A case of a 60 year old male , with a body weight of 17.9 kg/m2 , brought in the emergency room for shortness of breath.
The patient is a known smoker for 30 pack years. He occasionally drinks. He is a known hypertensive and has congestive heart failure. He is already on maintenance medications for hypertension for 10 years. He claims to have a lung problem but could not recall the diagnosis, but is currently taking a combination of inhaled long acting bronchodilators and steroids. He is already a retired public transportation driver.
His condition started around 4 days prior to admission as cough which was productive with whitish sputum. There was no associated fever. Patient just took in some cough medications which afforded only temporary relief.
3 days prior to admission noted to have body malaise this time associated with slight shortness of breath, tried having some nebulizations at a local clinic which afforded only slight relief, thus continued having it every 4 hours.
2 days prior to admission condition still persisted thus decided to seek consult with a doctor in their locality, was given some antibiotics, cough medications and was told to continue his nebulization.
On the day of admission, noted his shortness of breath to increase in severity despite of the nebulizations, thus decided to be brought in the emergency room at a hospital in their locality.
On Physical examination, patient was examined to be in distress:
BP: 110/80 mm Hg
HR-120 beats/min
RR: 28 cycles /min
T: 36.9 C
Skin: cold with clammy sweats,
Neck: prominent sternocleidomastoid muscles, no lymphadenopathy, (+) neck vein engorgement,
HEENT: non icteric, pinkish palpebral conjunctiva, no tonsillophryngeal congestion, uvula in the middle, tonsils not enlarged,
Chest/Lungs: no deformities, barrel chested, no scars,
On physical examination, Mr. Winstone was found to have a body mass index of 27.9, his blood pressure was 133/90, pulse was 110, respiratory rate was 14, and his oxygen saturation was 88% on room air. The results of his head and neck exam were unremarkable, with no jugular venous distension noted. His chest excursions were symmetric with evidence of hyperinflation. Mr. Winstone's breath sounds were decreased throughout, and the expiratory phase was prolonged. His heart exam was notable for distant but otherwise normal heart sounds. The abdominal exam was unremarkable. There was no clubbing of his digits noted, but there was mild cyanosis and peripheral edema. His neurologic exam was nonfocal. Arterial blood gas drawn on room air revealed a pH of 7.39, PaO2 of 53, and PaCO2 of 44.
His pulmonary function results before bronchodilators (% predicted) were forced expiratory volume in 1 second (FEV1): 1.25 L (41%), forced vital capacity (FVC): 2.53 L (60%), and FEV1/FVC: 49. Post bronchodilator, his results were: FEV1: 1.29 L (42%) and FVC: 2.64 L (62%). His residual volume was 6.74 L (329%), total lung capacity: 9.45 L (150%) and his diffusing capacity was 6.96 L (25%).
Questions:
1. What is your impression?
2. Give at least 5 differential diagnosis?
3. What is your management?
2007-12-20
17:03:13
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5 answers
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asked by
Mike
3