A lady with shortness of breath

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Emily Campbell is a 48-year-old female who has presented to A&E with a week of chest pain with some shortness of breath. Work through the case to reach a diagnosis and form a management plan.


History

Presenting complaint

“Doctor, I just don’t feel quite right. I’ve had this pain in my chest for a week now and I’ve been feeling breathless.”

When people present with chest pain and shortness of breath, it is important to quickly establish whether the patient is acutely unwell and requires immediate assessment and resus. If the patient had unstable vital signs, severe chest pain, or was feeling short of breath at rest then an ABCDE approach would be more appropriate.

Quick screening questions: How are feeling at the moment? How bad is the pain? Do you feel breathless now? Have you had anything like this before?

“I’ve not had anything like this before. I feel ok, I’ve got some niggling pain but it’s settling after some paracetamol. I’m not breathless at the moment.”

Can you tell me some more about the chest pain?

With a chest pain history, you will specifically want to enquire about breathlessness, dizziness, palpitations, nausea, character and radiation of pain, and diaphoresis.

The most thorough way to assess pain is to use the SOCRATES framework outlined below: 

  • Site – Where is the chest pain?
  • Onset- Gradual or sudden onset? What were you doing when the pain first started?
  • Character- What kind of pain is it (e.g. dull, sharp, crushing)? Is it constant or intermittent?
  • Radiation – Does the pain move anywhere else (e.g. your neck, arms, back)?
  • Associated symptoms – Are there any other symptoms with the pain (e.g. shortness of breath, dizziness, palpitations, nausea, diaphoresis)?
  • Timing – When exactly did it start? How long has it lasted?
  • Exacerbating/relieving factors – Does anything make it better or worse (e.g. deep breathing, leaning forwards, resting)? Does exertion bring on the pain?
  • Severity – On a scale of 1-10 how bad is the pain? Has it improved or worsened? What painkillers have you been taking?

Can you tell me more about feeling breathless?

With a shortness of breath history, you will specifically want to enquire about exercise tolerance, cough, wheeze, chest pain and haemoptysis.

  • Have you had shortness of breath in the past? Do you have a diagnosis of COPD or asthma?
  • When did the shortness of breath start? Did it coincide with the chest pain?
  • Are you short of breath at rest or only during exertion? How far can you walk before feeling breathless? Can you manage walking upstairs?
  • Have you had any other symptoms such as a cough, fever, or wheeze? Have you coughed up any blood? Do you have a runny nose or a sore throat?
  • Have you had contact with others who are unwell recently?

Other relevant questions

  • Have you seen your GP or anyone else for your symptoms?
  • Have you had anything like this before?
  • Do you feel like you’re getting worse or getting better?
  • ICE: Is there anything in particular that’s brought you in today, or that you are worried about? Do you have any idea of what might be going on?

Patient’s response

“I’ve never had chest pain before for any reason! The pain is a niggling sharp pain on the left side of my chest, nowhere else. It’s there all the time and ibuprofen and paracetamol don’t take it away completely- it’s about a 4 out of 10 at the moment. I think I was just sat on the sofa when it started. It’s the breathing that bothering me more – I feel like I can’t catch my breath, then when I take a deep breath the pain is worse! I can just about get up the stairs at home but I have to sit down and rest if I’m walking more than a couple of hundred metres which isn’t like me at all, I’m fighting fit usually. I’ve not got any problems with my lungs or heart usually.”

“I thought it might just be a chest infection at first but I’ve not had a cough and I’m not feverish, so I’m not sure. No-one else around me has been ill. I was going to see the GP tomorrow but I felt so breathless going to the shop earlier that I thought I’d come here instead. I hope it’s not my heart!”

Do you have a history of any chest pain or heart problems?

If the answer is yes, take details including findings of any recent investigations such as angiograms/echocardiograms.

Enquire specifically about cardiac risk factors:

  • Personal history
  • Hypertension
  • High cholesterol
  • Diabetes including glycaemic control if relevant
  • Obesity
  • Smoking history
  • Family history (including ages of significant cardiac events)

Have you ever had a blood clot in the past?

