Hi it's Christmas! Can you help me with my case...just any ideas you have...I would really apprreciate it...

Question

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?

(+) neck vein engorgement, DISREGARD "with no jugular venous distension noted.

Answer 1

First impressions - - Something has caused this 60 year old man to decompensate in the past four days. He has known chronic heart failure probably related to chronic hypertension, and he clearly has COPD. Most likely, there has been an exacerbation of his CHF (perhaps from too much salt in his diet recently - I've seen this happen with one pizza). If you put worsening CHF on top of barely compensated COPD, you can have a patient quickly deteriorate into distress.
First impression for lab work is that he has a lousy diffusing capacity. ("lousy" being metaphorical not literal). Any interstitial lung disease could do this, but it may also occur in the presence of emphysema or CHF with interstitial pulmonary edema or a combination of the above.
There are discrepancies in the data supplied. Initially you say (+) neck vein engorgement, then you note no jugular venous distension. His respiratory rate starts at 28 and drops to 14 with the second examination report. I assume you may have placed this man on nasal oxygen and perhaps given some intravenous lasix. A small dose of IV morphine can do wonders with an exacerbation of CHF as long as it does does not suppress respiration. It's tricky, but I've seen this work remarkably quickly in the ER or CCU.
You mention cyanosis, so this man has unsaturated hemoglobin sufficient to suggest he is not anemic (since you have not provided a CBC) - also his conjunctival exam indicates no major anemia which could cause decompensation. The absence of fever or colored sputum suggest no bacterial infection, but a viral lower respiratory infection could cause decompensation.
What's his renal funtion? Liver function? Electrolytes? Thyroid status? I'd like a complete chemistry panel to look for other contributing problems and of course a CBC with diff and platelet count.

Differential diagnosis
1. COPD
2. CHF
3. Possible component of interstitial lung disease
(This may be a "zebra" diagnosis - and it would not help very much with management - but in academia we usually included zebra possibilities. You would need a lung biopsy
to know, and I would NOT recommend this.)
4. Consider viral lower respiratory infection or partially treated bacterial respiratory infection (A WBC with diff. may help here unless you have given corticosteroids.) - - correction - I see he has been on oral corticosteroids at home, so the neutrophil count will probably be elevated.
5. Consider DVT with pulmonary emboli

Management - Fix what you can fix ! !
Diuretic Rx to optimize control of CHF
Digitalis if indicated or not contraindicated
Afterload reduction with appropriate blood pressure meds
Oxygen supplementation watching for CO2 retention
As a hematologist, I want to see a CBC and review the blood smear myself - - eosinophils might be interesting. (Probably not, but finding a zebra in a herd of horses is usually fun.)
Doesn't appear that bronchodilators help much, but some people would stick with nebulizer therapy.
Consider studies to rule out DVT/PE - - but be careful you don't order and execute so many studies that you wear the patient out in the process. He is fragile.
I would cover with an antibiotic based on the idea that it might help and probably will do no harm - - just in case a respiratory infection triggered this acute downturn.
{This is an old timer opinion. Perhaps things have changed since I saw this type of patient.} Merry Christmas.

Answer 2

Bronchodilators aren't helping. The problem is not his lungs. He's in florid CHF, and I agree with the above cor pulmonale diagnosis. This guy needs lasix and maybe a little dopamine and nitric oxide.

Answer 3

I am a MOM make I owe you FREE no yelling/ fighting coupons for her to CASH in an do chores or something you Hate just to make her EXTRA HAPPY. Then you can buy her something she already has but uses all the time and runs out of. Is she a coffee drinker? Or make her a special junk food sweet treat with the supplies money or DINNER if you can cook.

Answer 4

i am only amedical student, so here is what i think:
1- white frothy sputum is mostly caused by a cardiac problem.
the barrel chest is asign of chronic obstructive pulmonary disease.
peripheral oedema is a sign of heart failure.
2- right heart failure.
chronic asthma.
COPD caused by heart failure.
complications of hypertension.
3- consult a specialist
chest Xray
ECG
get th pt's file from his local clinic

Answer 5

I know you put questions but but don`t read answers.
Patient is having "Chronic congestive cor pulmonale with secondary infection".
There are more than 5 differential diagnoses.
My management includes even growth hormone and it is difficult for you to follow the logic.

Answer 6

hi, i will only give 2 diagnosis; viral chest infection( because sputum was white and it happens in viral infections, and cancer: i heard that white sputum and not responding to medication may be caused by cancer.