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

What questions do we want to ask this patient?

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment History of Present Illness The patient is a 49 year old caucasion female with a history of chronic obstructive pulmonary disease who presents to the ER after her PCP evaluated her with an oxygen saturation of 84%. The patient notes that she has become more short of breath since November and it has worsened in the past few days. This is apparent all day long and is worse with exertion. She notes that she feels better when she uses her boyfriends home oxygen. She also notes that her boyfriend is chronically tired and short of breath. At the time of her symptoms she denies having chest pain, palpitations, calf tenderness or recent upper respiratory infections. She was speaking really slow when examined but was alert and oriented x 3.

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Past Medical History COPD Hypercholesterolemia Non-Insulin Dependant Diabetes Milletus Seizure disorder – secondary mva Mitral Valve Prolapse Hypothyroidism

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment 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

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Allergies Dilantin - Nausea Tegretol – Dizziness Depakote - Nausea

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment 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.

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Family Medical History Mother- Father- Died of a heart attack late in life

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Review of systems General: weight change, fever, chills, weak Head: headache, nasuea, vomitting, no lip lacerations Respiratory: SOB, wheeze, cough, Hx COPD Cardiac: HTN, murmurs, angina, palpitations GI: appetite, n/v, incont., const/diarrhea GU: frequency, hesitancy, urgency, dysuria hematuria, incont., stones, no bowel or bladder incontinence no dyspareunia, no discharge MSK: muscle weakness, flank pain Neuro: parasthesias, loss of sensation Psychiatric- pt is not depressed

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Physical Exam VS- BP- 115/105 T-98.7 R-20 P-72 General- Pt is well nourished and AxOx3 Heent- EOMI, PERRLA, no vision changes, mydriasis CV- RRR w/o murmurs or rubs, or thrills RESP- Clear to auscultation bilaterally, exp wheeze Abdomen- Soft, NT, ND, no masses, BS, no bruits GU- No 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

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Differential COPD / Asthma Pneumonia Bronchitis Infiltrative (i.e. asbestos)

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment What do we want to order?

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Labs CBC Chemistry EKG ABG Spiral CT

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment CBC g/dl Chemistry ABG PH 7.370pCO2 51.6pO2 41 (69.5 on 3L) Bicarb 29.1coHb 11.2

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment Chest X-ray Cardiomegally, no flattening of diaphraghm, no barrel chest Spiral CT Negative for PE

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Diagnosis Treatment 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

CC HPI PMHx MEDS Allergies SocHx FMHx ROS Physical Exam Differential LABS Radiological Differential Diagnosis Treatment 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 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 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 Method –CO reversibly binds hemoglobin Relative anemia Small concentration can have large affect –Result in significant levels of carboxyhemoglobin (HbCO). Binds hemoglobin 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 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 –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 –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 –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

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