Enquire specifically about risk factors for VTE:

  • Personal history of thromboembolic disorder
  • Personal history of malignancy
  • Recent long-haul travel (aeroplane, but also bus/car journeys)
  • Recent surgical procedures
  • Recent immobilisation for any reason (e.g. illness, limb in plaster cast)
  • Obesity
  • Smoking history
  • Hormonal medications (e.g. COCP)
  • Family history

Patient’s response

“I’ve never had any heart problems in the past, although my mum had a heart attack when she was 76. I don’t take any medications and I don’t have high blood pressure or high cholesterol. I’m normally very well- the only thing is I had a hysterectomy three weeks ago, but there were no complications and I was home within a couple of days. I’ve not been on holiday in a while! I smoke about ten cigarettes a day and have done since I was a teenager.”

Past medical history

  • Cardiac conditions, respiratory conditions and thromboembolic disorders
  • Other medical problems
  • Previous surgery
  • Allergies

Drug history

  • Regular medication – ensure to ask about anticoagulants, antiplatelets and hormonal medication
  • Inhalers
  • Over the counter medications
  • Recreational drug use
  • Allergies

Social history

  • Living situation
  • Smoking status
  • Pets
  • Functional status- exercise tolerance, walking aids etc

Systemic enquiry

  • Any other symptoms in other body systems?

Patient’s response

“I’m generally well, I had some heavy bleeding with the menopause but that’s stopped after the hysterectomy. I just take ibuprofen and paracetamol when I need it. Sometimes I have some arthritis in one of my knees, but it doesn’t cause me too much trouble and I’ve never needed a stick to walk with. I’m allergic to penicillin- I had a rash as a baby and I’ve never taken it since. I live with my sister and the dog, we get along just fine!”


Examination

Your examination should encompass the respiratory and cardiac systems for this patient. Given the recent surgery, a check of the abdomen would also be warranted. A general ABCDE assessment would cover all bases.

Clinical findings

Airway

  • No concerns

Breathing

  • No increased work of breathing at rest
  • O2 saturation on room air 95%
  • Respiratory rate of 20
  • Chest clear to auscultation

Circulation

  • Peripherally warm
  • Central CRT <2s
  • Heart sounds normal, rate 112 regular
  • Blood pressure 118/90 on left, 124/92 on right
  • No peripheral oedema

Disability

  • GCS 15
  • PEARL
  • Temperature 36.4

Exposure

  • Abdomen soft throughout with no tenderness to examination, bowel sounds positive
  • Healing port sites in keeping with recent laparoscopic hysterectomy
  • Calves soft, non-tender

Differential diagnosis

  • Pulmonary embolism would be the primary differential diagnosis
  • Pneumothorax
  • Acute coronary syndrome
  • Pneumonia

Investigations

The Wells’ score takes various risk factors into account to predict the likelihood of PE.²

  • Clinically suspected DVT – 3 points
  • Alternative diagnosis equally/less likely than PE – 3 points
  • Heart rate >100 – 1.5 points
  • Immobilisation of 3 days/surgery in the previous 4 weeks – 1.5 points
  • History of DVT or PE – 1.5 points
  • Haemoptysis – 1 point
  • Malignancy (treatment in previous 6 months or palliative stage) – 1 point

A Well’s score of 4 or below means that a PE is less likely and as a result, a D-dimer test would an appropriate initial investigation to rule out PE.

A Well’s score of more than 4 suggests that PE is more likely and as a result, a CTPA should be arranged as a priority to confirm or rule out a diagnosis of PE.

Emily’s Wells’ score = 6

Bedside tests:

  • ECG – this shows a sinus tachycardia without ischaemic change or features of right heart strain

.Blood tests:

  • FBC, U&Es, LFT – unremarkable
  • Coagulation screen – unremarkable
  • Troponin – unremarkable

Imaging

  • Chest x-ray – unremarkable
  • CT Pulmonary Angiogram (CTPA):
    • The gold standard investigation for the diagnosis of PE.
    • Emily’s CTPA shows a sub-segmental pulmonary embolus in the left lung.

