Download 59-year old male with shortness of breath

59-year old male with shortness
of breath
State University of New York
Polytechnic Institute
Presented by Francine Bassett
Patient & Source of Encounter
• T.I., 59-year old male
• Elizabethtown Community Hospital –
Emergency Department
HPI
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59- year old male patient presents to the ER via personal vehicle with c/o
shortness of breath x 3 days. Pt reports his illness began on Monday morning. By
Monday evening, pt reports he lied down and it became difficult to breath, with
sudden onset. He had chest pressure that lasted approximately 30 seconds that
went away after he sat up and took a deep breath.
He was also clammy. Pt tried to take “cough syrup” once on Tuesday which didn’t
work. He hasn’t taken any since then. Denies taking any other medications,
antibiotics, or tried other interventions. Pt continues with a dry, non-productive
cough, worse when laying flat and at night. Pt states he has been sleeping in the
tripod position with pillows since Monday night.
Today (Thursday), the school pt works at called the ER stating he was coming in.
Upon arrival to the ER, pt admits to constant, non-radiating, mid-sternal chest
pressure, worse when lying down, improved by sitting up. Denies pain. Admits to
dyspnea, orthopnea, cough, body aches. Denies chills, fever, nausea, vomiting, abd
pain, ear pain, sore throat. Denies any recent travel/limited movement.
Daily cig Smoker = 10 pack years. Denies ETOH abuse or recreational drugs. Denies
any known past medical history. Doesn’t recall last visit to a health care provider.
Denies any medication history. Denies receiving flu and pneumonia vaccine.
Denies sick contacts.
ROS
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General: Denies fever, chills, night sweats.
Skin: Admits to sweating.
Ears: Denies ear ache.
Nose/sinus: Admits to clear nasal discharge. Denies post
nasal discharge, sinus pain or infections.
Mouth/throat: Denies sore throat.
Respiratory: Admits to pain, dyspnea, orthopnea,
wheezing, cough. Denies asthma, bronchitis, COPD,
sputum.
Cardiac: Admits to pressure, dyspnea. Denies HTN,
syncope, edema
Peripheral vascular: Denies blood clots.
GI: Denies nausea, vomiting, abd pain.
History
• PMHx
– Patient denies any known past
medical history.
– Medications:OTC Cough syrup
x1 past Tuesday – unknown
name.
– Hospitalizations/injuries/accide
nts: Denies.
– Allergies: Denies allergy to
food, latex, environment, or
medications.
– Immunizations: Denies flu and
pneumonia.
• Family Hx
– Denies any familial hx of
cardiac, blood disorders, or
respiratory problems.
• Social Hx
– Occupational: Maintenance at
grade school
– Habits: 10 pack year smoker.
Denies illicit drug use. Denies
ETOH abuse.
Physical Exam
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General appearance: 59-year old acutely ill male, pale, in moderate respiratory distress, sitting
upright on stretcher.
VS: T98.1, RR 20, P 90, BP 171/70, Spo2 92% RA (on arrival)97%2LNC
Ht/Wt/BMI: 72in/160lb/21.7
Skin: Pale, warm, dry. Absence of rashes.
Eyes: Sclera white, anicteric.
Ear: EAC’s without drainage or edema. TM’s pearly gray, cone of light 5 o’clock Right, 7 o’clock left.
Throat/mouth:. Posterior pharynx pink, without exudates. Uvula midline. Tonsils +1 bilaterally.
Neck: Absence of lymphadenopathy. Trachea midline.
Chest/lungs: Labored, deep, respirations. AP diameter 1:2. Coarse crackles bases bilaterally. Upper
lobes with expiratory wheezes. Using accessory muscles, supraclavicular retractions. Mid-sternal
pressure. Resonant to percussion.
CV/PV: RRR. S1:S2. No murmurs, gallos, rubs, clicks, heaves, thrills. Absence of carotid bruits. Cap
refill <2seconds. Strong 2+ radial and pedal pulses bilaterally. Absence of peripheral edema.
Abdomen: Flat. Absence of hepatosplenomegaly.
Neurological: Alert and oriented to self, place and time. Speech intact.
Differential Diagnosis (so far)
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DVT
Pulmonary Embolism
MI
CHF
Pneumonia
Bronchitis
COPD/asthma exacerbation
Diagnostics/Work-up
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CXR
EKG
CBC
CMP
D-Dimer
Troponin
BNP
Treatment
• Saline lock
• 2LNC Oxygen
• Duoneb (Albuterol/Ipratropium) INH x1
– Short acting bronchodilator/short acting
anticholinergic
Post-treatment
• Oxygen: Spo2 92%97% 2LNC95% RA at
discharge
• After Duoneb  Wheezes improved upper
lobea. Coarse crackles absent. Clear bases
bilaterally.
• VS: BP 148/76, HR 87, Spo2 99% 2LNC, rr 18
Diagnostics - Results
CXR  No infiltrates
or consolidation. Nml.
EKG  Sinus rhythm
CBC  WNL
CMP WNL
D-Dimer  50 (<=250)
Troponin  <0.02
BNP 586 (<200)
Diagnosis – Rule out
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DVT
Pulmonary Embolism
MI
CHF
Pneumonia
Bronchitis
COPD/asthma exacerbation
Diagnosis
• Obstructive chronic
bronchitis with
Exacerbation ICD-9
491.21
Etiology
• Prolonged exposure to bronchial irritants
– Smoking, environmental, occupational
– Chronic, poorly controlled respiratory allergies
– Chronic respiratory infections
– Low birth weight
(Hollier & Hensley, 2011, p. 576)(Global Initiative for Chronic Obstructive Lung Disease,
2015,p. 6)
Incidence
• 14.2 million people – COPD
• 12.5 million people – Chronic bronchitis
• Fourth leading cause of death in United States
(Hollier & Hensley, 2011, p. 576)
Pathophysiology
•Inflammatory disease of the
mucus membranes of the bronchi
•Increased amount of sputum
throughout part or the entire
year.
•Chronic irritation leads to
increase in mucus production
•Mucus gland hyperplasia and
increased risk for infection
•Airway narrowing and increased
airway resistance, fibrosis around
bronchioles
•All these factors result in airway
narrowing = obstructive disease
(Higginson, 2010, p.107-108)
Management Plan
• Ventolin MDI (Albuterol sulfate) 90mcg 2 puffs
INH Q4-6H PRN
– Short acting bronchodilator
• Prednisone taper (corticosteroid)
• Z-pak Zithromax (Azithromycin) 250mg PO
daily x6days
– Macrolide Abx
Education
• Minimize exposure to irritants
• Pneumococcal & influenza vaccine
• Reduce exposure to persons with respiratory
infection
• Increase fluid intake
• Pursed lip breathing (if needed)
• Smoking cessation
Follow-up
• Every 3-6 months for stable disease
• Maintain close follow-up with patients with
acute respiratory infections
• Review treatment plan with patient at each
visit (Hollier & Hensely, 2011,p. 576)
References
• Global Initiative for Chronic Obstructive Lung Disease.
(2015). Pocket guide to COPD diagnosis, management,
and prevention. Retrieved February 18, 2015 from
http://www.goldcopd.org/uploads/users/files/GOLD_P
ocket_2015.pdf
• Higginson, R. (2010). COPD: pathophysiology and
treatment. Nurse Prescribing, 8(3), 102-110.
• Hollier, A., & Hensley,R. (2011). Clinical guidelines in
primary care: A reference and review book.
Lafayette,LA: Advanced Practice Education Associates.