A case of deteriorating asthma

Today's scenario focused on a ficitious patient with longstanding asthma, who presents with impending respiratory failure.

The Scenario:

You are on call as the Internist for a community hospital. You are asked to see a 73 year old man who has come in with worsening shortness of breath over 6 weeks. He is known to have longstanding asthma over his entire adult life but has never had an exacerbation like this.

The clinical data are:

Non-smoker

Dry cough for 2 wks

Previously well, had gradual increase in dyspnea over the past 6 weeks.  At the start, he felt only mildly impaired, but at the time of presentation, he had difficulty crossing the room.
No fevers, chills or sweats.
No chest pain, but feels significant continuous chest tightness for the past 48 hours or so

Physical exam:

VS:  HR 122/sinus, BP 160/90, RR 26, significant accessory muscle use and signs of respiratory distress.  Temp 37.2 C, SaO2 97% on room air
Chest - faint breath sounds bilaterally, no dullness, no wheezing, trachea midline
Cardiac exam:  faint heart sounds, non palpable apex, normal JVP, no edema
Abdominal exam:  Obese, nil else
Extremities - no clubbing, no cyanosis

CXR:  Bilateral "dark lungs", flattened hemidiaphragms, increased retrosternal air, no infiltrates

ABG:  7.42/41/86/25 on room air

Other bloodwork normal.

Questions:


What is your initial assessment of this patient?

What are the immediate actions you would take?

What are the secondary assessments you would make?

Who else needs to be involved in this patient's care?

What can you foresee might be complications of his situation?

What causes of his situation might you look for?

Put your comments below, and check back for teaching points on these issues...

Pericarditis ? Or What ?

The case:  a fictitious 65 year old man, who came to the emergency department complaining of 6 hours of chest pain.  You are the Internal Medicine consultant who is asked to see him.

His background history:  healthy, previous asthma (now quiescent), hyperlipidemia on treatment, and a 1/2 pack per day smoker.  NO  known cardiac history, no other risk factors, and generally feeling at his usual state of health until today.

He woke up with a vague central chest ache without radiation, which gradually increased in intensity over the subsequent hours, becoming increasingly uncomfortable when he moved, breathed or coughed.  The pain never really let up and acetaminophen did not relieve it.  The pain was worst when he lay supine.

He came into the hospital because he was in agony, with diaphoresis but no shortness of breath.

Questions:

1.     How would you assess him further - what are the immediate assessments and subsequent steps?  What other information would you require?

2.     What is the differential diagnosis at this point?

3.     What are the priorities in his management?  What would you embark upon now and what would you wait to do?

4.     How can you Confirm what is going on?

5.     What possible Causes are you looking for?

6.     What possible Complications are you looking for?

7.     What will be your plans after your initial evaluation?

Here is an ECG that was done.





Work through the above questions, make comments below, and then check back for some teaching tips....

Anaphylaxis on the Ward

The Case:

You are called to the ward by a nurse because a patient is hypotensive. The patient is a 76 year old man admitted 3 days ago by your colleague because of pneumonia. He has a history of dementia and type 2 diabetes. The pneumonia was a clear-cut infiltrate on chest x-ray, and he has been treated with azithromycin and ceftriaxone.

The nurse says that when she gave the ceftriaxone dose (his 3rd), the patient was doing well. 20 minutes later she returned to check on the IV, and found that the patient had facial, lip and hand swelling, tachycardia (120/min), tachypnea (26/min) and a BP of 80/40.

What is your approach?

The Learning Issues:

1. How to react to unstable vital signs being given over the phone?

2. How to do a rapid initial assessment?

3. How to do a rapid secondary assessment?

4. When and how to react before you have full information in this situation?

5. What additional information do you need?

6. What is the emergency response to suspected anaphylaxis?

7. What precautions need to be taken for airway management?

8. What subsequent actions should be taken after emergency management?

Resources:

A very good full text reference from the CMAJ can be found here.

Please comment on this case!

Welcome to Internal Medicine Scenario Rounds!

Welcome!

This blog is a new venture, designed to augment the learning that goes on in the Internal Medicine Scenario Rounds at Mount Sinai Hospital, University of Toronto.

The purpose of these rounds is twofold:

• to help postgraduate trainees learn about less common diseases and presentations, and
• to teach trainees the skills they need when presenting their approach to understanding and managing a medical problem as it evolves.

At Mount Sinai, these rounds are held every 2 weeks on Fridays at noon. We ask that a senior resident "volunteer" to have a case presented to them, and to explain their thinking as the case unfolds. Each scenario presentation lasts between 10-20 minutes. Other trainees act as a supportive audience, and give helpful feedback at the end of the scenario. The scenario ends with a teaching "capsule" about the topic under discussion. The session is meant to be educational, friendly, supportive and fun. (BIG HUG!)

This blog is intended to help anyone interested in these sessions to continue to learn from them, through group discussions and postings of resources. Some ground rules for commenting and posting will be posted shortly. The overall theme: This is meant to help anyone interested in learning Internal Medicine, especially in a Canadian training context, and the more that participate, the more valuable it will be.

Enjoy, and let me know how it goes!