dr.imran mehfooz khan assitant professor east medical ward mayo hospital,lahore
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DR.IMRAN MEHFOOZ KHAN
ASSITANT PROFESSOR
EAST MEDICAL WARD
MAYO HOSPITAL,LAHORE
Breathlessness (LVF)
Case history A 70 years old lady presented with the complaint of shortness of breath for the last 6 months. This complain has been progressive . Initially breathlessness was on exertion only but now she feels breathless on lying in bed without three pillows . She also wakes up from sleep a number of times at night.
She lives on second floor and has to climb a flight of 10 stairs . Recently she has started to experience chest discomfort along with breathlessness.
WHAT IS THE DIAGNOSIS?
Heart failure Heart failure is a complex syndrome resulting from structural or functional
cardiac disorder that impairs the ability of heart to act as a pump to support physiologic circulation and is characterized by symptoms such as breathlessness and fatigue and signs of fluid retention.
Symptoms;
left ventricular failure (LVF) may result in dyspnea ,orthopnea , paroxysmal nocturnal dyspnea , nocturnal cough or fatigue.
Signs; Hypotension
Tachycardia
Third heart sound
Edema
Bibasal crepitations/crackles
NYHA classification of heart failure
Class 1 – no limitationsClass 2 – slight limitation of physical
activityClass 3 – marked limitation of physical
activityClass 4 – symptoms at rest
Definitions Breathlessness/dyspnea;
Undue awareness of breathing . It is normal with strenuous physical exercise.
Hypoapnea;
Shallow breathing or low respiratory rate. Orthopnea;
Breathlessness on lying flat. Paroxysmal nocturnal dyspnea;
Breathlessness that wakes up the patient from sleep.
Tachypnea;
Increased rate of breathing. Hyperventilation;
Inappropriate overbreathing
History
Mode of onsetDurationProgressionVariabilityAggravating /relieving factorsSeverityAssociated symptoms
Mode of onset , duration and progression of breathlessness In minutes;
Pulmonary thromboembolism Pneumothorax Acute pulmonary edema Acute attack of asthma Inhaled foreign body
In hours/day; Pneumonia Exacerbation of COPD
Mode of onset , duration and progression of breathlessness Weeks to months;
Pleural effusion Anemia Pulmonary tuberculosis
Months to years; COPD Pulmonary fibrosis Congestive cardiac failure
Severity of breathlessness:medical research council (MRC) classification Grade 1;
breathless when hurrying on the level ground or walking up a slight hill
Grade 2;
breathless when walking with people of own age on level ground
Grade 3;
has to stop because of breathlessness when walking on level ground at own pace
Associated symptoms
No chest pain; Pulmonary edema Metabolic acidosis Anemia
Pleuritic chest pain; Pneumonia Pneumothorax Pulmonary embolism Rib fracture
Associated symptoms
Central chest pain;Myocardial infarction leading to acute
left ventricular failureMassive pulmonary
embolism/infarctionWheeze cough;
AsthmaChronic obstructive pulmonary disease
Causes of heart failure Ischemic heart disease Hypertension Valvular heart disease. Aortic stenosis. Arrhythmias – AF Cardiomyopathy Myocarditis Pericardial disease High output failure – thyrotoxicosis, anemia.
Differential diagnosis Cardiac causes;
Left ventricular failure
Mitral valve disease
Congestive cardiac failure
Cardiomyopathy
Pericardial effusion
Respiratory causes; Airway:
Foreign body
Asthma
COPD
Bronchiectasis
Lung cancer
Differential diagnosis Parenchymal:
Pulmonary fibrosis
Tuberculosis
Pneumonia
Pulmonary circulation: Pulmonary thromboembolism
Pulmonary hypertension
Pleural: Pneumothorax
Effusion
Chest wall: Kyphoscoliosis
Neuromuscular: Myasthenia gravis
Guillian barre syndrome
THANKYOU
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