Transcript Current Case Review - Novi Family Doctor | Novi MI Family

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
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HPI
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History of Present Illness
MEDS
Allergies
The patient is a 49 year old caucasion female with a
history of chronic obstructive pulmonary disease who
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presents to the ER after her PCP evaluated her with an
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oxygen saturation of 84%. The patient notes that she
has become more short of breath since November and
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worsened in the past few days. This is apparent
Physical Exam itallhas
day long and is worse with exertion. She notes that
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she feels better when she uses her boyfriends home
oxygen. She also notes that her boyfriend is
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chronically tired and short of breath. At the time of her
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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.
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Past Medical History
COPD
Hypercholesterolemia
Non-Insulin Dependant Diabetes Milletus
Seizure disorder – secondary mva
Mitral Valve Prolapse
Hypothyroidism
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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
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Dilantin - Nausea
Tegretol – Dizziness
Depakote - Nausea
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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.
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Family Medical History
MotherFather- Died of a heart attack late
in life
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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
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VSBP- 115/105 T-98.7 R-20 P-72
General- Pt is well nourished and AxOx3
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
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Differential
COPD / Asthma
Pneumonia
Bronchitis
Infiltrative (i.e. asbestos)
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What do we want to order?
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Labs
CBC
Chemistry
EKG
ABG
Spiral CT
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CBC
16.2 g/dl
9.4
211
49.2
Chemistry
138
100
9.0
109
3.7
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0.7
ABG
PH
Bicarb
7.370
29.1
pCO2 51.6
coHb 11.2
pO2 41 (69.5 on 3L)
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Chest X-ray
Cardiomegally, no flattening of
diaphraghm, no barrel chest
Spiral CT
Negative for PE
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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
O2 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
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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 is formed as a by-product of burning organic compounds
– Fatalities result from
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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
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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
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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
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HbCO level
– Often does not correlate well with clinical status
• Implies possible additional impairment of cellular respiration.
Carbon Monoxide Poisioning
Pathophysiology
• 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 Poisioning
History
• Acute poisoning
– Malaise, flulike symptoms,
fatigue
– Dyspnea on exertion
– Chest pain, palpitations
– Lethargy
– Confusion
– Depression
– Impulsiveness
– Distractibility
– Hallucination
– Confabulation
– Agitation
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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
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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
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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)
• 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
• 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 Poisioning
Treatment
• 100% inspired oxygen
• Sometimes can use hyperbaric O2
• Careful correction of acidosis
– O2 is appropriate
Thank you!
• Questions, comments, concerns?