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The Case of the Elderly Man with Difficulty in Breathing on a Plane

The Case of the Elderly Man with Difficulty in Breathing on a Plane. Kristen Owen, DO MSUCOM October 12, 2014. Pertinent Positives. 78 y.o . male presents with severe DIB Recent plane trip from India History of asthma History of CAD w/ coronary stents. ROS. Associated symptoms:

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The Case of the Elderly Man with Difficulty in Breathing on a Plane

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  1. The Case of the Elderly Man with Difficulty in Breathing on a Plane Kristen Owen, DO MSUCOM October 12, 2014

  2. Pertinent Positives • 78 y.o. male presents with severe DIB • Recent plane trip from India • History of asthma • History of CAD w/ coronary stents

  3. ROS • Associated symptoms: • Fatigue • Diarrhea • Sweating • Lethargy • Wheezing

  4. Physical Exam • Vital Signs reveal a normal HR, increased RR, normal BP and a normal temp. • O2 saturation is 100% on Bipap • HEENT: dry mucous membranes, bilateral pharynx swelling, anterior cervical lymphadenopathy • Respiratory: severe resp. distress, bilateral diminished, severe, substernal retractions

  5. Pertinent Labs • CBC revealed a leukocytosis, neutrophilia, and increased bands. • Hypermagnesemia • Elevated Lactate • Elevated Alkaline phosphatase • ABG revealed a metabolic acidosis

  6. CXR

  7. CT Chest

  8. CT Chest

  9. CT Soft Tissue Neck

  10. CT Soft Tissue Neck

  11. Video of Oropharynx • Diffuse erythema with white exudate • Likely consistent with a candidal infection • Pt is likely immunocompromised-HIV, malignancy, infection, recent course of steroids, chemotherapy or radiation.

  12. What We Know • Pt has: • Respiratory Failure • Metabolic Acidosis • Sepsis (by definition) • Multilobar Pneumonia (by CT scan) • Diarrhea

  13. DDX for Respiratory Distress • PE • Asthma • Pneumonia • Pneumothorax • CHF • Mucous Plugging • Tuberculosis • SARS • Altitude Sickness

  14. DDX for Pneumonia • S. pneumonia • S. aureus • Legionella • Pneumocystis carinii • Pseudomonas • Influenza • Pertussis • H. influenza • RSV • Mycoplasma pneumonia • Chlamydia pneumonia • Moraxella catarrhalis • Gram negative enterics

  15. Diseases Common to India • HIV/AIDS • Tuberculosis • Pneumonia • Malaria • Food Borne Pathogens

  16. DDX for Diarrhea • Bacterial- E. coli, Campylobacter, Salmonella, Shigella, Clostridium dificile, Vibrio, Aeromonas, Pleisiomonas, Yersinia • Parasites- Giardia, Cryptosporidium, Cyclospora, Microsporidia, Isospora, Entameobahistolytica • Viral causes- Hepatitis A and E, Rotavirus, Adenovirus

  17. DDX for Malignancy Lung Cancer • Small Cell Carcinoma • Non-Small Cell Carcinoma Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Lymphoma Non-Hodgkins Lymphoma Hodgkins Lymphoma

  18. Things that we Need to Do • Establish 2 large bore IV’s and fluid resuscitate (sepsis protocal) • Check a core temp. • Start IV antibiotics-Zosyn, Levaquin, and Vancomycin. • Order Rapid HIV, Interferon Gold, and Influenza tests. • Stool studies-FOB, fecal lactoferrin

  19. My Best Guess • Candida from being immune compromised • Malignancy-Hodgkins lymphoma • Pneumonia-H. influenza • Diarrhea-Adenovirus

  20. Hodgkin’s Lymphoma Bimodal age distribution • One peak in the 20s-30s • Second peak over age 50 Usually people present with an asymptomatic enlarged lymph node or a mass on CXR Symptoms usually occur over several months-”B” symptoms-fever, night sweats, weight loss

  21. Diagnosis of Hodgkin’s Lymphoma • Biopsy of a Lymph Node • Confirmed by the presence of Reed-Sternberg cells.

  22. H. influenza • Second most common cause for pneumonia. • Transmitted person to person by droplets • Vaccinations in children have helped with decreasing infections • In adults, chronic pulmonary disease, smoking, HIV, alcoholism, pregnancy, malignancy, and older age can predispose patient to infection.

  23. H. influenza • Treatment • Rocephin , Zithromax, or Levaquin

  24. Resources • http://www.cdc.gov/globalhealth/countries/india/ • http://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-in-the-outpatient-setting?source=preview&search=pneumonia&selectedTitle=1%7E150&language=en-US&anchor=H468093943#H468093943 • http://www.uptodate.com/contents/clinical-presentation-and-patterns-of-disease-distribution-in-classical-hodgkin-lymphoma-in-adults?source=see_link • http://www.uptodate.com/contents/microbiology-epidemiology-and-treatment-of-haemophilus-influenzae?source=machineLearning&search=h.+influenza&selectedTitle=1%7E150&sectionRank=1&anchor=H13#H13

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