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2/17/06 Case presentation

2/17/06 Case presentation. Chief Complaint. The patient is a 49-year-old Caucasion female who complains of worsening dyspnea in the past few days. What questions do we want to ask this patient?. History of Present Illness. CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam

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2/17/06 Case presentation

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  1. 2/17/06 Case presentation

  2. Chief Complaint • The patient is a 49-year-old Caucasion female who complains of worsening dyspnea in the past few days

  3. What questions do we want to ask this patient?

  4. History of Present Illness • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment The patient is a 49 year old caucasion female with a history of chronic obstructive pulmonary disease who presents to the ER after her PCP evaluated her with an oxygen saturation of 84%. The patient notes that she has become more short of breath since November and it has worsened in the past few days. This is apparent all day long and is worse with exertion. She notes that she feels better when she uses her boyfriends home oxygen. She also notes that her boyfriend is chronically tired and short of breath. At the time of her symptoms she denies having chest pain, palpitations, calf tenderness or recent upper respiratory infections. She was speaking really slow when examined but was alert and oriented x 3.

  5. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Past Medical History COPD Hypercholesterolemia Non-Insulin Dependant Diabetes Milletus Seizure disorder – secondary mva Mitral Valve Prolapse Hypothyroidism

  6. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Medications Lipitor 10 mgPaxil 37.5 mgSingulair 10 mgInderal 80 mgClonidine 0.1 mgLevothyroxine 25 mcgDetrol LA 4 mgAdvair 250/50 one puff bidLisinopril 10 mgRisperdol 3 mg BIDGabapentin 300 tid

  7. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Allergies Dilantin - Nausea Tegretol – Dizziness Depakote - Nausea

  8. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Social History She smokes one pack of cigarettes per day for the past 30 years. She denies any use of alcohol or street drugs. She lives at home with her boyfriend.

  9. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Family Medical History Mother- Father- Died of a heart attack late in life

  10. Review of systems General:weight change, fever, chills, weak Head: headache, nasuea, vomitting, no lip lacerations Respiratory: SOB, wheeze, cough, Hx COPD Cardiac:HTN, murmurs, angina, palpitations GI:appetite, n/v, incont., const/diarrhea GU:frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no bowel or bladder incontinence no dyspareunia, no discharge MSK:muscle weakness, flank pain Neuro:parasthesias, loss of sensation Psychiatric- pt is not depressed • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment

  11. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Physical Exam VS- BP- 115/105 T-98.7 R-20 P-72 General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes, mydriasis CV- RRR w/o murmurs or rubs, or thrills RESP- Clear to auscultation bilaterally, exp wheeze Abdomen- Soft, NT, ND, no masses, BS, no bruits GU- No discharge, bleeding, nodules or masses Negative lloyds test MSK- No weakness, EXT- No edema, negative homans, pulses b/l SKIN- Macular rash on face both cheeks and nose Neuro- 2/4 refelxes bilaterally

  12. Differential • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment COPD / Asthma Pneumonia Bronchitis Infiltrative (i.e. asbestos)

  13. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment What do we want to order?

  14. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Labs CBC Chemistry EKG ABG Spiral CT

  15. CBC • CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment 16.2 g/dl 9.4 211 49.2 Chemistry 9.0 138 100 109 3.7 30 0.7 ABG PH 7.370 pCO2 51.6 pO2 41 (69.5 on 3L) Bicarb 29.1 coHb 11.2

  16. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment Chest X-ray Cardiomegally, no flattening of diaphraghm, no barrel chest Spiral CT Negative for PE

  17. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Diagnosis • Treatment • Assesment / Plan • 49 y/o caucasion female with dyspnea • Most likely COPD exacerbation, but must • rule out pneumonia vs. cardiac etiology vs. • Intrinsic lung disease vs. diffusion impairment • O2 to maintain saturation between 90 and 92% • Albuterol/ Atrovent SVN • Decadron • Mydriasis, probably related to atrovent • Urine Drug Screen • Diabetes – under control • Seizures - gabapentin

  18. CC • HPI • PMHx • MEDS • Allergies • SocHx • FMHx • ROS • Physical Exam • Differential • LABS • Radiological • Differential • Diagnosis • Treatment Hospital course Patient continued to desat to 70’s when taken off of nasal cannula. Multiple ABG show carboxy hemoglobin that is over 11. Upon further questioning patient notes that she has an old furnace and her boyfriend sleeps all day. Next day they send someone to the house who finds carbon monoxide leak in oven.

