60-something male with difficulty breathing

[Epi-do]

So I had this patient a while back that I wanted to get some opinions on. He was a 60-something fluffy white male. He was c/o difficulty breathing that had been going on all day. Today's episode began about an hour after he got up and it is now around 20-2100.

He denied any pain, including CP. When listening to breath sounds, he was very tight and expiratory wheezes could only faintly be heard in all lobes. He had been using his home nebulizer throughout the day with very little relief in symptoms. He was very puffy all over, but it was worst in his lower extremities, where he had pitting edema. (He looked like the love child of the Sta-Puff Marshmallow man and SpongeBob Squarepants.) He had a weak, nonproductive cough.

While I had him with me, I gave him two neb treatments of albuterol (5 mg)/atrovent (0.5 mg). He was sinus rhythm without ectopy on the monitor. Blood sugar was just over 100. (I don't remember exactly what it was.) The rest of his vital signs were unremarkable. They were relatively unchanged throughout transport and within what is considered a normal range. I can't give specific numbers, because it has been too long and I no longer remember them.

Additional reassessments of breath sounds over the course of the nebulizers revealed that he eventually opened back up and was clear and equal by the time we got to the ER. He continued to deny any other complaints at all the entire time he was with me.

He was adamant that the only medical history he had was asthma and htn and swears he has never been diagnosed with CHF or ever had any other "heart problems." His list of meds reflected this. (And, yes, I do realize our patients lie to us, and he very well could have other issues he wasn't sharing with me.) He had no allergies. He said he sleeps on one pillow and typically has no problems sleeping through the night.

When we got to the ER, the doc followed us into the room and took a listen to the guy's breathing. He then commented that he sounded "really good" and that they would work him up to "rule out heart failure." He began asking the pt several other questions and it seemed he was thinking something else was going on. Unfortunately, they had a critical pt arrive into the ER, and I never got a chance to talk with him about what he thought was going on. It is a hospital we rarely go to, so I haven't been able to follow up on the patient either. I really wanted to find out what was going on with this guy, and I know you guys won't be able to say definately what the diagnosis was, but was still interested in hearing you kick around some ideas.

I did entertain the idea of CHF initially, and while I am sure he was on that path, I am thinking that something other than cardiac problems were the initial precipitating event to head him down that road. Would it be reasonable to think that he may have developed renal insufficiency, which was causing the fluid retention, and the asthma exacerbation was the proverbial straw that broke the camels back? Is this unlikely, and it was most likely a new onset of CHF? What are your thoughts? I would love to hear them!

 

[skivail]

Any changes in urination frequency?

 

[medicstudent101]

I'm going to go with a new onset of CHF. As far as the renal insufficiency, I would expect him to be more junky upon auscultation along with some associated HTN if that were the case. As far as his initial complaint of dyspnea, I'd accredit that to his asthma. It sounds like the treatments took care of that pretty well.

Was his edema generalized or pitting? If so, what was his pitting edema rated at?

 

[skivail]

If the edeme was as gerealized as the OP states it could be Cardiac Asthma.

 

[medicstudent101]

Kinda skimmed through the post. He said there was pitting edema, especially in the lower extremities. With true cardiac asthma, more often than not you'll have some associated chest pain. I'm still going to stick with a new onset of CHF.

 

[Epi-do]

Any changes in urination frequency?

Unfortunately, I don't remember if I even asked, or what his answer may have been.

Was his edema generalized or pitting? If so, what was his pitting edema rated at?

Pitting up to the knee, probably a 3+ and generalized everywhere else. It was the all over puffiness that made me wonder about renal insufficiency. It just had something about it that was a different "look" than your "typical" CHF patient.

She said there was pitting edema, especially in the lower extremities.

Fixed it for you!

 

[johnmedic]

I know you said "WNL" for most vital signs, but I'm wondering about his initial vs final O2 sat? But here's where my brain's going, I'd be suspicious of a few things: Lying, of course, is my knee-jerk reaction. But maybe he has been avoiding going to the Doctor's office for quite some time, and therefore hasn't been diagnosed with the apparent CHF. Lastly, COPD especially Chronic Bronchitis can cause varying degrees of edema, I wouldn't be surprised if his "Asthma" is now actually CB with/without CHF.

Followup's the best, it's a shame it didn't work out for this one.. But overall, you saw the patient's living situation mentally & financially, you judged his responses for tells of dishonesty, and had other subtle cues from his skin & anxiety level. Trust your intuition on this one.

 

[MrBrown]

Could have been 300 different things, its hard to say.

Brown thinks it could be CHF, did you do a 12 lead?

 

[Epi-do]

The 12 lead was a nice, pretty sinus rhythm without ectopy.

I really wish I had remembered to post this sooner, when I remembered more of the numerical values for the various vital signs, among other things.

 

[Veneficus]

I don't think the 12 lead would really help in this case. But for sure one should be done.

With the basic things that cause massive edema: heart, kidney, liver, vasculature, and lymph, from the description, none can be effectively ruled out, though lymph is unlikely.

This condition can be caused by everything from the obvious heart failure to cancer.

But looking at what we know.

He has asthma, he was self treating and being treated for it. The lung issue could really and I would bet secondary to another problem, probably cardiac or renal related. With all chronic renal/cardiac problems, there is the chance of a corresponding liver problem as well.

HTN, depending on how long he had it, what's causing it, and how well controlled it was, he is at risk of concentric cardiomyopathy. With his hypertension medication preventing a compensatory response, if he had any level of renal stenosis, or major stenosis just above the level of the renal artery, his renal perfusion may have dropped low enough to cause an acute renal injury I would bet on top of a chronic renal injury insult.

With reduced filling capacity of the LV, and concurrent fluid back up, pulmonary edema is not an unsuspected finding. If it has been going on for some time RV hypertrophy, or if severe, fluid expanding the RV past it's contractile ability and systemic backup of fluid.

If we throw in a valvular defect/acute failure like mitral or aortic, you could get the symptoms presentd. Especially in a mitral failure.

Of course an MI can acutely create many of these sequele too, but I think the doppler ultrasound would be more diagnostic than a 12 lead, because it will allow you to check for multiple things at once, including wall dysfunction.

I am not even going to type out portal hypertension, fatty liver, cirrosis, vena cava syndrome, etc. But they are certainly possible

While it is impossible to do anything but speculate on the cause with the limited information, I am willing to bet it was a combination of things that were getting to him, rather than a single event.