21706 Case presentation Chief Complaint The patient is

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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

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?

• What questions do we want to ask this patient?

 • • • • CC HPI PMHx History of Present Illness MEDS Allergies

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx 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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Medications Lipitor 10 mg Paxil 37. 5 mg Singulair 10 mg Inderal 80 mg Clonidine 0. 1 mg Levothyroxine 25 mcg Detrol LA 4 mg Advair 250/50 one puff bid Lisinopril 10 mg Risperdol 3 mg BID Gabapentin 300 tid

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx 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.

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Physical Exam VSBP- 115/105 T-98. 7 R-20 P-72 General- Pt is well nourished and Ax. Ox 3 Heent- EOMI, PERRLA, no vision changes, mydriasis CVRRR w/o murmurs or rubs, or thrills RESP- Clear to auscultation bilaterally, exp wheeze Abdomen- Soft, NT, ND, no masses, BS, no bruits GUNo 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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment CBC 16. 2 g/dl 9. 4 211 49. 2 Chemistry ABG PH Bicarb 138 100 3. 7 30 7. 370 29. 1 9. 0 109 0. 7 p. CO 2 51. 6 co. Hb 11. 2 p. O 2 41 (69. 5 on 3 L)

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx 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

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Assesment / Plan 1. 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 O 2 to maintain saturation between 90 and 92% Albuterol/ Atrovent SVN Decadron 2. Mydriasis, probably related to atrovent Urine Drug Screen 3. Diabetes – under control 4. Seizures - gabapentin

 • • • • CC HPI PMHx MEDS Allergies Soc. Hx FMHx ROS

• • • • CC HPI PMHx MEDS Allergies Soc. Hx 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.

Carbon Monoxide Poisioning Background • Carbon monoxide (CO) – Colorless, odorless gas – CO

Carbon Monoxide Poisioning Background • 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 Poisioning Pathophysiology • CO toxicity causes – Impaired oxygen delivery and utilization

Carbon Monoxide Poisioning Pathophysiology • 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 (Hb. CO). • Binds hemoglobin 230 -270 times more avidly than oxygen – CO level of 100 ppm produces an Hb. CO of 16% at equilibration – CO binds to cardiac myoglobin • Greater affinity than to hemoglobin – Myocardial depression • Hb. CO level – Often does not correlate well with clinical status • Implies possible additional impairment of cellular respiration.

Carbon Monoxide Poisioning Pathophysiology • Hb. CO levels often do not reflect the clinical

Carbon Monoxide Poisioning Pathophysiology • Hb. CO 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% O 2 – 15 -23 minutes with hyperbaric oxygen at 2. 5 atm

Carbon Monoxide Poisioning History • Acute poisoning – Malaise, flulike symptoms, fatigue – Dyspnea

Carbon Monoxide Poisioning History • 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 Poisioning Physical • Vital signs – – Tachycardia Hypertension or hypotension Hyperthermia

Carbon Monoxide Poisioning Physical • 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 Poisioning Physical • Neurologic and/or neuropsychiatric – Memory disturbance (most common) •

Carbon Monoxide Poisioning Physical • 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 Poisioning Labs • Hb. CO – Elevated levels are significant – Low

Carbon Monoxide Poisioning Labs • Hb. CO – 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 Poisioning Treatment • 100% inspired oxygen • Sometimes can use hyperbaric O

Carbon Monoxide Poisioning Treatment • 100% inspired oxygen • Sometimes can use hyperbaric O 2 • Careful correction of acidosis – O 2 is appropriate

Thank you! • Questions, comments, concerns?

Thank you! • Questions, comments, concerns?