deborah212 Posted April 10, 2011 Share Posted April 10, 2011 72 yo male with chief complaint of "feeling more and more short of breath" Triage Vitals: T 98.2 P 101 RR 24 O2 Sat 90% on RA, 98% on 2L Remember to think systematically. And... go! Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted April 10, 2011 Share Posted April 10, 2011 GCS, and BP, skin color (pallor, cyanotic, flushed ect), pulse regularity, quality and symmetry please When did the SOB first begin<O:p</O:p Any CP associated with SOB or ever any CP? If so please describe (inspiration/expiration, location, radiation)<O:p</O:p <O:p</O:p Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted April 10, 2011 Share Posted April 10, 2011 Aggravating factors- (Orthopenia, exertional ect)<O:p</O:p Alleviating factors (rest, meds, change in position, O2 ect<O:p</O:p Smoker? (ever?) if yes pack/year<O:p</O:p Occupation/ exposures <O:p</O:p GCS, and BP, skin color (pallor, cyanotic, flushed ect), pulse regularity, quality and symmetry please When did the SOB first begin<O:p</O:p Any CP associated with SOB or ever any CP? If so please describe (inspiration/expiration, location, radiation)<O:p</O:p <O:p</O:p Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted April 10, 2011 Share Posted April 10, 2011 Lung sounds<O:p</O:p peripheral edema<O:p</O:p Abdominal distention<O:p</O:p <O:p</O:p Pmhx, meds,allergies, recent trauma or surgery? PS,sorry for the multi posts but for some reason there was an error message saying my reply was too long (??) <O:p</O:p Aggravating factors- (Orthopenia, exertional ect)<O:p</O:pAlleviating factors (rest, meds, change in position, O2 ect<O:p</O:p Smoker? (ever?) if yes pack/year<O:p</O:p Occupation/ exposures <O:p</O:p Link to comment Share on other sites More sharing options...
deborah212 Posted April 10, 2011 Author Share Posted April 10, 2011 That's a whole lot of smiley faces! GCS, and BP, skin color (pallor, cyanotic, flushed ect), pulse regularity, quality and symmetry please Sitting at the bedside, you assess the patient is stable, so let's first go with the history. HPI: When did the SOB first begin? Aggravating factors- (Orthopenia, exertional ect). Alleviating factors (rest, meds, change in position, O2 ect SOB began about a month ago and has been increasing in frequency from feeling dyspneic only with exertion once a week to now happening approximately once per day at rest. Describes having "to yawn frequently to get air." Cannot walk more than 150 feet before needing to stop and has been sleeping in recliner at 60 degrees due to orthopnea. No recent changes in medications. Hasn't seen his PCP in >6 months. Any CP associated with SOB or ever any CP? If so please describe (inspiration/expiration, location, radiation) Denies chest pain. Pmhx, meds,allergies, recent trauma or surgery?Smoker? (ever?) if yes pack/year. Occupation/ exposures PMHx: HTN DMII GERD Medications: (mail-order) Toprol XL 75 qd Lisinopril 5mg ASA 81 mg Metformin 1000 BID Omeprazole 20 mg qd Allergies: PCN-->hives SHx: Worked as a mason, now retired. Quit smoking at age of 55 with 20 pack-years. No IVDU. Very good start. What else do we want to know? Link to comment Share on other sites More sharing options...
Guest guthriesm Posted April 10, 2011 Share Posted April 10, 2011 Any recent travel? Have these sx occurred before? History of clots (I see he is on ASA)? pneumonia, syncope, dizziness, numbness/weakness, memory loss, ulceration or hair loss on legs? Any new chemicals (relatively new since sx started 6mo ago)? Abdominal complaints? (food intolerance, GI changes, etc) Thyroid history? anemia, abn bleeding/bruising? environmental allergies or asthma? How is his skin color (saw you said he was "stable" but is he red? pale? sweating?) Link to comment Share on other sites More sharing options...
