www.peerteaching.com
Download
Report
Transcript www.peerteaching.com
Phase 2
Stephen Lau & George Lam
The Peer Teaching Society is not liable for false or misleading information…
Outline
•
•
•
•
Pulmonary Embolism
Pneumothorax
Pneumonia
Pleural Effusion
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Causes of PE
– Thrombus (DVT, ?)
–?
–?
–?
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Causes of PE
– Thrombus (DVT, AF)
– Fat
– Air
– Bacterial Vegetation (EC)
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Causes of VTE
–?
•
–?
•
–?
•
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Causes of VTE
– Change in Blood Flow
• Immobility Post-Op, Paralysis
• Obesity
• Pregnancy
– Change in Blood Vessel
• Smoking
• HTN
– Change in Blood Constituent
•
•
•
•
•
•
Dehydration
Malignancy
High Oestrogen
Polycythaemia
Nephrotic Syndrome
Inherited Protein C/S Deficiency, Factor VLeiden
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Classification of Clinical Presentation
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Classification of Clinical Presentation
– Acute Sudden
• Massive Cardiogenic Shock (SBP < 90 mmHg or ↓ ≥
40 mmHg for > 15 min)
• Submassive No Shock
– Chronic Gradual P HTN
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Submassive
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Submassive
– Acute SOB
– Pleuritic Chest Pain
– Cough
– Haemoptysis
– Wheeze
– Tachycardia
– Tachypnoea
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Submassive
– Acute SOB ↓ PaO2 /↑ PaCO2 (due to V/Q mismatch +
opening of AV collaterals)
– Pleuritic Chest Pain Inflammatory Rxn Irritates Parietal
Pleura
– Cough ?Fluid Extravasation
– Haemoptysis Lung Infarction
– Wheeze Bronchospasm
– Tachycardia ↓ PaO2 /↑ PaCO2
– Tachypnoea ↑ PaCO2
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Massive
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Massive
– Shock Sx
– ↑ JVP
– Accentuated P2
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Sx – Massive
– Shock Sx ↓ LV Pre-Load = ↓ CO
– ↑ JVP RHF
– Accentuated P2 Delayed RV Emptying
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• 70 y/o man day 4 post-THR developed sudden-onset
SOB and pleuritic chest pain 2h ago. SOB occurs at
rest and worse on exertion. No associated leg
pain/swelling, cough, haemoptysis or wheeze.
• No PMH asthma/COPD, DVT/PE. 20 Pack Years.
• Ex
–
–
–
–
T 37.0, HR 110, BP 120/80, RR 24, SaO2 93%.
JVP 2 cm. HS normal, no Murmur.
Trachea central. Scattered creps @ lung base.
Mild calf tenderness.
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• 70 y/o man day 4 post-THR developed sudden-onset
SOB and pleuritic chest pain 2h ago. SOB occurs at
rest and worse on exertion. No associated leg
pain/swelling, cough, haemoptysis or wheeze.
• No PMH asthma/COPD, DVT/PE. 20 Pack Years.
• Ex
–
–
–
–
T 37.0, HR 110, BP 120/80, RR 24, SaO2 93%.
JVP 2 cm. HS normal, no Murmur.
Trachea central. Scattered creps @ lung base.
Mild calf tenderness.
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• DDx
– Submassive PE
– PTX
– Acute Pulmonary Oedema/ARDS
– Pneumonia
– Sepsis
– MI
– Arrhythmia
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• DDx
– Submassive PE D-Dimer, Leg USS
– PTX CXR
– Acute Pulmonary Oedema/ARDS CXR
– Pneumonia FBC, CXR
– Sepsis FBC, Lactate, Blood Culture, CXR
– MI ECG
– Arrhythmia ECG
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Ix
–
–
–
–
–
–
–
–
–
–
FBC
LFT ?Liver Mets/Ca
U&E ?Renal Function (?Shock)
Clotting ?Hypercoagulable
D-Dimer
ABG
Blood Culture
CXR
Leg USS
ECG
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Ix
– D-Dimer
• If +ve, next step?
