: symmetric chest expansionno retractions(+) occasional wheeze

No cyanosis/edema

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MISSING DATA General Data

Address, occupation, civil status, religion HPI

Type of vitamins taken when consult was done Other possible associated signs and symptoms

PE findings Specific RR Temp BMI JVP

Personal and Social History Type of diet, exercise Occupation (type, workload)

Environmental History Area of residence and associated living conditions

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SALIENT FEATURES

24 F BP: 120/80 HR: 70 bpm RR: 20s

Progressive shortness of breath

Symmetrical chest expansion

(-) Retractions (+) Wheeze

Apex beat: 5th LICS, MCL

(+) Accentuated S1 (+) Diastolic

murmur

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OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 1

3

APPROACH TO A PATIENT WITH DYSPNEA

Dyspnea

Pulmonary

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Dyspnea

Pulmonary

APPROACH TO A PATIENT WITH DYSPNEA

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DYSPNEA

a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity

derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses

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ASSOCIATION OF QUALITATIVE DESCRIPTORS AND PATHOPHYSIOLOGIC MECHANISMS OF SHORTNESS OF

BREATH

Descriptor PathophysiologyChest tightness or constriction Bronchoconstriction, interstitial

edema (asthma, myocardial ischemia)

Increased work or effort of breathing

Airway obstruction, neuromuscular disease (COPD, moderate to severe asthma, myopathy, kyphoscoliosis)

Air hunger, need to breathe, urge to breathe

Increased drive to breathe (CHF, pulmonary embolism, moderate to severe airflow obstruction)

Cannot get a deep breath, unsatisfying breath

Hyperinflation (asthma, COPD) and restricted tidal volume (pulmonary fibrosis, chest wall restriction)

Heavy breathing, rapid breathing, breathing more

Deconditioning 19

GRADING OF DYSPNEA

Grade Degree of Dyspnea

1 no dyspnea except with strenuous exercise

2 dyspnea when walking up an incline or hurrying on the level

3walks slower than most on the level, or stops after 15 minutes of walking on the level

4 stops after a few minutes of walking on the level

5dyspnea with minimal activity such as getting dressed, too dyspneic to leave the house

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CHEST PAIN

discomfort or pain anywhere along the front of your body between your neck and upper abdomen

Can be due to cardiopulmonary problems, chest wall problems, GI, psychological

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Typical Features of Chest Discomfort

Condition Duration Quality Location Associated Features

Angina More than 2 and less than 10 min

Pressure, tightness, squeezing, heaviness, burning

Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms—frequently on left

Precipitated by exertion, exposure to cold, psychologic stress

S4 gallop or mitral

regurgitation murmur during pain

Aortic stenosis

Recurrent episodes as described for angina

As described for angina

As described for angina

Late-peaking systolic murmur radiating to carotid arteries

Pulmonary hypertension

Variable Pressure Substernal Dyspnea, signs of increased venous pressure including edema and jugular venous distention

Esophageal reflux

10–60 min Burning Substernal, epigastric

Worsened by postprandial recumbency

Relieved by antacids

Peptic ulcer Prolonged Burning Epigastric, substernal

Relieved with food or antacids

Emotional and psychiatric conditions

Variable; may be fleeting

Variable Variable; may be retrosternal

Situational factors may precipitate symptoms

Anxiety or depression often detectable with careful history

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APEX BEAT DISPLACEMENT

Patient AB: 5th LICS, MCL Lateral and/or inferior displacement of the

apex beat usually indicates cardiomegaly. May also be displaced by other conditions:

Pleural or pulmonary diseases Deformities of the chest wall or the thoracic

vertebra

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(+) ACCENTUATED S1

Mitral valve snaps shut more vigorously, producing a louder S1 Blood velocity is increased-> anemia, fever,

hyperthyroidism, anxiety, and during exercise Mitral valve is stenotic

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(+) DIASTOLIC MURMUR

Early diastolic Begins with S2

Mid diastolic Begins at clear interval after S2

Late diastolic (presystolic)

Begins immediately before S1

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(+) DIASTOLIC MURMUR

Heard with bell at apex, patient in left lateral decubitus position

Findings on examination Low-frequency diastolic rumble, more intense in

early and late diastole, does not radiate; systole usually quiet; palpable thrill at apex in late diastole common; S1 increased and palpable at left sternal border

Description Narrowed valve restricts forward flow; forceful

ejection into the ventricle Often occurs with mitral regurgitation caused by

rheumatic heart fever or cardiac infection 26

LUNG FINDINGS

Occasional wheeze Musical respiratory sounds thaat may be

audible both to the patient and to others Suggests partial airway obstruction from

secretions, tissue inflammation, or a foreign body.

