2/19/06 Case

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2/19/06 Case

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Chief Complaint

• Pt is a 33 y/o aa male who presents with new
  onset dyspnea

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• What questions do we want to ask this patient?

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

History of Present Illness
Pt is a 33 y/o aa male w/ hx of a murmur in
childhood who presents w new onset dyspnea. Pt
noticed that he became short of breath while
driving today. This is the first time that he
has felt this way and it lasted for about twenty
minutes. It became better with time and was self
limiting. The patient denies having any chest
pain, palpitations, light headedness or recent
URI. He also denies any recent trauma, calf
tenderness, immobility, or history of clotting.
He does however admit to being an anxious person
and noticed some tingling down his left arm and
right side of his body. He also noticed having a
muscle cramp in his right arm and diffuse pain
across his abdomen.
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Past Medical History
Anxiety Hx of heart murmur No surgical history
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Medications
None
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

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

Social History
Smokes 3 cigars a day Drinks 24 oz beer / day
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Family Medical History Mother-
Sarcoidosis Father-
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• 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 Respiratory SOB, wheeze, no cough
or URI Cardiac HTN, murmurs, angina,
palpitations GI appetite, n/v, incont.,
const/diarrhea, mild abdomen pain GU
frequency, hesitancy, urgency,
dysuria hematuria, incont., stones, no
dyspareunia, no discharge MSK muscle
weakness, flank pain, muscle cramps Neuro
parasthesias, loss of sensation Psychiatric-
Pt is not depressed
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Physical Exam VS- BP- 146/80 T-98.8 R-15
P-120 General- Pt is well nourished and
AxOx3 Heent- EOMI, PERRLA, no vision
changes CV- RRR w/o murmurs or rubs, clicks or
gallops RESP- Clear to auscultation bilaterally,
no wheezes, rales or crackles Abdomen- Soft, NT,
ND, no masses, BS, no bruits GU- No discharge,
bleeding, nodules or masses Positive lloyds
test MSK- No weakness, mild tenderness in R
flank TTA T11-L-1 EXT- No edema, negative
homans, pulses b/l, negative troussau
sign Neuro- No neurodeficits, CN II-XII intact
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Differential
Psychiatric Anxiety Panic attack Pulmonary Most
probably acute PE Pneumothorax Less likely
chronic etiology COPD Cardiac Arrhythmia MI US
A
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

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

Labs
ChemistryCBCD-dimerEKGChest X-rayCardiac
enzymes
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

CBC
14.6 g/dl
6.9
221
43.2
Chemistry
Phos 1.1AST 61ALT 71Cardiac Enzymes X3
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140
104
94
3.5
22
1.0
D-dimer lt100
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Chest X-ray Right hilar vascularity No
flattening of diaghramEKG NSR
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• CC
• HPI
• PMHx
• MEDS
• Allergies
• SocHx
• FMHx
• ROS
• Physical Exam
• Differential
• LABS
• Radiological
• Diagnosis
• Treatment

Diagnosis

1. 33 y/o aa male presenting with hyperventilation
   and dyspnea with left arm tinglingMost likely
   panic attack must rule out pulmonary (PE) and
   cardiac process (MI) Cardiac enzymes, monitor
   patient for new episodes, D-dimer, out patient
   echo
2. HypophosphatemiaMost likely secondary to above
   and secondary to alcohol history0.1 mmol/ kg IBW
   potassium phosphate
3. Hx of sarcoid aa raceSerum angiotensin
   converting enzyme

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Hyperventilation

• Acid base balance maintained by kidney and lungs
• Carbon dioxide is removed via lungs
• Hyperventilation can cause respiratory alkalosis
• Acid removed via kidney
• Hydrogen and volatile acids like phosphate

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Hyperventilation

• Respiratory alkalosis
• Acute respiratory alkalosis
• Fall in partial pressure of carbon dioxide
• Similar change in the cells
• Carbon dioxide readily diffuses across cell
  membranes.
• Rise in intracellular pH
• Stimulates phosphofructokinase
• Stimulates glycolysis
• Extreme hyperventilation
• Can lower serum phosphate concentrations to below
  1.0 mg/dL
• Most common cause of marked hypophosphatemia in
  hospitalized patients

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Hyperventilation

• Hypophosphatemia
• Other causes
• Poor intake (rare)
• Kidney usually will reabsorb phosphate
• Antacids
• Hyperparathyrdoidism
• Vitamin D deficiency
• Renal wasting
• Alcoholism
• Hypersecretion
• Hungry bone syndrome
• During treatment of DKA

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HyperventilationHypophosphatemia

• Signs and symptoms
• CNS
• Irritability
• Paresthesias
• Confusion
• Seizures
• Delirium
• Coma
• MSK
• Proximal myopathy leading to rhabdomyolysis
• May mask low phosphate
• Hematological
• Hemolysis
• Poor phagocytosis
• Defective clotting

• Cardiopulmonary
• Impaired Myocardial contractility
• ATP depletion
• Respiratory failure
• Weakness of the diaphragm
• Reduction in cardiac output
• Congestive heart failure
• If plasma phosphate concentration falls to 1.0
  mg/dL

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Thank you!

• Questions, comments, concerns?