2/17/06 Case presentation. Chief Complaint The patient is a 49-year-old Caucasion female who...

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?

• CC• HPI• PMHx• MEDS• Allergies• SocHx• FMHx• ROS• Physical Exam• Differential• LABS• Radiological• Diagnosis• Treatment

History of Present Illness

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.


Past Medical History

COPD

Hypercholesterolemia

Non-Insulin Dependant Diabetes Milletus

Seizure disorder – secondary mva

Mitral Valve Prolapse

Hypothyroidism


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


Allergies

Dilantin - NauseaTegretol – DizzinessDepakote - Nausea


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.


Family Medical HistoryMother- Father- Died of a heart attack latein life


Review of systems

General: weight change, fever, chills, weakHead: headache, nasuea, vomitting, no lip

lacerationsRespiratory: SOB, wheeze, cough, Hx COPDCardiac: HTN, murmurs, angina, palpitationsGI: appetite, n/v, incont., const/diarrheaGU: frequency, hesitancy, urgency, dysuria

hematuria, incont., stones, no bowel or bladder incontinence no dyspareunia, no discharge

MSK: muscle weakness, flank painNeuro: parasthesias, loss of sensationPsychiatric- pt is not depressed


Physical ExamVS- BP- 115/105 T-98.7 R-20 P-72General- Pt is well nourished and AxOx3Heent- EOMI, PERRLA, no vision changes, mydriasisCV- RRR w/o murmurs or rubs, or thrillsRESP- Clear to auscultation bilaterally, exp wheezeAbdomen- Soft, NT, ND, no masses, BS, no bruitsGU- No discharge, bleeding, nodules or masses

Negative lloyds testMSK- No weakness, EXT- No edema, negative homans, pulses b/lSKIN- Macular rash on face both cheeks and noseNeuro- 2/4 refelxes bilaterally


Differential

COPD / Asthma

Pneumonia

Bronchitis

Infiltrative (i.e. asbestos)


What do we want to order?


Labs

CBC

Chemistry

EKG

ABG

Spiral CT


CBC

9.416.2 g/dl

49.2

211

Chemistry

138

3.7

100

30

9.0

0.7

109

ABGPH 7.370 pCO2 51.6 pO2 41 (69.5 on 3L)Bicarb 29.1 coHb 11.2


Chest X-ray

Cardiomegally, no flattening of diaphraghm, no barrel chest

Spiral CT

Negative for PE


Assesment / Plan

1. 49 y/o caucasion female with dyspneaMost 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 SVNDecadron

2. Mydriasis, probably related to atroventUrine Drug Screen

3. Diabetes – under control4. Seizures - gabapentin

• 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 whentaken off of nasal cannula. Multiple ABGshow carboxy hemoglobin that is over 11.

Upon further questioning patient notes thatshe has an old furnace and her boyfriendsleeps all day.

Next day they send someone to the housewho finds carbon monoxide leak in oven.

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

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.

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

Carbon Monoxide PoisioningHistory

• 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 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

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.

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

Carbon Monoxide PoisioningTreatment

• 100% inspired oxygen

• Sometimes can use hyperbaric O2

• Careful correction of acidosis– O2 is appropriate

Thank you!

• Questions, comments, concerns?

2/17/06 Case presentation. Chief Complaint The patient is a 49-year-old Caucasion female who...

Documents

Transcript of 2/17/06 Case presentation. Chief Complaint The patient is a 49-year-old Caucasion female who...