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OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 2

8

OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 2

9

CHEST PA CHEST LAT

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Trachea

Patient’s PA CXR

Normal PA CXR

(-) blunting of the costophrenic angle(-) pulmonary congestion

(-) pulmonary infiltrates (-) bone deformities

(-) flattening of the R&L hemidiaphragm(-) tracheal deviation

Patient’s PA CXR

Normal PA CXR

(+) heart enlargement

Slight straightening of the L cardiac border

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Normal location of the apex: 5th ICS, MCL

Normal PA CXR

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The patient’s apex is located on the 7th ICS MCL

– DOWNWARD DISPLACEMENT OF THE APEX

Patient’s PA CXR

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Patient’s PA CXRNormal PA CXR

CARDIO-THORACIC RATIO

WHICH CHAMBER/S IS/ARE ENLARGED?

Squire’s Fundamentals of Radiology, 6th ed.

1 – R brachiocephalic vessels

2 – Ascending aorta and superimposed SVC

3 – R atrium

5 – L brachiocephalic vessels

6 – Aortic arch

7 – Pulmonary trunk

8 – L atrial appendage

9 – L ventricle

Normal LVE LAE LAE & LVE (in long-standing MS)

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Patient’s PA CXRNormal PA CXR

Prominent L atrial appendage

Left Atrial Enlargement 3

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Patient’s PA CXR

Normal PA CXR

Carina not appreciated (cannot be measured for widening) 3

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Patient’s PA CXR

Normal PA CXR

No double density along the R cardiac border 3

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Normal PA CXR

Downward dipping of

the left heart

Patient’s PA CXR

POSSIBLE L VENTRICULAR ENLARGEMENT

Normal PA CXR

LV outflow tract

Patient’s PA CXR

POSSIBLE L VENTRICULAR ENLARGEMENT

POSSIBLE R VENTRICULAR ENLARGEMENT

Normal PA CXR

Rounding of the cardiac apex

Patient’s PA CXR

Normal Lateral CXR

Patient’s Lateral CXR

Trachea

EsophagusTrachea

Esophagus

Heart

Heart

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Left atrial enlargement

Esophagus

Retrocardiac free space

Esophagus

Retrocardiac free space

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LV outflow tract

Left cardiac border

Left cardiac border

LV outflow tract

Left venticular enlargement

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Convex posterior heart border

Posterior margin of the IVC Obliterated posterior

margin of the IVC

Left venticular enlargement

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Left venticular enlargement

Hoffman Rigler sign

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Right ventricular enlargement

Retrosternal space

2/31/3

Retrosternal space

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OUTLINE OF PRESENTAION

To present a case of a 24F presenting with shortness of breath

To present an approach and an algorithm in the diagnosis of a patient with shortness of breath

To present the differential diagnosis and clinical impression of the patient

To discuss the chest x-ray findings and correlate it with the PE examination findings

To discuss the roles of other imaging modalities 4

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ECHOCARDIOGRAM

Most specific and sensitive method of diagnosing and quantifying the severity of mitral stenosis

Graphic outline of the heart's movement .

Two- dimensional (2-D) Echo is capable of displaying a cross-sectional "slice" of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right ventricle

Echo is often combined with Doppler ultrasound and color Doppler to evaluate blood flow across the heart’s valves. 5

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2D ECG: SIGNIFICANCE

Assess the heart’s function

Determine the presence of disease of the heart muscle, valves and pericardium, heart tumors, and congenital heart disease

Evaluate the effectiveness of medical or surgical treatments

Follow the progress of valve disease

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2D ECHOCARDIOGRAM IN MS

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2D ECHOCARDIOGRAM IN MS

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2D ECHOCARDIOGRAM IN MS

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2D ECHOCARDIOGRAM IN MS

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2D ECHOCARDIOGRAM IN MS

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2D ECHOCARDIOGRAM IN MS

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SUMMARY

Presented a case of a 24F presenting with shortness of breath

Discussed the approach and the algorithm in the diagnosis of a patient with shortness of breath

Explained the differential diagnosis and clinical impression of the patient

Discussed the chest x-ray findings and correlate it with the PE examination findings

Explained the roles of other imaging modalities 5

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THANK YOU

LIKELY MECHANISMS OF DYSPNEA IN SELECTED CONDITIONS

Condition MechanismAsthma Increased sense of effort

Stimulation of irritant receptors in airways

Neuromuscular disease Increased sense of effort

COPD Increased sense of effortHypoxiaHypercapniaDynamic airway compression

Mechanical ventilation Afferent mismatchFactors associated with the underlying condition

Pulmonary embolism Stimulation of pressure receptors in pulmonary vasculature or right atrium(possible)

PATTERNS OF ABNORMALITY IN CARDIOPULMONARY EXERCISE TESTING

Cardiovascular limitation

Respiratory limitation

•Heart rate 85% of predicted maximum•Low anaerobic threshold•Reduced maximal oxygen consumption•Drop in blood pressure with exercise•Arrhythmias or ischemic changes on ECG•Does not achieve maximal predicted ventilation•Does not have significant desaturation

•Achieves or exceeds maximal predicted ventilation•Significant desaturation (90%)•Stable or increase dead space–to–tidal volume ratio•Development or bronchospasm with falling FEV1•Does not achieve 85% of predicted maximal heart rate•No ischemic ECG changes