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CASE
HISTORY - MASTER
DYSPNOEA
IN PALLIATIVE CARE
Brian is a 57 year old smoker. He presented to his GP with recent onset breathlessness. A chest x-ray was ordered which was reported as a showing a right hilar tumour. He was referred to the BGH where he underwent bronchoscopy and biopsy. Histology revealed that he had a small cell carcinoma of his lung and he underwent a course of chemotherapy with resolution of his breathlessness. Brian remained asymptomatic for three months.
One Sunday Brian's wife phones BORDOC requesting a comode for him. The call is passed to the district nurse on duty.
Question 1
You are the district nurse on duty and take the comode to Brian. You find that he requires it because he has become too breathless to get to the toilet. What assessment would you make?
- Medical history and evidence of recent deterioration
- cough, sputum, haemoptysis
- degree of breathlessness -- on exertion or at rest, ability to speak in sentences
- colour
- temperature
- pulse
- respiratory rate
Question 2
You are very concerned about his breathlessness and phone BORDOC. The duty doctors says that he will visit but will be about 45 minutes. What could you do to help ease Brian's distress in the meantime?
- Reassurance
- posture
- fan
Question 3.
You are the duty doctor for BORDOC and visit Brian at home. What are the possible causes of his deterioration and what features might you look for?
- Infection
- pulmonary embolism
- pleural effusion
- superior vena cava obstruction
- malignant pericardial effusion
- obstruction of bronchus
- lymphangiitis carcinomatosa
Over the past few days he had become progressively more short of breath. At first the breathlessness was only when he would lie down. Today, he found it difficult to breathe when sitting upright.
His wife observes, "Two days ago I noticed that when he would lie down he’d get flushed and then sit bolt upright gasping for his breath! I was terrified that he was having a heart attack! He refused to go to the hospital because he didn’t have any chest pain. Today he was short of breath when sitting still. I also noticed that his face was puffy and that scared me".
After his wife talks Brian admits that he’s been quite distressed. He has had to sleep with three pillows. He hasn’t had a cough, fever, or night sweats, but has noticed that recently he’s lost about 5 kg.
On examination you find that he has slight periorbital oedema. There are increased venous markings on his chest. The jugular venous pressure (JVP) is 8 cm above the sternal notch. After lying flat he becomes flushed and sits bolt upright to catch his breath. He has no lymphadenopathy. His liver is enlarged with a span of 14 cm. There is no detectable splenomegaly.
Question 4.
What is the clinical syndrome and what would be the likely management of this?
- Superior vena cava obstruction
- oxygen
- dexamethasone
- chemotherapy
A few months later Brian's condition deteriorates once again but he is told that there is nothing further that can be done to treat the cancer. He wants to remain at home but becomes distressed by breathlessness at rest.
Question 5
What palliative measures could you take to make him more comfortable?
- Posture
- Fan
- Nebulised saline
- Oxygen
- Opiates
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