  19. Carbon Monoxide PoisioningBackground • Carbon monoxide (CO) • Colorless, odorless gas • CO is formed as a by-product of burning organic compounds • Fatalities result from • Fires • Stoves • Portable heaters • Automobile exhaust • Cigarette smoke is a significant source of CO • Improperly vented gas water heaters • Kerosene space heaters • Charcoal grills • Hibachis • Methylene chloride vapors

  20. Carbon Monoxide PoisioningPathophysiology • CO toxicity causes • Impaired oxygen delivery and utilization at the cellular level • CO affects several different sites within the body • Most profound impact on organs with highest oxygen requirement • Brain • Heart • Method • CO reversibly binds hemoglobin • Relative anemia • Small concentration can have large affect • Result in significant levels of carboxyhemoglobin (HbCO). • Binds hemoglobin 230-270 times more avidly than oxygen • CO level of 100 ppm produces an HbCO of 16% at equilibration • CO binds to cardiac myoglobin • Greater affinity than to hemoglobin • Myocardial depression • HbCO level • Often does not correlate well with clinical status • Implies possible additional impairment of cellular respiration.

  21. Carbon Monoxide PoisioningPathophysiology • HbCO levels often do not reflect the clinical picture • Levels • Around 10% • Beginning of symptoms • Headache • 50-70% • Seizure • Coma • Fatality • Elimination • CO is eliminated through the lungs • Half-life • 3-4 hours at room temperature • 30-90 minutes with administration of 100% O2 • 15-23 minutes with hyperbaric oxygen at 2.5 atm

  22. Acute poisoning Malaise, flulike symptoms, fatigue Dyspnea on exertion Chest pain, palpitations Lethargy Confusion Depression Impulsiveness Distractibility Hallucination Confabulation Agitation Nausea, vomiting, diarrhea Abdominal pain Headache, drowsiness Dizziness, weakness, confusion Visual disturbance, syncope, seizure Fecal and urinary incontinence Memory and gait disturbances Bizarre neurologic symptoms, coma Cherry red rash Carbon Monoxide PoisioningHistory

  23. Carbon Monoxide PoisioningPhysical • Vital signs • Tachycardia • Hypertension or hypotension • Hyperthermia • Marked tachypnea (rare; severe intoxication often associated with mild or no tachypnea) • Skin: Classic cherry red skin is rare (ie, “When you're cherry red, you're dead”); pallor is present more often. • Ophthalmologic • Flame-shaped retinal hemorrhages • Bright red retinal veins (a sensitive early sign) • Papilledema • Homonymous hemianopsia • Noncardiogenic pulmonary edema

  24. Carbon Monoxide PoisioningPhysical • Neurologic and/or neuropsychiatric • Memory disturbance (most common) • Retrograde • Anterograde amnesia • Emotional lability • Impaired judgment • Decreased cognitive ability • Other signs include stupor, coma, gait disturbance, movement disorders, and rigidity.

  25. Carbon Monoxide PoisioningLabs • HbCO • Elevated levels are significant • Low levels cannot exclude exposure • Up to 10% can be seen in smokers • CK-MB / Troponin • Ischemia can be associated • EKG • Sinus tachycardia

  26. Carbon Monoxide PoisioningTreatment • 100% inspired oxygen • Sometimes can use hyperbaric O2 • Careful correction of acidosis • O2 is appropriate

  27. Thank you! • Questions, comments, concerns?

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