deborah212 Posted April 10, 2011 Author Share Posted April 10, 2011 Good for you, gutherism, for doing a fair ROS. This will be helpful. Any recent travel? Have these sx occurred before? History of clots (I see he is on ASA)?No recent travel. Hasn't been ambulating much for the past 2 months. No prior history of dyspnea before 6 months ago. No history of clots. (The patient is on ASA for cardiovascular primary prevention.) pneumonia, syncope, dizziness, numbness/weakness, memory loss, ulceration or hair loss on legs? Any new chemicals (relatively new since sx started 6mo ago)?No to the above except for weakness. About a year ago, patient felt like his legs were getting weaker. Tried increasing his mall walking exercise to build muscle tone, but didn't help. Friend brought over an old walker several weeks prior because the patient felt so debilitated: "my legs don't seem to work like they used to." No parasthesias. Abdominal complaints? (food intolerance, GI changes, etc) Thyroid history? anemia, abn bleeding/bruising? environmental allergies or asthma? No to the above. How is his skin color (saw you said he was "stable" but is he red? pale? sweating?) Denies fevers, chills, and diaphoresis. Link to comment Share on other sites More sharing options...
Guest guthriesm Posted April 10, 2011 Share Posted April 10, 2011 Are we missing any more history questions? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 10, 2011 Administrator Share Posted April 10, 2011 Hx: Need a BP. How well is his HTN controlled? On PE, check for retinopathy. Need details on his DM II. How long ago diagnosed? Overall, I want to know how compliant he is on his meds. DDx: Cardiac: dilated cardiomyopathy, volume overload, occult MI Lungs: PE Heme: Anemia On Physical exam, I want to get lungs, heart (JVP/edema/sounds), fundoscopy, neuro exam, skin (Once we get to labs, I want CBC, H&H, HbA1C/Glucose, iron studies if anemia, and a 12 lead for starters) Link to comment Share on other sites More sharing options...
deborah212 Posted April 10, 2011 Author Share Posted April 10, 2011 How well is his HTN controlled? Overall, I want to know how compliant he is on his meds. Occasionally forgets a dose of his antihypertensives, but otherwise is compliant. Has been diabetic for ~20 years. Fingersticks 150s-280s at home. Has issues adhering to his "diabetic diet." Family Hx Father died of "heart problems" at age 50. Several siblings with DMII. Physical Exam T 98.4 P 104 RR 21 O2 Sat 99% on 2L Gen- Dyspneic with prolonged talking but able to complete sentences. HEENT- PERRL. Optic discs sharp. EOMI. MMM Neck- JVP at 7 cm. No LAD. CV- S1 + S2 tachy rate. RR. no r/m/g Pulm- Slightly tachypneic but seems improved with oxygen. Decreased breath sounds at right base. Abd- +BS. Soft/NT No HSM Ext- No edema. No cords palpated. Neuro- A&O x 3. Appropriate. CNII-XII grossly intact. Grip stength equal. Upper extremity exam normal except for 4/5 left shoulder abduction. Atrophy of quadriceps and calfs R>L with 3 seconds of visible fasiculations. Hip flexion: R 2/5 L 3/5 Knee extension: R 1/5 L 3/5 Dorsi/plantar flexion: R 1/5 L 2/5. Right patellar reflex R 3+ L 2+. Upward babinski on R with equivocal on L. Rev Ronin has some requests for work-up... where should be start? Link to comment Share on other sites More sharing options...
acozadd Posted April 10, 2011 Share Posted April 10, 2011 CBC-- infectious, anemia, CMP-- with the fasiculations I'd check lytes TSH free T4 Chest X-ray to evaluate diminshed heart sounds, check cardiac enlargement, suspect COPD with smoking history EKG While unlikely, consider the following: D-dimer (would it really be useful?), cardiac enzymes (not consistent with history, but dyspnea is common presenting sign in elderly, especially a diabetic who may have neuropathy) Start there i suppose. Just read the neuro exam and the right extremity weakness, along with the abnormal babinki and right sided diminshed lung sounds makes me think there may be something neuro going on. Did you percuss to assess diaphragmatic motion? Link to comment Share on other sites More sharing options...
