Transcript Current Case Review

2/19/06 Case
Chief Complaint
• Pt is a 33 y/o aa male who presents
with new onset dyspnea
• What questions do we want to ask this
patient?
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CC
HPI
PMHx
History of Present Illness
MEDS
Allergies
SocHx
Pt is a 33 y/o aa male w/ hx of a murmur in
childhood who presents w new onset dyspnea. Pt
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noticed that he became short of breath while
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driving today. This is the first time that he has felt
Physical Exam this way and it lasted for about twenty minutes. It
became better with time and was self limiting. The
Differential
patient denies having any chest pain, palpitations,
light headedness or recent URI. He also denies
LABS
any recent trauma, calf tenderness, immobility, or
Radiological
history of clotting. He does however admit to being
an anxious person and noticed some tingling down
Diagnosis
his left arm and right side of his body. He also
Treatment
noticed having a muscle cramp in his right arm and
diffuse pain across his abdomen.
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Past Medical History
Anxiety
Hx of heart murmur
No surgical history
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Medications
None
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Allergies
NKDA
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Social History
Smokes 3 cigars a day
Drinks 24 oz beer / day
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Family Medical History
Mother- Sarcoidosis
Father-
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Review of systems
General:
Head:
Respiratory:
Cardiac:
GI:
GU:
MSK:
Neuro:
Psychiatric-
weight change, fever, chills, weak
headache, nasuea, vomitting
SOB, wheeze, no cough or URI
HTN, murmurs, angina, palpitations
appetite, n/v, incont., const/diarrhea,
mild abdomen pain
frequency, hesitancy, urgency, dysuria
hematuria, incont., stones,
no dyspareunia, no discharge
muscle weakness, flank pain, muscle
cramps
parasthesias, loss of sensation
Pt is not depressed
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Physical Exam
VSBP- 146/80 T-98.8 R-15 P-120
General- Pt is well nourished and AxOx3
Heent- EOMI, PERRLA, no vision changes
CVRRR w/o murmurs or rubs, clicks or gallops
RESP- Clear to auscultation bilaterally, no wheezes,
rales or crackles
Abdomen- Soft, NT, ND, no masses, BS, no bruits
GUNo discharge, bleeding, nodules or masses
Positive lloyd’s test
MSK- No weakness, mild tenderness in R flank
TTA T11-L-1
EXT- No edema, negative homans, pulses b/l,
negative troussau sign
Neuro- No neurodeficits, CN II-XII intact
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Differential
Psychiatric
Anxiety
Panic attack
Pulmonary
Most probably acute
PE
Pneumothorax
Less likely chronic etiology
COPD
Cardiac
Arrhythmia
MI
USA
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What do we want to order?
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Labs
Chemistry
CBC
D-dimer
EKG
Chest X-ray
Cardiac enzymes
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CBC
14.6 g/dl
6.9
221
43.2
Chemistry
140
104
15
94
3.5
22
1.0
D-dimer
<100
Phos 1.1
AST 61
ALT 71
Cardiac
Enzymes – X3
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Chest X-ray
Right hilar vascularity
No flattening of diaghram
EKG
NSR
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Diagnosis
1. 33 y/o aa male presenting with hyperventilation
and dyspnea with left arm tingling
Most likely panic attack; must rule out pulmonary
(PE) and cardiac process (MI)
Cardiac enzymes, monitor patient for new
episodes, D-dimer, out patient echo
2. Hypophosphatemia
Most likely secondary to above and secondary to
alcohol history
0.1 mmol/ kg IBW potassium phosphate
3. Hx of sarcoid; aa race
Serum angiotensin converting enzyme
Hyperventilation
• Acid base balance maintained by kidney
and lungs
– Carbon dioxide is removed via lungs
• Hyperventilation can cause respiratory alkalosis
– Acid removed via kidney
• Hydrogen and volatile acids like phosphate
Hyperventilation
• Respiratory alkalosis
– Acute respiratory alkalosis
• Fall in partial pressure of carbon dioxide
– Similar change in the cells
– Carbon dioxide readily diffuses across cell membranes.
– Rise in intracellular pH
» Stimulates phosphofructokinase
» Stimulates glycolysis
– Extreme hyperventilation
– Can lower serum phosphate concentrations to below 1.0 mg/dL
– Most common cause of marked hypophosphatemia in
hospitalized patients
Hyperventilation
• Hypophosphatemia
– Other causes
• Poor intake (rare)
– Kidney usually will reabsorb phosphate
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Antacids
Hyperparathyrdoidism
Vitamin D deficiency
Renal wasting
Alcoholism
Hypersecretion
Hungry bone syndrome
During treatment of DKA
Hyperventilation
Hypophosphatemia
• Signs and symptoms
– CNS –
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Irritability
Paresthesias
Confusion
Seizures
Delirium
Coma
– MSK
• Proximal myopathy leading to
rhabdomyolysis
– May mask low phosphate
– Hematological
• Hemolysis
• Poor phagocytosis
• Defective clotting
• Cardiopulmonary
– Impaired Myocardial
contractility
• ATP depletion
– Respiratory failure
• Weakness of the diaphragm
– Reduction in cardiac output
• Congestive heart failure
• If plasma phosphate
concentration falls to 1.0
mg/dL
Thank you!
• Questions, comments, concerns?