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45-year-old Asian male was admitted to the emergency room with chronic shortness and breathlessness. The symptoms began two days earlier and progressively worsened without any apparent underlying, relieving or aggravating factors. Similar symptoms were seen in the patient about a year ago. They were characterized by acute, chronic and obstructive lung disease (COPD), which required hospitalization. He uses ventilatory support to sleep at night. The patient requested that it be used in the hospital because it would allow him to sleep better and to help with breathing problems. He denies having chest pains, chest pains or coughs. He does however report mild fatigue, breathing difficulties at rest, increased frequency of the urinary stream, forgetfulness, and some other symptoms. The patient was eventually left bedridden due to fatigue, shortness of breath, and weakness.
His family history does not include any similar illnesses. His mother had a history of cardiovascular disease. His social history includes a ten-year stint as a smoker. Due to increasing breathing difficulties, he quit smoking three years back. He has not used any illegal substances or alcohol. The patient is not allergic to any particular food, drug or environmental factor. For COPD, myocardial injury, peripheral vascular disease and hypertension, as well as for hypothyroidism (hypothyroidism), coronary artery disease, hypertension, heart attack, hypertension, cardiomyopathy, hypothyroidism (hypothyroidism), obesity, tobacco use, hyperlipidemia and diabetes mellitus, it is important to review the patient’s medical history. The patient’s medical history is important for cardiac catheterization, appendectomy and hysterectomy. Current medications include hydrochlorothiazide (Breo Ellipta), hydrochlorothiazide (Duo-Neb), levothyroxine and metformin as well as vitamin D3, nebivolol and vitamin D3. Aspirin, Clopidogrel, isosorbide monnitrate, and Rosuvastatin are all recommended.
Physical Exam
Initial physical tests reveal temperature 96.7F, BP 105/56, O2 saturation 89% on room atmosphere, heart rate 75bpm, BMI 39.2, and respiratory rate 25.
Constitutional: the patient is an acutely obese, critically ill-appearing male with well-nourished and developed with BiPAP. The patient lies on a medical stretcher under two blankets.
HEENT Analysis
Head: Atraumatic as well as normocephalic
Mouth: The membranes are most and mucous
Eyes: The patient has normal EOM and conjunctiva. Pupils are round, uniform, and responsive to light. He also has bilateral periorbital edema but showed no scleral icterus.
Neck: The patient showed no JVD, surgical scarring, or masses. Neck supple present.
Macroglossia: Negative feedback
Throat: Not only patent but also moist
Cardiovascular: Normal heart sound, regular heartbeat rhythm, and standard rate. Intense pulses in addition to 2+ pitting edema in lower extremities.
Chest/Pulmonary: The tests did not indicate any respiratory status distress, but tachypnea is present. The findings also indicate the presence of (+) wheezing, reduced bilateral movement of air, and bilateral rhonchi. Patient unable to complete one sentence due to breathing difficulty.
Abdominal: The patient has a soft but obese abdomen with normal bowel sounds. No tenderness or distension noted.
Skin: The patient has dry skin.
Neurologic: The patient is awake, can protect his airway, and remain alert. There is no sensation loss—every extremity moves.
Initial and Differential Examination
The initial examination was necessary to determine the source of dyspnea. This evaluation included CBC required to identify the presence of an anemic or infectious source, CMP, to analyze the electrolyte balance. CMP test is also useful in reviewing renal functions and blood gas levels to detect the PO2 presence of hypoxia or a notable acid-base disorder. Other initial tests include troponin I and creatine kinase to determine the presence of rhabdomyolysis or myocardial infarction, chest x-rays, and brain natriuretic peptides. Considering the winter season as well as influenza is prevalent, a quick influenza assay is necessary. Differential diagnosis included tests on acute renal failure, pericardial effusion, chronic COPD exacerbation, congestive heart failure, pulmonary edema, bacterial pneumonia, hypothyroidism, NSTEMI, pulmonary embolism, and influenza pneumonia.