deborah212 Posted April 11, 2011 Author Share Posted April 11, 2011 I want CBC, H&H, HbA1C/Glucose, iron studies if anemia, and a 12 lead for starters WBC 8.4 HCT 34 Platelets 266 MCV 85 Normal Diff Na 134, K 3.8, CL 106, CO2 21, BUN 10, Cr 0.84 HgA1c 9.0 Fe 60, TIBC 270 Ferritin 240 CMP... TSH free T4 Chest X-ray to evaluate diminshed heart sounds, check cardiac enlargement, suspect COPD with smoking history EKG AST 30 ALT 42 Alk 120 T bili 1.0 Ca 8.0 Mg 1.8 PO4 2.6 TSH 3.0 Free T4 1.1 EKG: Sinus tach at 106 BPM. Normal axis. No ST changes. CXR: Lungs slightly hyperexpanded. Elevated right hemidiaphragm. No Infiltrate, effusion, or overt pulmonary edema. While unlikely, consider the following: D-dimer (would it really be useful? cardiac enzymes (not consistent with history, but dyspnea is common presenting sign in elderly, especially a diabetic who may have neuropathy) Good to think broadly. I'm not sure if I would have ordered a d-dimer on this patient (we can talk about later) but already done by ED. D-dimer 400 (normal <250) CPK 60, CK-MB 2.2 Troponin <assay So what do you think? What should we do or test for next? Link to comment Share on other sites More sharing options...
acozadd Posted April 11, 2011 Share Posted April 11, 2011 Id do a CT to r/o PE-- tachycardia, tachypnea, recent immobility is a clotting risk, renal function is fine to support the contrast. That would be my top dog. From what I've heard a D-dimer is more useful in a patient with low clinical suspicion of a PE.. a negative D-dimer with symptoms that lead you to believe they have a PE does little to r/o the possibility of a PE. Edit- I'd consider ABGs as well. Link to comment Share on other sites More sharing options...
deborah212 Posted April 11, 2011 Author Share Posted April 11, 2011 Id do a CT to r/o PE-- tachycardia, tachypnea, recent immobility is a clotting risk, renal function is fine to support the contrast. That would be my top dog. From what I've heard a D-dimer is more useful in a patient with low clinical suspicion of a PE.. a negative D-dimer with symptoms that lead you to believe they have a PE does little to r/o the possibility of a PE. Edit- I'd consider ABGs as well. Excellent. We didn't have a low suspicion for PE (tachycardia, immobility +/- PE most likely reason for hypoxia), so even if the d-dimer had been normal, I would not have have been reassured without imaging. CT PE protocol: Negative for PE. 7.44 / 33 / 75 / 21 / 99% on 2L So what do we think could be going on? What's the differential for dyspnea and what have we ruled out? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted April 11, 2011 Administrator Share Posted April 11, 2011 Normocytic anemia is consistent with chronic disease or malignancy. Iron studies are also low normal consistent with chronic disease. Not sure where to go with that initially, though. A1c is consistent with quite poor long term glucose control, so I'm worried about end organ damage. Calcium, Sodium are a hair lower than normal. ABG, Thyroid, liver look WNL. Thinking out loud here: * So, for a 72 YO with a history of HTN and a 20-year history of poorly controlled DM II, his BUN and Creatinine look great. * We got a CT of the area of decreased breath sounds, and saw nothing consistent with a PE... but what DID we see? Is there any abdominal content impingement into the chest? Do we see hepatomegaly? So, no evidence of anything in my initial DDx except Anemia, and that itself points to malignancy, and DDimer is consistent with that too, so I'm adding cancer as my new #1. Link to comment Share on other sites More sharing options...
acozadd Posted April 11, 2011 Share Posted April 11, 2011 Dyspnea- pneumothorax, hemothorax, foreign body, pneumonia, mass, effusion, PE, COPD, asthma, etc. Not sure what is all involved in being a mason but possible exposure? Mesothelioma? I Link to comment Share on other sites More sharing options...