• If –ve?
– ABG
• PaO2
• PaCO2
– CXR
• 3 Signs
– ECG
• What is the pathognomonic arrhythmia?
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Ix
– D-Dimer
• If +ve, next step? CTPA or V/Q Scan
• If –ve? Not PE
– ABG T1RF
• PaO2 Low
• PaCO2 Low
– CXR **COMMONLY NORMAL
•
•
•
•
Decreased Vascular Markings
Dilated PA
Wedge-Shaped Infarction
Pleural Effusion
– ECG
• What is the pathognomonic arrhythmia?
– S1Q3T3 Deep S (I), Q (III), T Inversion (III)
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Mx of Submassive PE (SBP > 90 mmHg)
– Initial
– Long-Term
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Mx
– Initial
• O2
• 1) LMWH SC (Enoxaparin, Dalteparin)
– / Fondaparinux
– / UFH
• 2) IVC Filters
– Long-Term
• Mobilization
• TED Stockings
• Warfarin PO for ≥ 3 Months INR 2-3
The Peer Teaching Society is not liable for false or misleading information…
Pulmonary Embolism
• Causes of PE
• Risk Factors for VTE Virchow’s Triad
• Clinical Presentation
– Acute Massive/Submassive
– Chronic
•
•
•
•
DDx of Acute SOB
Ix of Acute SOB
Ix Results of PE
Mx of Submassive PE
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
• Types
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
• Types
– Tension
– Non-Tension
• Spontaneous
– Primary No Lung Pathology (but probably small blebs)
– Secondary Lung Pathology (esp. COPD bullae)
• Traumatic
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
• 2 Symptoms
• 4 Examination Signs of Non-Tension PTX
• Which Side has PTX?
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
• 2 Symptoms
– SOB
– Pleuritic Chest Pain
• 4 Examination Signs of Non-Tension PTX
–
–
–
–
Tracheal Deviation Towards Side
↓ CE Affected Side
↑ PN
↓ BS
• Which Side has PTX?
– Left
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
•
•
•
•
•
Mx of Small Primary Spontaneous PTX?
Mx of Large Primary Spontaneous PTX?
Mx of Small Secondary Spontaneous PTX?
Mx of Large Secondary Spontaneous PTX?
Where Do You Stick the Cannula?
The Peer Teaching Society is not liable for false or misleading information…
Pneumothorax
• Mx of Small Primary Spontaneous PTX?
– Observe
• Mx of Large Primary Spontaneous PTX?
– 1) Aspiration
– 2) Chest Drain
• Mx of Small Secondary Spontaneous PTX?
– 1) Aspiration
– 2) Chest Drain
• Mx of Large Secondary Spontaneous PTX?
– Chest Drain
• Where Do You Stick the Cannula?
– 2nd Intercostal Space, Mid-Clavicular Line
The Peer Teaching Society is not liable for false or misleading information…
Pneumonia - Basics
• Signs and Symptoms of Acute Lower
Respiratory Tract Infection.
• Radiographic Change
The Peer Teaching Society is not liable for false or misleading information…
Pneumonia - Basics
• Causative Organisms
– Pathogens
• Streptococcus pneumoniae
• Klebsiella pneumoniae
• Haemophillus influenzae
• Staphlylococcus aureus
• Pseudomonas aeruginosa
– Atypical Pathogens
• Chlamydia pneumoniae
• Mycoplasma pneumoniae
• Legionella pneumophillia
The Peer Teaching Society is not liable for false or misleading information…
Types of Pneumonia
Hospital and Community Acquired
• Hospitalization for more than 2 days in the last 90 days
• IV therapy, chemotherapy, or wound care in last 30 days
• Residence in care home or long term care
• Attendance in hospital in the last 30 days.
