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...
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...
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