Approaching Respiratory Distress Cases

This issue of ‘So you think you can diagnose?’ will be a variation on the usual segment where there will be two separate cases. These are a culmination of ambulance calls I experienced while working as an EMT this past summer. I have been working in EMS for eight years; it is one of the things that affirmed my decision to become a doctor. I’ve always taken every opportunity to work in the field and this being my “last summer,” I made sure to take advantage of the time I had left to do so and was rewarded with some very fascinating cases. I’ve always found respiratory distress calls to be some of the most interesting I’ve encountered and so the two cases will both be based on instances where, at least initially, the patient’s complaint was just that. It has been my job (and now yours) to be able to take the basic presenting information and then delve out the rest. Here goes…

Case 1: 76 year old male with history of COPD, Congestive heart failure (CHF), and Alzheimer’s living at home

CC: difficulty breathing and fatigue

HPI: The patient has not been feeling well for the past few days and woke up this morning with difficulty breathing. He is too weak to stand up out of bed, and his family states his mental status seems “off” from usual.  Patient has a productive cough with yellow-green sputum. Patient states it hurts to breathe.

PE: HR 100, RR 30, BP 116/76. Patient appears ill and confused. Skin is diaphoretic and warm to touch.  Expiratory rales heard B/L on auscultation of lungs. Decreased breath sounds at left lung.

Patient responds to supplemental O2 therapy with a decrease in respiratory rate (26) but does not feel better.

Case 2: 73 year old female with history of COPD and CHF living in a nursing home

CC: difficulty breathing and fatigue

HPI: The patient has been feeling fatigued for the past few days with progressively difficult breathing and shortness of breath. Today she feels too weak and has too much trouble breathing to move around for extended periods of time. Patient has a productive cough which is stated to be clear. Patient states the difficulty breathing is worse when lying down and with exertion. Chest pain is denied.

PE: HR 108, RR 28, BP 100/72. Expiratory rales audible. Inspiratory and expiratory rales heard throughout lungs B/L on auscultation. Patient has pitting edema 2+ B/L to lower extremities.

Patient responds to supplemental O2 therapy with a decrease in respiratory rate (24) and states she feels better and stronger with it.

As stated at the beginning, these cases are based on real ambulance calls; and therefore, the material is presented similarly to what could be obtained pre-hospital. The information provided to you is mainly based on the patient’s history, the most important tool in your diagnosis arsenal. After looking through the cases, think of differentials for these two patients and what information/labs/tests you would want based on what you think is most likely causing the respiratory distress in each.  Both present similarly at first glance so start looking for what distinguishes them and consider why. Happy Diagnosing!

 

 

 

ANSWERS:

case 1: Bacterial Pneumonia – consider S. Pnuemoniae, H. Influenzae

case 2: Pleural Effusion from CHF exacerbation

The Season of Rashes

By: Molly Kelly, OMS-IV

1.) A 6 year old boy is brought to your office by his mother who states that the patient has been experiencing fevers of 101.3F and complaining of abdominal pain and vomiting for the past several hours. She also notes that the patient has developed an unusual rash on his legs and has been complaining of pain in his knees and ankles. Upon further review of his history, you learn the boy had a mild cold that resolved last week. Your physical exam reveals a reddish-purple palpable rash on his legs and buttocks and swelling of his knees and ankles with restriction in motion. What immunoglobulin is responsible for this child’s presentation?

2.) A 52 year old woman comes to the office for her annual wellness exam. She complains she is getting old when she attempts to stand up from a chair in the waiting room and finds herself needing to use her arms to push herself up out of the chair. She also complains about her new hair-do as she had to cut her hair shorter because she found it increasingly difficult to brush her hair in the morning. She states that it has been taking forever for her to get ready in the morning because of “getting old” and proudly shows off her new violet colored eyeshadow she says has developed naturally. Upon exam, you discover an erythematous rash in a V-like distribution on her shoulders and back. You also notice scaly erythematous eruptions or red patches overlying the knuckles as pictured below. What does this woman have?

3.) A 13 year old boy is brought to his pediatrician with complaints of a fever, headache, sore throat and a painful rash. The rash is versicular in appearance and localized to his palms and soles. In getting a throat culture, the you notice the patient has ulcers in his mouth and on his tongue. What is responsible for this patient’s illness?


ANSWERS:

1. Immunoglobulin A (IgA) and Complement component 3 (C3)
This boy has Henoch-Schonlein purpura (HSP or anaphylactoid purpura) is a form of blood vessel inflammation or vasculitis in which complexes of immunoglobulin A (IgA) and complement component 3 (C3) are deposited in the small arterial vessels in the skin, gastrointestinal tract and frequently the kidneys. HSP results in a skin rash, most prominent over the buttocks and behind the lower extremities associated with joint inflammation (arthritis), and cramping pain in the abdomen.
2. Dermatomyositis
This woman is not feeling her age because she has dermatomyositis, a connective-tissue disease related to polymyositis that is characterized by inflammation of the muscles and the skin. While dermatomyositis most frequently affects the skin and muscles, it is a systemic disorder that may also affect the joints, the esophagus, the lungs, and, less commonly, the heart. The main symptoms include skin rash and symmetric proximal muscle weakness which may be accompanied by pain. The heliotropic or “lilac” rash is a violaceous eruption on the upper eyelids, the shawl (or V-) sign is a diffuse, flat, erythematous lesion over the back and shoulders which worsens with UV light. The lesions seen on her hands are known as Grotton’s papules.
3. Coxsackie A Virus
Hand-foot-and-mouth disease (HFMD) is a moderately contagious viral illness most commonly caused by coxsackie A virus, a member of the picornaviridae family. This illness is characterized by fever, sores in the mouth, and a rash on the hands and feet with blisters. It mostly affects children younger than 10 years of age, but people of any age can be infected. HFMD is not to be confused with foot-and-mouth disease, also called hoof-and-mouth disease, which is a separate disease affecting sheep, cattle, and swine. Both diseases are caused by members of the picornaviridae family, but are not trans-communicable between humans and livestock.