The Peer Teaching Society is not liable for false or misleading information…
Clinical Evaluation - Symptoms
•
•
•
•
•
•
•
Fever
Pleuritic Chest Pain
Haemoptysis
Sputum Production ( purulent)
Dyspnea
Cough
Fever/Rigors
The Peer Teaching Society is not liable for false or misleading information…
Clinical Evaluation - Signs
•
•
•
•
•
•
Febrile
Raised Respiratory Rate
Reduced SpO2
Crackles
Bronchial Breathing
Dullness on percussion
The Peer Teaching Society is not liable for false or misleading information…
Diagnosis - Investigations
• Bloods
– ABG
– FBC
• CRP
• WCC + Differential
• Anaemia
– U/E
– LFT
The Peer Teaching Society is not liable for false or misleading information…
Diagnosis - Investigations
• Scoring System
–
–
–
–
–
Confusion
Urea
Respiratory Rate
Blood Pressure <90mmHg systolic
<65 years of age
• Imaging
– CXR
The Peer Teaching Society is not liable for false or misleading information…
Treatment
• Antibiotics
– Amoxicillin / Flucoxacillin (if S. aureus suspected)
• Oxygen
• Fluids
• Analgesia
The Peer Teaching Society is not liable for false or misleading information…
Pneumonia – Clinical Scenario 1
A 54-year-old smoker with multiple comorbidities (diabetes,
hypertension, coronary artery disease) presents with a 2-day
history of a productive cough with yellow sputum, chest
tightness, and fever. Physical examination reveals a
temperature of 38.3°C (101°F), BP of 150/95 mmHg, heart
rate of 85 bpm, and a respiratory rate of 20 breaths per
minute. His oxygen saturation is 95% at rest; lung sounds are
distant but clear, with crackles at the left base. CXR reveals a
left lower lobe infiltrate.
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion - Basics
• Fluid that occupies the space between the
visceral and parietal pleural
• Transudate
– Disruption of hydrostatic and oncotic forces across
pleural membrane
• Exudate
– Increases permeability of the pleural surface
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion - Basics
• Common Causes of Transudate
– Heart Failure
– Cirrhosis
– Hypoalbuminaemia
– Peritoneal Dialysis
– Nephrotic Syndrome
– Hypothyroidism
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion - Basics
• Common Causes of Exudate
– Pneumonia
– Malignancy
– Pulmonary Infarction (Embolism)
– Autoimmune
– Pancreatitis
– TB
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion - Symptoms
•
•
•
•
•
Shortness of Breath on Exertion
Cough
Pleuritic Pain
PMHx of smoking, asbestos exposure
PMHx of any previously mentioned diseases
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion - Signs
•
•
•
•
•
Dullness to percussion
Tracheal centrality
Vocal Fremitus
Asymmetric Chest Expansion
Reduced Breath Sounds
The Peer Teaching Society is not liable for false or misleading information…
Diagnosis - Investigations
• CXR – PA/Lateral
• Thoracentesis (Chest Drain)
• Diagnostic in up to 75% of cases
– Protein
– LDH
– Cholesterol
– Cytology
– Glucose
– RBC/WBC/pH
– Cultures
• Pleural Ultrasound
• FBC/CRP/Culture
The Peer Teaching Society is not liable for false or misleading information…
Treatment
• Treat the cause
• Thoracentesis
• Pleurodesis
The Peer Teaching Society is not liable for false or misleading information…
Pleural Effusion – Clinical Case 1
• A 70-year-old women presents with slowly increasing
dyspnoea. She cannot lie flat without feeling more short of
breath. She has a history of HTN and osteoarthritis, and she
has been taking NSAIDs with increasing frequency over the
previous few months. On physical examination, she appears
dyspnoeic at rest, her BP is 140/90 mm Hg, and pulse is 90
bpm. Her jugular venous pressure is elevated to the angle of
the jaw. The left lung field is dull to percussion with decreased
air entry basally. Crackles are heard in the right lung field and
above the line of dullness on the left. Lower extremities have
pitting oedema to the knee.
The Peer Teaching Society is not liable for false or misleading information…