Transcript DR.IMRAN MEHFOOZ KHAN

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 limitations
 Class
2 – slight limitation of physical
activity
 Class
3 – marked limitation of physical
activity
 Class
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 onset
 Duration
 Progression
 Variability
 Aggravating
/relieving factors
 Severity
 Associated
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
 Metabolic
edema
acidosis
 Anemia

Pleuritic chest pain;
 Pneumonia
 Pneumothorax
 Pulmonary
 Rib
embolism
fracture
Associated symptoms
 Central
chest pain;
Myocardial
infarction leading to acute
left ventricular failure
Massive
 Wheeze
pulmonary embolism/infarction
cough;
Asthma
Chronic
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