A-E Station 3

 

Station 3

A breathless patient

 

Candidate Instructions

Setting:

You are a Foundation Year doctor working a night shift. You have been called to see a patient who has become extremely breathless.


Name: Michael Ortega


Tasks:

1. Please examine the patient using an A-E approach.

2. Give you differential diagnosis to the examiner.

3. Give you management plan to the examiner.

You are not required to take a history.

Simulated Patient Instructions

Briefing

Please act as the patient and reveal signs and results only as the candidate performs actions or requests tests.

Diagnosis: Acute Heart Failure

You are Michael Ortega, aged 76

You have become very short of breath.

Appearance and Behaviour

you appear short of breath and a little drowsy. Please stop in the middle of each sentence to catch your breath if you’re asked to speak. Stay in the tripod position whilst catching your breath. If you’re on an adjustable bed, lie it completely flat. A very good clinical candidate will notice shortness of breath in heart failure can be improved by sitting you up.

Start the Timer and Begin

Examiner Instruction

 

As the candidate enters please give them this handover (acting as the nurse on the ward)

“Doctor, this patient has just been moved up to the ward from the medical assessment unit. His NEWS score is high, please can you assess him?”

Intro

 

Airway

 

Assessment

Breathing

 

Assessment

? Effusions cause reduced air entry at the bases. A differential to reduced air entry should be pneumothorax. Clinically a pneumothorax is resonant to percussion, whilst an effusion is dull to percussion (as found here).

Treatment

Cardio

 

Assessment

Treatment

? Ventricular hypertrophy is a common finding in heart failure. An ECG should always be done in decompensated or new heart failure as it can be caused by arrhythmias or MI.
? If diuretic naive start with 20-40mg IV furosemide or once only dose of 1mg Bumetanide. If already on diuretics you can give 1-2.5 times their normal dose. Reassess every 6 hours and once euvolaemic transition to PO diuretics.

Disability

 

Assessment

Exposure

 

Assessment

Examiner Instruction

 

At this point please direct the candidate to give their differential diagnosis and any further management plans.

Diagnosis & Further Management

 

Diagnosis

Further Managemnet

Summary

 

The key to this case is signs of fluid overload with breathlessness. This is a severe case of heart failure but it has responded to simple initial therapy with O2, posture change, and IV furosemide. Signs of HF that should cause ITU escalation include haemodynamic instability (low BP, slow cap refill, cold peripheries), arrhythmias, HF secondary to MI, or hypoxemia refractory to O2 treatment. Thankfully none of these are present here. The investigations are to search for a cause of acute failure such as MI, hypertensive emergency, valve rupture, PE, and Infection.

Top Tip

 

Remember LMNOP for management of CHF exacerbations:

Loop diuretic - IV furosemide

Morphine - can consider as venodilates (therefore reduces preload and strain on the heart) and depresses respiratory rate if patient is tachypnoeic

Nitrates - for cases of flash pulmonary oedema or symptoms resistant to diuretics, can consider nitrates (eg IV nitroglycerin) as they are potent venodilators. This will be a senior led decision.

Oxygen

Position - sit them upright!

Submit for Scoring

Tags | A-E | Cardiology | Acute Heart Failure

Station Written by: Dr Benjamin Armstrong

Peer Reviewed by: Dr Rishil Patel

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