Diagnosis

Pulmonary embolism 

Pulmonary embolism (PE) involves a blockage of the pulmonary arterial tree by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually, this is due to embolism of a thrombus (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion is due to the embolisation of air, fat, amniotic fluid or erroneous contaminants injected intravenously.
Symptoms of pulmonary embolism include difficulty breathing and chest pain, often worsened by inspiration. Clinical signs include low blood oxygen saturation, cyanosis, tachypnoea and tachycardia. Severe cases of PE can lead to collapse due to haemodynamic compromise, which can, in some cases, lead to sudden death. ¹

Management 2

There are four options for the management of PE:

  • Pharmacological treatment (most common)
  • Thrombolysis
  • Mechanical intervention
  • Surgery

Thrombolysis

This is generally considered when the patient is haemodynamically unstable. A thrombolytic agent, commonly Streptokinase, is injected intravenously with the aim of promoting the breakdown of blood clots.

Surgical approach

Rarely, an open pulmonary embolectomy can be performed.

Mechanical approach

Some patients may have a filter inserted into their inferior vena cava (IVC filter) either alone or alongside pharmacological management. These filters trap embolic fragments as they travel up from the legs to the lungs. These can be inserted on a temporary or permanent basis.

Pharmacological treatment

Pharmacological treatment options for confirmed pulmonary embolism (PE) include:

  • Low molecular weight heparin (LMWH), dosed by the patient’s weight
  • Fondaparinux
  • Unfractionated heparin
  • Oral anticoagulant treatment (warfarin, apixaban, or rivaroxaban)
  • LMWH followed by an oral anticoagulant (dabigatran or edoxaban)
  • Most treatments require some form of monitoring

Pharmacological management should be initiated as soon as possible. If there is a high index of suspicion, management with low molecular weight heparin (LMWH) should be started before the diagnosis has been confirmed. For many patients, LMWH will be started and then continued as a bridging therapy until adequate anticoagulation is achieved with other methods.

Choice of pharmacological treatment

The decision about which agent to take should be a shared choice by the patient and the healthcare provider. Factors to consider include the patient’s comorbidities (for example renal function, obesity, liver function, falls risk), the licensed use of the medication (for example in the UK, at present, not all agents are licensed for use in malignancy) and practicality of monitoring requirements..

Duration of treatment
  • Provoked pulmonary embolism (as in this scenario) – Treatment should be for at least 3 months. At 3 months, assess the risks and benefits of continuing treatment.
  • Unprovoked pulmonary embolism – treatment in these cases may be long term. This would be determined on a case by case basis by a specialist, taking into account the patient’s risk of VTE recurrence and whether they are at increased risk of bleeding.
  • The risk of bleeding should always be balanced with the risk of further VTE. ²

Patient education

Ensure Emily is provided with:

  • Verbal and written information on PE
  • An anticoagulant information booklet
  • An anticoagulant alert card (which they should be advised to carry at all times)
  • Verbal and written information on oral anticoagulation treatment, including:
    • How to use them and the duration of treatment.
    • Possible adverse effects and what to do if these occur.
    • The effects of other medications, foods, and alcohol on oral anticoagulation treatment.
    • Monitoring their anticoagulant treatment.
    • How anticoagulants may affect their dental treatment.
    • How anticoagulants may affect activities, such as sports and travel.
    • When and how to seek medical help.

Special circumstances

  • In patients with unprovoked PE, investigations should be performed to assess for an underlying cause such as malignancy. This should include a thorough clinical assessment, chest x-ray and blood tests including calcium levels. For some patients, a CT scan may also be performed. Further tests to consider would be a thrombophilia screen and antiphospholipid testing.
  • Pregnant patients should remain on LMWH as warfarin is teratogenic.
  • Patients with cancer are usually treated with treatment dose LMWH as INR control is difficult to achieve when patients are undergoing chemotherapy. In addition, patients with cancer are often at higher risk of bleeding on anticoagulation.

References

  1. Goldhaber SZ (2005). “Pulmonary thromboembolism”. In Kasper DL, Braunwald E, Fauci AS, et al. Harrison’s Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1561–65. ISBN 0-071-39140-1.
  2. NICE Guideline. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. Last updated in November 2015. Available from: [LINK]

Editor

Dr Grace Farrington


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