Case 2: 61 year old male with shortness of breath
Written by: Salaheldin Abusin, MD, MRCP. Resident in Internal Medicine, Cook County Hospital, Chicago, IL, USA Reviewed by: Ihab Babiker Abdalrahman, MD, Assistant Professor of Medicine, University of Khartoum, Sudan Faroug Yassin, MD. Attending in Internal Medicine, University of Iowa Hospital, Iowa City, IA, USAHistory: A 61 year old male with past history of hypertension and asthma presented to the Emergency Department with new onset shortness of breath for 4 days. Prior to that he was feeling well, and his asthma was well controlled with fluticasone/salmeterol combination inhaler. He also noticed a cough, with blood tinged sputum. He had no chest pain, no orthopnea or paroxysmal nocturnal dyspnea, or fever. He used his albuterol inhaler several times with no improvement in his shortness of breath. He had no other symptoms.
Past history: He gave remote history (10 years prior to current presentation) of left lower limb swelling that subsided after treatment for 6 months.
Social history: Smoker 40 pack year history
Family history: no relevant family history.
Drug history: fluticasone/Salmeterol combination inhaler twice daily, albuterol inhaler as needed for shortness of breath, hydrochlorothiazide 12.5mg once daily
Physical Examination:
Vital Signs: HR 113/min, BP 150/93, respiratory rate 22/min, oxygen saturation via pulse oximetry 89% on room air, temperature 97.2° F, (36.2 °C)
HEENT: (Head, Eyes, Ear, Nose, Throat examination) was normal.
JVP was not raised.
Chest clear no wheezes, or crackles.
Abdomen soft non tender, no palpable liver, spleen.
Lower extremities: no edema, no other abnormalities.
PEFR (peak expiratory flow rate) was above 75% of predicted
Investigations:
Basic metabolic panel (BMP) includes Na, K, HCO3, Chloride, BUN, Creatinine was within normal limits.
Complete blood count: Hb 15.9, WBC 7200 with normal differential, platelet count 270.
Liver function test, and liver enzymes were within normal limits.
Arterial blood gas on room air: pH 7.42, pCO2 33.2, pO2 55, Oxsat 87%.
Chest xray: clear lung fields.
ECG: sinus tachycardia.
Troponin I: 0.17 (normal range up to 0.034)