A case of deteriorating asthma

Today's scenario focused on a ficitious patient with longstanding asthma, who presents with impending respiratory failure.

The Scenario:

You are on call as the Internist for a community hospital. You are asked to see a 73 year old man who has come in with worsening shortness of breath over 6 weeks. He is known to have longstanding asthma over his entire adult life but has never had an exacerbation like this.

The clinical data are:

Non-smoker

Dry cough for 2 wks

Previously well, had gradual increase in dyspnea over the past 6 weeks.  At the start, he felt only mildly impaired, but at the time of presentation, he had difficulty crossing the room.
No fevers, chills or sweats.
No chest pain, but feels significant continuous chest tightness for the past 48 hours or so

Physical exam:

VS:  HR 122/sinus, BP 160/90, RR 26, significant accessory muscle use and signs of respiratory distress.  Temp 37.2 C, SaO2 97% on room air
Chest - faint breath sounds bilaterally, no dullness, no wheezing, trachea midline
Cardiac exam:  faint heart sounds, non palpable apex, normal JVP, no edema
Abdominal exam:  Obese, nil else
Extremities - no clubbing, no cyanosis

CXR:  Bilateral "dark lungs", flattened hemidiaphragms, increased retrosternal air, no infiltrates

ABG:  7.42/41/86/25 on room air

Other bloodwork normal.

Questions:


What is your initial assessment of this patient?

What are the immediate actions you would take?

What are the secondary assessments you would make?

Who else needs to be involved in this patient's care?

What can you foresee might be complications of his situation?

What causes of his situation might you look for?

Put your comments below, and check back for teaching points on these issues...

Pericarditis ? Or What ?

The case:  a fictitious 65 year old man, who came to the emergency department complaining of 6 hours of chest pain.  You are the Internal Medicine consultant who is asked to see him.

His background history:  healthy, previous asthma (now quiescent), hyperlipidemia on treatment, and a 1/2 pack per day smoker.  NO  known cardiac history, no other risk factors, and generally feeling at his usual state of health until today.

He woke up with a vague central chest ache without radiation, which gradually increased in intensity over the subsequent hours, becoming increasingly uncomfortable when he moved, breathed or coughed.  The pain never really let up and acetaminophen did not relieve it.  The pain was worst when he lay supine.

He came into the hospital because he was in agony, with diaphoresis but no shortness of breath.

Questions:

1.     How would you assess him further - what are the immediate assessments and subsequent steps?  What other information would you require?

2.     What is the differential diagnosis at this point?

3.     What are the priorities in his management?  What would you embark upon now and what would you wait to do?

4.     How can you Confirm what is going on?

5.     What possible Causes are you looking for?

6.     What possible Complications are you looking for?

7.     What will be your plans after your initial evaluation?

Here is an ECG that was done.





Work through the above questions, make comments below, and then check back for some teaching tips....