Just Steve Posted April 11, 2011 Share Posted April 11, 2011 Dyspnea- pneumothorax, hemothorax, foreign body, pneumonia, mass, effusion, PE, COPD, asthma, etc. Not sure what is all involved in being a mason but possible exposure? Mesothelioma? I I have worked with grout quite a bit and mixing of thinset which is used to adhere tile...I can vouch that the amount of airborne particles from the dry mix is fairly suffocating. It would not be a stretch at all to assume inhalation of all sorts of material that basically turns to stone when mixed with water. Do that for a career...watching this thread with interest, see what he has Link to comment Share on other sites More sharing options...
kirkc18 Posted April 11, 2011 Share Posted April 11, 2011 Consistent right side weakness and fasciculation makes me think neuro. Head ct to rule out past CVA? Link to comment Share on other sites More sharing options...
deborah212 Posted April 12, 2011 Author Share Posted April 12, 2011 Normocytic anemia is consistent with chronic disease. Iron studies are also low normal consistent with chronic disease Correct. Dyspnea- pneumothorax, hemothorax, foreign body, pneumonia, mass, effusion, PE, COPD, asthma, etc.Good differential, but you're forgetting this: Consistent right side weakness and fasciculation makes me think neuro. Head ct to rule out past CVA?Head CT without intracranial abnormality. Specifically, no evidence of prior CVA. Not sure what is all involved in being a mason but possible exposure?Heavy metals sent and negative. This is a very tough student case. I needed consultants, namely neurology (hint... hint), to assist with the diagnosis. It's a good illustration that not all dyspnea is PNA/CHF/COPD/PE. Take some time to think about it, and if we can't come up with more on the differential, maybe we can get some help. Link to comment Share on other sites More sharing options...
acozadd Posted April 12, 2011 Share Posted April 12, 2011 New differential: MS, MG, tumor/mass affecting the spinal column (were there any changes noted on the CT chest in regards to the spinal column?), The fact that he is having weakness in the right leg and an elevation of the hemidiaphragm noted on x-ray would make me think of something more global as opposed to focal since the innervation of these are opposite ends on the spine... Link to comment Share on other sites More sharing options...
deborah212 Posted April 12, 2011 Author Share Posted April 12, 2011 The fact that he is having weakness in the right leg and an elevation of the hemidiaphragm noted on x-ray would make me think of something more global as opposed to focal You're right on track. MS, MG, tumor/mass affecting the spinal column (were there any changes noted on the CT chest in regards to the spinal column?), MS... "white matter lesions separated in time and space" How do we work this up? Myasthenia Gravis... good thought. What can we send? No tumor/mass seen on chest CT Link to comment Share on other sites More sharing options...
acozadd Posted April 12, 2011 Share Posted April 12, 2011 You're right on track. MS... "white matter lesions separated in time and space" How do we work this up? Myasthenia Gravis... good thought. What can we send? No tumor/mass seen on chest CT MS- MRI head and C-spine with + without contrast. Can do an LP to confirm diagnosis, not sure how often it is done however. MG- Not sure on the lab. I believe you can give the patient edrophonium (spelling?) and see if their symptoms disappear. Link to comment Share on other sites More sharing options...
deborah212 Posted April 12, 2011 Author Share Posted April 12, 2011 MS- MRI head and C-spine with + without contrast. Can do an LP to confirm diagnosis, not sure how often it is done however. MRI brain and c-spine: No white matter lesions. Cervical spine with DJD. LP was not done MG- Not sure on the lab. I believe you can give the patient edrophonium (spelling?) and see if their symptoms disappear. We sent acetycholine receptor antibody (AChR) which was negative. Didn't pursue further testing for myasthenia gravis as something was done that helped solidify the diagnosis. Link to comment Share on other sites More sharing options...
acozadd Posted April 12, 2011 Share Posted April 12, 2011 Beats me-- I'll let others chime in before I cheat and start doing a little research. Link to comment Share on other sites More sharing options...
deborah212 Posted April 13, 2011 Author Share Posted April 13, 2011 Just going to summarize... 72 yo male with hx of HTN and DMII admitted with acute on subacute dypnea in setting of progressive weakness with evidence of possible upper (babinski/hyperreflexia) and lower motor neuron (fasiculations, atrophy, weakness) involvement on exam. On further history, patient also relates dysphagia with thin liquids over the past several weeks. Research away. Will give diagnosis after work tomorrow if no one can come up with it. This is a rare case. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.